Blue Shield Silver 94 PPO

Plan Cost Summary
Estimated Monthly premium  
Calendar year deductible $0
Calendar year pharmacy deductible $0
Calendar year out-of-pocket maximum $1,150 per individual / $2,300 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 Tier 1 = $3

Tier 2 = $10

Tier 3 = $15

Tier 4 = 10% up to $150 per prescription

 

Physician and medical services
Office Visit – Primary Care (internal medicine, family practice, OB/GYN, pediatrics) $5
Office Visit – Specialist Care $8
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) $5
Chiropractic (from an American Specialty Health Plans network chiropractor)

Not covered

 

Lab and X-ray diagnostics
Laboratory Tests $8
X-rays $8
Imaging (CT / PET scan, MRI) from an outpatient radiology center $50

 

Urgent and emergency
Urgent care $5
Emergency Room Services $50
Ambulance $30

 

Maternity care
Maternity – Prenatal office visits $0
Maternity – Other professional services 10%
Maternity – hospital stay 10%

 

Hospital and outpatient
Outpatient Surgery Services 10%
Hospital Stays 10%

 

 

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

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

TRUSTe