Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Blue Shield Full PPO $1,000 (CA & Non-CA)
Plan Information
Plan Name: Blue Shield PPO $1,000
Policy Number: W0067485
Effective Date: 01/01/2025
Network: Blue Shield of California Full PPO Network
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$1,000/$3,000
Out-of-Pocket Max (Individual/Family)
$4,000/$8,000
Preventive Care
$0
Primary Care Visit
$10 copay, deductible does not apply
Specialist Visit
$15 copay, deductible does not apply
Urgent Care
$10 copay, deductible does not apply
Emergency Room
$150 copay + 10% coinsurance (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
30% coinsurance, up to $250
Tier 1: $10 copay
Tier 2: $30 copay
Tier 3: $50 copay
Tier 4: 30 % coinsurance up to $250 /prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$100 copay
Specialty
30% coinsurance, up to $500
Out-of-Network
Deductible (Individual/Family)
$1,000/$3,000
Out-of-Pocket Max (Individual/Family)
$6,000/$12,000
Preventive Care
Not covered
Primary Care Visit
30% coinsurance
Specialist Visit
30% coinsurance
Urgent Care
30% coinsurance
Emergency Room
$150 copay + 10% coinsurance (copay waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
25% coinsurance + $10 copay
Preferred Brand
25% coinsurance + $30 copay
Non-Preferred Brand
25% coinsurance + $50 copay
Specialty
30% coinsurance up to $250 + 25% purchase price
Tier 1: $20 copay
Tier 2: $60 copay
Tier 3: $100 copay
Tier 4: 30% coinsurance up to $500/prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Carrier Flyers
Blue Shield Amazon Pharmacy Easy Sign-up Guide
Blue Shield Amazon Pharmacy Flyer
Blue Shield Away From Home Care Flyer
Blue Shield Be Healthy and Save
Blue Shield BlueCard Program FAQ
Blue Shield BlueCard WorldWide Claim Form
Blue Shield CVS Caremark Mail Service Order Form
Blue Shield CVS Mail Service Flyer
Blue Shield Fitness Your Way Flyer
Blue Shield HearTek Epic Hearing Aid Discount
Blue Shield HIPAA Release Form
Blue Shield International Claim Form
Blue Shield LifeReferrals 24 7 Flyer
Blue Shield Member ID Card Registration Flyer
Blue Shield NurseHelp 24 7 Flyer
Blue Shield Prescription Drug Benefit Form
Blue Shield Preventive Health Guidelines
Blue Shield Subscribers Statement of Claim Form
Plan Documents
Contact Information
Blue Shield PPO $0 (Non-CA)
Plan Information
Plan Name: Blue Shield PPO $0 (Non-California Only)
Policy Number: W0067485
Effective Date: 01/01/2025
Network: Blue Shield of California Full PPO Network
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
30% coinsurance, up to $250/prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$100 copay
Specialty
30% coinsurance, up to $500/prescription
Out-of-Network
Deductible (Individual/Family)
$3,000/$6,000
Out-of-Pocket Max (Individual/Family)
$9,000/$18,000
Preventive Care
Not covered
Primary Care Visit
50% coinsurance
Specialist Visit
50% coinsurance
Urgent Care
50% coinsurance
Emergency Room
$100 copay, deductible does not apply
Retail Rx (Up to 30-Day Supply)
Generic
25% coinsurance + $10 copay
Preferred Brand
25% coinsurance + $30 copay
Non-Preferred Brand
25% coinsurance + $50 copay
Specialty
30% coinsurance, up to $250/prescription + $25% off purchase price
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Carrier Flyers
Blue Shield Amazon Pharmacy Easy Sign-up Guide
Blue Shield Amazon Pharmacy Flyer
Blue Shield Away From Home Care Flyer
Blue Shield Be Healthy and Save
Blue Shield BlueCard Program FAQ
Blue Shield BlueCard WorldWide Claim Form
Blue Shield CVS Caremark Mail Service Order Form
Blue Shield CVS Mail Service Flyer
Blue Shield Fitness Your Way Flyer
Blue Shield HearTek Epic Hearing Aid Discount
Blue Shield HIPAA Release Form
Blue Shield International Claim Form
Blue Shield LifeReferrals 24 7 Flyer
Blue Shield Member ID Card Registration Flyer
Blue Shield NurseHelp 24 7 Flyer
Blue Shield Prescription Drug Benefit Form
Blue Shield Preventive Health Guidelines
Blue Shield Subscribers Statement of Claim Form
Plan Documents
Contact Information
Blue Shield Full HMO (CA Only)
Plan Information
Plan Name: Blue Shield HMO
Policy Number: W0067485
Effective Date: 01/01/2025
Network: Blue Shield of California Access+ HMO Network
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
Access+ specialist: $35 copay
Other specialist: $20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
