Page 4 - Brixton EE Benefits Guide 12-18

Benefits

Medical Insurance

Blue Shield
Platinum HMO 0/20

Trio ACO HMO Network (Base)
Network Name Full HMO Access+ Network (Buy-Up)
Health Benefits You have a choice of the Base or Buy-Up network

Lifetime Maximum Benefit Unlimited
Deductible (Annual)
ACO / HMO Medical - Individual / Family $0 / $0
Plans Co-Insurance (You Pay) N/A
With the Blue Shield Health Office Visit Copay
Maintenance Organization
- Primary Care Physician $20 Copay
(HMO) plans, you must choose
- Specialist Office Visit $40 Copay
a primary care physician (PCP)
or medical group within the Out-of-Pocket Maximum
plan’s network. All of your care - Individual / Family $1,350 / $2,700
must be directed through your
Hospitalization
PCP or medical group. Any
- Inpatient $500 / Admit Copay
specialty care you need will be
- Outpatient $100—$150 Copay
coordinated through your PCP
and will generally require a Lab and X-Ray $10 - $30 Copay
referral or authorization. You - Advanced $100 Copay
will receive benefits only if you
Emergency Services $200 Copay
use the doctors, clinics and
hospitals that belong to the Urgent Care $20 Copay
medical group in which you are Preventive Care No Charge
enrolled, except in the case of
an emergency. Chiropractic $15 Copay
15 Visits/Year
PPO Medical Plans
The Blue Shield Preferred Pharmacy Benefits
Provider Organization (PPO) Pharmacy Deductible None
plans allow you to direct your
own care. You are not limited Retail Pharmacy (30 Day Supply)
$5 Copay
to the physicians within the - Tier 1 $15 Copay
- Tier 2
PPO network and you may self-
- Tier 3 $25 Copay
refer to specialists. If you
receive care from a physician Mail Order Pharmacy (90 Day Supply)
who is a member of the PPO - Tier 1 $10 Copay
network, a greater percentage - Tier 2 $30 Copay
of the entire cost will be paid - Tier 3 $50 Copay
by the insurance plan. You may
also obtain services using a non
‐network provider; however, Finding an ACO / HMO Medical Provider
you will be responsible for the
difference between the Blue Shield ACO HMO participants should go to blueshieldca.com/
covered amount and the actual networktriohmo. Blue Shield HMO participants should go to
charges, and you may be blueshieldca.com/networkhmo.
responsible for filing claims.

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