Blue Cross HSA (Compatible) High Deductible PPO Medical Plan
Phone: 1-800-888-8288
Group no: 175028M005
ID no: Member ID (on ID card)
Website: www.bluecrossca.com
| | PPO | Non-PPO |
| General Information |
| Annual Deductible | Individual: $1200; Family: $2400 |
| Annual Out-of-Pocket Maximum (includes deductible) | Individual: $5000; Family: $10,000 |
| Lifetime Maximum Benefit | $5,000,000 |
| |
| Medical Benefits |
| Doctor Office Visits | Covered at 80% | Covered at 60% |
| Routine Physical Exam (ages 7 and over) | $25 copay (Deductible Waived)
$250 annual maximum | Not Covered |
| Well-Baby Care (birth through age 6) | $25 copay (Deductible Waived) | Covered at 60% (with limitations) |
| Adult Preventive Services | Covered at 80% | Covered at 60% |
Prescription Drugs Copays:
Pharmacy (30-day Supply)1 | Generic: $10 copay
Formulary Brand: $20 copay
Non-Formulary: $40 copay | Generic: $10 copay + 50%
Formulary Brand: $20 copay + 50%
Non-Formulary: $40 copay + 50% |
| Prescription Drugs Copays:
Mail Order (90-day Supply)1 | 2 times pharmacy copay | 2 times pharmacy copay |
| Physical Therapy, Chiropractic Care | Covered at 80%; limited to 24 visits per calendar year | Covered at 60%; limited to 24 visits per calendar year |
| Diagnostic X-ray/Lab | Covered at 80% | Covered at 60% |
| |
| Hospital Benefits |
Room & Board
| Covered at 80% | Covered at 60%
(after $500 per admission deductible) |
| Surgeon's Fees | Covered at 80% | Covered at 60% |
| Maternity/Delivery | Covered at 80% | Covered at 60% |
| Emergency Room | Covered at 80% after $100 copay; (copay waived if admitted) | Covered at 80% after $100 copay; (copay waived if admitted) |
| Out-Patient Services | Covered at 80% | Covered at 60% |
| In-Patient Services | Covered at 80% | Covered at 60% |
| |
| Vision Benefits |
| Vision Benefit provided through Vision Service Plan | See VSP Summary for covered benefits |
1Until the calendar year deductible is satisfied, the insured person pays the prescription drug covered expense, and not the copays listed.
More information can be found by downloading the Summary of Benefits (PDF, 9 pages, 222K). Once enrolled, members will receive a Combined Evidence of Coverage and Disclosure Form, which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail. Under all circumstances, policy form and wording take precedence over information contained in this summary.
