Blue Shield Gold 80 PPO

This plan are for those who are looking to comply with the individual mandate of the Affordable Care Act.

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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.Blue Shield of California 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 CareNo Charge
Other Services Gold 80 PPO
Mental/Behavioral Health Inpatient Services 20%
Durable Medical Equipment 20%
Hospice ServicesNo 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 CareNo Charge
Preventive Care/Screening/ImmunizationNo 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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