Blue Cross of California PPO 3500 HSA-Compatible - Individual California Health Insurance Plan Details

Insurance Plan Summary
Company
Blue Cross of California
Plan Name
PPO 3500 HSA-Compatible - Individual
Plan Type
PPO
Primary Care Physician Required
No 
Specialist Referrals Required
No 
HSA Eligible
Yes 
Out-of-Network Coverage
Yes
In-Network Coverage
Coinsurance
None 
Office Visit
 
Primary Doctor
No Charge after deductible 
Specialist
No Charge after deductible 
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
No Charge after deductible 
Well Baby Care
No Charge after deductible 
Chiropractic
No charge after deductible, 12 visits Max. Per Year 
Mental Health
Plan pays $25 per visit after deductible, up to 20 visits per calendar year 
Prescription Drugs
 
Generic
$10 Copay after deductible 
Brand
$30 Copay after deductible 
Non-Formulary
50% Coinsurance after deductible 
Separate Rx Deductible
Medical Plan Deductible Applies 
Mail Order
Available
Outpatient Lab/X-Ray
No Charge after deductible 
Emergency Room
$100 Copay (waived if admitted), then 0% of negotiated fee after deductible 
Outpatient Surgery
No Charge after deductible 
Hospitalization
No Charge 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
PPO 3500 HSA-Compatible - Individual
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