Blue Shield of California Essential PPO Plans

There are three different Blue Shield of California individual health plans in the Essential category. These are among the lowest cost plans offered by Blue Shield and combine coverage for medical expenses, dental and vision coverage all in the same plan. With all three Essential PPO Plans, the annual copayment maximum equals the deductible, which means that most covered medical expenses are provided at no charge after you meet the deductible. There are three deductible options with the Essential PPO Plans, $1,750, $3,000 and $4,500. Maternity benefits are not provided under these PPO plans, but Blue Shield of California will allow a free transfer to the Shield Spectrum $5,000 plan if you become pregnant while insured under an Essential PPO Plan. All plans in this category have a $6 million lifetime maximum benefit. All Blue Shield of California members enrolled in an Essential PPO Plan are eligible to receive discounts on Lasik eye surgery as part of the vision benefits.

Blue Shield of California Essential Plan 1750

Of the three Essential PPO plans, the Plan 1750 has the lowest deductible of $1,750 and a coinsurance maximum of the same amount when using Blue Shield preferred providers. When using non-preferred providers, the coinsurance is 50% plus any excess charges over the allowable amount. Some medical services are covered without having to meet the plan deductible. These include three office visits annually, routine physical exams, well-baby care and an annual OB/GYN exam. The copayment for these services is $40 but do not count toward the coinsurance maximum. After the $1,750 annual deductible has been met, you are covered in full for hospital and outpatient surgery services when accessing care through a preferred provider. For non-emergency out-patient surgery with a non-preferred provider, benefits are limited to $300 per procedure, of which the member will pay 50%, plus 100% of excess charges. Only generic drugs are covered under this plan at a $10 copay at participating pharmacies. Emergency room visits are $100 without having to meet the deductible. Vision exams are $5 and preventive dental procedures are provided free of charge.

Blue Shield of California Essential Plan 3000

This is the mid-range Essential PPO plan with an annual deductible and coinsurance maximum of $3,000. The first three office visits per year, per member, are not subject to the deductible and require a copayment of $40. Extra office visits are covered in full after the plan deductible has been met. The coinsurance maximum with all providers, included non-preferred, is $5,000. Prescription drugs and emergency room visits are covered at the same level and copayment amount at the Essential Plan 1750. Maternity benefits are not included in this plan, including outpatient prenatal and postnatal care. Chiropractic services are also excluded from the list of covered benefits. Dental services are limited to $500 per year and only provide benefits for preventive, diagnostic and minor restorative procedures. For most other covered medical expenses, there is no charge for the remainder of the calendar year after the $3,000 plan deductible has been met. Limitations and maximum daily benefits apply to services provided through non-preferred providers.

Blue Shield of California Essential Plan 4500

This is the least expensive of the three Essential PPO Plans offered through Blue Shield of California. The annual deductible and coinsurance maximum are $4,500, but increased to $6,500 if medical treatments are received from non-preferred providers. Office visits are provided at a $40 copayment, but limited to three per year until the deductible has been met. Bariatric surgery is covered under the Essential Plan 4500 if pre-authorization is received and the procedure is deemed medically necessary for weight loss or mobid obesity. Brand name drugs are not available through this plan. Generic drugs are $10 if prescriptions are filled at a participating pharmacy. As with all Essential PPO plans, there is a lifetime maximum benefit of $6 million. Mental health benefits are provided with MHSA participating providers and out-patient visits for non-severe mental conditions are limited to 20 per year.

The information provided on this page is subject to change and my not be current. Check with the insurance company or your insurance agent for verification of details. The information provided is for comparison purposes only and is not legally binding. Always review the plan brochure or your policy details for complete and accurate details about this policy.