PPO Health Coverage California

Authorized Agent

Blue Cross of California*
* is an Independent Licensee of the Blue Cross Association

GERRY CACCAMO
A-ADVANTAGE INSURANCE SERVICES
Calif. Lic #OB22296

1200 E. ROUTE 66 #108 GLENDORA, CALIFORNIA 91740
800-246-3330 or 626-857-9230

INSTANT HEALTH QUOTE

APPLICATION FORMS DOWNLOAD

DENTAL INSURANCE RATES

Basic PPO 1000/2500 These amounts show your share of cost after deductibles		VIEW RATES
Benefit
Benefit	In-Network	Out-of-Network
Annual Deductible(s)	$1,000/$2,500 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 apply	$3,500/$5,000 per member, only hospital costs apply (Once 2-members each reach the maximum, the maximum is satisfied for the entire family)
Doctors' Office Visits	No office visit benefit until out-of-pocket maximum is met, then plan pays 100% of negotiated fee	No office visit benefit until out-of-pocket maximum is met, then you pay 50% of negotiated fee plus all excess charges
Professional Services (x-ray, lab, anesthesia, surgeon, etc.)	20% of negotiated fee for inpatient or surgical procedures only. No office visit benefits until out-of-pocket maximum is met, then plan pays 100% of negotiated fee	50% of negotiated fee plus all excess charges for covered inpatient or surgical procedures only
Hospital Inpatient (Overnight Hospital Stays)	20% of negotiated fee²	All charges except $650/day
Hospital Outpatient (If You Don't Stay Overnight)	20% of negotiated fee²	All charges except $380/day
Emergency Room Services³	20% of negotiated fee	20% of customary & reasonable fees plus all excess charges
Maternity	Not covered
Preventive Care	Routine mammogram, Pap and PSA tests⁴ 30% of negotiated fee (deductible waived) HealthyCheck^SM Centers⁵: $25/$75 copay for basic/premium screening (deductible waived)	Routine mammogram, Pap and PSA tests⁴: 50% of negotiated fee plus all excess charges (deductible waived)
Ambulance	20% of negotiated fee	50% of negotiated fee plus all charges in excess of negotiated fee and in excess of the plan's $750 maximum payment per ground trip.
Physical and Occupational Therapy; Chiropractic Services	Not covered unless during inpatient admission
Acupuncture/Acupressure	Not covered
Prescription Drugs	Not covered

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.