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Blue Shield HMO

Blue Shield of California
800-393-6130
Group Number: W0067301 

Employees can access Blue Shield Health Maintenance Organization (HMO) Plans provides a high-quality network of doctors and hospitals and allows members to enjoy the freedom to choose from a variety of care options. Both Blue Shield Trio HMO and Blue Shield Access+ HMO require members to select an in-network Primary Care Provider (PCP). These plans are ideal if you prefer a lower payroll deduction and are comfortable with a PCP directing member's care. Both plans may provide coverage in California only. 

 

Medical Plan Comparisons:

2022 MEDICAL PLANS 

Blue Shield
Trio Network
HMO

Blue Shield
Access+ Network
HMO

Annual Deductible    
Individual None None
Individual within Family None None
Family None None
Annual Out of Pocket Maximum    
Individual  $2,000 $2,000
Family $4,000 $4,000

Medical Services

Primary Care Visit $20 copay $20 copay
Specialist Office Visit $20 copay with PCP Referral $40 copay
$20 with PCP referral
Basic X-ray and Laboratory No charge No charge
Inpatient Hospital $250 copay per admission $250 copay per admission
Emergency Room $100 copay $100 copay
Urgent Care $20 copay $20 copay
Chiropractic $15 copay per visit to 
20 visits per year
$15 copay per visit to 
20 visits per year
Hearing Aid 20% with $4,000 benefit maximum every 2 year 20% with $4,000 benefit maximum every 2 year
Prescription Drugs    
Generic / Tier 1 $10 copay $10 copay
Formulary / Tier 2 $25 copay $25 copay
Non-Formulary / Tier 3 $50 copay $50 copay
Speciality/ Tier 4 20% up to $200 Copay 20% up to $200 Copay
Monthly Employee Contribution    
Employee Only $16.10 $108.96
Employee + 1 $170.26 $462.74
Employee + Family $321.08 $702.50