Page 3 - VO 2021 Employee Benefits_No Notices

Ventura Orthopedics
2021 Employee Benefits Brochure

Medical Plans

Blue Shield Trio HMO per Admit 40-1000

In- Network only

Deductible:
Individual $0
Individual/Family $0/$0

Calendar Year Out-of-Pocket Maximum:
Individual $3,000
Individual/Family $3,000/6,000

Hospital Services:
Inpatient $1,000/admission
Outpatient Surgery $200 /surgery
Emergency Room $150/visit
(copay waived if admitted)

Physician Services:
Office Visit (PCP/Specialist) $40 / $40
Diagnostic Lab & X-Ray No charge
Imaging (CT/PET scans, MRIs) No charge
Urgent Care $40/visit
Acupuncture/Chiropractic $10 per visit
(30 combined visits) Referral needed
Teledoc Consultation No Charge

Routine Care:
Preventative Checkups No Charge
Pre-Natal Maternity No Charge

Prescription Drugs:
Tier 1 (Deductible waived) $15 retail/$30 Mailorder*
Tier 2 $30 retail/$60 Mailorder*
Tier 3 $45 retail/$90 Mail order*
Tier 4 (Specialty Drugs) 20% up to $200 per RX
DME (Durable Medical Equipment) 50%

Pharmacy Deductible: $150 Calendar Year per member

Retail Rx: Up to a 30 day supply from Blue Shields RX Ultra Network
Mail Oder Rx: Up to 90 day supply from Blue Shields RX Ultra Network*

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