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Access to care highlights
HDHP PPO PLAN
WITH VIRTUAL BLUE
WITH VIRTUAL BLUE
ACCESS+ HMO PLAN
TRIO HMO PLAN
Network
Virtual + VB PPO + non-network providers
Full HMO network of providers
Select network of local providers
Access to in-person doctors, hospitals, etc.
Visit any doctor you choose
PCP required;
self-refer to specialist possible
self-refer to specialist possible
PCP required;
self-refer to specialist possible
self-refer to specialist possible
Deductible: Individual
$5,000 (network + non-network)
None
None
Deductible: Family
$5,000: individual (network + non-network)
$10,000: family (network + non-network)
$10,000: family (network + non-network)
None
None
Out-of-pocket maximum
In-network: Individual
$6,000 (network + non-network)
$1,000
$1,000
In-network: Family
$6,000: individual (network + non-network)
$12,000: family (network + non-network)
$12,000: family (network + non-network)
$3,000
$3,000
Out-of-network: Individual
Combined with in-network deductible
N/A
N/A
Out-of-network: Family
Combined with in-network deductible
N/A
N/A
Medical benefits
HDHP PPO PLAN
WITH VIRTUAL BLUE (colspan-2)
WITH VIRTUAL BLUE (colspan-2)
ACCESS+ HMO PLAN
TRIO HMO PLAN
Costs per office visit / admission
In-network
Out-of-Network
In-network
In-network
Preventive health exam
$0
Not covered
$0
$0
Virtual Blue virtual providers: PCP/specialist visit
$0
N/A
N/A
N/A
Primary Care visit
20%*
50%*
$25
$25
Specialist visit
20%*
50%*
$25
$25
Specialist office visit (HMO self-referral)**
N/A
N/A
$35
$35
Prenatal and postnatal visit
20%*
50%*
$25
$25
Virtual Blue virtual providers: mental health
$0
N/A
$0
$0
Mental health visit
20%*
50%*
$0
$0
Mental health outpatient services
$0*
50%*
$0
$0
Substance abuse outpatient services
20%*
50%*
$0
$0
Substance abuse inpatient facility
$100 + 20%*
50%*
$500
$500
Lab work
20%*
50%*
$25
$25
Outpatient surgery (facility services)
20%*
50% (max benefit:
of $350/day)*
of $350/day)*
$0
$0
Inpatient hospital services and stay
$100 + 20%*
50%* (max benefit
of $600/day)
of $600/day)
$500 / admission
$500 / admission
Urgent care services
20%*
50%*
$25
$25
Emergency room services
$150 + 20%*
$150 + 20%*
$125
$125
Acupuncture services
20%*
50%*
$15
$15
Chiropractic services
20%*
50%*
$15
$15
Pharmacy benefits
HDHP PPO PLAN
WITH VIRTUAL BLUE (colspan-2)
WITH VIRTUAL BLUE (colspan-2)
ACCESS+ HMO PLAN
TRIO HMO PLAN
Costs per fill
In-network
Out-of-Network
In-network
In-network
Pharmacy deductible
Combined with medical
Combined with medical
None
None
RETAIL (30-day supply / prescription)
Contraceptive drugs/devices
$0
Cost based on tier.
$0
$0
Preventive drugs (value-based or HDHP)
$0
Not covered
$0
$0
Tier 1 drugs
$10*
$10 + 25% *
$10
$10
Tier 2 drugs
$25*
$25 + 25% of cost*
$25
$25
Tier 3 drugs
$40*
$40 + 25% of cost*
$40
$40
Tier 4 drugs
$40*
$40 + 25% of cost*
$40
$40
MAIL-SERVICE (90-day supply / prescription)
Contraceptive drugs/devices
$0
Not covered
$0
$0
Preventive drugs (value-based or HDHP)
$0
Not covered
$0
$0
Tier 1 drug
$20*
Not covered
$20
$20
Tier 2 drugs
$50*
Not covered
$50
$50
Tier 3 drugs
$80*
Not covered
$80
$80
Tier 4 drugs
$80*
Not covered
$80
$80
* Calendar-year deductible applies. This is the amount a Member pays each calendar year before Blue Shield pays for covered services under the Plan. Blue Shield pays for some covered services before the calendar year deductible is met, as noted in the benefits chart above.
** Self-referral to specialists may be available to members of participating medical groups – no need to see your primary care physician first. Please see your plan's Evidence of Coverage for more details.