Individual and Family Plans 2014 - Blue Shield of California
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2014 Individual and Family Plans

Blue Shield of California will offer PPO and EPO plans for 2014 in all 19 California pricing regions, available for purchase directly through Blue Shield or through Covered California. The plans are categorized into four metal levels of coverage based on the percentage of costs covered for an average population:

  • Platinum: You pay 10% of health costs, BlueShield's plan covers 90%

  • Gold: You pay 20% of health costs, BlueShield's plan covers 80%

  • Silver: You pay 30% of health costs, BlueShield's plan covers 70%

  • Bronze: You pay 40% of health costs, BlueShield's plan covers 60%

We also offer a Catastrophic level of coverage for those in the individual and family plan market under age 30, or those age 30 and above who can provide a certification that they are without affordable coverage, or experiencing financial hardship. On this plan, you pay 40% of health costs, and the plan covers 60%. 

We also offer Native American plans at each metal level to eligible Native Americans.

Ultimate PPO/EPO Plans (Platinum 90) Benefits Overview

Benefits1Ultimate
  With participating providers, you pay:
Office visit: primary care doctor$20
Office visit: specialist doctor$40
Urgent care visit$40
Preventive health benefits$0
Inpatient hospitalization 10%
Outpatient surgery 10%
Lab$20
X-ray$40
Emergency room services not resulting in admission$150
Maternity10%
Generic drugs $5
Preferred brand drugs$15
Non-perferred brand drugs$25
ChiropracticNot covered
Acupuncture (from a licensed acupuncturist)$20
Pediatric eye exam$0
Pediatric eyeglasses$0
Calendar year medical deductible$0
Calendar year out-of-pocket maximum (includes deductible)$4,000 per individual
and $8,000 per family 
Calendar year brand drug deductible$0

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Preferred PPO/EPO Plans (Gold 80) Benefit Overview

Benefits1Preferred
  With participating providers, you pay:
Office visit: primary care doctor$30
Office visit: specialist doctor$50
Urgent care visit$60
Preventive health benefits$0
Inpatient hospitalization 20%
Outpatient surgery 20%
Lab$30
X-ray$50
Emergency room services not resulting in admission$250
Maternity20%
Generic drugs $19
Preferred brand drugs$50
Non-perferred brand drugs$70
ChiropracticNot covered
Acupuncture (from a licensed acupuncturist)$30
Pediatric eye exam$0
Pediatric eyeglasses$0
Calendar year medical deductible$0
Calendar year out-of-pocket maximum (includes deductible)$6,350 per individual
and $12,700 per family 
Calendar year brand drug deductible$0

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Enhanced PPO/EPO Plans (Silver 70) Benefit Overview

Benefits1EnhancedEnhanced
150 Subsidy
Enhanced
200 Subsidy
Enhanced
250 Subsidy
 With participating providers, after the deductible, you pay:With participating providers, you pay: With participating providers, after the deductible, you pay: With participating providers, after the deductible, you pay:
Office visit: primary care doctor$452$3$152$402
Office visit: specialist doctor$652$5$202$502
Urgent care visit$902$6$302$802
Preventive health benefits$02$0$02$02
Inpatient hospitalization 20%10%15%20%
Outpatient surgery 20%210%15%220%2
Lab$452$3$152$402
X-ray$652$5$202$502
Emergency room services not resulting in admission$250$25$75$250
Maternity20%10%15%20%
Generic drugs $192$3$52$192
Preferred brand drugs$50$5$15$30
Non-perferred brand drugs$70$10$25$50
ChiropracticNot Covered
Acupuncture (from a licensed acupuncturist)$452$3$152$402
Pediatric eye exam$02$0$02$02
Pediatric eyeglasses$02$0$02$02
Calendar year medical deductible$2,000 per individual
and $4,000 per family
$0 $500 per individual
and $1,000 per family
$1,500 per individual
and $3,000 per family
Calendar year out-of-pocket maximum (includes deductible)$6,350 per individual
and $12,700 per family 
$2,250 per individual
and $4,500 per family
$2,250 per individual
and $4,500 per family
$5,200 per individual
and $10,400 per family
Calendar year brand drug deductible$250 per individual/$500 per family$0$50 per individual/$100 per family$250 per individual/$500 per family

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Basic PPO/EPO Plans (Bronze 60) Benefit Overview

Benefits1BasicBasic for HSA*
 With participating providers, after the deductible, you pay:With participating providers, after the deductible, you pay:
Office visit: primary care doctor$60 for first 3 visits per calendar year prior to deductible2 , then $60 after deductible3 40%
Office visit: specialist doctor$70 40%
Urgent care visit$120 for first 3 visits per calendar year prior to deductible2 , then $120 after deductible 3 40%
Preventive health benefits$02$02
Inpatient hospitalization 30%40%
Outpatient surgery 30%40%
Lab30%40%
X-ray30%40%
Emergency room services not resulting in admission$30040%
Maternity30%40%
Generic drugs $1940%
Preferred brand drugs$5040%
Non-perferred brand drugs$7540%
ChiropracticNot coveredNot covered
Acupuncture (from a licensed acupuncturist)$6040%
Pediatric eye exam$02$02
Pediatric eyeglasses$02$02
Calendar year medical deductible$5,000 per individual and $10,000 per family $4,500 per individual and $9,000 per family
Calendar year out-of-pocket maximum (includes deductible)$6,350 per individual
and $12,700 per family 
 $6,350 per individual and $12,700 per family
Calendar year brand drug deductible4$0$0

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Get Covered PPO/EPO Plans (Catastrophic/Minimum Coverage) Benefit Overview 

Benefits1Get Covered
 With participating providers, after the deductible, you pay:

Office visit: primary care doctor

$0 for first 3 visits per calendar year prior to
deductible2, then $0 after deductible3

Office visit: specialist doctor

0%

Urgent care visit

$0 for first 3 visits per calendar year prior to
deductible2, then $0 after deductible3
Preventive health benefits$02
Inpatient hospitalization 0%
Outpatient surgery 0%
Lab0%
X-ray0%
Emergency room services not resulting in admission0%
Maternity0%
Generic drugs 0%
Preferred brand drugs0%
Non-perferred brand drugs0%
ChiropracticNot covered
Acupuncture (from a licensed acupuncturist)0%
Pediatric eye exam$02
Pediatric eyeglasses$02
Calendar year medical deductible$6,350 per individual / $12,700 per family
Calendar year out-of-pocket maximum (includes deductible)$6,350 per individual / $12,700 per family
Calendar year brand drug deductible4$0

Native American Plans

We also offer Native American plans at each metal level to eligible Native Americans. These plans provide the same benefits as the standard metal level plans when accessing covered services from network and non-network providers, but also allow Native American members to access covered services from Native American providers for $0 out of pocket.  In addition to the Native American metal level plans, we also offer Native Americans the Native American 300 Subsidy plan. This plan allows Native American members to access covered services from Native American providers, Blue Shield network providers – and in some locations, even non-network providers – for $0 out of pocket.

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