Blue Shield of California Authorized Agent for Blue Shield of California   

Oleg Skurskiy (818) 654-4548


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Blue Shield Spectrum PPO Savings Plan - HSA

1800/3600 , 2400/ 4800, 4000 / 8000

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We offer 3 high-deductible health plans -- called Shield Spectrum PPO Savings Plans -- that are eligible for use with a Health Savings Account (HSA).

These plans offer affordable coverage for a high-cost medical event while helping you meet your essential healthcare needs. They are often selected by people who go to the doctor occasionally.

Submitting through the online tool today! . If you are using the Mac computer , please print out the paper application and mail or fax to us .

 

By Fax : 818-776-9865 By Mail: Oleg Skurskiy
18375 Ventura Blvd. # 226
Tarzana , CA 91356

Ready to Apply? Call us (818) 654-4548
Summary of Benefits Shield SpectrumSM PPO Savings Plan 4000 (HSA eligible plan)†‡
See details (PDF)		 Shield SpectrumSM PPO Savings Plan 1800 (HSA eligible plan)‡
See details (PDF)		 Shield SpectrumSM PPO Savings Plan 2400 (HSA eligible plan)‡
See details (PDF)
Medical Benefits
Plan Type PPO (Health Savings Account- eligible)‡ PPO (Health Savings Account- eligible)‡ PPO (Health Savings Account- eligible)‡
Annual Deductible $4,000 per individual $1,800 per individual $2,400 per individual
Annual Copayment Maximum N/A N/A $3,200 per individualƒ
Out-of-Pocket Maximum with Preferred Providers (includes plan deductible) $4,000 per individualƒ $5,600 per individualƒ $3,200 per individualƒ
Preventive Care
Annual Physical Exam,
Well-Baby Care, Gynecological
Exam		 $35 until deductible is met, then no charge $35 (Not subject to deductible) $35 (Not subject to deductible)
Laboratory, X-Ray, Major
Diagnostic Services		 No charge 30% 30%
Professional Services
Physician Office Visits No charge $35 30%
Hospital Inpatient
(Non-Emergency)		 No charge 30% 30%
Maternity Services
(Resulting in Delivery)		 Not covered Not covered 30%
Outpatient Services (Non-Emergency)
Surgery No charge 30% 30%
Treatment/Procedure No charge 30% 30%
Emegency Room Services
Emergency Room Visits No charge $75 per visit + 30%π $75 per visit + 30%π
Ambulance No charge 30% 30%
Physician Visits/Consultations No charge 30% 30%
Prescription Benefits No charge retail pharmacy: generic $10, brand formulary $35, non-formulary $50 or 50% whichever is greater up to $150, (after medical deductible) mail order: generic $20, brand formulary $70, non-formulary $100 or 50% whichever is greater member pays up to $300, (after medical deductible) 30% after meeting annual medical deductible
Dental Services
Dental Services N/A (optional benefit) N/A (optional benefit) N/A (optional benefit)
Shield SpectrumSM PPO Savings Plan 4000 (HSA eligible plan)†‡ Shield SpectrumSM PPO Savings Plan 1800 (HSA eligible plan)‡ Shield SpectrumSM PPO Savings Plan 2400 (HSA eligible plan)‡
Please select the Application method below

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Active Start Plan 35 PPO - No Medical Deductible   Shield Spectrum PPO 5000   Access®+ Value HMO
Active Start Plan 25 PPO - No Medical Deductible   Shield Spectrum PPO 2000   Access®+ HMO
Balance Plan PPO 1000 - no Maternity   Shield Spectrum PPO 1500    
Balance Plan PPO 1700 - no Maternity   Shield Spectrum PPO 750   Blue Shield Senior
Balance Plan PPO 2500 - no Maternity   Shield Spectrum PPO 500    
Essential Plan PPO 1750 Dental & Vision Included   Blue Shield Short Term
Essential Plan PPO 3000 Dental & Vision Included HSA Savings Plan 2400 / 4800  
Essential Plan PPO 4500 Dental & Vision Included HSA Savings Plan 4000 / 8000 Blue Shield Spectrum Savings Plan 1800 / 3600

 

Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification! The rate and benefit information provided herein was generated by the Quotit Corporation's individual health insurance quoting system. The Quotit Corporation or It's Licensee's do not guarantee or warrant the correctness or completeness of the rate and benefit information contained herein and shall not be liable for any loss or damage arising out of use of the quoted rate and benefit information.

Additionally, information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage. Your grant of access to the rate and benefit summaries contained herein may not be relied upon as a guarantee of your eligibility or coverage under these benefit plans.

Blue Shield of California Life & Health Insurance Company Life was formed in 1954 as a wholly owned subsidiary of Blue Shield of California to provide a full range of insurance products for their customers. With 3.3 million members and $7.5 billion in annual revenue, Blue Shield of California is the state's third largest health plan. Founded in 1939 and headquartered in San Francisco, Blue Shield is a not-for-profit corporation with approximately 4,300 employees and more than 20 offices throughout California.

Blue Shield of California Life & Health Insurance Company Life has grown by offering competitive insurance products including Group Term Life, Accidental Death & Dismemberment, Blue Shield of California Life & Health Insurance Company Life Vision Plan, Stop Loss and Exec-U-Med medical reimbursement plans in tandem with Blue Shield of California health plans or on a stand-alone basis . In the early 1980s, introduced their Short-Term Health products. The Option One and Option Twelve plans remain one of the leading products of their kind in California
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