Blue Shield Bronze 60 PPO
| Plan Cost Summary | |
|---|---|
| Estimated Monthly premium | |
| Calendar year deductible | $5,800 per individual / $11,600 per family |
| Calendar year pharmacy deductible | $450 per individual / $900 per family |
| Calendar year out-of-pocket maximum | $8,850 per individual / $17,700 per family |
| No cost preventive care | |
|---|---|
| Preventive Care | $0 |
| Well Baby Care | $0 |
| Prenatal Office Visits | $0 |
| Pediatric Dental Benefits: Preventive | $0 |
| Pediatric Vision Benefits: Exams | $0 |
| No cost extras | |
|---|---|
| 24/7 Nurse Hotline | No additional cost |
| Shield Concierge | Not available |
| Health and Wellness Discounts (gym, weight loss programs, and more) | No additional cost |
| Prescription drugs | |
|---|---|
| Retail Prescription Drugs | Before pharmacy deductible: Tier 1 = $19 Tier 2-4 = Full cost |
After pharmacy deductible: Tiers 2-4 = 40% up to $500 per prescription
|
|
| Physician and medical services | |
|---|---|
| Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics) | $60 |
| Office Visit - Specialist Care | Before deductible: Visits 1-3 = $95 Visits 4+ = Full cost |
After deductible: $95 |
|
| Teladoc | $0 |
| Retail clinics | Cost depends on the service performed. Cost is the same as if the service was performed elsewhere. |
| Acupuncture (from an American Specialty Health Plans network acupuncturist) | $60 |
| Chiropractic (from an American Specialty Health Plans network chiropractor) | Not covered |
| Lab and X-ray diagnostics | |
|---|---|
| Laboratory Tests | Before and after deductible: $40 |
| X-rays | Before deductible: Full cost |
After deductible: 40% |
|
| Imaging (CT / PET scan, MRI) from an outpatient radiology center | Before deductible: Full cost |
After deductible: 40% |
|
| Urgent and emergency | |
|---|---|
| Urgent care | $60 |
| Emergency Room Services | Before deductible: Full cost |
After deductible: 40% |
|
| Ambulance | Before deductible: Full cost |
After deductible: 40% |
|
| Maternity care | |
|---|---|
| Maternity - Prenatal office visits | $0 |
| Maternity - Other professional services | Before deductible: Full cost |
After deductible: 40% |
|
| Maternity - hospital stay | Before deductible: Full cost |
After deductible: 40% |
|
| Hospital and outpatient | |
|---|---|
| Outpatient Surgery Services | Before deductible: Full cost |
After deductible: 40% |
|
| Hospital Stays | Before deductible: Full cost |
After deductible: 40% |
|
| Dental and vision | |
|---|---|
| Pediatric Dental Benefits: Preventive | $0 |
| Pediatric Dental Benefits: Restorative Procedures | 20% |
| Pediatric Dental Benefits: Medically Necessary Orthodontics | 50% |
| Pediatric Vision Benefits: Exams | $0 |
| Pediatric Vision Benefits: Eye Glasses | 1 pair per year |