Make the most of your medical benefits
Kaiser
- Phone: 800-464-4000
- Website: my.kp.org/occidentalcollege/plan-details/california-southern-actives/
BlueShield
- Phone: 888-256-1915; Trio: 855-829-3566
- Website: www.blueshieldca.com
- Plan Documents
To check for participating providers within Blue Shield’s network, go to:
- Trio – blueshieldca.com/networktriohmo
- Access+ – blueshieldca.com/networkhmo
BlueShield PPO Plan
The PPO (Preferred Provider Organization) plan provides two tiers of benefits – PPO and out-of-network tiers. At each point of service, you decide the tier of benefits to use.
The PPO plan has an extensive network that allows you to choose a physician from within or outside of the network. For the PPO tier a member is able to access any provider of choice within the PPO network. For the out-of-network tier, any provider can be accessed for service regardless of their contract with Blue Shield.
How to File a Claim
If you have out-of-pocket expenses for covered services, please contact your insurance company at the phone number on the back of your ID card for a claim form and instructions.
Kaiser
You can obtain a claim form by visiting Kaiser’s website at kp.org or by calling Member Services Contact Center at 1-800-464-4000. Send your completed claim form to:
Kaiser Foundation Health Plan, Inc.
Claims Department
P.O. Box 7004
Downey, CA 90242-7004
BlueShield
For medical services, send a completed claim form within one year of the date of service to:
Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540
Call Blue Shield’s Customer Contact Center at the phone number on the back of your ID card or visit Blue Shield’s website at www.blueshieldca.com to obtain the claim form.
Note: Claims for covered expenses filed more than one year from the
date of service will not be paid unless you can show that it was
not reasonably possible to file your claim within that time limit
and that you filed as soon as was reasonably possible.
Kaiser HMO
Medical Benefits | Kaiser HMO |
---|---|
Deductible In-Network Out-of-Network | None |
Out-Of-Pocket Maximum In-Network Out-of-Network | Includes copays $1,500 / $3,000 |
Coinsurance In-Network Out-of-Network | None |
Lifetime Max | Unlimited |
Preventive Care In-Network Out-of-Network | No charge |
Telehealth/Virtual Visit | No charge |
Physician Office Visit In-Network Out-of-Network | $10 copay |
Specialist Office Visit In-Network Out-of-Network | $10 copay |
Basic Lab & Radiology In-Network Out-of-Network | No charge |
Emergency Room In-Network Out-of-Network | $50 copay per visit |
Urgent Care In-Network Out-of-Network | $10 copay |
Major Lab & Radiology (MRI/CT/PET) In-Network Out-of-Network | Prior Authorization Required No charge |
Inpatient Hospital In-Network Out-of-Network | No charge |
Outpatient Surgery In-Network Out-of-Network | $10 copay |
Prescriptions | |
Network Retail Pharmacy Network Mail Order (90-day supply) Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $10/$20 $10/$20 (100 day supply) |
Blue Shield Trio HMO
Medical Benefits | Blue Shield Trio HMO |
---|---|
Deductible In-Network Out-of-Network | None |
Out-Of-Pocket Maximum In-Network Out-of-Network | Includes copays $1,500 / $3,000 |
Coinsurance In-Network Out-of-Network | None |
Lifetime Max | Unlimited |
Preventive Care In-Network Out-of-Network | No charge |
Telehealth/Virtual Visit | No charge |
Physician Office Visit In-Network Out-of-Network | $10 copay |
Specialist Office Visit In-Network Out-of-Network | $10 copay |
Basic Lab & Radiology In-Network Out-of-Network | No charge |
Emergency Room In-Network Out-of-Network | $100 copay per visit |
Urgent Care In-Network Out-of-Network | $10 copay |
Major Lab & Radiology (MRI/CT/PET) In-Network Out-of-Network | Prior Authorization Required No charge |
Inpatient Hospital In-Network Out-of-Network | No charge |
