California Health Insurance: Blue Shield Silver 1850 PPO

Blue Shield Silver 1850 PPO

In-Network

Out-Network
Cost Share Information 
Individual Deductible  $1,850 $3,700
Family Deductible  $3,700 $7,400
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  30% 50% 
Lifetime Maximum  None None 
Office Visits 
Primary Care  $45 deductible waived 50% after deductible
Specialist  $70 deductible waived 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  30% after deductible 50% after deductible  
Chiropractic Care  Not Covered  Not Covered 
Inpatient Services 
Inpatient Hospital 30% after deductible  50% after deductible; $2,000 max benefit per day 
Maternity Delivery/Inpatient  30% after deductible  50% after deductible; $2,000 max benefit per day 
Outpatient Services 
Outpatient Facility  30% after deductible  50% after deductible; $300 max benefit per day 
Mental Health Outpatient  $45 deductible waived 50% after deductible 
Lab/X-Ray  30% after deductible  50% after deductible 
Emergency Care 
Emergency Room  30% after deductible  30% after deductible 
Urgent Care  $90 deductible waived   50% after deductible 
Ambulance  30% after deductible  30% after deductible 
Prescription Drugs 
Rx Deductible  $250 individual/ $500 family  N/A 
Rx Generic  $15 deductible waived Not covered 
Rx Preferred  $50 after deductible  Not covered 
Rx Non-Preferred  $70 after deductible  Not covered 
Recovery/ Special Needs 

Home Health Care 

$45 deductible waived;

100 visits per year 

Not covered 

Durable Medical Equipment  30% after deductible  50% after deductible 
 
Optional Benefits  None  None 

Complete Benefit Summary


If you you have questions about the Blue Shield Silver 1850 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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