Plan Details - Balance Plan 1700 - Blue Shield of California

	Balance Plan 1700

Overview

Details at a Glance

Plan Type
PPO
Office Visit for Primary Doctor
$30 Copay, deductible waived
Office Visit for Specialist
$30 Copay, deductible waived
Coinsurance
30% after deductible
Separate Prescription Drugs Deductible
$500 Individual
applies to
Brand
Prescription Drugs
Generic: $10 Copay
Brand: $35 Copay after Rx deductible
Non-Formulary: $50 Copay or 50% Coinsurance after Rx deductible, whichever is greater
Health Savings Account (HSA) Eligible
No
Out-of-Network Coverage
Yes (Details in plan brochure below)
Out of Country Coverage
Yes. Paid as in-network benefits if through a WorldWide BlueCard Provider (View Details)

Generic Prescription Drugs
$10 Copay
Brand Prescription Drugs
$35 Copay after Rx deductible
Non-Formulary Prescription Drugs Coverage
$50 Copay or 50% Coinsurance after Rx deductible, whichever is greater
Mail Order for Prescription Drugs
Generic: $20 Copay
Brand: $70 Copay after Rx deductible
Non-Formulary: $100 Copay or 50% Coinsurance after Rx deductible, whichever is greater
Days Supply: 60
Separate Prescription Drugs Deductible
$500 Individual
applies to
Brand

Chiropractic Coverage
50% after deductible up to $25 (member responsible for all charges over $25), up to 15 Visits per year
Mental Health Coverage
Non-severe mental illness: 30% Coinsurance after deductible, Severe mental illness: $30 Copay, deductible waived