Trio Gold 80 HMO 250/35 + Child Dental - 70285CA8230058 Health Insurance Plan
California Physicians' Service, dba Blue Shield of California health insurance plan with the Plan ID 70285CA8230058. The plan is called Trio Gold 80 HMO 250/35 + Child Dental.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.67% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.33% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 70285CA8230058 | ||||||||||||||||||
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| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | California | ||||||||||||||||||
| Health Insurance Issuer | California Physicians' Service, dba Blue Shield of California | ||||||||||||||||||
| Health Insurance Plan Variant | 70285CA8230058-01 | ||||||||||||||||||
| Provider Network(s) | ['CAN010'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Trio Gold 80 HMO 250/35 + Child Dental Health Insurance Plan Variant 70285CA8230058-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 20.00% |
| Drug EHB Deductible, In Network (Tier 2), Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, In Network (Tier 2), Individual | Not Applicable |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| First Tier Utilization | 100% |
| Formulary ID | CAF008 |
| HIOS Product ID | 70285CA823 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 80.67% |
| Issuer ID | 70285 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $250 per person | $500 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $250 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 2), Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, In Network (Tier 2), Individual | Not Applicable |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | CAN010 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 70285CA8230058-01 |
| Plan Marketing Name | Trio Gold 80 HMO 250/35 + Child Dental |
| Plan Type | HMO |
| Plan Variant Marketing Name | Trio Gold 80 HMO 250/35 + Child Dental |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,800 |
| SBC Scenario, Having a Baby, Deductible | $250 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $250 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 0% |
| Service Area ID | CAS037 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Other than Primary Care Physician, Family Practice, General Practice, Internal Medicine, Obstetrician/Gynecologist or Pediatrician. |
| Specialty Drug Maximum Coinsurance | $250 |
| Plan ID | 70285CA8230058 |
| State Code | CA |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $7800 per person | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family | $0 per person | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Trio Gold 80 HMO 250/35 + Child Dental Health Insurance Plan, 70285CA8230058
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Trio Gold 80 HMO 250/35 + Child Dental, 70285CA8230058 Health Insurance Plan, 70285CA8230058
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Does Trio Gold 80 HMO 250/35 + Child Dental Health Insurance Plan, 70285CA8230058 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (70285CA8230058) Health Insurance Plan, Variant (70285CA8230058-01) have Out Of Country Coverage?
Does (70285CA8230058) Health Insurance Plan, Variant (70285CA8230058-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API