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The PPO Share 5000 plan from Blue Cross of California (Anthem Blue Cross) features the following:

Plan Type: PPO
Deductible: $5,000
In-Patient Hospital Co-Payment/Coinsurance: 30%
Prescription Drug Coverage (Out Patient): Yes
Maternity Coverage Included: Yes
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PPO Share 5000 Summary:

In Network Out of Network
Annual Deductible Individual: $5,000 Family: $10,000 Individual: $5,000 Family: $10,000
Annual Out-Of-Pocket Limit Individual: $2,500/member (Deductible not Included) Individual: $2,500/member (Deductible not Included)
Lifetime Maximum $5,000,000 $5,000,000
Office Visits $40 50% of negotiated fee plus all excess charges (Deductible waived)
Prescription Drugs Generic: $15 Brand Formulary: $35 ($750 Brand Deductible; 2 member max) 50% of the Drug Limited Fee Schedule ($750 Brand Deductible)
Laboratory and Radiology 30% of negotiated fee 50% of negotiated fee plus all excess charges
Annual Physical Exam 30% of negotiated fee, Deductible waived (See brochure for complete details) 50% of negotiated fee plus all excess charges (Deductible Waived)
Annual OB-GYN Exam 30% of negotiated fee (Deductible Waived) 50% of negotiated fee plus all excess charges (Deductible Waived)
Well Baby Care 40% of negotiated fee (Deductible Waived) 50% of negotiated fee plus all excess charges (Deductible Waived)
Outpatient Surgery 30% of negotiated fee All Charges Except $380/day
Emergency Room 30% of negotiated fee plus $100 (Waived if admitted) 30% of customary and reasonable fees plus all excess charges
Ambulance See Brochure See Brochure
Home Health Care See Brochure See Brochure
Mental Health Services - Outpatient See Brochure See Brochure
Chiropractic Care 30% of negotiated fee (24 visits/year) All charges except $25/visit (24 visits/year)
Acupuncture / Acupressure All charges except $30/visit (Deductible Waived, 24 visits/year) All charges except $30/visit (Deductible Waived, 24 visits/year)
Inpatient Hospital 30% of negotiated fee All Charges Except $650/day after Deductible
Maternity Care 30% of negotiated fee 50% of negotiated fees plus all excess charges
Mental Health - Inpatient See Brochure See Brochure
Chemical Dependency See Brochure See Brochure

 

IMPORTANT NOTICE: Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Out of pocket maximum shown includes the plan deductible unless otherwise noted. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification!

Information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage.

 

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