Your primary care physician provides preventative care, arrange admissions to hospitals, coordinates care you get from specialists, and helps you make decisions about your health.
Referrals: Required If your primary care physician determines that you need care from a specialist, your physician will co-ordinate the referral. Makes getting a referral fast and easy.Except for Emergency medical care situations, your plan does not cover out of network care.
Change medical group or PCP:Contact Customer Service by the 15th of the month, so that your change becomes effective on the first of the following month.
You can locate providers at
www.blueshieldca.com
| Blue Shield of CA Silver TRIO HMO 2350/65 OffEx |
|
| Group: W0098486 Shield Concierge / Member Services: (855) 664-5577 Network: TRIO ACO HMO Network |
|
| Annual Deductible | $2,350 / Individual; $4,700 / Family |
| PCP Office Visit & Specialist Office Visit |
$65 copay / $75 copay (deductible waived) |
| Max. Out-of-Pocket Limit | $8,150 / Individual; $16,300 / Family |
| Lifetime Plan Max | Unlimited |
| Inpatient Hospital | 45% coinsurance |
| Outpatient Surgery | ASC: $250 (after deductible) Hospital: $1,000 (after deductible) |
| Preventive Care Well Child Care Periodic Physical Exams (Children & Adults) Routine Immunizations |
No copay |
| Urgent Care | $65 copay (deductible waived) |
| Emergency Room | 50% coinsurance |
| Prescription Drug Benefits $350 Individual / $700 Family Deductible |
|
| Tier 1 A/B Tier 2 A/B Tier 3 A/B Tier 4 |
$20 Copay / $25 Copay $85 copay / $110 Copay $115 copay / $155 Copay 45%, up to $250 per Rx |
Your primary care physician provides preventative care, arrange admissions to hospitals, coordinates care you get from specialists, and helps you make decisions about your health.
Referrals: RequiredIf your primary care physician determines that you need care from a specialist, your physician will co-ordinate the referral. Makes getting a referral fast and easy.
Out of Network Benefits: Not availableExcept for Emergency medical care situations, your plan does not cover out of network care.
Change medical group or PCP:Contact Customer Service by the 15th of the month, so that your change becomes effective on the first of the following month.
You can locate providers at
www.blueshieldca.com
| Blue Shield of CA Platinum TRIO HMO 0/30 OffEx |
|
| Group: W0098486 Shield Concierge / Member Services: (855) 664-5577 Network: TRIO ACO HMO Network |
|
| Annual Deductible | None |
| PCP Office Visit & Specialist Office Visit |
$30 copay / $50 copay |
| Max. Out-of-Pocket Limit | $2,700 / Individual; $5,400 / Family |
| Lifetime Plan Max | Unlimited |
| Inpatient Hospital | $500 per day; 4 days max |
| Outpatient Surgery | ASC: $100 copay Hospital: $150 copay |
| Preventive Care Well Child Care Periodic Physical Exams (Children & Adults) Routine Immunizations |
No copay |
| Urgent Care | $30 copay |
| Emergency Room | $250 |
| Prescription Drug Benefits | |
| Tier 1 A/B Tier 2 A/B Tier 3 A/B Tier 4 |
$5 Copay / $10 Copay $15 copay / $30 Copay $25 copay / $45 Copay 20%, up to $250 per Rx |
Your primary care physician provides preventative care, arrange admissions to hospitals, coordinates care you get from specialists, and helps you make decisions about your health.
Referrals: RequiredExcept for Emergency medical care situations, your plan does not cover out of network care.
Change medical group or PCP:Contact Customer Service by the 15th of the month, so that your change becomes effective on the first of the following month.
You can locate providers at
www.blueshieldca.com
| Blue Shield of CA Gold Access+ HMO 500/35 OffEx |
|
| Group: W0098486 Shield Concierge / Member Services: (888) 319-5999 Network: Access+ HMO |
|
| Annual Deductible | $500 / Individual; $1,000 / Family |
| PCP Office Visit & Specialist Office Visit |
$35 copay / $55 copay (deductible waived) |
| Max. Out-of-Pocket Limit | $7,500 / Individual; $15,000 / Family |
| Lifetime Plan Max | Unlimited |
| Inpatient Hospital | 20% coinsurance |
| Outpatient Surgery | ASC: $150 (after deductible) Hospital: $300 (after deductible) |
| Preventive Care Well Child Care Periodic Physical Exams (Children & Adults) Routine Immunizations |
No copay |
| Urgent Care | $35 copay (deductible waived) |
| Emergency Room | $300 (after deductible) |
| Prescription Drug Benefits | |
| Tier 1 A/B Tier 2 A/B Tier 3 A/B Tier 4 |
$15 Copay $35 Copay $55 Copay 20%, up to $250 per Rx |
You can make your own decisions about your doctors, your care and your costs.
