Page 10 - Optima Tax EE Guide 01-19 CA_FINAL

Medical Plan Highlights

Blue Shield Blue Shield
Plan Name Trio HMO Access+ HMO

Network Name Trio ACO HMO Access+ HMO
Plan Differences
Employee Premiums $ $$
Employee Cost Sharing Contribution, Copay Contribution, Copay

Network
- Network Size  
- In-Network Benefits ✓ ✓
- Non-Network Benefits
Access to Providers Managed by Your PCP Managed by Your PCP
Health Benefits
Lifetime Max Benefit Unlimited Unlimited
Deductible (Cal Year)
- Individual $0 $0
- Family $0 $0
Out-of-Pocket Maximum
- Individual $1,500 $2,000
- Family $3,000 $4,000
Coinsurance (Plan Pays) 100% 100%
Office Visit Copay
- Preventive Care No Charge No Charge
- PCP $30 Copay $20 Copay
- Specialist $30 Copay PCP Referred $20 Copay PCP Referred
$30 Copay Self-Referred Trio $30 Copay Self Referred Access+
- Urgent Care $30 Copay $20 Copay
- Virtual Visits: Teladoc $5 Copay $5 Copay
- House Calls: Heal Not Covered Not Covered
24/7 Nurseline No Charge No Charge
Hospitalization
- Inpatient No Charge $250/Admit

- Outpatient Surgery No Charge $50-$200 Copay
Lab and X-Ray
- Diagnostic No Charge No Charge

- Complex No Charge No Charge

Emergency Room Services $100 Copay $150 Copay
Chiropractic Not Covered Not Covered
Acupuncture Not Covered Not Covered

10 Employee Benefits