Blue Cross of California PPO Share 500

Lifetime Maximum
Participating Provider	$5,000,000/member
Non-participating Provider	$5,000,000/member
Annual Out-of-Pocket Maximum (includes deductible)
Participating Provider	$5,000/single (2-member maximum) Participating and non-participating combined¹
Non-participating Provider	$5,000/single (2-member maximum) Participating and non-participating combined¹
Annual Deductible
Participating Provider	$500/member (2-member maximum) All covered benefits
Non-participating Provider	$500/member (2-member maximum) All covered benefits
Office Visits
Participating Provider	Well-child, 40% of negotiated fee; office visits, 30% of negotiated fee (deductible waived)
Non-participating Provider	Well-child, 50% of negotiated fee; office visits, 50% of negotiated fee (deductible waived)
Professional Services (other office visits, X-ray, lab, anesthesia, surgeon, etc.)
Participating Provider	30% of negotiated fee
Non-participating Provider	50% of negotiated fee plus 100% of excess
Hospital Inpatient/Outpatient
Participating Provider	30% of negotiated fee²
Non-participating Provider	All charges except: $650/day inpatient, $380/day outpatient
Emergency Services
Participating Provider	30% of negotiated fee³
Non-participating Provider	30% of customary & reasonable for the first 48 hours plus 100% of excess; after 48 hours, you pay all charges except $650/day for covered services³
Maternity
Participating Provider	30% of negotiated fee
Non-participating Provider	50% of negotiated fee plus 100% of excess
Preventive Care
Participating Provider	HealthyCheck Centers: $25 or $75 copay for basic screenings; routine mammogram, PSA and cancer screening, ordered by physician: 25% of negotiated fee; well-baby and well-child, 40% of negotiated fee; Annual Physical Exam, 30% of negotiated fee (deductible
Non-participating Provider	Routine mammogram, PSA and cancer screening, ordered by physician: 50% of negotiated fee plus 100% of excess; Annual Physical Exam, 50% of negotiated fee plus excess for covered services (deductible waived)⁴
Ambulance
Participating Provider	30% of negotiated fee
Non-participating Provider	50% of customary & reasonable plus 100% of excess
Physical and Occupational Therapy; Chiropractic Services
Participating Provider	30% of negotiated fee; limited to 12 visits/year, participating and non-participating combined
Non-participating Provider	All charges except $25/visit; limited to 12 visits/year, participating and non-participating combined
Acupuncture/Acupressure
Participating Provider	All charges except $25/visit; limited to 24 visits/year, participating and non-participating combined (deductible waived)
Non-participating Provider	All charges except $25/visit; limited to 24 visits/year, participating and non-participating combined (deductible waived)
Drug Benefits (retail or mail order: 30-day supply)
Participating Provider	$10 generic⁵; $30 brand copay plus $250 brand deductible⁶ (2 Member Maximum); 30% of negotiated fee for self-administered injectables except insulin Non-Formulary: Participating Provider: Generic⁵ 50%; Brand 100% of negotiated Fee Rate for Bra
Non-participating Provider	50% generic⁵ or 50% of brand drug limited-fee schedule within California; $250 brand deductible⁶

Notes:

	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 and do not apply to the out-of-pocket maximum.
2	Additional $500 admission charge at Participating Hospitals (no additional for Preferred Participating Hospitals) is for surgery or infusion therapy. This charge is not required for Ambulatory Surgical Centers or medical emergencies.
3	Additional $100 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
4	Members covered more than six (6) months, up to $200; members covered less than six (6) months, up to $100
5	Generic drugs are based upon the Blue Cross drug formulary
6	Brand drug deductible does not apply to out-of-pocket maximum.

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