Blue Shield

Platinum 90 Trio HMO

Plan Overview

Medical Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Prescription Drug Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $4,500
  • Family: $9,000
  • Per Person: $4,500

Office Visit

Primary Doctor
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialist
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Non Preferred Brand Drugs
  • CoPay: $25.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Generic Drugs
  • CoPay: $5.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 10.00%
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Inpatient Coverage

Hospital Services
  • CoPay: $250.00 Copay per Day
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Inpatient Services
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: This Includes labor and delivery, mental health, and substance use disorder professional fee.

Emergency and Urgent Care

Emergency Room
  • CoPay: $150.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Urgent Care Facility
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: $250.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Pre and Postnatal Office Visit
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Routine Dental Checkups for Adults
  • Covered: Not Covered
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© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN70285CA8050004ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN70285CA8050004ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN70285CA8050004ACA1