Blue Cross of California Individual PPO $3500 with HSA Compatibility Plan Information

Plan Name:
Individual PPO $3500 with HSA Compatibility

Plan Type:
HSA

Physician Choice:
You choose specialist(s)

Annual Out-of-Pocket Maximum (includes deductible):
$5,000/single, $10,000/family

Annual Deductible:
$3,500/single, $7,000/family

Office Visits:
After deductible 0% of negotiated fee

Professional Services:
After deductible 0% of negotiated fee

Hospital Inpatient/Outpatient:
After deductible 0% of negotiated fee

Emergency Services:
After deductible $100 copay plus 0% of negotiated fee. $100 copay for each visit - waived if admitted.

Maternity:
Not covered

Preventive Care - General:
After deductible 0% of negotiated fee

Drug Benefits:
$10 copay generic formulary (each 30-day supply); $30 copay brand formulary name (each 30-day supply) after combined deductible. Self-administered injectable drugs, except insulin, 30% of the negotiated fee. 50% Co-Insurance for Non-Formulary drugs.

Financial/Tax Incentive:
Yes

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.

Blue Cross of California and Blue Cross Life & Health Insurance Company are independent licensees of the Blue Cross Association and are licensed to conduct business in the State of California.

Other Blue Cross of California health insurance plans:

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