Page 3 - Identity MSO 2021 Employee Benefits - Semi Monthly

Identity MSO
2021 Employee Benefits Brochure

NEW! Blue Shield Medical Plans

Trio HMO Per Admit Trio HMO Zero Admit Full Split Ded PPO H.S.A.*
40-1000*** 10 PPO*

Deductible:
Individual none none $500 $3,000
Family none none $1,500 $6,000

Annual Out of
Pocket Maximum:
Individual $3,000 $1,500 $3,000 $5,500
Family $6,000 $3,000 $6,000 $11,000

Hospital Services:
Inpatient $1,000 per No charge 20% 20% coinsurance**
admission coinsurance**
Outpatient Surgery No charge 10% coinsurance**
$200 per surgery 10%
Emergency Room $100 per visit coinsurance** $150 + 20%
$150 per visit coinsurance**
$150 + 20%
coinsurance**

Physician Services:
Office
Visit (PCP/Specialist) $40 / $50 $10 / $10 $20 / $20 20% coinsurance**

Urgent Care $40 $10 $20 20% coinsurance**

Preventive Care: No charge No charge No charge No charge

Prescription Drugs:
Rx Deductible None None None Combined with
medical
Tier 1 $15 $15 $15 $10**
Tier 2 $30 $30 $30 $25**
Tier 3 $45 $45 $45 $40**
Tier 4 20% coinsurance up 20% coinsurance up to 30% coinsurance 30% coinsurance up
to $250 per Rx $250 per Rx up to $250 per to $250 per Rx**
Rx**
*Please refer to carrier benefit summaries for more detailed information & out-of-network benefits.
**Deductible applies.

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