Blue Cross of California Basic PPO 2500 California Health Insurance Plan Details

Insurance Plan Summary
Company
Blue Cross of California
Plan Name
Basic PPO 2500
Plan Type
PPO
Primary Care Physician Required
No 
Specialist Referrals Required
No 
HSA Eligible
No 
Out-of-Network Coverage
Yes
In-Network Coverage
Coinsurance
20% after deductible 
Office Visit
 
Primary Doctor
Not Covered until out-of-pocket limit met; then covered 100% 
Specialist
Not Covered until out-of-pocket limit met; then covered 100% 
Periodic Health Exam
HealthyCheck Centers: $25 Copay for basic screenings or $75 Copay for premium screenings (ages 7 to adult), deductible waived 
Periodic OB-GYN Exam
20% Coinsurance, deductible waived 
Well Baby Care
Not Covered 
Chiropractic
Not Covered 
Mental Health
Plan pays $25 per visit after out-of-pocket is met, up to 20 visits per calendar year 
Prescription Drugs
 
Generic
Not Covered 
Brand
Not Covered 
Non-Formulary
Not Covered 
Separate Rx Deductible
None 
Mail Order
Not Available
Outpatient Lab/X-Ray
No Charge after out-of-pocket maximum is met 
Emergency Room
$100 Copay (waived if admitted)
Plus 20% Coinsurance after deductible 
Outpatient Surgery
20% Coinsurance after deductible 
Hospitalization
20% Coinsurance after deductible 
Maternity
 
Pre & Postnatal Office Visit
Not Covered 
Labor & Delivery Hospital Stay
Not Covered 
Additional Information
Will insurance company obtain and pay for medical records?
Yes
eSign
(electronic signature)
Yes
A.M. Best Rating
A
as of 11/06/2006
More Insurance Plan Details
More Details
Exclusions and Limitations
Exclusions and Limitations
Actions
Company
Blue Cross of California
Plan Name
Basic PPO 2500
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