California Health Insurance: Blue Shield Minimum Coverage PPO

Blue Shield Minumum Coverage PPO

In-Network

Out-Network
Cost Share Information 
Individual Deductible  $7,150 $10,150
Family Deductible  $14,300 $20,300 
Out of Pocket Limit-Individual  $7,150 (including deductible) $10,150 (including deductible) 
Out of Pocket Limit-Family  $14,300 (including deductible) $20,300 (including deductible) 
Co-Insurance  0% 50% 
Lifetime Maximum  None None 
Office Visits 

Primary Care 

No charge visits 1-3;

0% after deductible visits 4+

50% after deductible

Specialist  0% after deductible 50% after deductible
Adult Preventive Care  No Charge Not Covered 
Child Preventive Care  No Charge Not Covered 
Maternity Prenatal/Postnatal Care  No Charge 50% after deductible 
Rehabilitation Services  0% after deductible 50% after deductible  
Chiropractic Care  Not Covered  Not Covered 
Inpatient Services 
Inpatient Hospital 0% after deductible  50% after deductible; $2,000 max benefit per day 
Maternity Delivery/Inpatient  0% after deductible  50% after deductible; $2,000 max benefit per day 
Outpatient Services 
Outpatient Facility  0% after deductible  50% after deductible; $300 max benefit per day 

Mental Health Outpatient 

No charge visits 1-3;

0% after deductible visits 4+

50% after deductible 

Lab/X-Ray  0% after deductible  50% after deductible 
Emergency Care 
Emergency Room  0% after deductible  0% after deductible 

Urgent Care 

No charge visits 1-3;

0% after deductible visits 4+ 

50% after deductible 

Ambulance  0% after deductible  0% after deductible 
Prescription Drugs 
Rx Deductible  Integrated Medical/Rx  N/A 
Rx Generic  0% after deductible Not covered 
Rx Preferred  0% after deductible Not covered 
Rx Non-Preferred  0% after deductible  Not covered 
Recovery/ Special Needs 

Home Health Care 

0% after deductible;

100 visits per year 

Not covered 

Durable Medical Equipment  0% after deductible  50% after deductible 
 
Optional Benefits  None  None 

Complete Benefit Summary


If you you have questions about the Blue Shield Minimum Coverage 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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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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