Blue Shield Bronze 60 HDHP PPO

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Calendar year deductible $7,000 per individual / $14,000 per family
Calendar year pharmacy deductible N/A
Calendar year out-of-pocket maximum $7,000 per individual / $14,000 per family

Preventive Care $0
Well Baby Care $0
Prenatal Office Visits $0
Pediatric Dental Benefits: Preventive $0
Pediatric Vision Benefits: Exams $0

24/7 Nurse Hotline No additional cost
Shield Concierge Not available
Healthy Savings Not available
Health and Wellness Discounts (gym, weight loss programs, and more) No additional cost

Retail Prescription Drugs Before deductible:
  Tiers 1-4 = Full cost
   
  After deductible:
  Tiers 1-4: $0

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics) Before deductible:
  Full cost
  After deductible:
  $0
Office Visit - Specialist Care Before deductible:
  Full cost
  After deductible:
  $0
Teladoc 0% after ded
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:
  Full cost
  After deductible:
  $0
Chiropractic (from an American Specialty Health Plans network chiropractor) Not covered

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 care Before deductible:
  Full cost
  After deductible:
  $0
Emergency Room Services Before deductible:
  Full cost
  After deductible:
  $0
Ambulance Before deductible:
  Full cost
  After deductible:
  $0

Maternity - Prenatal Office Visits $0
Maternity - Other professional services Before deductible:
  Full cost
  After deductible:
  $0
Maternity - hospital stay After deductible:
  $0
  Before deductible:
  Full cost

Outpatient Surgery Services Before deductible:
  Full cost
  After deductible:
  $0
Hospital Stays Before deductible:
  Full cost
  After deductible:
  $0

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


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To learn about your options, call our health experts.

(888) 273-0010
Monday through Friday: 8 am to 5:30 pm