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PPO 3500 1 MemberAnthem Logo

Blue Cross PPO 3500 1 Member Plan Information

The PPO 3500 1 Member plan from Blue Cross of California (Anthem Blue Cross) features the following:

Plan Type: PPO
Deductible: $3,500
In-Patient Hospital Co-Payment/Coinsurance: $0
Prescription Drug Coverage (Out Patient): Yes
Maternity Coverage Included: No

Demarketed




PPO 3500 1 Member Summary:

In Network Out of Network
Annual Deductible $3,500/member $3,500/member
Annual Out-Of-Pocket Limit $3,500/member $6,500/member
Lifetime Maximum $5,000,000 $5,000,000
Office Visits No Charge after Deductible 50% of negotiated fee plus all excess charges
Prescription Drugs Generic: $15 Brand Formulary: $35 ($500 Brand Deductible) 2 member max 50% of the Drug Limited Fee Schedule ($500 Brand Deductible) See brochure for complete details
Laboratory and Radiology No Charge after Deductible 50% of negotiated fee, plus all excess charges
Annual Physical Exam $25/$75 Co-Pay at HealthyCheck Centers for Basic/Premium Screening 50% of negotiated fee, plus all excess charges
Annual OB-GYN Exam No Charge after Deductible 50% of negotiated fee, plus all excess charges
Well Baby Care No Charge after Deductible 50% of negotiated fee, plus all excess charges
Outpatient Surgery No Charge after Deductible, see brochure for complete details All Charges Except $380/day after Deductible
Emergency Room No Charge after Deductible plus $100 (Waived if admitted) $100 (Waived if admitted) plus all charges in excess of customary and reasonable fees
Ambulance No Charge after Deductible 50%
Home Health Care No Charge after Deductible (60 visits/year, 4 hours each visit maximum) No Charge after Deductible (60 visits/year, 4 hours each visit maximum)
Mental Health Services - Outpatient See Brochure See Brochure
Chiropractic Care No Charge after Deductible (24 visits/year) All charges except $25/visit after Deductible (24 visits/year)
Acupuncture / Acupressure All charges except $30/visit after Deductible (24 visits/year) All charges except $30/visit after Deductible (24 visits/year)
Inpatient Hospital No Charge after Deductible, see brochure for complete details All Charges Except $650/day after Deductible
Maternity Care Not Covered Not Covered
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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Copyright © 2017 Dave Terpening Insurance Agency, Inc. |  CA Lic# 0G47857
Blue Cross of California is an independent licensee of the Blue Cross Association. The Blue Cross name and symbol are registered service marks of the Blue Cross Association.

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