Plan Information

Blue Shield Preferred Medical Plans

 Preferred Plan Name  
Medical Plan DesignPPO-812PPO-815PPO-829
In-Network
DeductibleN/AN/A$250/$500
CoinsuranceN/AN/A0.1
Out of Pocket Maximum$6,350/$12,700$6,350/$12,700$1,000/$2,000
Office Visit Copay1025$25/$40
Emergency Room Copay50100150
Urgent Care Copay102540
Inpatient Copay0$250 PADeductible & Coinsurance
Outpatient Copay0200Deductible & Coinsurance
Out-of-Network
Deductible$250/$500$500/$1,000$500/$1,000
Coinsurance0.20.30.3
Out of Pocket Maximum$2,500/$5,000$2,500/$5,000$2,500/$5,000

 

Preferred Pharmacy Plans (Currently with CVS/Caremark)

Benefit Option NameRetail Copay/Coinsurance per Prescription Fill
(30-Day Supply)
Mail Copay/Coinsurance per Prescription Fill
(90-Day Supply)
Tier 1Tier 2Tier 3Tier 1Tier 2Tier 3
Preferred Plan 10153003060
Preferred Plan 252540105080
Preferred Plan 30.20.20.20.20.20.2
Preferred Plan 41030502060100
Preferred Plan 51535603070120
Preferred Plan 60.30.30.30.30.30.3