Blue Shield Trio Plan - Group ID: W0051428, Plan ID: HMOX0001
Basics
Full-Time Employee * Contribution Per Pay Period
Employee Only: $30.00
Employee & Spouse/Registered Domestic Partner: $232.32
Employee & Children: $201.78
Employee & Family: $301.78
Employee & Spouse/Registered Domestic Partner: $232.32
Employee & Children: $201.78
Employee & Family: $301.78
Part-Time Employee * Contribution Per Pay Period
Employee Only:$177.24
Employee & Spouse/Partner: $448.17
Employee & Children: $384.15
Employee & Family: $618.91
Employee & Spouse/Partner: $448.17
Employee & Children: $384.15
Employee & Family: $618.91
Lifetime maximum
No maximum
Plan Year
2022
Pre-Authorization Requirement
Pre-authorization required for all hospital stays and outpatient procedures by your Medical Group.
Offered To
Employees
Care Management
Participation in care management is optional
Our Shield Concierge program takes a comprehensive population health approach to care management. Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.
Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.
Our Shield Concierge program takes a comprehensive population health approach to care management. Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.
Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.
Body/Description
This Plan uses a specific network of Health Care Providers, called the Trio ACO HMO provider network. Medical Groups, Independent Practice Associations (IPAs), and Physicians in this network are called Participating Providers. You must select a Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this Plan. You can find Participating Providers in this network at blueshieldca.com.
Coinsurance
100% after applicable co-pays
Office co-pay
$30 co-pay primary/$50 co-pay specialist
Deductible
No deductible
Benefit Type
Medical
Annual maximum
$3,500 per individual (in single employee enrollment or in family enrollment), $7,000 family
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover medical expenses at 100% once the Out-of-Pocket Maximum is met).
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover medical expenses at 100% once the Out-of-Pocket Maximum is met).
X-rays
100%
Maternity Hospital Stay
$150 co-pay per admission
Baby's First Exam
100%
Birthing Centers
100%
Midwives
100%
Midwife needs to be part of the ACO Trio network.
Midwife needs to be part of the ACO Trio network.
Prenatal Visits
100%
Doctor Delivery Charge
100%
Reproductive Health
100%
If services are not available within 100 miles of the member home zip code travel expenses (airfare, mileage, rental car, lodging and meals) will be reimbursable after the deductible up to $2,000 per year.
If services are not available within 100 miles of the member home zip code travel expenses (airfare, mileage, rental car, lodging and meals) will be reimbursable after the deductible up to $2,000 per year.
Mental Health
In-patient care require pre-certifaction.
INPATIENT CARE
$150 co-pay per admission.
OUTPATIENT CARE (no visit limit)
$30 co-pay per visit.
Mental health and substance abuse provided through Blue Shields administrator (MHSA)
INPATIENT CARE
$150 co-pay per admission.
OUTPATIENT CARE (no visit limit)
$30 co-pay per visit.
Mental health and substance abuse provided through Blue Shields administrator (MHSA)
Autism
Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.
Substance Abuse
INPATIENT DETOXIFICATION
$150 co-pay per admission
OUTPATIENT CARE
[no visit limit]
$30 co-pay per visit, individual
Transitional Residential Recovery Services
$150 co-pay per admission
$150 co-pay per admission
OUTPATIENT CARE
[no visit limit]
$30 co-pay per visit, individual
Transitional Residential Recovery Services
$150 co-pay per admission
Acupuncture
$15 co-pay
Up to 20 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Acupuncturists and Chiropractors
Up to 20 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Acupuncturists and Chiropractors
Allergy Tests
$30 co-pay PCP; $50 co-pay Specialist
Allergy Treatment
Serum - 100% - Office Visit billed by PCP $30 co-pay; Specialists is $50 co-pay - if no Office Visit billed $0 co-pay
Alternative Medicine
Not covered
Ambulance charges
100% after $50 co-pay
CT Scans
100%
Chiropractors
$15 co-pay
Up to 20 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Acupuncturists and Chiropractors
Up to 20 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Acupuncturists and Chiropractors
Christian Science Practitioners
Not covered
Cosmetic Surgery
Not covered
Dental Treatment
Coverage limited to certain conditions only. Contact Blue Shield for more information.
