California Health Insurance: Blue Shield Platinum 90 PPO

Blue Shield Platinum 90 PPO

In-Network

Out-Network
Cost Share Information 
Individual Deductible  $0 $0
Family Deductible  $0 $0
Out of Pocket Limit-Individual  $4,000 $7,000
Out of Pocket Limit-Family  $8,000 $14,000
Co-Insurance  10% 50% 
Lifetime Maximum  None None 
Office Visits 
Primary Care  $15 50%
Specialist  $40 50%
Adult Preventive Care  No Charge Not Covered 
Child Preventive Care  No Charge Not Covered 
Maternity Prenatal/Postnatal Care  No Charge 50%
Rehabilitation Services  $15 50%
Chiropractic Care  Not Covered  Not Covered 
Inpatient Services 
Inpatient Hospital 10% 50%; $2,000 max benefit per day 
Maternity Delivery/Inpatient  10% 50%; $2,000 max benefit per day 
Outpatient Services 
Outpatient Facility  10%   50%; $300 max benefit per day 
Mental Health Outpatient  $15 50%  
Lab/X-Ray  $20/$40 50%
Emergency Care 
Emergency Room  $150 (waived if admitted) $150 (waived if admitted)
Urgent Care  $15  50%
Ambulance  $150  $150
Prescription Drugs 
Rx Deductible  N/A N/A 
Rx Generic  $5 Not covered 
Rx Preferred  $15 Not covered 
Rx Non-Preferred  $25 Not covered 
Recovery/ Special Needs 

Home Health Care

10%; 100 visits per year

Not covered 

Durable Medical Equipment  10% 50%  
 
Optional Benefits  None  None 

Complete Benefit Summary


If you you have questions about the Blue Shield Platinum 90 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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