Blue Shield Gold 80 Trio HMO
| Plan Cost Summary | |
|---|---|
| Estimated Monthly premium | |
| Calendar year deductible | $0 |
| Calendar year pharmacy deductible | $0 |
| Calendar year out-of-pocket maximum | $8,700 per individual / $17,400 per family |
| No cost preventive care | |
|---|---|
| Preventive Care | $0 |
| Well Baby Care | $0 |
| Prenatal Office Visits | $0 |
| Pediatric Dental Benefits: Preventive | $0 |
| Pediatric Vision Benefits: Exams | $0 |
| No cost extras | |
|---|---|
| 24/7 Nurse Hotline | No additional cost |
| Shield Concierge | No additional cost |
| Health and Wellness Discounts (gym, weight loss programs, and more) | No additional cost |
| Prescription drugs | |
|---|---|
| Retail Prescription Drugs | Tier 1 = $15 Tier 2 = $60 Tier 3 = $85 Tier 4 = 20% up to $250 per prescription |
| Physician and medical services | |
|---|---|
| Office Visit – Primary Care (internal medicine, family practice, OB/GYN, pediatrics) | $35 |
| Office Visit – Specialist Care | $65 |
| Teladoc | $0 |
| Retail clinics | Cost depends on the service performed. Cost is the same as if the service was performed elsewhere. |
| Acupuncture (from an American Specialty Health Plans network acupuncturist) | $35 |
| Chiropractic (from an American Specialty Health Plans network chiropractor) |
Not covered |
| Lab and X-ray diagnostics | |
|---|---|
| Laboratory Tests | $40 |
| X-rays | $75 |
| Imaging (CT / PET scan, MRI) from an outpatient radiology center | $75 |
| Urgent and emergency | |
|---|---|
| Urgent care | $35 |
| Emergency Room Services | $330 |
| Ambulance | $250 |
| Maternity care | |
|---|---|
| Maternity – Prenatal office visits | $0 |
| Maternity – Other professional services | $0 |
| Maternity – hospital stay | $350 per day up to 5 days per admission |
| Hospital and outpatient | |
|---|---|
| Outpatient Surgery Services | $130 |
| Hospital Stays | $350 per day up to 5 days per admission |
| Dental and vision | |
|---|---|
| Pediatric Dental Benefits: Preventive | $0 |
| Pediatric Dental Benefits: Restorative Procedures | $25 |
| Pediatric Dental Benefits: Medically Necessary Orthodontics | $1,000 |
| Pediatric Vision Benefits: Exams | $0 |
| Pediatric Vision Benefits: Eye Glasses | 1 pair per year |
