Cost of Coverage (Monthly)
Blue Shield Narrow Network Plus - CA Only
January 2025 - December 2025
Your Cost
Employee Only: $47 per month
Employee + Partner: $349 per month
Employee + Kid(s): $210 per month
Employee + Family: $489 per month
Narrow Network
The Narrow network does NOT include Sutter providers in California. If you want access to the Sutter network, check out the Blue Shield Full Network Core plan with HRA funding or the Blue Shield Full Network Plus.
What's Covered
In-Network
Annual Deductible: none
Annual Out-of-Pocket Max: $2,500 per individual, $5,000 per family
Lifetime Max: unlimited
Primary Office Visit: $20 copay
Specialist: $30 copay
Preventive Services: $0
Urgent Care center services: $20/visit
Standard Services (not limited to): 10% coinsurance
Allergy
Inpatient/outpatient hospitalization
Lab and x-Ray
Chiropractic Services: $25/visit, up to 20 visits per year
Advance Imaging: $100 copay + 10% coinsurance
Emergency Room: $150 copay + 10% coinsurance
OptumRx:
Pharmacy (Standard): supply limit 30 days
Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $50 copay
Tier 4: 30% coinsurance up to $200
Contraceptive drugs and devices: $0
Pharmacy (Mail Order): supply limit 90 days
Tier 1: $10 copay
Tier 2: $60 copay
Tier 3: $100 copay
Tier 4: 30% coinsurance up to $400
Out-of-Network
Annual Deductible: $250 per individual, $500 per family
Annual Out-of-Pocket Max: $5,000 per individual, $10,000 per family
Lifetime Max: unlimited
Primary Office Visit: 40% coinsurance
Specialist: 40% coinsurance
Preventive Services: not covered
Urgent Care center services: 40%
Standard Services (not limited to): 40% coinsurance
Allergy
Inpatient/outpatient hospitalization
Lab and x-Ray
Chiropractic Services: 40% coinsurance
Advance Imaging: $100 copay + 10% coinsurance
Emergency Room $150 copay + 10% coinsurance
OptumRx:
Pharmacy (Standard): supply limit 30 days
Tier 1: 25% plus $5 copay
Tier 2: 25% plus $30 copay
Tier 3: 25% plus $50 copay
Tier 4: 30% up to $200 copay plus 25% of purchase price
Contraceptive drugs and devices: Applicable Tier 1, 2 or 3 copay
Pharmacy (Mail Order): supply limit 90 days
Tier 1: not covered
Tier 2: not covered
Tier 3: not covered
Tier 4: not covered
Plan Documents
Heading to an Appointment?
Below you'll find what you need to take with you to your appointments.
Group Number: 54027
Blue Shield ID Card: A digital card is available from the Blue Shield app and member portal if you don’t have your physical card.