Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Blue Shield HMO Trio
Plan Information
Plan Name: Blue Shield HMO Trio
Policy Number: W0051168
Effective Date: 07/01/2024
Provider Network: Blue Shield
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
20% to $250
Mail-Order RX
(Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$75 copay
Non-Preferred Brand
$120 copay
Specialty
20% up to $750
Plan Documents
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible
(Individual/Family)
$0/$0
Out-of-Pocket Max
(Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived
if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
20% to $250
Mail-Order RX
(Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$75 copay
Non-Preferred Brand
$120 copay
Specialty
20% up to $750
Plan Documents
Contact Information
Blue Shield EPO
Plan Information
Plan Name: Blue Shield EPO
Policy Number: W0051168
Effective Date: 07/01/2024
Provider Network: Blue Shield
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$500/$1,500
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$25 copay
Urgent Care
$20 copay
Emergency Room
$150 copay + 20% coinsurance (waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
30% to $250
Mail-Order RX
(Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$80 copay
Specialty
30% up to $500
Plan Documents
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible
(Individual/Family)
$500/$1,500
Out-of-Pocket Max
(Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$25 copay
Urgent Care
$20 copay
Emergency Room
$150 copay + 20% coinsurance (waived
if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
30% to $250
Mail-Order RX
(Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$80 copay
Specialty
30% up to $500
Plan Documents
Contact Information
Blue Shield HMO
Plan Information
Plan Name: Blue Shield HMO
Policy Number: W0051168
Effective Date: 07/01/2024
Provider Network: Blue Shield
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
Access+: $35 copay
Other: $20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
20% to $250
Mail-Order RX
(Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$75 copay
Non-Preferred Brand
$120 copay
Specialty
Plan Documents
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible
(Individual/Family)
$0/$0
Out-of-Pocket Max
(Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
Access+: $35 copay
Other: $20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
20% to $250
Mail-Order RX
(Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$75 copay
Non-Preferred Brand
$120 copay
Specialty
Plan Documents
Contact Information
Kaiser DHMO
Plan Information
Plan Name: Kaiser DHMO
Policy Number: 600848
Effective Date: 07/01/2024
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$250/$500
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$10 copay
Specialist Visit
$10 copay
Urgent Care
$10 copay
Emergency Room
10% coinsurance after deductible
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Specialty
20% to $250
Mail-Order RX
(Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Specialty
Not Covered
Plan Documents
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible
(Individual/Family)
$250/$500
Out-of-Pocket Max
(Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$10 copay
Specialist Visit
$10 copay
Urgent Care
$10 copay
Emergency Room
10% coinsurance after deductible
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Specialty
20% to $250
Mail-Order RX
(Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Specialty
Not Covered
Plan Documents
Contact Information
Blue Shield CDHP
Plan Information
Plan Name: Blue Shield CDHP
Policy Number: W0051168
Effective Date: 07/01/2024
Provider Network: Blue Shield
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,600/$3,200
Out-of-Pocket Max (Individual/Family)
$3,500/$7,000
Preventive Care
$0
Primary Care Visit
10%*
Specialist Visit
10%*
Urgent Care
10%*
Emergency Room
$150 copay + 10% after deductible
(copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
30% to $250*
Mail-Order RX
(Up to 90-Day Supply)
Generic
$20 copay*
Preferred Brand
$50 copay*
Non-Preferred Brand
$80 copay*
Specialty
30% up to $500*
*After Deductible
Out-of-Network
Deductible (Individual/Family)
$1,600/$3,200
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
Not covered
Primary Care Visit
40%*
Specialist Visit
40%*
Urgent Care
40%*
Emergency Room
$150 copay + 10%*
(copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay + 25%*
Preferred Brand
$25 copay + 25%*
Non-Preferred Brand
$40 copay + 25%*
Specialty
30% up to $250 + 25% of purchase price*
Mail-Order RX
(Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
*After Deductible
Plan Documents
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible
(Individual/Family)
$1,600/$3,200
Out-of-Pocket Max
(Individual/Family)
$3,500/$7,000
Preventive Care
$0
Primary Care Visit
10% after deductible
Specialist Visit
10% after deductible
Urgent Care
10% after deductible
Emergency Room
$150 copay + 10% after deductible (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
30% to $250
Mail-Order RX
(Up to 90-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$50 copay after deductible
Non-Preferred Brand
$80 copay after deductible
Specialty
30% up to $500 after deductible
Out-of-Network
Deductible
(Individual/Family)
$1,600/$3,200
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
Not covered
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Urgent Care
40% after deductible
Emergency Room
$150 copay + 10% after deductible (copay
waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay + 25% after deductible
Preferred Brand
$25 copay + 25% after deductible
Non-Preferred Brand
$40 copay + 25% after deductible
Specialty
30% up to $250 + 25%
of purchase price
after deductible
Mail-Order RX
(Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Documents
Contact Information
Blue Shield PPO
Plan Information
Plan Name: Blue Shield PPO
Policy Number: W0051168
Effective Date: 07/01/2024
Provider Network: Blue Shield
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$250/$750
Out-of-Pocket Max (Individual/Family)
$2,250/$4,500
Preventive Care
$0
Primary Care Visit
$10 copay
Specialist Visit
$15 copay
Urgent Care
$10 copay
Emergency Room
$150 copay + 10% coinsurance
(copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$5 copay
Preferred Brand
$10 copay
Non-Preferred Brand
$25 copay
Specialty
N/A
Mail-Order RX
(Up to 90-Day Supply)
Generic
$10 copay
Preferred Brand
$20 copay
Non-Preferred Brand
$50 copay
Specialty
Out-of-Network
Deductible (Individual/Family)
$750/$2,250
Out-of-Pocket Max (Individual/Family)
$3,500/$7,000
Preventive Care
Not covered
Primary Care Visit
$30% after deductible
Specialist Visit
$30% after deductible
Urgent Care
$30% after deductible
Emergency Room
$150 copay + 10% coinsurance
(copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$5 copay + 25% coinsurance
Preferred Brand
$10 copay + 25% coinsurance
Non-Preferred Brand
$25 copay + 25% coinsurance
Specialty
N/A
Mail-Order RX
(Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
N/A
Plan Documents
Year Carrier Document Name
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible
(Individual/Family)
$250/$750
Out-of-Pocket Max
(Individual/Family)
$2,250/$4,500
Preventive Care
$0
Primary Care Visit
$10 copay
Specialist Visit
$15 copay
Urgent Care
$10 copay
Emergency Room
$150 copay + 10% coinsurance (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$5 copay
Preferred Brand
$10 copay
Non-Preferred Brand
$25 copay
Specialty
N/A
Mail-Order RX
(Up to 90-Day Supply)
Generic
$10 copay
Preferred Brand
$20 copay
Non-Preferred Brand
$50 copay
Specialty
Out-of-Network
Deductible
(Individual/Family)
$750/$2,250
Out-of-Pocket Max (Individual/Family)
$3,500/$7,000
Preventive Care
Not covered
Primary Care Visit
$30% after deductible
Specialist Visit
$30% after deductible
Urgent Care
$30% after deductible
Emergency Room
$150 copay + 10% coinsurance (copay waived if admitted)
Retail RX
(Up to 30-Day Supply)
Generic
$5 copay + 25% coinsurance
Preferred Brand
$10 copay + 25% coinsurance
Non-Preferred Brand
$25 copay + 25% coinsurance
Specialty
N/A
Mail-Order RX
(Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
N/A
Plan Documents
Blue Shield PPO Benefit Summary