Blue Shield Silver 87 Trio HMO

Deductible and out-of-pocket maximum
Calendar year deductible $0
Calendar year pharmacy deductible $0
Calendar year out-of-pocket maximum $3,000 per individual / $6,000 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 = $5
  Tier 2 = $25

Tier 3 = $45

Tier 4 = 15% up to $150 per prescription

 

Physician and medical services
Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics) $15
Office Visit - Specialist Care $25
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 $20
X-rays $40
Imaging (CT / PET scan, MRI) from an outpatient radiology center $100

 

Urgent and emergency
Urgent care $15
Emergency Room Services $150
Ambulance $75

 

Maternity care
Maternity - Prenatal office visits $0
Maternity - Other professional services 20%
Maternity - hospital stay 20%

 

Hospital and outpatient
Outpatient Surgery Services 20%
Hospital Stays 20%

 

 

Dental and vision
Pediatric Dental Benefits: Preventive $0
Pediatric Dental Benefits: Restorative Procedures 20%
Pediatric Dental Benefits: Medically Necessary Orthodontics 50%
Pediatric Vision Benefits: Exams $0
Pediatric Vision Benefits: Eye Glasses 1 pair per year

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