Blue Shield of California
Active Start 25 Generic Rx Health Insurance Plan
A plan summary of the Blue Shield of California Active Start 25 Generic Rx Plan is detailed out below for both In Network and Out of Network coverage.
In Network |
Out of Network |
Copay |
40% |
50% or Not Covered |
Office Visits |
$25 |
50% |
Annual Deductible |
None |
None
|
Annual Out-Of-Pocket Limit |
Individual: $6,000 |
Individual: $8,000 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
Generic: $10
|
Not Covered |
Laboratory & X-Ray |
40% |
50% |
Annual Physical Exam |
No Charge |
Not Covered |
Annual OB-GYN Exam |
No Charge |
Not Covered |
Well Baby Care |
No Charge |
Not Covered |
Outpatient Surgery |
40% plust $500 per visit |
50% |
Emergency Room |
$100 / visit (waived if admitted), then 40% |
$100 / visit (waived if admitted), then 40% |
Inpatient Hospital |
$250 per admission after deductible |
50% |
Ambulance |
40% |
40% |
Home Health Care |
40% (90 visits per year) |
Not Covered |
Mental Health - Outpatient |
40% (20 visits per year) |
Not Covered |
Chiropractic Care |
40% (12 visits per year) |
Not Covered |
Acupuncture |
50% (maximum benefit $25 per visit, 12 visit per year) |
50% (maximum benefit $25 per visit, 12 visit per year) |
Mental Health - Inpatient |
40% (20 visits per year) |
Not Covered |
Chemical Dependency |
40% plust $500 per admission |
50% |
Maternity Care |
Not Covered |
Not Covered |

To learn more about your individual and family California health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.
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