Blue Shield of California
Vital Shield Plus 400 Health Insurance Plan
A plan summary of the Blue Shield of California Vital Shield Plus 400 Plan is detailed out below for both In Network and Out of Network coverage.
| In Network |
Out of Network |
Copay |
40% |
50% |
Office Visits |
$30 (First 4 visits per year, See Brochure) |
No Charge after Out of Pocket is met |
Annual Deductible |
Individual: $400 Family: $800 |
Individual: $5,000 Family: $10,000 |
Annual Out-Of-Pocket Limit |
Individual: $2,900 Family: $5,800 |
Individual: $15,000 Family: $30,000 |
Lifetime Maximum |
Unlimited |
Unlimited |
Prescription Drugs |
Generic: $10
Brand Formulary: $45 ($500 Brand Deductible) |
Not Covered |
Laboratory & X-Ray |
No Charge after Out of Pocket is met |
No Charge after Out of Pocket is met |
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% |
50% |
Emergency Room |
$100 / visit (waived if admitted), then 40% |
$100 / visit (waived if admitted), then 40% |
Inpatient Hospital |
40% |
50% |
Ambulance |
40% |
40% |
Home Health Care |
No Charge after Out of Pocket is met (90 visits per year)
|
Not Covered |
Mental Health - Outpatient |
Not Covered
|
Not Covered |
Chiropractic Care |
Not Covered |
Not Covered |
Acupuncture |
Not Covered |
Not Covered |
Mental Health - Inpatient |
Not Covered |
Not Covered |
Chemical Dependency |
40% |
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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