Medical

• Blue Shield Platinum Access HMO 0/25

  HMO

  Deductible (ind / fam)

  $0 / $0

  Out-of-pocket max

  $2,350 / $4,700

  PCP / specialist

  $25 / $55

  Rx tiers 1 / 2 / 3

  $5 / $25 / $30

• Blue Shield Platinum Full PPO 0/10

  PPO

  Deductible (ind / fam)

  $0 / $0

  Out-of-pocket max

  $4,700 / $9,400

  PCP / specialist

  $10 / $35

  Rx tiers 1 / 2 / 3

  $30 / $105 / $165

• Blue Shield Platinum Tandem PPO 0/10

  PPO

  Deductible (ind / fam)

  $0 / $0

  Out-of-pocket max

  $4,700 / $9,400

  PCP / specialist

  $10 / $35

  Rx tiers 1 / 2 / 3

  $10 / $35 / $55

• Blue Shield Platinum Trio HMO 0/25

  HMO

  Deductible (ind / fam)

  $0 / $0

  Out-of-pocket max

  $2,350 / $4,700

  PCP / specialist

  $25 / $55

  Rx tiers 1 / 2 / 3

  $5 / $25 / $30

• Blue Shield Gold Access HMO 0/35

  HMO

  Deductible (ind / fam)

  $0 / $0

  Out-of-pocket max

  $7,500 / $15,000

  PCP / specialist

  $35 / $70

  Rx tiers 1 / 2 / 3

  $20 / $50 / $70

• Blue Shield Gold Access HMO 500/35

  HMO

  Deductible (ind / fam)

  $500 / $1,000

  Out-of-pocket max

  $7,500 / $15,000

  PCP / specialist

  $35 / $60

  Rx tiers 1 / 2 / 3

  $15 / $50 / $70

• Blue Shield Gold Full PPO 0/35

  PPO

  Deductible (ind / fam)

  $0 / $0

  Out-of-pocket max

  $7,900 / $15,800

  PCP / specialist

  $35 / $60

  Rx tiers 1 / 2 / 3

  $75 / $150 / $210

• Blue Shield Gold Full PPO 1000/30

  PPO

  Deductible (ind / fam)

  $1,000 / $2,000

  Out-of-pocket max

  $7,900 / $15,800

  PCP / specialist

  $30 / $50

  Rx tiers 1 / 2 / 3

  $45 / $150 / $240

• Blue Shield Gold Full PPO 500/30

  PPO

  Deductible (ind / fam)

  $500 / $1,000

  Out-of-pocket max

  $7,900 / $15,800

  PCP / specialist

  $30 / $60

  Rx tiers 1 / 2 / 3

  $45 / $150 / $240

• Blue Shield Gold Tandem PPO 0/35

  PPO

  Deductible (ind / fam)

  $0 / $0

  Out-of-pocket max

  $7,900 / $15,800

  PCP / specialist

  $35 / $60

  Rx tiers 1 / 2 / 3

  $75 / $150 / $210

• Blue Shield Gold Tandem PPO 1000/30

  PPO

  Deductible (ind / fam)

  $1,000 / $2,000

  Out-of-pocket max

  $7,900 / $15,800

  PCP / specialist

  $30 / $50

  Rx tiers 1 / 2 / 3

  $15 / $50 / $80

• Blue Shield Gold Tandem PPO 500/30

  PPO

  Deductible (ind / fam)

  $500 / $1,000

  Out-of-pocket max

  $7,900 / $15,800

  PCP / specialist

  $30 / $60

  Rx tiers 1 / 2 / 3

  $15 / $50 / $80

• Blue Shield Gold Trio HMO 0/35

  HMO

  Deductible (ind / fam)

  $0 / $0

  Out-of-pocket max

  $7,500 / $15,000

  PCP / specialist

  $35 / $70

  Rx tiers 1 / 2 / 3

  $20 / $50 / $70

• Blue Shield Gold Trio HMO 500/35

  HMO

  Deductible (ind / fam)

  $500 / $1,000

  Out-of-pocket max

  $7,500 / $15,000

  PCP / specialist

  $35 / $60

  Rx tiers 1 / 2 / 3

  $15 / $50 / $70

• Blue Shield Silver Full PPO 2350/70

  PPO

  Deductible (ind / fam)

  $2,350 / $4,700

  Out-of-pocket max

  $8,750 / $17,500

  PCP / specialist

  $70 / $85

  Rx tiers 1 / 2 / 3

  $50 / $150 / $230

• Blue Shield Silver Tandem PPO 2350/70

  PPO

  Deductible (ind / fam)

  $2,350 / $4,700

  Out-of-pocket max

  $8,750 / $17,500

  PCP / specialist

  $70 / $85

  Rx tiers 1 / 2 / 3

  $50 / $150 / $230

• Blue Shield Bronze Full PPO 5700/40

  PPO

  Deductible (ind / fam)

  $5,700 / $11,400

  Out-of-pocket max

  $7,500 / $15,000

  PCP / specialist

  40% after deductible

  Rx tiers 1 / 2 / 3

  40% coinsurance, up to $1,500 per prescription

• Blue Shield Bronze Tandem PPO 5700/40

  PPO

  Deductible (ind / fam)

  $5,700 / $11,400

  Out-of-pocket max

  $7,500 / $15,000

  PCP / specialist

  40% after deductible

  Rx tiers 1 / 2 / 3

  40% coinsurance, up to $500 per prescription

See the complete plan description or Summary of Benefits and Coverage (SBC) for full details.