Benefits You Will Use the Most
| Vital Shield Plus Plan 900 Generic Rx | Balance Plan 2500 | Essential Plan 4500 | Vital Shield Plus Plan 400 | |
| Starting Monthly Rate | $78* | $88** | $101** | $118* |
| Annual Deductible | $900 | $2,500 | $4,500 | $400 |
| Out-of-Pocket Maximum | $3,900 | $7,500 | $4,500 | $2,900 |
| Preventive Care Exams | See "Office Visits" below | $30 | $40 | See "Office Visits" below |
| Office Visits | $30 for first 5 visits per calendar year1 | $30 | $40 for first 3 visits per calendar year2 | $30 for first 5 visits1 per calendar year |
| Hospitalization | 40% after annual deductible is met | 30% after annual deductible is met | $0 after annual deductible is met | 40% after annual deductible is met |
| Maternity? | No | No | No | No |
| ER Visit | $100 + 40% after annual deductible is met | $100 + 30% | $100 | $100 + 40% after annual deductible is met |
| Prescription Drugs | $10 for generic; brand name drugs not covered | $10 for generic; $35 for brand name drugs after a $500 Brand Rx deductible is met3 (Blue Shield pays up to $2,500 per year) | $10 for generic; brand name drugs not covered | $10 for generic; $45 for formulary brand name drugs after a $500 Brand Rx deductible is met3 |
| Download Plan Details | Vital Shield Plus Plan 900 Generic Rx Details | Balance Plan 2500 Details | Essential Plan 4500 Details | Vital Shield Plus Plan 400 |
Essential Plan 4500 is available for individuals only. Vital Shield Plus plans are subject to regulatory approval.
* Monthly rates shown apply to individual males age 19-29 in good health, for the following counties: Alameda, Contra Costa, and Santa Clara counties except ZIP codes beginning with 940-943. Rates may vary by age and region.
** Monthly rates are for individual males age 19-29 in good health, for the following counties: Alpine, Butte, Colusa, Del Norte, Humboldt, Imperial, Inyo, Kern, Kings, Madera, Mendocino, Plumas, San Benito, San Joaquin, Santa Barbara, San Luis Obispo, Siskiyou, Sonoma, Stanislaus, and Trinity counties. Rates may vary by age and region.
1 Limited to first five visits per calendar year for any combination of preventive care and physician office visits. After five visits have been used, the member pays 100% of the allowable amount until the calendar year copayment maximum is met, and costs for the visits do not accrue to deductible or copayment maximum.
2 Limited to first three visits per calendar year (preventive care exams & office visits not combined). After three visits have been used, the member pays 100% of the allowable amount until the calendar year deductible is met. No charge after deductible is met.
3 Brand name benefit shown applies to formulary drugs. Member’s costs may increase for non-formulary brand name drugs if covered by the benefit plan.
