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Covered California
Individual and Family Plans

Cost-Sharing Reduction Plans

Effective January 1, 2016

We offer three PPO Silver cost-sharing reduction plans through Covered California for consumers whose income is between 138% to 250% of the federal poverty level (FPL). These silver plans offer lower copayments  deductibles, and out-of-pocket costs than the Silver 70 PPO plan, so your clients will pay less when they get care from network providers. These plans are available only through Covered California.
Benefit Silver 94 Silver 87 Silver 73
With participating providers Member pays1,2  After deductible,
member pays1,2 
After deductible,
member pays1,2 
Office visit – primary care doctor $5 $15 $40
Office visit – specialist doctor $8 $25  $55
Urgent care visit  $6 $30  $80

Preventive health benefits

$0 $0

$0

Inpatient hospitalization Deductible + 10% Deductible + 15% Deductible + 20%
Outpatient surgery 10% 15% 20%
Lab $8 $15 $35
X-ray  $8 $25  $50
Emergency room services not resulting in admission Deductible + $30 Deductible + $75 Deductible + $250
Maternity Deductible + 10% Deductible + 15% Deductible + 20%
Tier 1 drugs $3 $5 $15
Tier 2 drugs $10 Pharmacy deductible + $20 Pharmacy deductible + $45
Tier 3 drugs $15 Pharmacy deductible + $35 Pharmacy deductible + $70
Acupuncture 
(from a licensed acupuncturist)
$5 $15 $40
Pediatric dental exam $0 $0 $0
Pediatric eye exam $0 $0 $0
Pediatric eyeglasses 1 pair per year 1 pair per year 1 pair per year
Calendar-year medical deductible $75 per individual/
$150 per family
$500 per individual/$1,000 per family $1,900 per individual/$3,800 per family
Calendar-year out-of-pocket maximum
(includes deductible)
$2,250 per individual/
$4,500 per family
$2,250 per individual/
$4,500 per family
$5,450 per individual/$10,900 per family
Calendar-year pharmacy deductible $0 $50 per individual/
$100 per family
$250 per individual/
$500 per family

For complete medical plan details, see the Benefit Summaries and Legal Disclosure.

Rates for our vision plans are available in our IFP rate books or through our Quote & Apply tool.

1. The amounts indicated are a percentage of the allowable amounts. Participating providers accept Blue Shield's allowable amounts as payment-in-full for covered services.
2. This Blue Shield plan must be purchased through Covered California, and your broker can help you with the processs. All other Blue Shield medical plans displayed on this chart can be purchased through Blue Shield or Covered California, unless indicated otherwise.
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