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Platinum 90 Trio HMO
Health Insurance Plan Details (2025 Plan)
by Blue Shield of California
Monthly Premium
HMO
$ubsidy
Platinum
- Deductible
- $0 /yr
- Max Out-of-Pocket
- $4,500 /yr
Details
| Deductible (per individual) | $0 /yr |
| Deductible (per family) | $0 /yr |
| Max Out-of-Pocket (per individual) | $4,500 /yr |
| Max Out-of-Pocket (per family) | $9,000 /yr |
| Drug Deductible (per individual) | |
| Drug Deductible (per family) | |
| Drug Max Out-of-Pocket (per individual) | |
| Drug Max Out-of-Pocket (per family) | |
| Plan Type | HMO |
| Includes Child Dental? | Yes |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $15 Copay |
| Specialist Visit | $30 Copay |
| Emergency Room | $150 Copay |
| Inpatient Facility | $225 Copay per Day |
| Inpatient Physician | No Charge |
| Generic Drugs | $7 Copay |
| Preferred Brand Drugs | $16 Copay |
| Non-preferred Brand Drugs | $25 Copay |
| Specialty Drugs | 10.00% Coinsurance |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | n/a |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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