HEALTH INSURANCE


EMPLOYEE BENEFIT SUMMARY

BLUE SHIELD 80/60 PPO AND TRIO HMO PLANS

Blue Shield Group Number and Contact Information

Group Number: W0002943
Blue Shield Member Services: (800) 424-6521
Website: www.blueshieldca.com

*Blue Shield 80/60 PPO

Blue Shield 80/60 PPO Benefit Summary
Plan Year October 1, 2018 to September 30, 2019

 TRIO ACO HMO

Blue Shield TRIO ACO HMO Benefit Summary
Plan Year October 1, 2018 to September 30, 2019

Chiropractic/Acupuncture Information

Prescription Drug Mail Order Center

Group Number: 977986-0003 
Member Services: (866) 346-7200     
Website: www.myprimemail.com

Blue Shield Summary PPO Prescription Drug Coverage

Blue Shield Summary TRIO ACO HMO Prescription Drug Coverage

Claim Form

Subscriber's Statement of Claim

KAISER PERMANENTE HMO PLAN

Kaiser Permanente Group Number and Contact Information 

 Group Number: 109082-0000
Kaiser Member Services: (800) 464-4000
Website: kp.org

Kaiser Summary of Benefits 

Plan Year October 1, 2018 to September 30, 2019

Chiropractic/Acupuncture Information

DELTA DENTAL PPO PLAN

Delta Dental PPO Group Number and Contact Information

Group Number: 07023-05205
Delta Dental Member Services: (866) 499-3001
Website: www.deltadental.com  

Plan Year: October 1, 2018 to September 30, 2019

Delta Dental - Plan 2 Summary of Benefits
I
ncludes Orthodontic Coverage
Plan Year:  October 1, 2018 to September 30, 2019


In-Network Dentist: $0 Calendar Year Deductable/$2000 maximum benefit  
Out-of-Network Dentist: $100 Calendar Year Deductable/$1500 maximum benefit 
70/30 Coverage First Calendar Year or First Year of Utilization
80/20 Coverage if Plan is Utilized in the Previous Year
90/10 Coverage if Plan is Utilized in the Previous Year
100% Coverage if Plan is Utilized in the Previous Year and each year thereafter

MEDICAL EYE SERVICES (MES) VISION PLAN

Medical Eye Services (MES) Vision Plan Information

MES Group Number:  32083
MES Services: 800-877-6372
Website: www.mesvision.com

 MES Summary of Benefits
Plan Year:  October 1, 2018 to September 30, 2019

Claim Form

Claim Form

BLUE SHIELD TERM LIFE AND ACCIDENTAL DEATH/DISMEMBERMENT PLAN

CONTACT US

550 Blumont St. 
Laguna Beach, CA 92651 
P:949-497-7700
F:949-497-6021
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