Our Blue Shield Silver 73 PPO, Blue Shield Silver 87 PPO, and Blue Shield Silver 94 PPO plans offer lower out of pocket costs for covered services compared to other Silver plans. Each plan gives you access to the Exclusive PPO Network and many routine services (like preventive care) before the deductible.
These plans are only available to purchase from Covered California, and you must meet certain income requirements and other criteria to enroll. Eligibility is determined by Covered California.
Designed to balance lower premiums and costs for unplanned care. Blue Shield pays approximately 70% of covered expenses.
Delivers mid-range premium and lower costs for doctor visits. Blue Shield pays approximately 80% of expenses with this plan.
Offers the lowest out-of-pocket costs for covered services, with a significantly lower medical deductible and no prescription drug deductible. Blue Shield pays approximately 90% of covered expenses with this plan.
The Exclusive PPO Network includes more than 71,000 doctors, 325 hospitals, and 1,000 urgent care centers statewide. Find in-network doctors, medical groups, and hospitals near you.
Some doctors offer both in-person and virtual visits. You can even choose a virtual-only doctor to be your primary care physician.
A primary care doctor is one you see regularly for ongoing care. For urgent needs, you can choose to speak with a virtual doctor at Teladoc Health for $0.
You can see any provider in our Exclusive PPO Network. You also have the option to use providers who do not participate in that network – but your out-of-pocket costs will be higher if you do.
| Blue Shield Silver 73 PPO | Blue Shield Silver 87 PPO | Blue Shield Silver 94 PPO | ||
|---|---|---|---|---|
Deductibles and maximum out-of-pocket | ||||
| Calendar year medical deductible | $4,700 per individual / $9,400 per family1 | $1,100 per individual / $2,200 per family1 | $200 per individual / $400 per family1 | |
| Calendar year medical deductible | $50 per individual / $100 per family1 | $50 per individual / $100 per family1 | $0 | |
| Calendar year out-of-pocket maximum2 | $9,600 per individual / $19,200 per family | $4,000 per individual / $8,000 per family | $3,000 per individual / $6,000 per family | |
Care from your providers (physician services) | ||||
| Primary Care | Preventive care | $0 | $0 | $0 |
| Office visit (in-person or telehealth) | $50 | $15 | $5 | |
| Specialist | Office visit (in-person or telehealth) | $100 | $30 | $8 |
| Mental health / substance use disorders | Office visit (in-person or telehealth) | $50 | $15 | $5 |
Labs and tests (diagnostic X-ray, imaging, pathology, and laboratory services) | ||||
| Laboratory and pathology services at a laboratory center | $50 | $35 | $10 | |
| Basic imaging services (including X-rays and ultrasounds) at an outpatient radiology center | $95 | $50 | $10 | |
Emergency and urgent care services | ||||
| Emergency room | Physician services | $0 | $0 | $0 |
| Facility services (waived if admitted to the hospital) | $400 per visit | $200 per visit | $50 per visit | |
| Urgent care center services | (in-person or telehealth) | $50 per visit | $15 per visit | $5 per visit |
Care at the hospital (inpatient and outpatient services in a hospital setting) | ||||
| Inpatient | Physician services | 30% | 20% | 10% |
| Facility services | 30% (subject to deductible) | 20% (subject to deductible) | 10% (subject to deductible) | |
| Outpatient | Physician services | 30% | 20% | 10% |
| Facility services | 30% | 20% | 10% | |
Dental and vision care for kids (pediatric dental and vision for children up to age 19) | ||||
| Dental | Oral exam | $0 | $0 | $0 |
| Preventive cleaning | $0 | $0 | $0 | |
| Topical fluoride | $0 | $0 | $0 | |
| Vision | Comprehensive eye exam | $0 | $0 | $0 |
| Glasses (collection frames)3 | $0 | $0 | $0 | |
| Contacts (hard or soft, elective or non-elective) | $0 | $0 | $0 | |
Prescription drugs from your local network pharmacy or Amazon Pharmacy home delivery | ||||
| Contraceptive drugs and devices | 30 day supply | $0 | $0 | $0 |
| 90 day supply home delivery | $0 | $0 | $0 | |
| Tier 1 | 30 day supply | $20 per prescription | $10 per prescription | $3 per prescription |
| 90 day supply home delivery | $60 per prescription | $30 per prescription | $9 per prescription | |
| Tier 2 | 30 day supply | $65 per prescription (subject to pharmacy deductible) | $30 per prescription (subject to pharmacy deductible) | $10 per prescription |
| 90 day supply home delivery | $195 per prescription (subject to pharmacy deductible) | $90 per prescription (subject to pharmacy deductible) | $30 per prescription | |
| Tier 3 | 30 day supply | $95 per prescription (subject to pharmacy deductible) | $50 per prescription (subject to pharmacy deductible) | $15 per prescription |
| 90 day supply home delivery | $285 per prescription (subject to pharmacy deductible) | $150 per prescription (subject to pharmacy deductible) | $45 per prescription | |
| Tier 4 | 30 day supply | 20% (up to $250 per prescription and subject to pharmacy deductible) | 15% (up to $150 per prescription and subject to pharmacy deductible) | 10% (up to $150 per prescription) |
| 90 day supply home delivery | 20% (up to $750 per prescription and subject to pharmacy deductible) | 15% (up to $450 per prescription and subject to pharmacy deductible) | 10% (up to $450 per prescription) | |
Additional features | ||||
| Health savings account (HSA) eligible | Consult with your financial or tax advisor if you have questions about HSAs. | No | No | No |
| Out of state care coverage | BlueCard® service area | Limited coverage - refer to the Evidence of Coverage | Limited coverage - refer to the Evidence of Coverage | Limited coverage - refer to the Evidence of Coverage |
| Other professional services | Teladoc Health consultation | $0 | $0 | $0 |
| Chiropractic services | Not covered | Not covered | Not covered | |
1. Family coverage has an individual deductible within the family deductible. Blue Shield will pay benefits for an individual member on the family plan once the member meets the individual deductible amount. Blue Shield will pay benefits for all covered family members once the family deductible is satisfied. The family deductible can be satisfied when two family members meet their individual deductibles, or when the combined deductible contributions of three or more members reaches the family deductible limit.
2. Family coverage includes an individual out‑of‑pocket maximum (OOPM) within the overall family OOPM. Blue Shield pays 100% for covered services for a family member once that person meets their individual OOPM. Blue Shield pays 100% for all covered family members once the family OOPM is met. The family OOPM can be reached when two members meet their individual OOPM or when the combined OOPM amounts of three or more members reach the family limit.
3. Collection frames are pre-selected frames by insurance providers which are fully covered with no out of pocket costs. Non-collection frames are other standard retail or designer frames with a fixed allowance.
This page provides details on plan deductibles, copayments, and coinsurance amounts for common services when using in-network providers. It is not a contract. For complete plan details, including non-network benefits, refer to the Evidence of Coverage (EOC) available under Individual and Family plan documents, or call us at (888) 256-3650.