Blue Shield of California
800-393-6130
Group Number: W0067301
The Blue Shield Preferred Provider Organization (PPO) plan offers employees the flexibility to see different doctors, whether or not they are in your plan’s network. High Deductible Health Plan (HDHP) combines traditional medical coverage with a Health Savings Account (HSA). As evident by the name, this plan has a higher deductible members must reach before the plan kicks in.
|
Blue Shield HDHP PPO |
In-Network |
Out-Network |
|---|---|---|
| Annual Deductible | ||
| Individual | $2,000 | $4,000 |
| Individual within Family | $2,800 | $5,200 |
| Family | $4,000 | $8,000 |
| Annual Out of Pocket Maximum | ||
| Individual | $3,425 | $12,000 |
| Family | $6,850 | $24,000 |
|
Medical Services |
||
| Primary Care Visit | 10% | 30% |
| Specialist Office Visit | 10% | 30% |
| Basic X-ray and Laboratory | 10% | 30% |
| Inpatient Hospital | 10% | 30% |
| Emergency Room | 10% | 10% |
| Urgent Care | 10% | 30% |
| Chiropractic | 10% | 30% |
| Hearing Aid | 20% | 20% |
| Prescription Drugs | After Deductible | After Deductible |
| Generic / Tier 1 | $10 copay | $10 copay +25% |
| Formulary / Tier 2 | $40 copay | $40 copay +25% |
| Non-Formulary / Tier 3 | $60 copay | $60 copay+25% |
| Speciality/ Tier 4 | 25% of purchase price+ 30% up to $250 copay | Not covered |
| Monthly Employee Contribution | |
|---|---|
| Employee Only | $164.78 |
| Employee + 1 | $560.20 |
| Employee + Family | $888.68 |