California Health Insurance: Blue Shield Bronze 60 PPO

Blue Shield Bronze 60 PPO

In-Network

Out-Network
Cost Share Information 
Individual Deductible  $6,300 $9,800
Family Deductible  $12,600 $19,600 
Out of Pocket Limit-Individual  $6,800 (including deductible) $9,800 (including deductible) 
Out of Pocket Limit-Family  $13,600 (including deductible) $19,600 (including deductible) 
Co-Insurance  100% 100% 
Lifetime Maximum  None None 
Office Visits 
Primary Care  $75 deductible waived for 1st 3 visits 100% after deductible (up to OOP)
Specialist  $105 deductible waived for 1st 3 visits 100% after deductible (up to OOP)
Adult Preventive Care  No Charge Not Covered 
Child Preventive Care  No Charge Not Covered 
Maternity Prenatal/Postnatal Care  No Charge 100% after deductible (up to OOP)
Rehabilitation Services  $75 deductible waived 100% after deductible (up to OOP)
Chiropractic Care  Not Covered  Not Covered 
Inpatient Services 
Inpatient Hospital 100% after deductible (up to OOP)

100% after deductible (up to OOP);

$2,000 max benefit per day 

Maternity Delivery/Inpatient  100% after deductible (up to OOP)

100% after deductible (up to OOP);

$2,000 max benefit per day 

Outpatient Services 
Outpatient Facility  100% after deductible (up to OOP)

100% after deductible (up to OOP);

$300 max benefit per day 

Mental Health Outpatient  $75 deductible waived 1st 3 visits  100% after deductible (up to OOP)
Lab/X-Ray  $40 deductible waived/100% after deductible  100% after deductible (up to OOP)
Emergency Care 
Emergency Room  100% after deductible (up to OOP) 100% after deductible (up to OOP)
Urgent Care  $75 deductible waived 1st 3 visits  100% after deductible (up to OOP)
Ambulance  100% after deductible (up to OOP) 100% after deductible (up to OOP)
Prescription Drugs 
Rx Deductible  $500 individual/$1000 family  N/A 
Rx Generic 

100% after deductible (up to OOP);

$500 max/script 

Not covered 
Rx Preferred 

100% after deductible (up to OOP);

$500 max/script 

Not covered 
Rx Non-Preferred 

100% after deductible (up to OOP);

$500 max/script 

Not covered 
Recovery/ Special Needs 
Home Health Care 

100% after deductible (up to OOP);

100 visits per year 

Not covered 
Durable Medical Equipment  100% after deductible (up to OOP) 100% after deductible (up to OOP)
 
Optional Benefits  None  None 

Complete Benefit Summary


If you you have questions about the Blue Shield Bronze 60 PPO plan or any other plans from Blue Shield of California please call The Lynn Company at (800)-326-5966 for more information on California Health Insurance Plans
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