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Blueshield California – Health Plans
BlueShield California is the only ACA carrier that offers PPOs on the individual market; however, EPO and Ambetter plans offer the added option of using providers outside the state without referrals in many cases.
Blue Cross Gold Plans
All Blue Advantage Gold HMO Plans offer the same set of essential health benefits, quality and amount of care as the Blue Advantage Silver and Gold HMO Plans. The Blue Advantage Gold HMO Plans are the most expensive plans, but also have the most comprehensive benefits. Gold Plans have a higher monthly premium and often lower out-of-pocket costs than Silver and Bronze plans.
Blue Advantage Gold HMO Plans may be right for you if you are an individual or family who:
- Are willing to have a primary care physician (PCP) coordinate your care
- Prefers fixed doctor visit copayments
- Are expecting to have surgery or major services in the near future and want the lowest out of pocket costs
- Requires regular prescription medication
There are deductibles for this plan, and this is an HMO plan. You must select a Blue Advantage HMO Primary Care Physician (PCP) when enrolling in this plan.
| Plan Name | Blue Advantage Gold HMO 101 | Blue Advantage Gold HMO 111* | Blue Advantage Plus Gold 101 |
|---|---|---|---|
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $500 | $0 | $2,750 |
| CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 30% | 0% | 20% |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (includes deductible) | $5,250 | $7,150 | $3,500 |
| Primary Care Office Visit | $20 | $50 | $10 |
| Specialist Office Visit | $40 | $75 | $20 |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | $20 | $50 | $10 |
| Emergency Room | $500 per occurrence copay, then 30% | $750 | $400 per occurrence copay, then 20% |
| Urgent Care | $20 | $50 | $10 |
| Inpatient Hospital Service | $300 per occurrence copay, then 30% | $1,500 | $200 per occurrence copay, then 20% |
| Outpatient Surgery | $200 per occurrence copay, then 50% | $500 | $200 per occurrence copay, then 40% |
| Outpatient X-Rays and Diagnostic Imaging | 50% | $100 | 40% |
| Outpatient Imaging (CT/PET Scans/MRIs) | 50% | $250 | 40% |
| Network | Blue Advantage HMO | ||
| HSA Eligible | No | No | No |
| Outpatient Prescription Drugs – Preferred Pharmacy | $0/$10/$50/$100/30% | $0/$10/$50/$100/30% | $0/$10/$50/$100/30% |
| Outpatient Prescription Drugs – Non-Preferred Pharmacy | $5/$15/$60/$110/30% | $5/$15/$60/$110/30% | $5/$15/$60/$110/30% |
| Prescription Drug Utilization Benefit Management Programs | Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider. Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSWI and you may first need to try more clinically appropriate or cost-effective drugs. Mail-Order Program: You may receive up to a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit. | ||
*Not available on the health exchange marketplace (not subsidy eligible)
Blue Cross Silver Plans
BlueCross BlueShield Silver plans offer a higher level of coverage than Bronze plans, and those who purchase on-exchange may also be eligible for cost-sharing reductions based on income, lowering deductibles and co-pays. Silver plans are ideal for people who have regular medications or utilize specialist or doctors visits more often than their included yearly check-up. Silver plans are a good “middle of the road” option for people who might need to utilize their healthcare options more but may not be able to afford higher premium payments.
