Blue Shield of California
Shield Spectrum PPO Savings 1800 Health Insurance Plan (HSA Compatible)
A plan summary of the Blue Shield of California Shield Spectrum PPO Savings Plan 1800 is detailed out below for both In Network and Out of Network coverage.
| In Network |
Out of Network |
Copay |
30% |
50% or Not Covered |
Office Visits |
$35 after Deductible |
50% |
Annual Deductible |
Individual: $1,800 Family: $3,600 |
Individual: $1,800 Family: $3,600 |
Annual Out-Of-Pocket Limit |
Individual: $5,950 Family: $11,900 |
Individual: $10,000 Family: $20,000 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
AFTER DEDUCTIBLE
Generic: $10
Brand Formulary: $35
Brand Non-Formulary $50 or 50%, whichever is greater (Maximum of $150 per perscription) |
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 |
$75 / visit after deductible (waived if admitted), then 30% |
$75 / visit after deductible (waived if admitted), then 30% |
Inpatient Hospital |
30% |
50% |
Ambulance |
30% |
30% |
Home Health Care |
30% (90 visits per year) |
Not Covered |
Mental Health - Outpatient |
30% (20 visits per year) |
Not Covered |
Chiropractic Care |
50% (maximum benefit $25 per visit, 12 visit per year) |
Not Covered |
Acupuncture |
See Benefit Contract |
See Benefit Contract |
Mental Health - Inpatient |
30% (20 visits per year) |
Not Covered |
Chemical Dependency |
30% |
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.
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.
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