Blue Shield

Silver 70 PPO

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $5,400 Family: $10800 Per Person: $5400
Prescription Drug Deductible	Individual: $50 Family: $100 Per Person: $50
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17400 Per Person: $8700

Office Visit

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialist	CoPay: $90.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $60.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Non Preferred Brand Drugs	CoPay: $90.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Generic Drugs	CoPay: $18.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Covered: Covered Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder professional fee.

Emergency and Urgent Care

Emergency Room	CoPay: $400.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Urgent Care Facility	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Vision

Routine Eye Exams for Children

CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered Benefit Explanation: Please see plans Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Routine Dental Checkups for Adults	Covered: Not Covered