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Ultimate plan (Platinum)

Ultimate plan (Platinum)

Blue Shield pays, on average, 90% of covered medical expenses

Our Ultimate plan offers you the lowest out-of-pocket costs for medical services. There are no deductibles, so we start paying for covered benefits right from the start. By paying a higher monthly premium, you’ll pay less for medical services such as doctor visits, prescription drugs, and hospitalization.

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

Ultimate plan (Platinum) – Benefit Overview

Benefit Participating providers1 (PPO and EPO): Non-participating providers1 (PPO only):
Office visit - primary care doctor $202 50%2
Office visit - specialist doctor $402 50%2
Urgent care visit $402 50%2
Preventive health benefits $02 Not covered
Inpatient hospitalization 10% 50%
Outpatient surgery 10%2 50%2
Lab $202 50%2
X-ray $402 50%2
Emergency room services not resulting in admission $150 $150
Maternity 10% 50%
Generic drugs $52 Not covered
Preferred brand drugs $15 Not covered
Non-preferred brand drugs $25 Not covered
Chiropractic Not covered Not covered
Acupuncture
(from a licensed acupuncturist)
$202 $202
Pediatric eye exam $02 Up to $302
Pediatric eyeglasses $02 $55 single vision2
Calendar-year medical deductible $0 $0
Calendar-year out-of-pocket maximum
(includes deductible)
$4,000 per individual / $8,000 per family $7,000 per individual / $14,000 per family
Calendar-year brand drug deductible $0 Not covered

Get complete health plan details

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

Benefit Summary for Ultimate PPO (PDF, 446KB)
Benefit Summary for Ultimate EPO (PDF, 456KB)

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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