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Blue Cross of California Health Insurance Plan

Basic PPO 1000 +
In­Network Benefits
Annual Deductible(s)
Take advantage of participating provider discounts before and after meeting the deductible.

$1,000/$2,500 per member Once 2 members each reach the deductible, the deductible is satisfied for the entire family.
Annual Out-of-Pocket Maximum(includes deductible)
Participating and non-participating provider covered services apply.

$3,500/$5,000 per member Once 2 members each reach the maximum, the maximum is satisfied for the entire family.
Doctors' Office Visits

No office visit benefits until out­of­pocket maximum is met, then plan pays 100% of negotiated fee
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.).

20% of negotiated fee, inpatient or surgical procedures only; no office visits until out­of­pocket maximum is met, then plan pays 100% of negotiated fee
Hospital Inpatient/Outpatient.

20% of negotiated fee 1
Emergency Room Services
(Additional $100 copay applies; waived if admitted).

20% of negotiated fee
Maternity

Not covered
Preventive Care

HealthyCheck SM Centers: $25/$75 copay for basic/premium screening, deductible waived Routine mammogram, Pap, and PSA ordered by physician: 20% of negotiated fee, deductible waived
Prescription Drugs
(Amounts shown are copays for each 30-day retail or mail order supply).

Not covered
Other Information.

 +$1,000 Term Life policy for the subscriber is included with these medical plans. 1 Additional $500 admission charge at Participating Hospitals (no additional charge for Preferred Participating) is for inpatient stays or outpatient surgery or infusion therapy.The charge is not required for Ambulatory Surgical Centers or medical emergencies. Before enrolling, ask your agent for plan­specific sales brochures so you can review detailed benefits, exclusions and limitations. If you select a brand­name drug when a generic equivalent drug is available, even if the physician writes a ``dispense as written'' or ``do not substitute'' prescription, you will be responsible for the generic copay plus the difference in cost between the brand­ name drug and the generic equivalent drug. None of the amount paid applies to the member's brand­name drug deductible.