Blue Shield Gold 80 Trio HMO

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Calendar year deductible $0
Calendar year pharmacy deductible $0
Calendar year out-of-pocket maximum $8,200 per individual / $16,400 per family

Preventive Care $0
Well Baby Care $0
Prenatal Office Visits $0
Pediatric Dental Benefits: Preventive $0
Pediatric Vision Benefits: Exams $0

24/7 Nurse Hotline No additional cost
Shield Concierge No additional cost
Healthy Savings No additional cost
Health and Wellness Discounts (gym, weight loss programs, and more) No additional cost

Retail Prescription Drugs Tier 1 = $15
  Tier 2 = $55
  Tier 3 = $80
  Tier 4 = 20% up to $250 per prescription

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

Laboratory Tests $40
X-rays $75
Imaging (CT / PET scan, MRI) from an outpatient radiology center $150

Urgent care $35
Emergency Room Services $350
Ambulance $250

Maternity - Prenatal Office Visits $0
Maternity - Other professional services $0
Maternity - hospital stay $600 per day up to 5 days per admission

Outpatient Surgery Services $300
Hospital Stays $600 per day up to 5 days per admission

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


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You may be eligible for financial assistance from the government to help you pay for a plan. Now that you’ve browsed our plans, please call us at the number listed below to get a quote.

To learn about your options, call our health experts.

(888) 273-0010
Monday through Friday: 8 am to 5:30 pm