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Shield Savings 3500 (HSA Compatible)Blue Shield Logo

Blue Shield Shield Savings 3500 (HSA Compatible) Plan Information

The Shield Savings 3500 (HSA Compatible) plan from Blue Shield of California features the following:

Plan Type: HSA
Deductible: $3,500
In-Patient Hospital Co-Payment/Coinsurance: $0
Prescription Drug Coverage (Out Patient): Yes
Maternity Coverage Included: No


Demarketed

 

 

 

Shield Savings 3500 (HSA Compatible) Summary:

In Network Out of Network
Annual Deductible Individual: $3,500 Family: $7,000 Individual: $5,000 Family: $10,000
Annual Out-Of-Pocket Limit Individual: $5,000 Family: $10,000 Individual: $15,000 Family: $30,000
Lifetime Maximum $6,000,000 $6,000,000
Office Visits
No Charge after Deductible 50%
Prescription Drugs After deductible, Generic: $10 Brand Formulary: $35 Brand Non-Formulary $50 or 50%, whichever is greater (maximum of $150 per prescription) Not Covered
Laboratory and Radiology No Charge after Deductible 50%
Annual Physical Exam $25/$75 Co-Pay at HealthyCheck Centers for Basic/Premium Screening Not Covered
Annual OB-GYN Exam No Charge Not Covered
Well Baby Care No Charge Not Covered
Outpatient Surgery No Charge after Deductible 50% ($300 maximum benefit per day)
Emergency Room $100/visit (waived if admitted) $100/visit (waived if admitted)
Ambulance No Charge after Deductible No Charge after Deductible
Home Health Care No Charge after Deductible (90 visits per year) Not Covered
Mental Health Services - Outpatient No Charge after Deductible (20 visits per year) Not Covered
Chiropractic Care 30% (maximum benefit $25, 20 visits per year) Not Covered
Acupuncture / Acupressure 25% MyLifePath Discount Not Covered
Inpatient Hospital No Charge after Deductible 50% ($300 maximum benefit per day)
Maternity Care Not Covered Not Covered
Mental Health - Inpatient No Charge after Deductible 50% ($300 maximum benefit per day)
Chemical Dependency No Charge after Deductible 50% ($300 maximum benefit per day)

 

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification!

Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.

 

 
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Copyright © 2017 Dave Terpening Insurance Agency, Inc. |  CA Lic# 0G47857
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