Blue Cross California PPO 3500.

BC Life & Health 3500 Deductible PPO (R420) Apply Now Rates by county Some counties have special rates by Zip code
Calendar year deductible (combined for all providers)
In-Network	$3,500/member; 2 family member max
Out-of-Network[1]	$3,500/member; 2 family member max
Lifetime Maximum (combined for all providers)
In-Network	$5,000,000/member
Annual Out-of-Pocket Maximum
In-Network	Member must meet Yearly deductible only (2 family member max)
Out-of-Network	$10,000/member; 2 family member max
Office Visits
In-Network	Covered in full after deductible met
Out-of-Network	50% of negotiated fee plus excess of negotiated fee after deductible met
Professional Services (X-ray, lab, anesthesia, surgeon, etc)
In-Network	Covered in full after deductible met
Out-of-Network	50% of negotiated fee plus excess of negotiated fee (including x-ray) after deductible met
Inpatient Hospital Services
In-Network	Covered in full after deductible met²
Out-of-Network	All charges except $650/day after deductible met
Outpatient Hospital Services
In-Network	Covered in full after deductible met
Out-of-Network	All charges except $380/day after deductible met
Emergency Care
In-Network	Covered in full after deductible met³
Out-of-Network	1st 48 hours: all charges in excess of 100% of C & R after deductible met; after 48 hours, all charges except $650/day
Pregnancy & Maternity Services
In-Network	Not Covered
Out-of-Network	Not Covered
Preventive Care
In-Network	Routine mammogram, PSA and Pap test: Covered in full after deductible met⁴; Well Baby & Well Child (through age 6): Covered in full after deductible met; HealthyCheck Centers⁵: $25 or $75 copay
Out-of-Network	Routine mammogram, PSA and Pap test: 50% of negotiated fee plus excess of negotiated fee after deductible met; Well Baby & Well Child (through age 6): 50% of negotiated fee plus excess of negotiated fee after deductible met; HealthyCheck Centers: Not Cove
Ambulance Service
In-Network	Covered in full after deductible met
Out-of-Network	50% of negotiated fee plus excess of negotiated fee after deductible met
Physical Therapy, Physical Medicine & Occupational Therapy, including Chiropractic Services limited to 24 visits/calendar year; additional visits may be authorized)
In-Network	Covered in full after deductible met
Out-of-Network	All charges except $25/visit after deductible met
Acupunture / Acupressure (limited to maximum Blue Cross payment of $25/visit; limited to 24 visits/calendar year in & out-of-network combined)
In-Network	All charges except $25/visit after deductible met
Out-of-Network	All charges except $25/visit after deductible met
Outpatient Speech Therapy When following surgery, injury or non-congenital organic disease excess of C& R (limited to 50 visits/year in and out-of-network combined)
In-Network	Covered in full after deductible met
Out-of-Network	50% of C&R plus excess of C&R after deductible met
Skilled Nursing Facility Semi-private room, services & supplies (limited to 100 days per calendar year in and out-of-network combined)
In-Network	Covered in full after deductible met
Out-Network	All charges except $150/day after deductible met
Home Health Care Services & supplies from a home health agency (limited to 60 visits/calendar year, one visit by a home health aide equals four hours or less; not covered while member receives hospice care)
In-Network	Covered in full after deductible met
Out-of-Network	All charges except $75/day after deductible met
Infusion Therapy Combined admin, prof and drug for out-of-network will not exceed $500/day Includes medication, caregiver training & visits by provider to monitor therapy; durable medical equipment
In-Network	Covered in full after deductible met
Out-of-Network	Admin & Prof. Srvcs: All charges in excess of $50/day after deductible met Drugs: All charges in excess of Drug AWP after deductible met
Medical Supplies, Equipment & Footwear Footwear limited to $400 per year maximum combined for $400/calendar year in and out-of-network combined
In-Network	Covered in full after deductible met
Out-of-Network	50% of negotiated fee plus excess of negotiated fee after deductible met
Mental or Nervous Disorders Inpatient Hospital & Day Treatment Programs (limited to 30 days/year in & out-of network combined) Professional Services (Inpatient or Outpatient physician charges except services (limited to 1 visit/day; 20 visits/year)
In-Network	Inpatient Hospital & Day Treatment Programs (limited to 30 days/year in & out-of network combined): All charges except $175/day after deductible met; Professional Services (Inpatient or Outpatient physician charges except services (limited to 1 visit/day;
Out-of-Network	Inpatient Hospital & Day Treatment Programs (limited to 30 days/year in & out-of network combined): All charges except $175/day after deductible met; Professional Services (Inpatient or Outpatient physician charges except services (limited to 1 visit/day;
Severe Mental Illness and serious Emotional Disturbances of a Child (Services provided as any other medical condition)
In-Network	Covered in full after deductible met
Out-of-Network	50% of negotiated fee plus excess of negotiated fee after deductible met
Hospice (limited to a lifetime maximum BC Life benefit of $10,000 in and out of network combined)
In-Network	Covered in full after deductible met
Out-of-Network	50% of negotiated fee plus excess of negotiated fee after deductible met
Prescription Drug Coverage Retail and Mail order combined (Subject to $500 brand name drug deductible )⁶
In-Network	Generic: $10 copay Brand: $30 copay Non-formulary: 50% of negotiated fee Self Admin Injectibles: 30% of negotiated fee
Out-of-Network	50% of Drug Limited Fee Schedule plus excess

Please Note: When locating a provider, PPO plans are also referred to as Prudent Buyer Please Note: When locating a provider, PPO plans are also referred to as Prudent Buyer1Members are responsible for any difference between the allowed amount and the actual charges, as well as any deductible and percentage copay.1Members are responsible for any difference between the allowed amount and the actual charges, as well as any deductible and percentage copay.2There is no additional charge for Preferred Participating Hospitals. Additional $500 hospital admission copay for Participating Hospitals.2There is no additional charge for Preferred Participating Hospitals. Additional $500 hospital admission copay for Participating Hospitals.3Additional emergency room $100 copay until the annual out-of-pocket maximum is reached. Copay waived if admitted.3Additional emergency room $100 copay until the annual out-of-pocket maximum is reached. Copay waived if admitted.4Tests ordered by a physician are covered, including appropriate screening for breast, cervical and ovarian cancer.4Tests ordered by a physician are covered, including appropriate screening for breast, cervical and ovarian cancer.5One HealthyCheck visit at HealthyCheck Center only allowed for each 12-month period. HealthyCheck applies only to adults and children aged 7 and above. HealthyCheck services are not subject to the calendar year deductible.5One HealthyCheck visit at HealthyCheck Center only allowed for each 12-month period. HealthyCheck applies only to adults and children aged 7 and above. HealthyCheck services are not subject to the calendar year deductible.6If a member selects brand-name drug when a generic equivalent drug is available, even if the physician writes a "dispense as written" or "do not substitute" prescription, the member will be responsible for the copayment plus the difference in cost, based on the negotiated fee, between the brand name drug and the generic equivalent drug. The amount paid does not apply to the member's brand-name deductible.6If a member selects brand-name drug when a generic equivalent drug is available, even if the physician writes a "dispense as written" or "do not substitute" prescription, the member will be responsible for the copayment plus the difference in cost, based on the negotiated fee, between the brand name drug and the generic equivalent drug. The amount paid does not apply to the member's brand-name deductible.

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