Health and Welfare Plan BenefitTabs™
Blue Shield HMO
Blue Shield HMO is one of the three medical plans available to eligible participants.
Choice of Providers
Must use Health Plan Providers
No plan maximum
Room and Board, surgery,
anesthesia and miscellaneous
Your copayment is:
$25 per visit
In-Patient Hospital Copay
Your copayment is $100 per confinement
Out-Patient Surgery and Emergency Room Copay
Your copayment is $100
Outpatient Lab & X-Ray
Preventive Health Care
well baby care, immunizations,
preventative screenings, etc.)
100% preventive care coverage is available in accordance with the Affordable Care Act. Click here for more information.
No charge if authorized
All prescriptions must comply with the formulary unless preauthorized.
Copayment for Generic Copayment for Name-Brand Retail Pharmacy
(up to 30 day prescription)
$15 $30 Mail Service Pharmacy
(up to 90 days)
Mother's Hospital Expenses
Mother's Expenses - Office
No charge in hospital if enrolled within 31 days of birth
Main Telephone Number: 1-800-642-6155
Hearing Impaired (TTY): 1-800-442-8833
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.
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