Blue Shield Platinum 90 Trio HMO

Deductible and out-of-pocket maximum
Calendar year deductible $0
Calendar year pharmacy deductible $0
Calendar year out-of-pocket maximum $4,500 per individual / $9,000 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 = $7
  Tier 2 = $16
  Tier 3 = $25
  Tier 4 = 10% up to $250 per prescription

 

Physician and medical services
Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics) $15
Office Visit - Specialist Care $30
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) $15
Chiropractic (from an American Specialty Health Plans network chiropractor)

Not covered

 

Lab and X-ray diagnostics
Laboratory Tests $15
X-rays $30
Imaging (CT / PET scan, MRI) from an outpatient radiology center $75

 

Urgent and emergency
Urgent care $15
Emergency Room Services $150
Ambulance $150

 

Maternity care
Maternity - Prenatal office visits $0
Maternity - Other professional services $0
Maternity - hospital stay $225 per day up to 5 days per admission

 

Hospital and outpatient
Outpatient Surgery Services $75
Hospital Stays $225 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

 

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