Page 6 - L'Abri Management 2020 Benefits Guide

Medical Benefits

Blue Shield Blue Shield
Plan Features Trio HMO Access+ HMO

Trio HMO Access+ HMO
Network Name In-Network Only In-Network Only
Health Benefits

Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual / Family None None
Co-Insurance (Plan Pays) N/A N/A
Office Visit (PCP/Specialist) $20 copay / $20 copay $20 copay / $20 copay

Out of Pocket Maximum
- Individual / Family $2,500 / $5,000 $2,500 / $5,000

Hospitalization
- Inpatient $500 per admit $500 per admit
- Outpatient Surgery $100 ASC / $300 Hospital $100 ASC / $300 Hospital
Lab and X-Ray No Charge No Charge
-Complex No Charge No Charge
Emergency Services $100 copay $100 copay
waived if admitted waived if admitted
Urgent Care $20 copay $20 copay

Preventive Care No charge No Charge
Mental Health & Substance Abuse
- Inpatient $500 per admit $500 per admit
- Outpatient $20 copay $20 copay
Chiropractic / Acupuncture $10 copay $10 copay

30 combined visits / year 30 combined visits / year
Pharmacy Benefits

Pharmacy Deductible
- Individual None None
- Family None None

Retail Pharmacy
- Generic Formulary $15 $15
- Brand Name Formulary $30 $30
- Non-Formulary $45 $45
- Supply Limit 30 days 30 days
Mail Order Pharmacy
- Generic Formulary $30 $30
- Brand Name Formulary $60 $60
- Non-Formulary $90 $90
- Supply Limit 90 days 90 days

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