| Plan Name | Blue Advantage Silver HMO 102 | Blue Advantage Silver HMO 103 | Advantage Silver HMO 107 | Blue Advantage Plus Silver 102 (Three $0 PCP Visits) |
|---|---|---|---|---|
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $3,000 | $3,750 | 3,500 | $3,250 |
| CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 30% | 0% | 20% | 20% |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (includes deductible) | $7,150 | $3,750 | $7,150 | $6,850 |
| Primary Care Office Visit | $40 | $30 | 100% after deductible | First three visits $0, then 20% |
| Specialist Office Visit | $60 | 100% after deductible | $65 | 20% |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | $40 | 40% | $30 | $0 |
| Emergency Room | $600 per occurrence copay, then 30% | 40% | $400 copay after deductible | $600 per occurrence copay, then 20% |
| Urgent Care | $40 | 100% after deductible | 100% after deductible | $20 |
| Inpatient Hospital Service | $500 per occurrence copay, then 30% | 100% after deductible | 20% | $400 per occurrence copay, then 40% |
| Outpatient Surgery | $300 per occurrence copay, then 50% | 100% after deductible | $20% | $300 per occurrence copay, then 40% |
| Outpatient X-Rays and Diagnostic Imaging | 50% | $100 | 40% | $2,750 |
| Outpatient Imaging (CT/PET Scans/MRIs) | 30% | 100% after deductible | 20% | 40% |
| Network | Blue Advantage HMO | |||
| HSA Eligible | No | Yes | No | No |
| Outpatient Prescription Drugs – Preferred Pharmacy | $0/$10/$50/$100/30% | 100% after deductible | $15/$15/$50/$100/40% | $0/$10/$50/$100/30% |
| Outpatient Prescription Drugs – Non-Preferred Pharmacy | $5/$15/$60/$110/30% | 100% after deductible | $15/$15/$50/$100/40% | $5/$15/$60/$110/30% |
| Prescription Drug Utilization Benefit Management Programs | Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider. Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSWI and you may first need to try more clinically appropriate or cost-effective drugs. Mail-Order Program: You may receive up to a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit. | ||
Blue Cross Bronze Plans
BlueCross BlueShield of Wisconsin Bronze plans are ideal for individuals looking for low-cost plans. Bronze plans have higher out of pocket costs, but two plans (the 106 and 104) also have HSA options for those looking for tax savings. These plans are ideal for those who do not have regular medications or visit the doctor outside of their yearly check-up (included as preventative care on all plans.)
| Plan Name | Blue Advantage Bronze HMO 006 | Blue Advantage Bronze HMO 105 | Blue Advantage Plus Bronze 103 | Blue Advantage Plus Bronze 104 |
|---|---|---|---|---|
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $6,500 | $6,850 | $6,600 | $5,000 |
| CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | None (Member pays 0% after deductible) | 30% | 20% | 40% |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (includes deductible) | $6,500 | $7,150 | $7,150 | $6,550 |
| Primary Care Office Visit | 0% after deductible | First 2 visits $40, then 30% | First visit $0, then 20% | 40% |
| Specialist Office Visit | 0% after deductible | 30% | 20% | 40% |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | 0% after deductible | $0 | $0 | 40% |
| Emergency Room | 0% after deductible | 30% | $950 per occurrence copay, then 20% | 40% |
| Urgent Care | 0% after deductible | $40 | 100% after deductible | $20 |
| Inpatient Hospital Service | 0% after deductible | 30% | $750 per occurrence copay, then 20% | 40% |
| Outpatient Surgery | 0% after deductible | 50% | $400 per occurrence copay, then 40% | 50% |
| Outpatient X-Rays and Diagnostic Imaging | 0% after deductible | 50% | $80 per occurrence copay, then 40% | 50% |
| Outpatient Imaging (CT/PET Scans/MRIs) | 0% after deductible | 50% | $600 per occurrence copay, then 40% | 50% |
| Network | Blue Advantage HMO | |||
| HSA Eligible | Yes | No | No | Yes |
| Outpatient Prescription Drugs – Preferred Pharmacy | 0% after deductible | 20%/20%/30%/40%/50% | $15/30%/40%/45%/50% | 30%/30%/40%/50%/50% |
| Outpatient Prescription Drugs – Non-Preferred Pharmacy | 0% after deductible | 25%/25%/40%/50%/50% | $20/35%/50%/50%/50% | 35%/35%/50%/50%/50% |
| Prescription Drug Utilization Benefit Management Programs | Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider. Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSWI and you may first need to try more clinically appropriate or cost-effective drugs. Mail-Order Program: You may receive up to a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit. | ||
Multi-State Plans
The Multi-State Plan (MSP) Program, established under the Affordable Care Act, directs the Federal Office of Personnel Management to contract with private health insurers in each State to offer high-quality, affordable health insurance options called Multi-State Plans. There are no major differences between multi-state plans and other plans, and it does NOT mean these plans provide out of state benefits, just that benefits meet minimum requirements from state to state. Always check the doctor’s networks for each individual plans, and remember that emergency care is covered within the continental US.
