Page 7 - Premier EE Guide 01-20 - CA- Updated 01.03.2020
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BENEFITS
MEDICAL INSURANCE
Blue Shield Blue Shield
Plan Name Trio HMO Access+ HMO
Network Name Trio ACO HMO Access+ HMO
Health Benefits
Deductible (Annual)
- Individual $0 $0
- Family $0 $0
Co-Insurance (Plan Pays) 100% 100%
Office Visit Copay
- Primary Care Physician $20 Copay/visit $20 Copay/visit
- Specialist Office Visit $20 Copay/visit $20 Copay/visit
$20 Copay/visit (Trio+) $35 Copay/visit (Access+)
Out-of-Pocket Maximum
- Individual $1,500 $1,500
- Family $3,000 $3,000
Hospitalization
- Inpatient No charge No charge
- Outpatient Surgery No charge No charge
Lab and X-Ray $0 Copay $0 Copay
Emergency Services $100 Copay/visit $100 Copay/visit
Urgent Care $20 Copay/visit $20 Copay/visit
Preventive Care $0 Copay $0 Copay
Physical, Occupational, Respiratory and $20 Copay/visit $20 Copay/visit
Speech Therapy
Pharmacy Benefits
Retail Pharmacy (Up to 30 Days)
Tier 1 drugs $15 Copay $15 Copay
Tier 2 drugs $30 Copay $30 Copay
Tier 3 drugs $45 Copay $45 Copay
Tier 4 drugs 20% up to $200/Rx 20% up to $200/Rx
Mail Order Pharmacy (Up to 90 Days)
Tier 1 drugs $30 Copay $30 Copay
Tier 2 drugs $60 Copay $60 Copay
Tier 3 drugs $90 Copay $90 Copay
Tier 4 drugs (Specialty 30 Days) 20% up to $400/Rx 20% up to $400/Rx
*Limitations apply. See SBC for details.
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