Covered Features |
Blue Shield HMO is one of the three medical plans available to eligible participants. |
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Choice of Providers |
Must use Health Plan Providers |
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Plan Maximums |
No plan maximum |
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Out-Of-Pocket Maximums |
$2,000 individual
$6,000 family |
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Hospital Confinement
Room and Board, surgery,
anesthesia and miscellaneous |
No charge |
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Doctor Visits
Office
Hospital |
Your copayment is:
$25 per visit
No charge |
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In-Patient Hospital Copay |
Your copayment is $100 per confinement |
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Out-Patient Surgery and Emergency Room Copay |
Your copayment is $50 |
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Outpatient Lab & X-Ray |
No charge |
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Preventive Health Care
(Routine check-ups,
well baby care, immunizations,
preventative screenings, etc.)
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100% preventive care coverage is available in accordance with the Affordable Care Act. Link to http://www.healthcare.gov/law/about/provisions/services/lists.html for more information. |
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Ambulance Services |
No charge if authorized |
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Prescriptions |
All prescriptions must comply with the formulary unless preauthorized.
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Copayment for Generic |
Copayment for Name-Brand |
Retail Pharmacy
(up to 30 day prescription) |
$15 |
$30 |
Mail Service Pharmacy
(up to 90 days) |
$30 |
$60 |
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Mother's Hospital Expenses |
No charge |
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Mother's Expenses - Office
Newborn Care |
No charge
No charge in hospital if enrolled within 31 days of birth |
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Contact Info |
Main Telephone Number: 1-800-642-6155
Hearing Impaired (TTY): 1-800-442-8833 |
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Evidence of Coverage |
The Evidence of Coverage and Disclosure Form booklet describes the terms and conditions of coverage of your Blue Shield health Plan. Click here to view the booklet. |
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Mental Health and Substance Abuse Treatment Benefits |
Effective 8/1/11, Substance Abuse Treatment and Mental Health benefits will be available through Blue Shield. Blue Shield HMO participants have access to Blue Shield's Life Referrals 24/7, which is similar to the Member Assistance Program (MAP) formerly available through OptumHealth. This program allows members to access a 24/7 help line (800-985-2405) to speak with a mental health counselor, life coach, or even a financial advisor. As with regular medical benefits, HMO Participants will be required to use Blue Shield's network.
$0 Copay per out patient treatment
$0 Copay per in patient confinement |
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