| This matrix is inteneded to be used to help you compare coverage benefits and is a summary only. The policy for individuals and families should be consulted for a detailed description of coverage benefits and limitations. |
Plan Benefits |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
 |
Annual Deductible
(Not combined for In-Network & Out-of-Network) |
Individual: $400
Family : $800 |
Individual: $400
Family : $800 |
If the annual plan deductible has not been met, any charges that accumulate toward the plan deductible in the last three month of the calendar year will be credited towards the plan deductible for the following calendar year will be credited towards the plan deductilble for the following calendar year. |
Calendar-year copayment / coinsurance maximum
(Includes the plan deductible - some service do not apply)
|
Individual: $2,900 |
Individual: $15,000 |
| Family: $5,800 aggregate |
Familiy: $30,000 aggregate |
Lifetime Maximum
(Combined for In-Network & Out-of-Network) |
Plan pays up to $3 Million per member |
Covered Services
The amounts shown are your share of costs after any deductible unless noted. |
In-Network
(Coinsurance amounts are
percentage
of negotiated fee) |
Out-of-Network
(Coinsurance amounts are percentage
of negotiated fee, plus any amounts
charged over that fee) |
| Professional Services |
|
|
| Office Visits - (first 5 visits/calendar year for any combination of preventive care and physician office visits - subsequent visits are subject to the copayment maximum) |
$30 |
No charge after copay maximum |
| Preventive Care |
|
|
| Annual routine phsyical exam, well-baby care office visits, and gynological exam office vist -
(first 5 visits/calendar year for any combination of preventive care and physician office visits - subsequent visits are subject to the copayment maximum) |
$30 |
Not Covered |
| Annual Pap test or other or other approved cervical cancer screening tests, routine mammography, and immunizations when received as part of the annual exam or preventive care visit |
40% of negotiated fee |
Not Covered |
| Outpatient Services |
|
|
| Non-emergency services and procedures, outpatient surgery in hospital |
40% of negotiated fee |
50% |
| Outpatient surgery performed in an ambulatory surgery center |
40% of negotiated fee |
50% |
Outpatient or out-of-hospital X-ray & laboratory |
No charge after copay maximum |
No charge after copay maximum |
Covered Services
Subject to the plan deductible unless noted |
In-Network
(Receive negotiated savings) |
Out-of-Network
(Pay higher costs) |
| Hospitalization Services |
|
|
| Inpatient physician visits and consultations, surgeons and assistants, and anesthesiologists |
40% of negotiated fee |
50% |
| Inpatient semiprivate room and board, services and supplies, and subacute care |
40% of negotiated fee |
50% |
| Bariatric surgery inpatient services (pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity) |
40% of negotiated fee |
50% |
| Emergency Health Care |
|
|
| Emergency room services ($100 copayment/visit waived if member is admitted directly to the hospital as in inpatient) |
$100/visit +40% |
$100/visit + 40% |
| ER Physician visits |
40% |
40% |
| Ambulance Services |
40% |
40% |
| Prescription Drug Coverage |
Participating Pharmacies
(up to 30-day supply) |
Mail Service Prescriptions
(up to a 60-day supply) |
| Vital Shield Plus 400, 900 and 2900 Generic Rx are also available. These plans do not cover Brand-name drugs. All other benefits are the same. |
| Generic formulary drugs |
$10/presecription |
$20/prescription |
| Formulary brand-name drugs |
Not Covered |
Not Covered |
| Non-formulary brand-name drugs |
Not Covered |
Not Covered |
| Brand-name drug Deductible (brand-name drugs are subject to a brand-name drug deductible per person, per calendar year) |
n/a |
n/a |
Consider Other Blue Shield of California PPO Plans |
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Blue Shield of California now offers a range of affordable and comprehensive dental plans available to residents of California with or without a Blue Shield health plan. With Blue Shield's broad dental network including nearly 20,000 dental PPO providers and more than 8,600 HMO providers in California it is easy to access one of the largest networks in California.
Aetna
