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Blue Cross of California Health Insurance Plan

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

This plan features two separate medical deductibles: $500 per member for emergency and hospital inpatient/outpatient services; and $5,000 per member for other covered services. Once 2 members each reach the deductibles, the deductibles are satisfied for the entire family.
Annual Out-of-Pocket Maximum(includes deductible)
Participating and non-participating provider covered services apply.

Both medical deductibles apply to satisfy a total of $5,000 per member. Once 2 members each reach the maximum, the maximum is satisfied for the entire family.
Doctors' Office Visits

Children: 4 office visits per year at $30 copay per visit; Adults: 2 office visits per year at $30 copay per visit; deductible waived
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.).

20% of negotiated fee, inpatient or surgical procedures only.You pay for other covered services until out­of­pocket maximum is met, then plan pays 100% of negotiated fee
Hospital Inpatient/Outpatient.

20% of negotiated fee after $500 deductible 1
Emergency Room Services
(Additional $100 copay applies; waived if admitted).

20% of negotiated fee after $500 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: 20% of negotiated fee, deductible waived Well Child: 50% of negotiated fee, deductible waived
Prescription Drugs
(Amounts shown are copays for each 30-day retail or mail order supply).

Blue Cross Formulary Drugs: $10 generic; $30 brand­name 2 copay after $500 brand­name deductible (2­member maximum); 30% of negotiated fee for self­administered injectables, except insulin
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.