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Home   >  Health Insurance Companies   >   Blue Shield of CA Plans   >   Shield Spectrum PPO Savings 5200 (HSA)
 
 

Blue Shield of California

Shield Spectrum 5200Health Insurance Plan (HSA Compatible)

A plan summary of the Blue Shield of California Shield Spectrum 5200 Plan is detailed out below for both In Network and Out of Network coverage.

                                                In Network Out of Network

  Copay

No Charge after Deductible

50%

  Office Visits

No Charge after Deductible 50%

  Annual Deductible

Individual: $5,200 Family: $10,400

Individual: $5,200 Family: $10,400

  Annual Out-Of-Pocket  Limit

Individual: $4,000 Family: $8,000

Individual: $15,000 Family: $30,000

  Lifetime Maximum

Unlimited Unlimited

  Prescription Drugs

No Charge after Deductible

Not Covered

  Laboratory & X-Ray

No Charge after Deductible 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

No Charge after Deductible 50%

  Emergency Room

No Charge after Deductible No Charge after Deductible

  Inpatient Hospital

No Charge after Deductible 50%

  Ambulance

No Charge after Deductible No Charge after Deductible

  Home Health Care

No Charge after Deductible

(90 visits per year)

Not Covered

  Mental Health - Outpatient

No Charge after Deductible

(20 visits per year)

Not Covered

  Chiropractic Care

Not Covered Not Covered

  Acupuncture

See Benefit Contract See Benefits Contract

  Mental Health - Inpatient

  Not Covered

  Chemical Dependency

No Charge after Deductible 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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