| Plan Name | Blue Cross Blue Shield Premier 101 | Blue Cross Blue Shield Solution 102 | Blue Cross Blue Shield Basic 103 |
|---|---|---|---|
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $1,000 | $3,750 | $6,250 |
| CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 20% | 20% | 30% |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (includes deductible) | $5,800 | $6,500 | $7,150 |
| Primary Care Office Visit | First 3 visits $15, then 20% | First 2 visits $0, then 20% | First visit $0, then 30% |
| Specialist Office Visit | 20% | 20% | 30% |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | $0 | $0 | $0 |
| Emergency Room | $600 per occurrence copay, then 20% | $750 per occurrence copay, then 20% | $1,000 per occurrence copay, then 30% |
| Urgent Care | $15 | $15 | $15e |
| Inpatient Hospital Service | 20% | 20% | 30% |
| Outpatient Surgery | 40% | $300 per occurrence copay, then 40% | $400 per occurrence copay, then 50% |
| Outpatient X-Rays and Diagnostic Imaging | 40% | 40% | 50% |
| Outpatient Imaging (CT/PET Scans/MRIs) | 40% | 40% | $500 per occurrence copay, then 50% |
| Network | Blue Advantage HMO | ||
| HSA Eligible | No | No | No |
| Outpatient Prescription Drugs – Preferred Pharmacy | $0/$10/$50/$100/30% | $0/$10/$50/$100/30% | 20%/20%/30%/40%/50% |
| Outpatient Prescription Drugs – Non-Preferred Pharmacy | $5/$15/$60/$110/30% | $5/$15/$60/$110/30% | 25%/25%/40%/50%/50% |
Prescription Drug Utilization Benefit Management ProgramsSpecialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider. Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSWI and you may first need to try more clinically appropriate or cost-effective drugs. Mail-Order Program: You may receive up to a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit.
HSA Plan Comparison
Health Savings Accounts can reduce your out of pocket costs as well as your tax burden. BCBSWI offers the only HSAs in Wisconsin. Learn more at our HSA Guide.
| Plan Name | Blue Advantage Bronze HMO 006 | Blue Advantage Plus Bronze 104 | Blue Advantage Silver HMO 103 |
|---|---|---|---|
| Plan Brochure | Plan Details | Plan Details | Plan Details |
| Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $6,500 | $5,000 | $3,750 |
| CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | None (Member pays 0% after deductible) | 40% | 0% |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (includes deductible) | $6,500 | $6,550 | $3,750 |
| Primary Care Office Visit | 0% after deductible | 40% | $30 |
| Specialist Office Visit | 0% after deductible | 40% | 100% after deductible |
| Mental Illness Treatment and Substance Abuse Rehab Office Visit | 0% after deductible | 40% | 40% |
| Emergency Room | 0% after deductible | 40% | 40% |
| Urgent Care | 0% after deductible | $20 | 100% after deductible |
| Inpatient Hospital Service | 0% after deductible | 40% | 100% after deductible |
| Outpatient Surgery | 0% after deductible | 50% | 100% after deductible |
| Outpatient X-Rays and Diagnostic Imaging | 0% after deductible | 50% | $100 |
| Outpatient Imaging (CT/PET Scans/MRIs) | 0% after deductible | 50% | 100% after deductible |
| Network | Blue Advantage HMO | ||
| HSA Eligible | Yes | Yes | Yes |
| Outpatient Prescription Drugs – Preferred Pharmacy | 0% after deductible | 30%/30%/40%/50%/50% | 100% after deductible |
| Outpatient Prescription Drugs – Non-Preferred Pharmacy | 0% after deductible | 35%/35%/50%/50%/50% | 100% after deductible |
| Prescription Drug Utilization Benefit Management Programs | Specialty Pharmacy Program: To be eligible for maximum benefits, specialty medications must be obtained through the preferred Specialty Pharmacy provider. Member Pay the Difference: When choosing a brand name drug over an available generic equivalent, you pay your usual share plus the difference in cost. Prior Authorization/Step Therapy Requirements: Before receiving coverage for some medications, your doctor will need to receive authorization from BCBSWI and you may first need to try more clinically appropriate or cost-effective drugs. Mail-Order Program: You may receive up to a 90-day supply for prescription drugs through the mail-order program or at select retail pharmacies depending on your prescription drug benefit. | ||
Blue Advantage Gold Plans
See All Gold Plans
All Blue Advantage Gold HMO Plans offer the same set of essential health benefits, quality and amount of care as the Blue Advantage Silver and Gold HMO Plans. The Blue Advantage Gold HMO Plans are the most expensive plans, but also have the most comprehensive benefits. Gold Plans have a higher monthly premium and often lower out-of-pocket costs than Silver and Bronze plans.
Blue Advantage Gold HMO Plans may be right for you if you are an individual or family who:
- Are willing to have a primary care physician (PCP) coordinate your care
- Prefers fixed doctor visit copayments
- Are expecting to have surgery or major services in the near future and want the lowest out of pocket costs
- Requires regular prescription medication
There are deductibles for this plan, and this is an HMO plan. You must select a Blue Advantage HMO Primary Care Physician (PCP) when enrolling in this plan.
