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Blueshield California – Health Plans

BlueCross BlueShield California is the largest health insurance company in the state with over 5 million members in almost all California counties. They offer health plans that can be customized for individuals, children, and families that include consumer-directed plans, Health Savings Accounts, and Medicare Supplements.

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 California Blue 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

Our Rating:

See All Gold 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

Dental Plans Brochure

Application

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

Phone: (312) 726-6565
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