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Basic plan (Bronze)

Basic plan (Bronze)

Blue Shield pays, on average, 60% of covered medical expenses

With low monthly rates in exchange for a higher deductible and more out-of-pocket costs when accessing services, the Basic plan is a good choice if you want to know you’ve got the coverage you need when you need it most. Most services are subject to the medical deductible, but you’ll still receive important benefits like preventive care and three doctor visits for a fixed copayment before meeting the deductible.

This plan is available for purchase directly through Blue Shield or through Covered California.

Basic plan (Bronze) – Benefit Overview

Benefit Participating providers1 (PPO and EPO): Non-participating providers1 (PPO only):
Office visit - primary care doctor $60 for first 3 visits per calendar year prior to deductible, then $60 after deductible2 50%
Office visit - specialist doctor $70 50%
Urgent care visit $120 for first 3 visits per calendar year prior to deductible, then $120 after deductible2 50%
Preventive health benefits $02 Not covered
Inpatient hospitalization 30% 50%
Outpatient surgery 30% 50%
Lab 30% 50%
X-ray 30% 50%
Emergency room services not resulting in admission $300 $300
Maternity 30% 50%
Generic drugs $194 Not covered
Preferred brand drugs $504 Not covered
Non-preferred brand drugs $754 Not covered
Chiropractic Not covered Not covered
Acupuncture
(from a licensed acupuncturist)
$60 $60
Pediatric eye exam $02 Up to $302
Pediatric eyeglasses $02 $55 single vision2
Calendar-year medical deductible3 $5,000 per individual / $10,000 per family $5,000 per individual / $10,000 per family
Calendar-year out-of-pocket maximum
(includes deductible)
$6,350 per individual / $12,700 per family $9,350 per individual / $18,700 per family
Calendar-year brand drug deductible $04 Not covered

Get complete health plan details

For complete plan details on our Basic PPO and Basic EPO plans, see the Benefit Summaries and Legal Disclosures below:

Benefit Summary for Basic PPO (PDF, 485KB)
Benefit Summary for Basic EPO (PDF, 475KB)

Legal Disclosure (PDF, 916KB)

We also have Summary of Benefits and Coverage Forms that can help you make a decision by providing you with an easy to understand overview of what these plans cover. Visit blueshieldca.com/sbc to obtain the forms.

Pediatric dental

Pediatric dental is an essential health benefit for children under age 19, and must be purchased when applying for a medical plan directly through Blue Shield. We offer four pediatric dental plans to choose from. Download our pediatric dental plans flier for more information.

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