Balance 2500

The Balance 2500 plan from Blue Shield of California features the following:

Plan Type: PPO
Deductible: $2,500

In-Patient Hospital Co-Payment/Coinsurance: 30%
Prescription Drug Coverage (Out Patient): Yes
Maternity Coverage Included: No

Balance 2500 Summary:

	In Network	Out of Network
Annual Deductible	Individual: $2,500 Family: $5,000	Individual: $2,500 Family: $5,000
Annual Out-Of-Pocket Limit	Individual: $7,500 Family: $15,000	Individual: $10,500 Family: $21,000
Lifetime Maximum	$6,000,000	$6,000,000
Office Visits	$30	50%
Prescription Drugs	Generic: $10 Brand Formulary: $35 Brand Non-Formulary $50 or 50%, whichever is greater ($500 Brand Deductible, $2,500 Brand max/calendar year)	Not Covered
Laboratory and Radiology	30%	50%
Annual Physical Exam	$30	Not Covered
Annual OB-GYN Exam	$30	Not Covered
Well Baby Care	$30	Not Covered
Outpatient Surgery	30% plus $250 per visit	50% ($250 maximum benefit per day)
Emergency Room	$100/visit (waived if admitted), then 30% (deductible waived)	$100/visit (waived if admitted), then 30% (deductible waived)
Ambulance	30%	30%
Home Health Care	30% (90 visits per year)	Not Covered
Mental Health Services - Outpatient	30% (20 visits per year)	Not Covered
Chiropractic Care	50% (maximum benefit $25 per visit, 15 visits per year)	Not Covered
Acupuncture / Acupressure	50% (maximum benefit $25 per visit, 15 visits per year)	50% (maximum benefit $25 per visit, 15 visits per year)
Inpatient Hospital	30%	50% ($250 maximum benefit per day)
Maternity Care	Not Covered	Not Covered
Mental Health - Inpatient	30%	50% ($250 maximum benefit per day)
Chemical Dependency	30%	50% ($250 maximum benefit per day)

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.