Blue Shield Gold 80 Trio HMO

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 Deductible & Out-Of-Pocket Maximum

Calendar year deductible

Calendar year pharmacy deductible

Calendar year out-of-pocket maximum

$0

$0

$8,200 per individual / $16,400 per family

 

 No Cost Preventive Care

Preventive Care

Well Baby Care

Prenatal Office Visits

Pediatric Dental Benefits: Preventive

Pediatric Vision Benefits: Exams

$0

 

$0

 

$0

 

$0

 

$0

 

 No Cost Extras

24/7 Nurse Hotline

Shield Concierge

Healthy Savings

Health and Wellness Discounts (gym, weight loss programs, and more)

No additional cost

No additional cost

No additional cost

No additional cost

 

 Prescription Drugs

Retail Prescription Drugs

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

 

 Physician & Medical Services

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics)

Office Visit - Specialist Care

Teladoc

HEAL

Retail clinics

Acupuncture (from an American Specialty Health Plans network acupuncturist)

Chiropractic (from an American Specialty Health Plans network chiropractor)

$35

 

$65

 

$0

 

First visit = $0
Subsequent visits = $30

 

Cost depends on the service performed. Cost is the same as if the service was performed elsewhere.

 

$35

 

Not covered

 

 Lab & X-ray Diagnostics

Laboratory Tests

X-rays

Imaging (CT / PET scan, MRI) from an outpatient radiology center

$40

 

$75

 

$275

 

 Urgent & Emergency Care

Urgent care

Emergency Room Services

Ambulance

$35

 

$350

 

$250

 

 Maternity Care

Maternity - Prenatal Office Visits

Maternity - Other professional services

Maternity - hospital stay

$0

 

$0

 

$600 per day up to 5 days per admission

 

 Hospital & Outpatient

Outpatient Surgery Services

Hospital Stays

$300

 

$600 per day up to 5 days per admission

 

 Dental & Vision

Pediatric Dental Benefits: Preventive

Pediatric Dental Benefits: Restorative Procedures

Pediatric Dental Benefits: Medically Necessary Orthodontics

Pediatric Vision Benefits: Exams

Pediatric Vision Benefits: Eye Glasses

$0

 

$25

 

$1,000

 

$0

 

1 pair per year

 

Call us today!

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