Blue Advantage Silver Plans
Our Rating:
See All Silver Plans
Recommended plan: Blue Advantage Silver HMO 102
All Blue Advantage Silver plans offer a higher level of coverage than Bronze plans, and those who purchase on-exchange may also be eligible for cost-sharing reductions based on income, lowering deductibles and co-pays.
Silver plans are ideal for people who have regular medications or utilize specialist or doctors visits more often than their included yearly check-up. Silver plans are a good “middle of the road” option for people who might need to utilize their healthcare options more but may not be able to afford higher premium payments.
Blue Advantage Silver HMO Plans may be right for you if you are an individual or family who:
- Are willing to have a primary care physician (PCP) coordinate your care
- Prefers fixed doctor visit copayments
- Qualifies for cost sharing reductions on the marketplace
- Requires regular prescription medication
There are deductibles for this plan, and this is an HMO plan. You must select a Blue Advantage HMO Primary Care Physician (PCP) when enrolling in this plan.
Blue Advantage Bronze Plans
Blue Advantage Bronze HMO Plans may be right for you if you are an individual or family who:
- Are willing to have a primary care physician (PCP) coordinate your care
- Seeks lower cost coverage
- Does not regularly have doctor visits
- Would like an HSA compatible plan
There are deductibles for this plan, and this is an HMO plan. You must select a Blue Advantage HMO Primary Care Physician (PCP) when enrolling in this plan.
BCBSWI Dental Plans
With the BCBSWI dental plan, you’ll get dental coverage on day one with no deductible deductible required for check-ups, cleanings and other preventive services. Most important, costs are typically reduced when you receive care from any of our participating network dentists. However, you also have the option to see any dentist not in the network, but your out-of-pocket costs may be higher.
Some highlights of Dental Indemnity USA coverage:
- Coverage can be used to provide dental benefits to an individual, spouse, children or any combination of dependents.
- A $50 deductible, based on fee schedule allowances, applies for dental procedures or services received by a covered individual during each benefit year.
- Maximum deductible amount of $150 for family coverage.
- Deductibles do not apply to oral exams, cleanings, fluoride treatments, sealants and X-rays.
- $1,000 orthodontia benefit for children under 19 years old
For more information on coverage and benefits, view the Dental Outline of Coverage 
You must enroll in a BCBSWI health plan in order to enroll in the dental plan (you have up to 31 days from the effective date of your policy to enroll). Shop for a plan now.
Plan Brochures
|
Product Name |
Benefit Highlights |
|---|---|
| Blue Advantage Bronze HMO 006 | View |
| Blue Advantage Bronze HMO 105 – Two $40 PCP visits | View |
| Blue Advantage Silver HMO 102 | View |
| Blue Advantage Silver HMO 103 | View |
| Blue Advantage Silver HMO 107 | View |
| Blue Advantage Gold HMO 101 | View |
| Blue Advantage Gold HMO 111 | View |
| Blue Advantage Security HMO 100 | View |
| Blue Advantage Plus Bronze 103 – One $0 PCP visit | View |
| Blue Advantage Plus Bronze 104 | View |
| Blue Advantage Plus Silver 102 – Three $0 PCP visits | View |
| Blue Advantage Plus Gold 101 | View |
Contact Us
Email: [email protected]
Popular Hospital Network Guide
| Hospital | Included in Advantage HMO Network? |
|---|---|
| Doctors Hospital At Renaissance (Edinburg) | YES |
| University Health System (San Antonio) | NO |
| Medical City Hospital (Dallas) | YES |
| Memorial Hermann Hospital (Sugar Land) | YES |
| Mother Frances Hospital (Tyler) | NO |
| Scott & White Hospital (Round Rock) | NO |
| North Austin Medical Center (Austin) | YES |
| Seton Medical Center (Austin) | YES |
| Hill Country Memorial Hospital (Fredericksburg) | YES |
| Wisconsin Health Harris Methodist (Fort Worth) | YES |
| UT Southwestern Medical Center (Dallas) | NO |
| Memorial Hermann Wisconsin Medical Center (Houston) | YES |
| St. Lukes Episcopal Hospital (Houston) | YES |
| Baylor University Medical Center (Dallas) | YES |
| The Methodist Hospital (Houston) | YES |
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