Outpatient Surgery In-Network Out-of-Network | No charge |
Prescriptions | |
Network Retail Pharmacy Network Mail Order (90-day supply) Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $10/$15/$30/20% to $250 $20/$30/$60/20% to $500 |
Blue Shield Access+ HMO
Medical Benefits | Blue Shield Access+ HMO |
---|---|
Deductible In-Network Out-of-Network | None |
Out-Of-Pocket Maximum In-Network Out-of-Network | Includes copays $1,500 / $3,000 |
Coinsurance In-Network Out-of-Network | None |
Lifetime Max | Unlimited |
Preventive Care In-Network Out-of-Network | No charge |
Telehealth/Virtual Visit | No charge |
Physician Office Visit In-Network Out-of-Network | $10 copay |
Specialist Office Visit In-Network Out-of-Network | $10 copay if referred $20 copay if self-referred |
Basic Lab & Radiology In-Network Out-of-Network | No charge |
Emergency Room In-Network Out-of-Network | $100 copay per visit |
Urgent Care In-Network Out-of-Network | $10 copay |
Major Lab & Radiology (MRI/CT/PET) In-Network Out-of-Network | Prior Authorization Required No charge |
Inpatient Hospital In-Network Out-of-Network | No charge |
Outpatient Surgery In-Network Out-of-Network | No charge |
Prescriptions | |
Network Retail Pharmacy Network Mail Order (90-day supply) Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $10/$15/$30/20% to $250 $20/$30/$60/20% to $500 |
Blue Shield PPO
Medical Benefits | Blue Shield PPO |
---|---|
Deductible In-Network Out-of-Network | $250/$750 $250/$750 |
Out-of-Pocket Maximum In-Network Out-of-Network | Includes deductible, coinsurance and copays $1,750/$3,500 $3,250/$6,500 |
Coinsurance In-Network Out-of-Network | 90% 70% |
Lifetime Max | Unlimited |
Preventive Care In-Network Out-of-Network | Plan pays 100% Not covered |
Telehealth/Virtual Visit | No charge |
Physician Office Visit In-Network Out-of-Network | $10 copay Plan pays 70% after deductible is met |
Specialist Office Visit In-Network Out-of-Network | $10 copay Plan pays 70% after deductible is met |
Basic Lab & Radiology In-Network Out-of-Network | Plan pays 90% after deductible is met Plan pays 70% after deductible is met |
Emergency Room In-Network Out-of-Network | $150 copay plus 10% |
Urgent Care In-Network Out-of-Network | $10 copay Plan pays 70% after deductible is met |
Major Lab & Radiology (MRI/CT/PET) In-Network Out-of-Network | Prior Authorization Required Plan pays 90% after deductible is met Plan pays 70% after deductible is met |
Inpatient Hospital In-Network Out-of-Network | Plan pays 90% after deductible is met Plan pays 70% after deductible is met |
Outpatient Surgery In-Network Out-of-Network | Plan pays 95% after deductible is met Plan pays 70% after deductible is met |
Prescriptions | |
Network Retail Pharmacy Network Mail Order (90-day supply) Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $10/$30/$50/30% to $250 $20/$60/$100/30% up to $500 |
Kaiser HMO
Medical Benefits | Kaiser HMO |
---|---|
Deductible In-Network Out-of-Network | None |
Out-Of-Pocket Maximum In-Network Out-of-Network | Includes copays $1,500 / $3,000 |
Coinsurance In-Network Out-of-Network | None |
Lifetime Max | Unlimited |
Preventive Care In-Network Out-of-Network | No charge |
Telehealth/Virtual Visit | No charge |
Physician Office Visit In-Network Out-of-Network | $15 copay |
Specialist Office Visit In-Network Out-of-Network | $15 copay |
Basic Lab & Radiology In-Network Out-of-Network | No charge |
Emergency Room In-Network Out-of-Network | $100 copay per visit |
Urgent Care In-Network Out-of-Network | $15 copay |
Major Lab & Radiology (MRI/CT/PET) In-Network Out-of-Network | Prior Authorization Required No charge |
Inpatient Hospital In-Network Out-of-Network | No charge |
Outpatient Surgery In-Network Out-of-Network | $15 copay per procedure |
Prescriptions | |
