Health and Welfare Plan BenefitTabs™

  • Blue Shield HMO

  • Covered Features

    Blue Shield HMO is one of the three medical plans available to eligible participants.

  • Choice of Providers

    Must use Health Plan Providers

  • Plan Maximums

    No plan maximum

  • Out-Of-Pocket Maximums

    $2,000 individual
    $6,000 family

  • Hospital Confinement
    Room and Board, surgery,
    anesthesia and miscellaneous

    No charge

  • Doctor Visits

    Your copayment is:
    $25 per visit
    No charge

  • 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

    No charge

  • Preventive Health Care
    (Routine check-ups,
    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.

  • Ambulance Services

    No charge if authorized

  • Prescriptions

    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)
    $30 $60
  • Mother's Hospital Expenses

    No charge

  • Mother's Expenses - Office
    Newborn Care

    No charge
    No charge in hospital if enrolled within 31 days of birth

  • Contact Info

    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