Blue Shield Gold 80 PPO

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Calendar year deductible $0
Calendar year pharmacy deductible $0
Calendar year out-of-pocket maximum $8,200 per individual / $16,400 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 Tier 1 = $15
  Tier 2 = $55
  Tier 3 = $80
  20% up to $250 per prescription

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics) $35
Office Visit - Specialist Care $65
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) $35
Chiropractic (from an American Specialty Health Plans network chiropractor) Not covered

Laboratory Tests $40
X-rays $75
Imaging (CT / PET scan, MRI) from an outpatient radiology center 20%

Urgent care $35
Emergency Room Services $350
Ambulance $250

Maternity - Prenatal Office Visits $0
Maternity - Other professional services 20%
Maternity - hospital stay 20%

Outpatient Surgery Services 20%
Hospital Stays 20%

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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You may be eligible for financial assistance from the government to help you pay for a plan. Now that you’ve browsed our plans, please call us at the number listed below to get a quote.

To learn about your options, call our health experts.

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