Blue Shield of California
Shield Spectrum 5000Health Insurance Plan
A plan summary of the Blue Shield of California Shield Spectrum 5000 Plan is detailed out below for both In Network and Out of Network coverage.
| In Network |
Out of Network |
Copay |
30% |
50% |
Office Visits |
$35 after Deductible |
50% |
Annual Deductible |
Individual: $5,000 Family: $10,000 |
Individual: $5,000 Family: $10,000 |
Annual Out-Of-Pocket Limit |
Individual: $7,000 Family: $14,000 |
Individual: $10,000 Family: $20,000 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
Generic: $10
Brand Formulary: $35
Brand Non-Formulary $50 or 50%, whichever is greater ($500 Brand Deductible) |
Not Covered |
Laboratory & X-Ray |
30% |
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 |
30% |
50% |
Emergency Room |
30% |
30% |
Inpatient Hospital |
30% |
50% |
Ambulance |
30% |
35% |
Home Health Care |
30% (90 visits per year)
|
Not Covered |
Mental Health - Outpatient |
30% (20 visits per year)
|
Not Covered |
Chiropractic Care |
Not Covered |
Not Covered |
Acupuncture |
See Benefit Contract |
See Benefits Contract |
Mental Health - Inpatient |
30% (20 visits per year) |
Not Covered |
Chemical Dependency |
30% |
50% |
Maternity Care |
30% |
50% |
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.
NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the health plan's underwriting guidelines.
|
