Page 8 - 2019 Blacoh Benefit Guide Final 11/13/18
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Medical Benefits
Plan Features Blue Shield HMO—Available to California Employees Only
Gold Trio ACO HMO 500/35
Network HMO
Deductible (Annual)
- Individual/Family $500 / $1,000 (embedded)
Out of Pocket Maximum $5,600 / $11,200
- Individual/Family (embedded, includes deductible)
Physician Services
- Office Visits $35/$55 (deductible waived)
- Preventive Care No charge
- Teledoc consultation $5 per consultation (deductible waived)
- Diagnostic Lab/X-Ray Free Standing: $35/Outpatient: $50 (deductible waived)
- Imaging Free Standing: $50 (deductible waived)
Outpatient Hospital: $250 after deductible
- Rehab (Visit limits apply) $35 (deductible waived)
- Chiropractic Care (Visit limits apply) $15 (deductible waived)
Hospitalization
- Inpatient 20% after deductible
- Outpatient 20% after deductible
Mental Health & Substance Abuse
- In-Patient 20% after deductible
- Out-Patient No charge
Emergency Services
- Emergency Room $250 after deductible
- Ambulance Transport $100 (deductible waived)
- Urgent Care $35 (deductible waived)
Maternity
- Prenatal Care No charge
- Postnatal Care No charge
- Inpatient Delivery 20% after deductible
Prescription Drugs
Deductible (Subject to Tiers 2-4)
- Tier 1: Generic $15 Copay
- Tier 2: Preferred Brand $30 Copay
- Tier 3: Non-Preferred Brand $50 Copay
- Tier 4: Specialty 20% up to $250
Supply Limit 30 Days
Mail Order Pharmacy 2 times retail
Mail Order Supply Limit 90-days
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