Blue Shield Gold 80 PPO
This plan are for those who are looking to comply with the individual mandate of the Affordable Care Act.
Blue Shield Gold 80 PPO - Effective 2018
Health Insurance Plans for Individuals and Families
This plan are for those who are looking to comply with the individual mandate of the Affordable Care Act with comprehensive coverage. Office visits are $25.
There are no deductibles on this plan but there is an out of pocket maximum of $6,000 for individual and a family of $12,000.
| Plan Name | Gold 80 PPO |
| Medical Deductible | Individual: None - Family: None |
| Annual Out-of-Pocket | Gold 80 PPO |
| Out of Pocket Maximum for Medical | Individual: $6,000 Family: $12,000 |
| Emergency Health | Gold 80 PPO |
| Urgent Care Centers or Facilities | $25/visit |
| Emergency Room Services | $325/visit |
| Emergency Transportation/Ambulance | $250/transport |
| Home Health Care | Gold 80 PPO |
| Home Health Care Services | 20% |
| Hospitalization Services | Gold 80 PPO |
| Inpatient Physician and Surgical Services | 20% |
| Habilitation Services | $25/visit |
| Inpatient Hospital Services (e.g., Hospital Stay) | 20% |
| Skilled Nursing Facility | 20% |
| Substance Abuse Disorder Outpatient Services | $25/visit |
| Substance Abuse Disorder Inpatient Services | 20% |
| Maternity Care | Gold 80 PPO |
| Delivery and All Inpatient Services for Maternity Care | 20% |
| Prenatal and Postnatal Care | No Charge |
| Other Services | Gold 80 PPO |
| Mental/Behavioral Health Inpatient Services | 20% |
| Durable Medical Equipment | 20% |
| Hospice Services | No Charge |
| Bariatric Surgery | 20% |
| Mental/Behavioral Health Outpatient Services | $25/visit |
| Acupuncture | $25/visit |
| Rehabilitative Speech Therapy | $25/visit |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $25/visit |
| Abortion for Which Public Funding is Prohibited | 20% |
| Allergy Testing | 20% |
| Chemotherapy | 20% |
| Diabetes Education | $0 |
| Dialysis | 20% |
| Infusion Therapy | 20% |
| Prosthetic Devices | 20% |
| Radiation | 20% |
| Reconstructive Surgery | 20% |
| Transplant | 20% |
| Treatment for Temporomandibular Joint Disorders | 20% |
| Outpatient Services | Gold 80 PPO |
| Outpatient Surgery Physician/Surgical Services | 20% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 20% |
| Outpatient Rehabilitation Services | 20% |
| Prescription Drug Coverage | Gold 80 PPO |
| Tier 1 Drugs | $15 |
| Tier 2 Drugs | $55 |
| Tier 3 Drugs | $75 |
| Tier 4 Drugs | 20% up to $250/prescription |
| Preventative Care | Gold 80 PPO |
| Well Baby Visits and Care | No Charge |
| Preventive Care/Screening/Immunization | No Charge |
| Professional Services | Gold 80 PPO |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $25/visit |
| Imaging (CT/PET Scans, MRIs) | $55/visit |
| X-rays and Diagnostic Imaging | $55/visit |
| Specialist Visit | $55/visit |
| Laboratory Outpatient and Professional Services | $55/visit |
| Primary Care Visit to Treat an Injury or Illness | $25/visit |
Benefits stated above are using in network preferred providers only. Click here for provider information.
Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.
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