California Health Insurance: Blue Shield Gold 80 HMO

Blue Shield Gold 80 HMO

In-Network

Cost Share Information 
Individual Deductible  $0
Family Deductible  $0
Out of Pocket Limit-Individual  $6,750
Out of Pocket Limit-Family  $13,500
Co-Insurance  20%
Lifetime Maximum  None
Office Visits 
Primary Care  $30
Specialist  $55
Adult Preventive Care  No Charge
Child Preventive Care  No Charge
Maternity Prenatal/Postnatal Care  No Charge
Rehabilitation Services  $30
Chiropractic Care  Not Covered 
Inpatient Services 

Inpatient Hospital

$600 per day;

5 days/admit

Maternity Delivery/Inpatient 

$600 per day;

5 days/admit

Outpatient Services 
Outpatient Facility  $600  
Mental Health Outpatient  $30
Lab/X-Ray  $35/$55
Emergency Care 
Emergency Room  $325 (waived if admitted)
Urgent Care  $30  
Ambulance  $250 
Prescription Drugs 
Rx Deductible  N/A
Rx Generic  $15
Rx Preferred  $55
Rx Non-Preferred  $75
Recovery/ Special Needs 

Home Health Care

$30; 100 visits per year

Durable Medical Equipment  20%
 
Optional Benefits  None 

Complete Benefit Summary


If you you have questions about the Blue Shield Gold 80 HMO 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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Please note that we cannot bind insurance via email, fax, or voicemail. Any quotes given are subject to underwriting guidelines by the respective insurance carriers. Any reference of coverage used are not intended to express legal opinion as to the nature of coverage, but rather just a brief generalization of coverages. Please read your policy for coverage details.
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