Puting You in Control
| Shield Savings 5200 | Shield Savings 4000 | Shield Savings 3500 | Shield Savings 1800 | |
| Starting Monthly Rate | $64* | $64** | $66** | $80** |
| Annual Deductible | $5,200 | $4,000 | $3,500 | $1,800 |
| Out-of-Pocket Maximum | $5,200 | $4,000 | $5,000 | $5,800 |
| Preventive Care Exams | Yes | Yes | Yes | Yes |
| Office Visits | $0 | $0 | $0 | $35 |
| Hospitalization | $0 after annual deductible is met | $0 after annual deductible is met | $0 after annual deductible is met | $35 after annual deductible is met |
| Maternity? | No | No | No | No |
| ER Visit | $0 after annual deductible is met | $0 after annual deductible is met | $100 after annual deductible is met | $75 + 30% after annual deductible is met |
| Prescription Drugs | $0 after annual deductible is met1 | $0 after annual deductible is met1 | $10 for generic; $35 for brand name drugs after annual deductible is met1 | $10 for generic; $35 for brand name drugs after annual deductible is met1 |
| Download Plan Details | Shield Savings 5200 Details | Shield Savings 4000 Details | Shield Savings 3500 Details | Shield Savings 1800 Details |
† HSAs are personal savings accounts or investment accounts intended for payment of qualified medical expenses. Although most consumers who enroll in a High Deductible Health Plan (HDHP) are eligible to open an HSA, consumers should consult with a financial adviser to determine if an HSA/HDHP is a good financial fit for them. Blue Shield does not offer tax advice or HSAs. HSAs are offered through financial institutions. For more information about HSAs, eligibility and the law’s current provisions, consumers should ask their financial or tax adviser. HSA plan features may vary by institution and may be subject to change by those institutions.
Shield Savings plans 3500 and 5200 are subject to regulatory approval.
* 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.
** Monthly rates are for 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.
1Brand name benefit shown applies to formulary drugs. Member’s costs may increase for non-formulary brand name drugs if covered by the benefit plan.