Emergency Room
$200 co-pay (waived if admitted)
Urgent Care
$30 co-pay - This Plan uses a specific network of Health Care Providers, called the Trio ACO HMO provider network. Medical Groups, Independent Practice Associations (IPAs), and Physicians in this network are called Participating Providers. You must select a Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this Plan. You can find Participating Providers in this network at blueshieldca.com.
Hearing Care
Exam Network: 100% as part of preventive care
Hearing aids not covered
Hearing aids not covered
Home Health Care
100%
Hospice Care
100%
Hospital Stay
Pre-Certification required by you or your provider. $150 co-pay per admission
Infertility Treatment
Natural artificial inseminations
3/lifetime
Without ovum [oocyte or ovarian tissue (egg)] stimulation
Stimulated artificial inseminations
3/lifetime
With ovum [oocyte or ovarian tissue] stimulation
Gamete intrafallopian transfer (GIFT)
1/lifetime
Cryopreservation of embryos, oocytes, ovarian tissue, sperm
1/lifetime
Retrieved from the Subscriber, spouse or Domestic Partner. Includes one retrieval and three years of storage per person. No lifetime max
3/lifetime
Without ovum [oocyte or ovarian tissue (egg)] stimulation
Stimulated artificial inseminations
3/lifetime
With ovum [oocyte or ovarian tissue] stimulation
Gamete intrafallopian transfer (GIFT)
1/lifetime
Cryopreservation of embryos, oocytes, ovarian tissue, sperm
1/lifetime
Retrieved from the Subscriber, spouse or Domestic Partner. Includes one retrieval and three years of storage per person. No lifetime max
Laboratory Charges
100%
Magnetic resonance imaging - MRI
100%
Durable Medical Equipment
100%
Occupational Therapy
$30 co-pay
Organ Transplants
Contact Blue Shield for information on transplant coverage benefits
Skilled Nursing
$150 per admit (up to 100 days)
Physical Therapy
$30 co-pay
Surgery : Physician Services
100%
Surgery : Facility Charges
INPATIENT
$150 co-pay per admission
OUTPATIENT
$150 co-pay per surgery
$150 co-pay per admission
OUTPATIENT
$150 co-pay per surgery
Speech Therapy
$30 co-pay
Tubal Ligation
INPATIENT
100%
OUTPATIENT
100%
100%
OUTPATIENT
100%
Vasectomy
$50 co-pay
X-rays
100%
Pharmacy (Retail)
Retail pharmacy prescription Drugs
Per prescription, up to a 30-day supply.
Contraceptive Drugs and devices $0
Tier 1 Drugs $10/prescription
Tier 2 Drugs $40/prescription
Tier 3 Drugs $100/prescription
Tier 4 Drugs (excluding Specialty Drugs) 20% up to $200/prescript
Per prescription, up to a 30-day supply.
Contraceptive Drugs and devices $0
Tier 1 Drugs $10/prescription
Tier 2 Drugs $40/prescription
Tier 3 Drugs $100/prescription
Tier 4 Drugs (excluding Specialty Drugs) 20% up to $200/prescript
Mail order drug program
Mail service pharmacy prescription Drugs
Per prescription, up to a 90-day supply.
Contraceptive Drugs and devices $0
Tier 1 Drugs $20/prescription
Tier 2 Drugs $80/prescription
Tier 3 Drugs $200/prescription
Tier 4 Drugs (excluding Specialty Drugs) 20% up to $400/prescription
Specialty Drugs 20% up to $200/prescription
Oral anticancer Drugs 20% up to $200/prescription
Per prescription, up to a 30-day supply.
Per prescription, up to a 90-day supply.
Contraceptive Drugs and devices $0
Tier 1 Drugs $20/prescription
Tier 2 Drugs $80/prescription
Tier 3 Drugs $200/prescription
Tier 4 Drugs (excluding Specialty Drugs) 20% up to $400/prescription
Specialty Drugs 20% up to $200/prescription
Oral anticancer Drugs 20% up to $200/prescription
Per prescription, up to a 30-day supply.
Birth Control Pills
Contraceptive Drugs and Devices $0
Physical exams for adults
100%
Physical exams for children
100%
Pap smears
100%
Mammograms
100%
Immunizations
100%
Prostate Specific Antigen test - PSA
100%
Well-woman visits
100%
Vision care
Not Covered