Network Retail Pharmacy Network Mail Order (90-day supply) Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $10 / $20 / N/A / 20% to $250 $20/$40 (100 day supply) |
Blue Shield Trio HMO
Medical Benefits | Blue Shield Trio HMO |
---|---|
Deductible In-Network Out-of-Network | None |
Out-Of-Pocket Maximum In-Network Out-of-Network | Includes copays $1,500 / $3,000 |
Coinsurance In-Network Out-of-Network | None |
Lifetime Max | Unlimited |
Preventive Care In-Network Out-of-Network | No charge |
Telehealth/Virtual Visit | No charge |
Physician Office Visit In-Network Out-of-Network | $10 copay |
Specialist Office Visit In-Network Out-of-Network | $10 copay |
Basic Lab & Radiology In-Network Out-of-Network | No charge |
Emergency Room In-Network Out-of-Network | $150 copay per visit |
Urgent Care In-Network Out-of-Network | $10 copay |
Major Lab & Radiology (MRI/CT/PET) In-Network Out-of-Network | Prior Authorization Required No charge |
Inpatient Hospital In-Network Out-of-Network | $250 copay |
Outpatient Surgery In-Network Out-of-Network | $50 copay |
Prescriptions | |
Network Retail Pharmacy Network Mail Order (90-day supply) Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $10/$20/$35/20% to $250 $20/$40/$70/20% to $500 |
Blue Shield Access+ HMO
Medical Benefits | Blue Shield Access+ HMO |
---|---|
Deductible In-Network Out-of-Network | None |
Out-Of-Pocket Maximum In-Network Out-of-Network | Includes copays $1,500 / $3,000 |
Coinsurance In-Network Out-of-Network | None |
Lifetime Max | Unlimited |
Preventive Care In-Network Out-of-Network | No charge |
Telehealth/Virtual Visit | No charge |
Physician Office Visit In-Network Out-of-Network | $10 copay |
Specialist Office Visit In-Network Out-of-Network | $10 copay if referred $20 copay if self-referred |
Basic Lab & Radiology In-Network Out-of-Network | No charge |
Emergency Room In-Network Out-of-Network | $150 copay per visit |
Urgent Care In-Network Out-of-Network | $10 copay |
Major Lab & Radiology (MRI/CT/PET) In-Network Out-of-Network | Prior Authorization Required No charge |
Inpatient Hospital In-Network Out-of-Network | $250 copay |
Outpatient Surgery In-Network Out-of-Network | $50 copay |
Prescriptions | |
Network Retail Pharmacy Network Mail Order (90-day supply) Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $10/$20/$35/20% to $250 $20/$40/$70/20% to $500 |
Blue Shield PPO
Medical Benefits | Blue Shield PPO |
---|---|
Deductible In-Network Out-of-Network | $250/$750 $250/$750 |
Out-of-Pocket Maximum In-Network Out-of-Network | Includes deductible, coinsurance and copays $1,750/$3,500 $3,250/$6,500 |
Coinsurance In-Network Out-of-Network | 90% 70% |
Lifetime Max | Unlimited |
Preventive Care In-Network Out-of-Network | Plan pays 100% Not covered |
Telehealth/Virtual Visit | No charge |
Physician Office Visit In-Network Out-of-Network | $10 copay Plan pays 70% after deductible is met |
Specialist Office Visit In-Network Out-of-Network | $10 copay Plan pays 70% after deductible is met |
Basic Lab & Radiology In-Network Out-of-Network | Plan pays 90% after deductible is met Plan pays 70% after deductible is met |
Emergency Room In-Network Out-of-Network | $150 copay plus 10% |
Urgent Care In-Network Out-of-Network | $10 copay Plan pays 70% after deductible is met |
Major Lab & Radiology (MRI/CT/PET) In-Network Out-of-Network | Prior Authorization Required Plan pays 90% after deductible is met Plan pays 70% after deductible is met |
Inpatient Hospital In-Network Out-of-Network | Plan pays 90% after deductible is met Plan pays 70% after deductible is met |
Outpatient Surgery In-Network Out-of-Network | Plan pays 95% after deductible is met Plan pays 70% after deductible is met |
Prescriptions | |
Network Retail Pharmacy Network Mail Order (90-day supply) Preventive Generics CDHP Preventive Drug List Step Therapy / Mandatory Generic | $10/$30/$50/30% to $250 $20/$60/$100/30% up to $500 |