3500 Deductible PPO Plan

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The 3500 Deductible PPO and PPO 3500 (HSA-Compatible) plans are high-deductible health care plans designed to help keep your premiums low. Both plans provide simple, yet comprehensive coverage. Just meet your annual deductible and then the plans will cover most network services at 100%. Please note, however, that maternity benefits are not included with these plans.  
 
With the 3500 Deductible PPO plan, the annual out-of-pocket limit is met once the medical deductible is met. The plan also offers a separate $500 brand-name prescription drug deductible, which means that your drug benefits begin when this deductible is met.  
 
With a PPO (preferred provider) health plan, you’ll pay a lower share of your medical expenses when you use doctors or hospitals that participate in our PPO provider network. And with more than 50,000 PPO doctors and nearly 400 hospitals throughout the state of California, the changes are that your doctor is one of ours.  
For a total benefit solution, we also offer a wide range of dental and term life coverage options.  
 
PPO 3500 Plan Features:
  • Easy-to-use coverage Once you meet your deductible, you don't pay anything for most medical services when you use in-network providers. Covered services include doctor's visits, hospital stays, lab work, and emergency room care.
  • Access to one of California's largest networks of providers The Blue Cross network includes more than 50,000 doctors and over 400 hospitals in California. So it’s easy to find a healthcare provider, no matter what part of the state you live in.
  • Affordable drug coverage
    For generic drugs, you only pay $10 for each prescription. If you prefer brand-name drugs, you only have to meet a $500 deductible then prescriptions are just $30 each.
  • Flexible coverage that lets you get out-of-network care If you want to see a healthcare provider outside the Blue Cross network, you can and you'll still get coverage. You'll save more by taking advantage of the convenient Blue Cross network of providers. But you won't have to foot the entire bill if you decide to get care from an out-of-network provider.
  • More control over your healthcare with an HSA The PPO 3500 is also available as an HSA-compatible plan. Get more control over your healthcare, make meeting your deductible more affordable, and save money for retirement with a Health Savings Account.
 
Want to know more? See the following benefits-at-a-glance for a detailed look at the benefits our 3500 Deductible PPO Plan offers.  
If you have any questions, you can:
 
 
 
3500 Deductible PPO Plan benefits at-a-glance
These amounts show your share of costs after deductibles, if any. 
Plan Benefit 
In-Network
Receive negotiated savings 
Out-of-network
Pay higher costs 

Lifetime Maximum
(combined for in-network and out-of-network)
Health plan pays up to $5,000,000 per member 
Annual Deductible (combined for in-network and out-of-network) 
Single Member: $3,500 per member 
Family Maximum: Each family member has an individual deductible Once 2 members each reach the deductible, the deductible is satisfied for the entire family. 
Annual Out-of-Pocket Limit1
(in addition to deductible) 
Single Member and Family Maximum: Satisfied once the annual deductible is met. 
Single Member and Family Maximum: $6,500 per member (once 2 members each reach the maximum, the maximum is satisfied for entire family). 
Doctors’ Office Visits  
$0 after deductible 
50% of negotiated fee plus all excess charges (after deductible) 
Professional Services
(x-ray, lab, anesthesia, surgeon, etc.) 
$0 after deductible 
50% of negotiated fee plus all excess charges (after deductible) 
Hospital Inpatient
(overnight hospital stays) 
$0 after deductible2  
All charges except $650 per day (after deductible) 
Hospital Outpatient
(if you don’t stay overnight) 
$0 after deductible2  
All charges except $380 per day(after deductible) 

Emergency Room Services
($100 copay applies for each visit; waived if admitted as inpatient.)
$0 after deductible 
All charges in excess of customary and reasonable fees (after deductible) 
Maternity 
Not covered  
Not covered 

Preventive Care
(tests ordered by physician are covered, including appropriate screening for breast, cervical, ovarian and prostate cancer)
Routine mammogram, Pap and PSA tests: $0 after deductible 
HealthyCheckSM Centers: $25/$75 copay for basic/premium screening (deductible waived)  
50% of negotiated fee plus all excess charges (after deductible) 
Well Baby and Well Child (through age 6): $0 after deductible 

Acupuncture/Acupressure
(combined for in-network and out-of-network and up to 12 visits per year)
All charges except $30 per visit (after deductible) 
Chiropractic Services
(combined for in-network and out-of-network and up to 12 visits per year) 
0% after deductible 
All charges except $25 per visit (after deductible) 
 

Prescription Drug Coverage Options
(see brochure for more information)
In-Network
Receive negotiated savings 
Out-of-network
Pay higher costs 
Generic (Tier 1): $15 copay   
Brand-name (Tier 2): $35 copay after annual $500 brand-name prescription drug deductible (2-member maximum)  
50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits, subject to the $500 annual brand-name prescription drug deductible  

1 Excludes non-participating charges in excess of the Anthem Blue Cross negotiated fee and non-participating charges in excess of customary and reasonable fees for emergency care. Copays/coinsurance to participating and non-participating providers apply to the annual calendar out-of-pocket limit except where specifically noted in the policy.

2 Additional $500 admission charge at participating hospitals (no additional charge for preferred participating) is for inpatient stays or outpatient surgery or infusion therapy. The charge is not required for ambulatory surgical centers or medical emergencies.