PPO Health Coverage California

Note:
Benefits for cancer clinical trials in accordance with Health and Safety Code Section 1370.6 will be available administratively.

¹ Non-participating charges in excess of the negotiated fee will not be paid and do not apply to the out-of-pocket maximum.
² Participating provider discount apply to covered services before and after the deductible is met.
³ Additional $500 admission charge at Participating Hospitals (no additional charge for Preferred Participating Hospitals) is for surgery or infusion therapy. This charge is not required for Ambulatory Surgical Centers or medical emergencies.
4 Additional $30 copay fro PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
5 Tests ordered by a physician are covered. 6 Benefits include visits to participating and non-participating providers combined.
7 Generic drugs are based upon the Blue Cross drug formularly.
8 Brand-name drug deductible does not apply to out-of-pocket maximum.

* If 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 substitue" 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 members's brand-name deductible.

PPO Saver Plan These amounts show your share of cost after deductibles		VIEW RATES
Benefit
Benefit	In-Network	Out-of-Network
Annual Deductible(s)	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.)
Lifetime Maximum	$5,000,000/member
Annual Out-of-Pocket Maximum¹ 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 Number of office visits is combined for participating and non-participating providers	Children: 4 office visits per year at $30 copay per visit; Adults: 2 office visits per year at $30 copay per visit (deductible waived)	Children: 4 office visits per year; Adults: 2 office visits per year; 50% of negotiated fee plus all excess charges (deductible waived)
Professional Services (x-ray, lab, anesthesia, surgeon, etc.)	20% of negotiated fee for inpatient or surgical procedures only. You pay for other covered services unti8l the 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. You pay for other covered services until out-of-pocket maximum is met.
Hospital Inpatient (Overnight Hospital Stays)	20% of negotiated fee²after $500 deductible	All charges except $650/day
Hospital Outpatient (If You Don't Stay Overnight)	20% of negotiated fee²after $500 deductible	All charges except $380/day
Emergency Room Services³	20% of negotiated fee after $500 deductible	20% of customary & reasonable fees plus all excess charges
Maternity	Not covered
Preventive Care	Routine mammogram, Pap and PSA tests⁴ 20% of negotiated fee (deductible waived) Well Baby and Well Child (through age 6): 50% 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) Well Baby and Well Child (through age 6): 50% of negotiated fee through age 6 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	20% of negotiated fee, up to 12 visits/year⁶	All charges except $25/visit, up to 12 visits/year ⁶
Acupuncture/Acupressure	All charges except $25 per visit, up to 24 visits per year
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-name⁸ after $500 brand-name prescription drug deductible (2-member maximum); 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 the in-network benefits; subject fo the annual $500 brand-name prescription drug deductible