Blue Cross California Basic PPO 2500.

BC Life & Health Basic PPO 2500 (R418) Apply Now Rates by county Some counties have special rates by Zip code
Lifetime Maximum
Participating Provider	$5,000,000/member
Non-participating Provider	$5,000,000/member
Annual Out-of-Pocket Maximum (includes deductible)
Participating Provider	$5,000/single (2-member maximum) Participating and non-participating combined¹
Non-participating Provider	$5,000/single (2-member maximum) Participating and non-participating combined¹
Annual Deductible
Participating Provider	$2,500/member (2-member maximum) All covered benefits
Non-participating Provider	$2,500/member (2-member maximum) All covered benefits
Office Visits
Participating Provider	No office visit benefit until out-of-pocket maximum met, then 100% of negotiated fee
Non-participating Provider	No office visit benefit until out-of-pocket maximum met, then 100% of negotiated fee
Professional Services (other office visits, X-ray, lab, anesthesia, surgeon, etc.)
Participating Provider	20% of negotiated fee, hospital only. No office visit benefits until out-of-pocket maximum met, then covered at 100% of negotiated fee
Non-participating Provider	Covered expenses paid at 50% of the limited-fee schedule plus 100% of excess
Hospital Inpatient/Outpatient
Participating Provider	20% of negotiated fee
Non-participating Provider	All charges except: $650/day inpatient, $380/day outpatient
Hospice
Participating Provider	$10,000 lifetime maximum, participating and non-participating providers combined
Non-participating Provider	$10,000 lifetime maximum, participating and non-participating providers combined
Emergency Services
Participating Provider	20% of negotiated fee³
Non-participating Provider	20% 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 (after deductible)
Participating Provider	Not covered
Non-participating Provider	Not covered
Preventive Care
Participating Provider	HealthyCheck Centers: $25 or $75 copay for basic screenings; routine mammogram, PSA and cancer screening, ordered by physician: 20% of negotiated fee (deductible waived)
Non-participating Provider	Outside California, 50% of customary & reasonable to maximum of $250/year; routine mammogram, PSA and cancer screening, ordered by physician: 50% of customary & reasonable plus 100% of excess
Ambulance
Participating Provider	20% of negotiated fee ($750/trip maximum paid by BC Life & Health Insurance Company)
Non-participating Provider	50% of customary & reasonable plus 100% of excess
Physical and Occupational Therapy; Chiropractic Services
Participating Provider	Not covered unless during inpatient admission
Non-participating Provider	Not covered unless during inpatient admission
Acupuncture/Acupressure
Participating Provider	Not covered
Non-participating Provider	Not covered
Drug Benefits (retail or mail order: 30-day supply)
Participating Provider	Not covered
Non-participating Provider	Not covered

Please Note: When locating a provider, PPO plans are also referred to as Prudent Buyer1Non-participating charges in excess of the negotiated fee will not be paid and do not apply to the out-of-pocket maximum.2Additional $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.3Additional $30 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).

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PPO Basic 2500 rate Areas by County

Basic PPO 2500 Rates

Rates by county

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