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:
$20 per visit
No charge |
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Outpatient Lab & X-Rays |
No charge |
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Preventive Health Care
(Routine check-ups,
well baby care, immunizations,
pap smears, etc.)
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Your copayment is:
$20 per visit
No charge for well baby |
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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: 1-800-624-8822
Hearing Impaired (TTY): 1-800-442-8833 |
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