Blue Shield Silver 87 PPO

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Calendar year deductible $800 per individual / $1,600 per individual
Calendar year pharmacy deductible $0
Calendar year out-of-pocket maximum $2,850 per individual / $5,700 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 = $5
  Tier 2 = $25
  Tier 3 = $45
  Tier 4 = 15% up to $150 per prescription

Office Visit - Primary Care (internal medicine, family practice, OB/GYN, pediatrics) $15
Office Visit - Specialist Care $25
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) $15
Chiropractic (from an American Specialty Health Plans network chiropractor) Not covered

Laboratory Tests $20
X-rays $40
Imaging (CT / PET scan, MRI) from an outpatient radiology center $100

Urgent care $15
Emergency Room Services $150
Ambulance $75

Maternity - Prenatal Office Visits $0
Maternity - Other professional services 15%
   
Maternity - hospital stay Before deductible:
   
  Full cost
   
  After deductible:
  15%

Outpatient Surgery Services 15%
Hospital Stays Before deductible:
  Full cost
   
  After deductible:
  15%

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