Platinum 90 Trio HMO
Blue Shield
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: $5000
Family: $10000
Per Person: $5000
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: $16.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
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: $9.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
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: $225.00 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: $175.00
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: $225.00
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
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
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
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).