Blue Cross of California BCL&H Basic PPO 2500 with Life Plan Information

Plan Type: PPO

Physician Choice: You choose specialist(s)

Annual Out-of-Pocket Maximum (includes deductible): $5000/member, 2 member maximum participating and non-participating combined

Annual Deductible: $2500/member, 2 member maximum

Office Visits: No office visits until out-of-pocket maximum is met, then plan pays 100%

Professional Services: 20% of negotiated fee, hospital only

Hospital Inpatient/Outpatient: 20% of negotiated fee

Emergency Services: 20% of negotiated fee; $100 copay, waived if admitted

Maternity: Not covered

Preventive Care - General: $25 or $75 copay for basic HealthyCheck screenings. Routine mammogram, PSA and Pap tests @ 20% of negotiated fee (deductible waived)

Drug Benefits: Not covered

Financial/Tax Incentive: No

Optometrist Benefit: Optometrists network has been created for BC Life so insureds will have a participating provider network to choose from for medical services.

Preservice Review: Preservice review will be required for all inpatient hospital stays and certain diagnostic and radiological procedures.

Specialty Pharmacy Drug Benefit: Certain drugs will be obtainable only through Precision Rx Specialty Solutions.

Other Blue Cross of California health insurance plans:

• BCL&H CORE 5000
• BCL&H Basic PPO 1000 with Life
• Individual PPO $3500 with HSA Compatibility
• Lumenos HSA 5000/10000/100
• Lumenos HIA 5000/10000/100
• BCL&H 3500 Deductible
• BCL&H RightPlan PPO 40 w/No Rx
• BCL&H RightPlan PPO 40 w/Generic Rx
• BCL&H PPO Share 5000
• Lumenos HIA Plus 5000/10000/100
• BCL&H RightPlan PPO 40 w/Rx
• BCL&H PPO Saver with Life
• Individual Select HMO
• Lumenos HSA 3000/6000/100
• Lumenos HIA 3000/6000/100
• Blue Cross PPO Share 2500
• Lumenos HSA 2500/5000/100
• Lumenos HIA 2500/5000/100
• Lumenos HIA Plus 3000/6000/100
• Blue Cross HMO Saver
• Lumenos HIA Plus 2500/5000/100
• Blue Cross PPO Share 1500
• Lumenos HSA 1500/3000/100
• Lumenos HIA 1500/3000/100
• BCL&H PPO Share 1000
• BCL&H PPO Share 500
• Blue Cross Individual HMO