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Covered California
Individual and Family Plans

Cost-Sharing Reduction Plans

Effective January 1, 2015

We offer three PPO and three EPO Silver cost-sharing reduction plans through Covered California for consumers whose income is between 133% to 250% of the federal poverty level (FPL). These plans offer lower cost-sharing to reduce your clients' out-of-pocket costs when accessing medical care. These plans are available only through Covered California.
Benefit Silver 94 Silver 87 Silver 73
With participating providers Member pays1  After deductible,
member pays1 
After deductible,
member pays1 
Office visit – primary care doctor $3 $152  $402
Office visit – specialist $5 $202  $502
Urgent care visit  $6 $302  $802
Preventive health benefits $0 $02  $02
Inpatient hospitalization 10% 15% 20%
Outpatient surgery 10% 15%2 20%2
Lab $3 $152  $402
X-ray  $5 $202  $502
Emergency room services not resulting in admission $25 $75 $250
Maternity 10% 15% 20%
Generic drugs $3 $52  $152
Preferred brand drugs $5 $15 $35
Non-preferred brand drugs $10 $25 $60
Chiropractic Not covered Not covered Not covered
Acupuncture 
(from a licensed acupuncturist)
$3 $152  $402 
Pediatric dental cleaning and X-rays $0 $0  $0
Pediatric dental filling - 1 surface (amalgam) 20% 20%  20% 
Pediatric dental root canal - molar 50% 50% 50%
Pediatric eye exam $0 $02 $02 
Pediatric eyeglasses $0 $02  $02 
Calendar year medical deductible $0 $500 per individual/$1,000 per family $1,600 per individual/$3,200 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
$5,200 per individual/$10,400 per family
Calendar year brand drug 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 Disclosures.

Rates for our medical plans can be obtained immediately from our IFP rate books, or through our online Quote & Apply tool beginning November 15, 2014.

* These plans are pending regulatory approval.
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. Benefit is available prior to meeting any deductible.
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