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Please review the Benefits below
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Blue Cross of California
Basic PPO 1000
Lifetime Maximum

$5,000,000/member

Annual Out-of-Pocket Maximum
(includes deductible)
Annual Out-of-Pocket Maximum (includes deductible)

$3,500/single (2-member maximum)
Participating and non-participating combined

Annual Deductible
Annual Deductible

$1,000/member
(2-member maximum)
All covered benefits

Office Visits
Office Visits

No office visit benefits until out-of-pocket
maximum is met then plan pays 100% of negotiated fee

Professional Services
Professional Services (other office visits, X-ray, lab, anesthesia, surgeon, etc.)

20% of negotiated fee, hospital only;
no office visits until out-of-pocket maximum is met,
then plan pays 100% of negotiated fee

Hospital Inpatient/Outpatient
Hospital Inpatient/Outpatient

20% of negotiated fee

Hospice
Hospice

$10,000 lifetime maximum
participating and non-participating providers combined

Emergency Services
Emergency Services

20% of negotiated fee

Maternity
(after deductible)
Maternity (after deductible)

Not covered

Preventive Care
Preventive Care

HealthyCheck Centers:
$25 or $75 copay for basic screenings;
Routine mammogram, Pap, and
PSA ordered by physician: 20% of negotiated fee, deductible waived

Ambulance
Ambulance

20% of negotiated fee
($750/trip maximum paid by BC Life &
Health Insurance Company)

Physical and Occupational Therapy;
Chiropractic Services
Physical and Occupational Therapy; Chiropractic Services

Not covered unless during inpatient admission

Acupuncture/Acupressure
Acupuncture/Acupressure

Not covered

Drug Benefits
(retail or mail order: 30-day supply)
Drug Benefits (retail or mail order: 30-day supply)

Not covered

Additional Information
Physician Directory

Panel Provider

Insurance Company's Plan Details

More Plan Details

Plan Exclusions and Limitations

Exclusions and Limitations


 *  This is a summary of plan benefits, for complete details refer to the Master Contract or Benefits Booklet.


This information is presented only as a very brief overview of some of the benefits of this plan, and is intended only for general education. The amount of benefits provided depends upon the plan selected. Premium will vary with the type of benefits selected. These plans contain exclusions from and limitations of coverage. Please see the product brochure for more complete information, as well as information about terms of renewability, preexisting conditions, out-of-network penalties, and notification requirements. Plans are subject to health underwriting. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits, unless you use a PPO, and all other policy provisions, including determinations of medical necessity.


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