Blue Cross of California PPO Share 1500 (7889)


  Lifetime Maximum
  Participating Provider - $5,000,000/member
  Non-participating Provider - $5,000,000/member
 
  Annual Out-of-Pocket Maximum
  (includes deductible)
  Participating Provider - $6,000/single (2-member maximum)
  Participating and non-participating combined1 - Non-participating Provider
  $6,000/single (2-member maximum) - Participating and non-participating combined1

  Annual Deductible
  Participating Provider - $1,500/member (2-member maximum) All covered benefits
  Non-participating Provider - $1,500/member (2-member maximum) All covered benefits
 
  Office Visits
  Participating Provider - Well-child, 40% of negotiated fee; office visits, 30% of negotiated fee (deductible waived)
  Non-participating Provider Well-child, 50% of negotiated fee; office visits, 50% of negotiated fee (deductible 
  waived)

  Professional Services
  (other office visits, X-ray, lab, anesthesia, surgeon, etc.)  Participating Provider -  30% of negotiated fee
  Non-participating Provider -  50% of negotiated fee plus 100% of excess
 
  Hospital Inpatient/Outpatient
  Participating Provider -  30% of negotiated fee2 -  Non-participating Provider
  All charges except: $650/day inpatient, $380/day outpatient
 
  Emergency Services
  Participating Provider -  30% of negotiated fee3 -  Non-participating Provider - 30% of customary & reasonable
  for the first 48 hours plus 100% of excess; after 48 hours, you pay all charges except $650/day for covered
  services3

  Maternity
  Participating Provider - 30% of negotiated fee - Non-participating Provider
  50% of negotiated fee plus 100% of excess
 
  Preventive Care
  Participating Provider - HealthyCheck Centers: $25 or $75 copay for basic screenings; routine mammogram, PSA
  and cancer screening, ordered by physician: 25% of negotiated fee; well-baby and well-child, 40% of negotiated
  fee (deductible waived) - Non-participating Provider - Routine mammogram, PSA and cancer screening, ordered
  by physician: 50% of negotiated fee plus 100% of excess

  Ambulance
  Participating Provider - 30% of negotiated fee - Non-participating Provider
  50% of customary & reasonable plus 100% of excess

  Physical and Occupational Therapy; Chiropractic Services
  Participating Provider - 30% of negotiated fee; limited to 12 visits/year, participating and non-participating  
  combined Non-participating Provider All charges except $25/visit; limited to 12 visits/year, participating and non-
  participating combined

  Acupuncture/Acupressure
  Participating Provider - All charges except $25/visit; limited to 24 visits/year, participating and non-participating 
  combined (deductible waived) - Non-participating Provider All charges except $25/visit; limited to 24 visits/year,
  participating and non-participating combined (deductible waived)
 
  Drug Benefits
  (retail or mail order: 30-day supply) - Participating Provider - $10 generic4; $30 brand copay plus $250 brand  
  deductible5 (2 Member Maximum); 30% of negotiated fee for self-administered injectables except insulin

  Non-Formulary:
  Participating Provider: Generic4 50%; Brand 100% of negotiated Fee Rate for Brand Name Drugs until the  
  Brand   Name Prescription Drug Deductible5 is satisfied. After the Brand Name Drug Deductible is satisfied, 50% 
  of  the Negotiated Fee Rate for Brand Name Drugs if no Generic Equivalent is available

  If you select a Brand Name Drug when a generic equivalent is available even if a physician writes a “dispense as  
  written” or “do not substitute” prescription you pay the generic drug copayment plus the cost between the Brand
  Name drug and the generic equivalent drug. None of the amount paid applies toward your Brand Name Drug
  Deductible Non-participating Provider 50% generic4 or 50% of brand drug limited-fee schedule within California; 
  $250 brand deductible5

  Please Note: When locating a provider, PPO plans are also referred to as Prudent Buyer
  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 Additional $500 admission charge at Participating Hospitals (no additional for Preferred Participating Hospitals) 
  is for surgery or infusion therapy. This charge is not required for Ambulatory Surgical Centers or medical 
  emergencies.  3 Additional $100 copay for PPO Plans applies for each emergency room visit (waived if admitted 
  as inpatient). 4 Generic drugs are based upon the Blue Cross drug formulary 5 Brand drug deductible does not 
  apply to out-of-pocket maximum