PPO 3500 (HSA-Compatible) Plan

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The PPO 3500 (HSA-Compatible) and 3500 Deductible PPO 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 PPO 3500 (HSA-Compatible) plan, you have the opportunity to combine a tax-advantaged HSA with your health plan. The plan also offers a combined medical/pharmacy deductible so your payments for prescription drugs apply toward your deductibles and out-of-pocket limit.
 
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.
 
Want to know more? See the following benefits-at-a-glance for a detailed look at the benefits our PPO 3500 HSA-Compatible Plan offers. 
If you have any questions, you can:  

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PPO 3500 (HSA-Compatible) 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 (combined for medical benefits and prescription drugs)  
Family Maximum: $7,000 aggregate (combined for medical benefits and prescription drugs)  
Annual Out-of-Pocket Limit1
(in addition to deductible) 
Single Member: $1,500 (combined for medical benefits and prescription drugs) 
Family Maximum: $3,000 aggregate (combined for medical benefits and prescription drugs)  
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 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 
After annual deductible is met:   
Generic(Tier 1): $15 copay  
Brand-name (Tier 2): $35 copay   
After annual deductible is met:  
50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits   

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 out-of-pocket maximum except where specifically noted in the policy.

2Additional $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.