Tonik has been breaking records for Blue Cross of California new sales. This simple plan covers dental and vision, with only 3 deductibles to choose from. Very easy!
BC Life & Health RightPlan PPO 40 with no prescription drug coverage (P958)
50% of negotiated fee plus 100% of charges in excess of negotiated fee 1
Professional Services
In-Network
40% of negotiated fee
Out-of-Network
50% of negotiated fee plus 100% of charges in excess of of negotiated fee
Inpatient Hospital Services (Includes organ and tissue transplants)
In-Network
40% of negotiated fee plus $400 copay per day/4 day max per admission 2,4,5
Out-of-Network
All charges except $650 per day
Outpatient Hospital Services/Ambulatory Surgical Center
In-Network
40% of negotiated fee plus $400 copay per outpatient surgery admit 2,4,5
Out-of-Network
All charges except $380 per day
Emergency Care
In-Network
40% of negotiated fee 3,5
Out-of-Network
40% of C&R for first 48 hours plus 100% of charges in excess of C&R. After 48 hours all charges in excess of $650 per day 3,5
Maternity
In-Network
Not Covered
Out-of-Network
Not Covered
Preventive Care/HealthyCheck Center
In-Network
$25 or $75 option
Out-of-Network
Not covered
Preventive Care
In-Network
$40 office visit plus 40% of negotiated fee for well-baby and well-child thru age 6
$40 office visit plus 40% of negotiated fee for Covered Services other than the Office Visit for Annual Pap exam Breast exams Mammogram testing and appropriate screeni
Out-of-Network
All charges in excess of 50% of negotiated fee for well-baby and well-child thru age 6
All Charges in excess of 50% of negotiated fee
Ambulance Service
In-Network
40% of negotiated fee
Out-of-Network
All charges in excess of 50% of negotiated fee
Physical Therapy, Occupational Therapy/Chiro
In-Network
40% of negotiated fee; limited to 12 visits/year, participating and non-participating combined
Out-of-Network
All charges except $25 per visit
Acupuncture/Acupressure
In-Network
All charges except $25 per visit; limited to 24 visits/year, participating and non-participating combined
Out-of-Network
All charges except $25 per visit; limited to 24 visits/year, participating and non-participating combined
Prescription Drug Benefit
In-Network
Not Covered 6
Out-of-Network
Not Covered
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.
2
$500 admission charge for admit to Participating (tier II) Hospital Same benefits for BlueCard providers
3
Additional $30 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
4
Once OOP max is met, $400 copayment will not be required to remainder of that Year
5
$400 CoPay as explained in Hospital In-Network inpatient/outpatient benefits
6
Members on RightPlan PPO 40 with No Prescription Drug Coverage and RightPlan PPO 40 with Generic Only Prescription Drug Coverage can access Blue Cross Pharmacy discounts when filling a prescription for a non-covered drug. Members must present the Blue Cross member ID card when they have their prescription filled.
