Blue Shield Minimum Coverage PPO
| Plan Cost Summary | |
|---|---|
| Estimated Monthly premium | |
| Calendar year deductible | $9,200 per individual / $18,400 per family |
| Calendar year pharmacy deductible | N/A |
| Calendar year out-of-pocket maximum | $9,200 per individual / $18,400 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 deductible: Tiers 1-4 = Full cost |
After deductible: Tiers 1-4: $0 |
|
Physician and medical services |
|
|---|---|
| Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics) | Before deductible: Visits 1-3 = $0 Visits 4+ = Full cost |
After deductible: $0 |
|
| Office Visit - Specialist Care | Before deductible: Full cost |
After deductible: $0 |
|
| 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) | Before deductible: Visits 1-3 = $0 Visits 4+ = Full cost |
After deductible: $0 |
|
| Chiropractic (from an American Specialty Health Plans network chiropractor) | Not covered |
| Lab and X-ray diagnostics | |
|---|---|
| Laboratory Tests | Before deductible: Full cost |
After deductible: $0 |
|
| X-rays | Before deductible: Full cost |
After deductible: $0 |
|
| Imaging (CT / PET scan, MRI) from an outpatient radiology center | Before deductible: Full cost |
After deductible: $0 |
|
| Urgent and emergency | |
|---|---|
| Urgent care | Before deductible: Visits 1-3 = $0 Visits 4+ = Full cost |
After deductible: $0 |
|
| Emergency Room Services | Before deductible: Full cost |
After deductible: $0 |
|
| Ambulance | Before deductible: Full cost |
After deductible: $0 |
|
| Maternity care | |
|---|---|
| Maternity - Prenatal office visits | $0 |
| Maternity - Other professional services | Before deductible: Full cost |
After deductible: $0 |
|
| Maternity - hospital stay | Before deductible: Full cost |
After deductible: $0 |
|
| Hospital and outpatient | |
|---|---|
| Outpatient Surgery Services | Before deductible: Full cost |
After deductible: $0 |
|
| Hospital Stays | Before deductible: Full cost |
After deductible: $0 |
|
| Dental and vision | |
|---|---|
| Pediatric Dental Benefits: Preventive | $0 |
| Pediatric Dental Benefits: Restorative Procedures | Before deductible: Full cost |
After deductible: $0 |
|
| Pediatric Dental Benefits: Medically Necessary Orthodontics | Before deductible: Full cost |
After deductible: $0 |
|
| Pediatric Vision Benefits: Exams | $0 |
| Pediatric Vision Benefits: Eye Glasses | Before deductible: Full cost |
After deductible: 1 pair per year |
|
