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Blue Cross of California Health Insurance Plan

RightPlan PPO 40
In胤etwork Benefits
Annual Deductible(s)
Take advantage of participating provider discounts before and after meeting the deductible.

No deductible
Annual Out-of-Pocket Maximum(includes deductible)
Participating and non-participating provider covered services apply.

$7,500 per member
Doctors' Office Visits

$40 copay
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.).

40% of negotiated fee
Hospital Inpatient/Outpatient.

40% of negotiated fee plus $500 copay 1, 2
Emergency Room Services
(Additional $100 copay applies; waived if admitted).

40% of negotiated fee
Maternity

Not covered
Preventive Care

HealthyCheck SM Centers: $25/$75 copay for basic/premium screening Routine mammogram, Pap, and PSA ordered by physician: $40 office visit plus 40% of negotiated fee Well Child: $40 office visit plus 40% of negotiated fee
Prescription Drugs
(Amounts shown are copays for each 30-day retail or mail order supply).

. NoPrescription Drug Coverage (P958): Not covered . Generic Prescription Drug Coverage (PE48):$10 generic (for drugs on Generic Rx Formulary only) . Comprehensive Prescription Drug Coverage (PE49): Blue Cross Formulary Drugs: $10 generic; $30 brand要ame 3 copay after $500 brand要ame deductible; 30% of negotiated fee for self苔dministered 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/4苓ay maximum copay per admission; For Hospital Outpatient, the $500 copay is per surgical admission. 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.