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Blue Shield Trio Plan - Group ID: W0051428, Plan ID: HMOX0001

Basics

Full-Time Employee * Contribution Per Pay Period

Employee Only $36.47
Employee & Spouse/Registered Domestic Partner $282.37
Employee & Child(ren) $245.25
Employee & Family $366.79

Part-Time Employee * Contribution Per Pay Period

Employee Only $209.46
Employee & Spouse/Registered Domestic Partner $522.33
Employee & Child(ren) $447.71
Employee & Family $721.31

Lifetime maximum

No maximum

Plan Year

2023

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.

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).

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.

Prenatal Visits

100%

Doctor Delivery Charge

100%

Reproductive Health

100% If services are not available within 100 miles of the member's 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)

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

Acupuncture

$15 co-pay

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

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

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

In-vitro fertilization (IVF) 3/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

Speech Therapy

$30 co-pay

Tubal Ligation

INPATIENT
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

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.

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