20% coinsurance, up to $250/prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$100 copay
Specialty
20% coinsurance, up to $500/prescription
Carrier Flyers
Blue Shield Amazon Pharmacy Easy Sign-up Guide
Blue Shield Amazon Pharmacy Flyer
Blue Shield Away From Home Care Flyer
Blue Shield Be Healthy and Save
Blue Shield BlueCard Program FAQ
Blue Shield BlueCard WorldWide Claim Form
Blue Shield CVS Caremark Mail Service Order Form
Blue Shield CVS Mail Service Flyer
Blue Shield Fitness Your Way Flyer
Blue Shield HearTek Epic Hearing Aid Discount
Blue Shield HIPAA Release Form
Blue Shield International Claim Form
Blue Shield LifeReferrals 24 7 Flyer
Blue Shield Member ID Card Registration Flyer
Blue Shield NurseHelp 24 7 Flyer
Blue Shield Prescription Drug Benefit Form
Blue Shield Preventive Health Guidelines
Blue Shield Subscribers Statement of Claim Form
Plan Documents
Contact Information
Blue Shield Trio HMO (CA Only)
Plan Information
Plan Name: Blue Shield Trio HMO $1,000
Policy Number: W0067485
Effective Date: 01/01/2025
Network: Blue Shield of California Trio ACO HMO Network
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,000/$4,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
Trio+ specialist: $35 copay
Other specialist: $20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$50 copay
Specialty
20% coinsurance, up to $250/prescription
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$100 copay
Specialty
20% coinsurance, up to $500/prescription
Carrier Flyers
Blue Shield Amazon Pharmacy Easy Sign-up Guide
Blue Shield Amazon Pharmacy Flyer
Blue Shield Away From Home Care Flyer
Blue Shield Be Healthy and Save
Blue Shield BlueCard Program FAQ
Blue Shield BlueCard WorldWide Claim Form
Blue Shield CVS Caremark Mail Service Order Form
Blue Shield CVS Mail Service Flyer
Blue Shield Fitness Your Way Flyer
Blue Shield HearTek Epic Hearing Aid Discount
Blue Shield HIPAA Release Form
Blue Shield International Claim Form
Blue Shield LifeReferrals 24 7 Flyer
Blue Shield Member ID Card Registration Flyer
Blue Shield NurseHelp 24 7 Flyer
Blue Shield Prescription Drug Benefit Form
Blue Shield Preventive Health Guidelines
Blue Shield Subscribers Statement of Claim Form
Plan Documents
Contact Information
Kaiser HMO (CA Only)
Plan Information
Plan Name: Kaiser HMO
Policy Number: 228610
Effective Date: 01/01/2025
Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$30 copay
Specialist Visit
$40 copay
Urgent Care
$30 copay
Emergency Room
$250 copay
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$35 copay
Specialty
30% coinsurance, up to $250/prescription
Mail-Order Rx (Up to 100-Day Supply)
Generic
$30 copay
Preferred Brand
$70 copay
Non-Preferred Brand
$70 copay
Specialty
Not covered
Carrier Flyers
2025 Kaiser HMO Summary of Benefits & Coverage
2025 Kaiser HMO Benefit Summary
Kaiser All Digital Health Care App
Kaiser All More Care Options While Away From Home
Kaiser All Telehealth National
Kaiser Claim for Emergency Medical Services
Kaiser Facility Guide – Spanish
Kaiser Getting Care Away From Home
Kaiser Group Enrollment Change Form
Kaiser One Pass Select Affinity
Plan Documents
Contact Information
Kaiser Deductible HMO (CA Only)
Plan Information
Plan Name: Kaiser Deductible HMO
Policy Number: 228610
Effective Date: 01/01/2025
Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$750/$1,500
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0, deductible does not apply
Primary Care Visit
$30 copay, deductible does not apply
Specialist Visit
$40 copay, deductible does not apply
Urgent Care
$25 copay, deductible does not apply
Emergency Room
20% coinsurance
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay
Specialty
20% coinsurance, up to $250/prescription
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay, deductible does not apply
Preferred Brand
$60 copay, deductible does not apply
Non-Preferred Brand
$60 copay, deductible does not apply
Specialty
Not covered
Carrier Flyers
2025 Kaiser HMO Summary of Benefits & Coverage
2025 Kaiser HMO Benefit Summary
Kaiser All Digital Health Care App
Kaiser All More Care Options While Away From Home
Kaiser All Telehealth National
Kaiser Claim for Emergency Medical Services
Kaiser Facility Guide – Spanish
Kaiser Getting Care Away From Home
Kaiser Group Enrollment Change Form
Kaiser One Pass Select Affinity