PPO Health Coverage California

¹Excludes non-participating charges in excess of the Blue Cross negotiated fee and non-participating charges in excess of customary and reasonable fees for emergency care. Copays/coinsurance to participating and non-participating providers apply to out-of-pocket maximum except where specifically noted in the policy.

²Additional $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.

³Additional $100 copay applies for each emergency room visit. Waived if admitted as inpatient.

⁴Tests ordered by a physician are covered, including appropriate screening for breast, cervical and ovarian cancer.

⁵One HealthyCheck visit at a HealthyCheck Center only allowed for each 12-month period. HealthyCheck applies only to adults and children age 7 and above.

⁶Visits to participating and non-participating providers combined. Additional visits may be authorized.

⁷Non-Formulary Drugs: You pay 50% for generic, 100% for brand-name up to the brand-name deductible, then either: 50% if no generic is available, or generic copay plus the difference between brand-name and available generic equivalent.

⁸If a member selects a brand-name drug when a generic equivalent drug is available, even if the physician writes a "dispense as written" or "do not substitute" prescription, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member’s brand-name deductible.

3500 Deductible PPO Plan These amounts show your share of cost after deductible Blue Cross of California		VIEW RATES
Benefit
Benefit	In-Network	Out-of-Network
Annual Deductible	$3,500 per member (Once 2 members each reach the deductible, the deductible is satisfied for the entire family.)
Lifetime Maximum	$5,000,000/member
Annual Out-of-Pocket Maximum¹ (inclueds deductible) Participating and non-participating provider covered services combined	This is satisfied once the annual deductible is met	$10,00 per member (Once 2-members each reach the maximum, the maximum is satisfied for the entire family.)
Doctors' Office Visits	$0 after deductible	50% of negotiated fee plus all excess charges (after deductible)
Professional Services (x-ray, lab, anesthesia, surgeon, etc.)	$0 after deductible	50% of the negotiated fee plus all excess charges (after deductible)
Hospital Inpatient (Overnight Hospital Stays)	$0 after deductible	All charges except $650 per day (after deductible)
Hospital Outpatient (If You Don't Stay Overnight)	$0 after deductible	All charges except $380 per day (after deductible)
Emergency Room Services³	$0 after deductible	All charges in excess of customary and reasonable fees (after deductible)
Maternity	Not covered
Preventive Care	Routine mammogram, Pap and PSA tests⁴ $0 after deductible Well Baby and Well Child (through age 6): $0 after deductible HealthyCheck_SMCenters₅: $25/$75 copay for basic/premium screening (deductible waived)	Routine mammogram, Pap and PSA tests⁴: 50% of negotiated fee plus all excess charges (after deductible) Well Baby and Well Child (through age 6): 50% of negotiated fee through age 6 plus all excess charges (after deductible)
Ambulance	$0 after deductible	50% of negotiated fee plus all excess charges (after deductible)
Physical and Occupational Therapy; Chiropractic Services	$0 after deductible⁶	All charges except $25/visit ⁶ (after deductible)
Acupuncture/Acupressure	All charges except $25 per visit, up to 24 visits per year (after deductible)
Prescription Drugs (Blue Cross Formulary⁷) Amounts shown are for each 30-day retail or in-network mail order supply	$10 copay generic; $30 copay brand-name⁸after annual $500 brand-name prescription drug deductible;30% of negotiated fee for self-administered injectables, except insulin	50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits; subject fo the annual $500 brand-name prescription drug deductible