Blue Cross California EPO HSA.

EPO (7892) 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	$3,000/single, $5,500/family All covered benefits for medical and drug combined
Non-participating Provider	$3,000/single, $5,500/family All covered benefits for medical and drug combined
Annual Deductible
Participating Provider	$2,400/single, $4,500/family All covered benefits for medical and drug combined
Non-participating Provider	$2,400/single, $4,500/family All covered benefits for medical and drug combined
Office Visits
Participating Provider	After deductible, 50% of negotiated fee
Non-participating Provider	Not covered
Professional Services (other office visits, X-ray, lab, anesthesia, surgeon, etc.)
Participating Provider	50% of negotiated fee
Non-participating Provider	Not covered
Hospital Inpatient/Outpatient
Participating Provider	50% of negotiated fee
Non-participating Provider	Not covered
Emergency Services
Participating Provider	50% of negotiated fee³
Non-participating Provider	50% of customary & reasonable for first 48 hours plus 100% of excess; no coverage after 48 hours
Maternity (after deductible)
Participating Provider	50% of negotiated fee
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: 50% of negotiated fee; well-child, 50% of negotiated fee (deductible waived)
Non-participating Provider	Not covered
Ambulance
Participating Provider	50% of negotiated fee
Non-participating Provider	Emergency only, then 50% of customary & reasonable
Physical and Occupational Therapy; Chiropractic Services
Participating Provider	50% of negotiated fee limited to 12 visits/year
Non-participating Provider	Not covered
Acupuncture/Acupressure
Participating Provider	All charges except $25/visit; limited to 12 visits/year combined
Non-participating Provider	Not covered
Drug Benefits (retail or mail order: 30-day supply)
Participating Provider	Combined with medical deductible. 15% of negotiated fee, generic; 35% of negotiated fee, brand; 30% of negotiated fee, self-administered injectables except insulin
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 $30 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).3Maternity copay is per pregnancy and does not apply to out-of-pocket maximum.4Generic drugs are based upon the Blue Cross drug formulary.5Brand drug deductible does not apply to out-of-pocket maximum.

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EPO Rate Areas by County

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