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Blue Shield of California – Shield Spectrum PPO 2000 – California

A comparison of the Shield Spectrum PPO 2000 offered by BSCA is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
Network See Provider See Provider
Application Shield Spectrum PPO 2000 Application Shield Spectrum PPO 2000 Application
Brochure Shield Spectrum PPO 2000 Brochure Shield Spectrum PPO 2000 Brochure
Copay $45 with Preferred Choice Providers Not applicable with Non-Preferred Providers.
Office Visit $45 with Preferred Choice Providers You pay
Deductible $2,000 Individual/$4,000 Family $2,000 Individual/$4,000 Family
Coinsurance 70% with Preferred Providers 50% with Non-Preferred Providers
Coinsurance Limit see brochure see brochure
Out-of-Pocket Maximum
  • Calendar-Year Copayment/Coinsurance Maximum (Includes the plan deductible. Some services do not apply):
    • Services with Preferred Providers: $5,000($10,000 Family)
    • Services with All Providers: $7,000($14,000 Family)
    		•
  • Calendar-Year Copayment/Coinsurance Maximum (Includes the plan deductible. Some services do not apply):
    • Services with Preferred Providers: $5,000($10,000 Family)
    • Services with All Providers: $7,000($14,000 Family)
    		•
    Lifetime Maximum $6,000,000 $6,000,000
    Prescription Drugs
  • Generic- $10/Rx
  • Brand-name drugs (formulary)- $35/Rx (after $500 brand-name deductible)
  • Brand-name drugs (non-formulary)- $50 or 50%, whichever is greater ($150 max)/Rx (after $500 brand-name deductible)
    		•
  • Generic- $10/Rx
  • Brand-name drugs (formulary)- $35/Rx (after $500 brand-name deductible)
  • Brand-name drugs (non-formulary)- $50 or 50%, whichever is greater ($150 max)/Rx (after $500 brand-name deductible)
    		•
    Emergency Room
  • You pay 30%
  • Outpatient Emergency room facility services
  • Inpatient physician visits
  • Inpatient semiprivate room and board, services and supplies, and subacute care
    		•
  • You pay 30%
  • Outpatient Emergency room facility services
  • Inpatient physician visits
  • Inpatient semiprivate room and board, services and supplies, and subacute care
    		•
    Adult Preventative Care
  • Annual Routine Physical Exam, Gynecological Exam, Well-baby care office visits: $45
  • Annual Pap test or other approved cervical cancer screening tests and routine mammography, immunizations, routine screenings(If part of Annual Exam or preventive care visit): No charge
    		•  See Adult Preventive Care
    Child Preventative Care See Adult Preventive Care See Adult Preventive Care
    Lab / X-Ray
  • Annual Pap test or other approved cervical cancer screening tests and routine mammography, immunizations, routine screenings(If part of Annual Exam or preventive care visit): No charge
  • Outpatient Radiological procedure requiring prior authorization(such as CT scans, MRI's and MRA's, Outpatient X-ray and lab): You pay 30%
    		•
  • Outpatient Radiological procedure requiring prior authorization(such as CT scans, MRI's and MRA's, Outpatient X-ray and lab): You pay 50%
    		•
    Maternity
  • Outpatient prenatal and postnatal care
  • Delivery and all necessary inpatient hospital services
  • you pay 30% with Preferred Providers
    		•
  • Outpatient prenatal and postnatal care
  • Delivery and all necessary inpatient hospital services
  • you pay 50% with Non-Preferred Providers
    		•
    Physical Therapy
  • Provided by MD or physical therapist
  • You pay 30% with Preferred Providers
    		•
  • Provided by MD or physical therapist
  • You pay 50% with Non-Preferred Providers
    		•
    Skilled Nursing
  • Semiprivate accomodations following transfer from hospital unless Blue Shield gives written authorization;upto 100 days per calendar year: You pay 30% in hospital SNF or freestanding SNF
    		•
  • Semiprivate accomodations following transfer from hospital unless Blue Shield gives written authorization;upto 100 days per calendar year: You pay 50% in hospital SNF or 50% in freestanding SNF
    		•
    Home Health Care
  • Up to 90 preauthorized visits per calendar year, including services received at home for physical medicine and speech therapy
  • You pay 30%
    		•
  • Up to 90 preauthorized visits per calendar year, including services received at home for physical medicine and speech therapy
  • You pay 50% (after Blue Shield approves providers)
    		•
    Mental Health
  • Inpatient Hospital Facility Services: You pay 30%
  • Inpatient Physician Services: You pay 30%
  • Outpatient visits for severe mental health conditions: You pay $45
  • Outpatient visits for non-severe mental health conditions (up to 20 visits per calendar year combined with chemical dependency visits): You pay 30%
    		•
  • Inpatient Hospital Facility Services: You pay 50%
  • Inpatient Physician Services: You pay 50%
  • Outpatient visits for severe mental health conditions: You pay 50%
  • Outpatient visits for non-severe mental health conditions: Not covered
    		•
    Hospital Care
  • Inpatient physician visits and consultations, surgeons and assistants, anesthesiologists,pathologists, radiologists
  • Inpatient semiprivate room and board, services
  • You pay 30% for Preferred Providers
    		•
  • Inpatient physician visits and consultations, surgeons and assistants, anesthesiologists,pathologists, radiologists
  • Inpatient semiprivate room and board, services and supplies, and subacute care
  • You pay 50% for Non-Preferred Providers
    		•
    Optional Benefits see brochure see brochure
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