California Health Insurance: Blue Shield Gold 80 PPO

Blue Shield Gold 80 PPO

In-Network

Out-Network
Cost Share Information 
Individual Deductible  $0 $0
Family Deductible  $0 $0
Out of Pocket Limit-Individual  $6,750 $9,750
Out of Pocket Limit-Family  $13,500 $19,500
Co-Insurance  20% 50% 
Lifetime Maximum  None None 
Office Visits 
Primary Care  $30 50%
Specialist  $55 50%
Adult Preventive Care  No Charge Not Covered 
Child Preventive Care  No Charge Not Covered 
Maternity Prenatal/Postnatal Care  No Charge 50%
Rehabilitation Services  $30 50%
Chiropractic Care  Not Covered  Not Covered 
Inpatient Services 
Inpatient Hospital 20% 50%; $2,000 max benefit per day 
Maternity Delivery/Inpatient  20% 50%; $2,000 max benefit per day 
Outpatient Services 
Outpatient Facility  20%   50%; $300 max benefit per day 
Mental Health Outpatient  $30 50%  
Lab/X-Ray  $35/$55 50%
Emergency Care 
Emergency Room  $325 (waived if admitted) $325 (waived if admitted)
Urgent Care  $30   50%
Ambulance  $250  $250
Prescription Drugs 
Rx Deductible  N/A N/A 
Rx Generic  $15 Not covered 
Rx Preferred  $55 Not covered 
Rx Non-Preferred  $75 Not covered 
Recovery/ Special Needs 

Home Health Care

20%; 100 visits per year

Not covered 

Durable Medical Equipment  20% 50% after deductible 
 
Optional Benefits  None  None 

Complete Benefit Summary


If you you have questions about the Blue Shield Gold 80 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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