Blue Cross of California Health Insurance Plan |
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PPO Share 2500 |
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In胤etwork Benefits | |
| Annual Deductible(s) Take advantage of participating provider discounts before and after meeting the deductible. | $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. | $7,500 per member Once 2 members each reach the maximum, the maximum is satisfied for the entire family. |
| Doctors' Office Visits | $35 copay, deductible waived |
| Professional Services (X-ray, lab, anesthesia, surgeon, etc.). | 30% of negotiated fee |
| Hospital Inpatient/Outpatient. | 30% of negotiated fee 1 |
| Emergency Room Services (Additional $100 copay applies; waived if admitted). | 30% of negotiated fee |
| Maternity | 30% of negotiated fee |
| Preventive Care | Annual physical exam(s): 30% of negotiated fee 2 , deductible waived OR HealthyCheck SM Centers:$25/$75 copay for basic/premium screening deductible waived Routine mammogram, Pap, and PSA ordered by physician: 30% of negotiated fee, deductible waived Well Child: 40% 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 brand要ame 3 copay after $500 brand要ame deductible (2衫ember maximum); 30% of negotiated fee for self苔dministered injectables, 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 Maximum annual physical exam benefit is $200 for members covered more than 6 months; $100 for members covered less than 6 months. 3 If you select a brand要ame 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要ame drug and the generic equivalent drug. None of the amount paid applies to the member's brand要ame drug deductible. |