Referrals: Not RequiredYou have freedom to choose any licensed provider. However you can receive significant cost savings when you visit a network provider for covered services. You pick who you want to see.
Preauthorization or Predetermination may be required based on certain procedures.
Claim Forms: No claim forms to submit when using network providers. Network providers will submit claims for you.
You can locate providers at
www.blueshieldca.com
| Blue Shield of CA Gold Full PPO 750/30 OffEx |
||
| Group: W0098486 Member Services: (888) 319-5999 |
In Network | Out of Network |
| Annual Deductible | $750 / Individual $1,500 / Family |
$1,500 / Individual $3,000 / Family |
| Out-of-Pocket Limit | $8,150 / Individual $16,300 / Family |
$16,300 / Individual $32,00 / Family |
| Primary Care & Specialist Office Visit | $30 Copay / $55 Copay (deductible waived) |
40% |
| Lifetime Plan Max | Unlimited | |
| Inpatient Hospital | 20% | 40% |
| Outpatient Surgery | ASC: 20% Hospital: $150 + 20% |
40% |
| Preventive Care |
No copay (deductible waived) |
Not Covered |
| Urgent Care | $30 copay (deductible waived) |
40% |
| Emergency Room | $250 + 20% (after deductible) | |
| Prescription Drug Benefits $250 Individual / $500 Family Deductible |
||
| Tier 1 A/B Tier 2 A/B Tier 3 A/B Tier 4 |
$10 Copay (Ded. Waived) $40 Copay $70 Copay 30%, up to $250 per Rx |
|
The Kaiser Permanente Silver HMO plan requires that all services be provided at a Kaiser facility.
If you seek medical care outside of the Kaiser network, services will not be covered. (except in the case of an emergency)
When you’re a member registered at www.kp.org, you can use this online feature to help manage your care:
For more information about Kaiser Permanente, call Member Services weekdays from 7 am to 7 pm and weekends from 7am to 3pm.
Network facilities can be found at:
www.kp.org
| Kaiser Permanente Silver 70 HMO 1650/55 |
|
| Group: 347646 Shield Concierge / Member Services: (800) 464-4000 Network: Kaiser Permanente HMO |
|
| Annual Deductible | $1,650 / Individual; $3,300 / Family |
| PCP Office Visit & Specialist Office Visit |
$55 copay / $80 copay (deductible waived) |
| Max. Out-of-Pocket Limit | $8,200 / Individual; $16,400 / Family |
| Lifetime Plan Max | Unlimited |
| Inpatient Hospital | 40% coinsurance |
| Outpatient Surgery | 40% coinsurance |
| Preventive Care Well Child Care Periodic Physical Exams (Children & Adults) Routine Immunizations |
No copay (deductible waived) |
| Urgent Care | $55 copay (deductible waived) |
| Emergency Room | 40% coinsurance |
| Prescription Drug Benefits $350 Individual / $700 Family Deductible |
|
| Generic Brand Name Specialty |
$20 copay (Ded. Waived) $75 copay 20%, up to $250 per Rx |
The Kaiser Permanente Silver HMO plan requires that all services be provided at a Kaiser facility.
If you seek medical care outside of the Kaiser network, services will not be covered. (except in the case of an emergency)
When you’re a member registered at www.kp.org, you can use this online feature to help manage your care:
For more information about Kaiser Permanente, call Member Services weekdays from 7 am to 7 pm and weekends from 7am to 3pm.
Network facilities can be found at:
www.kp.org
| Kaiser Permanente Gold 80 HMO 250/35 |
|
| Group: 347646 Member Services: (800) 464-4000 Network: Kaiser Permanente HMO |
|
| Annual Deductible | $250 / Individual; $500 / Family |
| PCP Office Visit & Specialist Office Visit |
$35 copay / $55 copay (deductible waived) |
| Max. Out-of-Pocket Limit | $7,800 / Individual; $15,600 / Family |
| Lifetime Plan Max | Unlimited |
| Inpatient Hospital | $600 per day, 5 days max (after deductible) |
| Outpatient Surgery | $335 copay (after deductible) |
| Preventive Care Well Child Care Periodic Physical Exams (Children & Adults) Routine Immunizations |
No copay (after deductible) |
| Urgent Care | $35 copay (deductible waived) |
| Emergency Room | $250 (after deductible) |
| Prescription Drug Benefits | |
| Generic Brand Name Specialty |
$15 Copay $40 Copay 20%, up to $250 per Rx |