Off exchange Blue Shield Silver 70 1850 PPO Details
Benefits in blue: Subject to a deductible
Benefits in black: Not subject to a deductible
The following benefits are for in-network services only. Before selecting a plan we recommend reviewing the plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) documents for specific costs and out-of-network benefits for PPO plans. There may be variations between plans that are not reflected here.
Standard Benefits for Individuals
Key benefits
Silver 70 1850 PPO
Individual Deductible
$1,850 (medical deductible)
$250 (pharmacy deductible)
$250 (pharmacy deductible)
Family Deductible
$3,700(medical deductible)
$500 (pharmacy deductible)
$500 (pharmacy deductible)
Preventative Care Copay
No cost
Primary Care Visit Copay
You pay $45
Specialty Care Visit Copay
You pay $75
Urgent Care Visit Copay
You pay $45
Lab Testing Copay
You pay 30% Co-Insurance after deductible
X-Ray Copay
You pay 30% Co-Insurance after deductible
Emergency Room Copay
You pay 30% Co-Insurance after deductible
Hospitalization (and high cost and infrequent services)
You pay 30% Co-Insurance after deductible
Tier 1 (most generics) Drug Copay
You pay $15 after drug deductible
Tier 2 (preferred brand) Drug Copay
You pay $55 after drug deductible
Tier 3 (non-preferred brand) Drug Copay
You pay $75 after drug deductible
Tier 4 (specialty drugs)
You pay 30% Co-insurance after drug deductible
(Maximun cost per prescription of $250 after drug deductible)
(Maximun cost per prescription of $250 after drug deductible)
Maximum Out-of-Pocket For One
$7,550
Maximum Out-of-Pocket For Family
$15,100