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Blue Shield HMO – Gold Access+ HMO 500/35
Medical coverage provides you with benefits that help keep you healthy like preventive care
screenings and access to urgent care. It also provides important financial protection if you
have a serious medical condition. Pacific Southwest Realty Services gives you a choice
between the two HMO plans managed by Blue Shield.
Gold Access+ HMO 500/35 OffEx
In-Network
Annual Deductible
Individual
Family
$500
$1,000
Annual Out-of-Pocket Max
Individual
Family
$5,600
$11,200
Office Visit
Primary Provider
$35 copay
Specialist
$55 copay
Preventive Services
No charge
Chiropractic Care
$15 copay
(up to 15 visits per year)
Basic Lab
Basic X-ray
Complex Imaging
(CT Scan, MRI, PET, etc.)
$35 copay per visit
$50 copay per visit
$250 copay per visit (after deductible)
Inpatient Hospitalization
20% after deductible
Outpatient Surgery
Free-Standing Ambulatory Surgery Center
Hospital
20%
$300 copay per surgery
(after deductible)
Urgent Care
$35 copay
Emergency Room
(facility fee)
$250 copay after deductible
(copay waived if admitted)
Retail Pharmacy
Tier 1
$15 copay
Tier 2
$30 copay
Tier 3
$50 copay
Tier 4
1
20% up to a max of $250 per RX
Supply Limit
30 days
Mail Order Pharmacy
Tier 1
$30 copay
Tier 2
$60 copay
Tier 3
$100 copay
Tier 4
1
20% up to a max of $500 per RX
Supply Limit
90 days
1
Specialty drugs are available from a Network Specialty Pharmacy by mail or upon member request, retail stores for pick up. Blue Shield’s short
cycle Specialty Drug Program allows initial Specialty Drugs to be dispensed in 15-day supply trials.