Blue Cross of California Health Insurance Plan |
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PPO 3500 (HSACompatible) |
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InNetwork Benefits | |
| Annual Deductible(s) Take advantage of participating provider discounts before and after meeting the deductible. | Single member: $3,500 Families: $7,000 aggregate (combined for medical and prescription drugs) |
| Annual Out-of-Pocket Maximum(includes deductible) Participating and non-participating provider covered services apply. | Single member: $5,000 Families: $10,000 aggregate (combined for medical and prescription drugs) |
| Doctors' Office Visits | $0 after deductible |
| Professional Services (X-ray, lab, anesthesia, surgeon, etc.). | $0 after deductible |
| Hospital Inpatient/Outpatient. | $0 after deductible 1 |
| Emergency Room Services (Additional $100 copay applies; waived if admitted). | $0 after deductible |
| 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: $0 after deductible Well Child: $0 after deductible |
| Prescription Drugs (Amounts shown are copays for each 30-day retail or mail order supply). | Blue Cross Formulary Drugs: $10 generic; $30 brandname 3 copay after annual deductible; 30% of negotiated fee for selfadministered injectable drugs, except insulin |
| Other Information. | 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. 2 RightPlan PPO 40: For Hospital Inpatient, the $500 copay is per day/4day maximum copay per admission; For Hospital Outpatient, the $500 copay is per surgical admission. 3 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 brandname drug and the generic equivalent drug. None of the amount paid applies to the member's brandname drug deductible. |
