Skip to main content

Blue Shield PPO

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