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 $8,550 per individual / $17,100 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
Health and Wellness Discounts (gym, weight loss programs, and more) No additional cost

Retail Prescription Drugs Tier 1 = $15
  Tier 2 = $60
  Tier 3 = $85
  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 $75

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

Maternity - Prenatal Office Visits $0
Maternity - Other professional services $0
Maternity - hospital stay $350 per day up to 5 days per admission

Outpatient Surgery Services $150
Hospital Stays $350 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