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

Insurance Plan Summary
Company
Blue Cross of California
Plan Name
PPO Share 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
30% after deductible 
Office Visit
 
Primary Doctor
$35 Copay, deductible waived 
Specialist
$35 Copay, deductible waived 
Periodic Health Exam
30% coinsurance for annual physical exam or $25/$75 copay for basic/premium screening at HealthyCheck Center - deductible waived 
Periodic OB-GYN Exam
30% Coinsurance, deductible waived 
Well Baby Care
40% Coinsurance, deductible waived 
Chiropractic
30% Coinsurance 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 
Brand
$30 Copay 
Non-Formulary
50% Coinsurance 
Separate Rx Deductible
$500 Individual
$1,000 Family
applies to
Brand 
Mail Order
Available
Outpatient Lab/X-Ray
30% Coinsurance after deductible 
Emergency Room
$100 Copay (waived if admitted)
Plus 30% Coinsurance after deductible 
Outpatient Surgery
30% Coinsurance after deductible 
Hospitalization
30% Coinsurance after deductible 
Maternity
 
Pre & Postnatal Office Visit
30% Coinsurance after deductible 
Labor & Delivery Hospital Stay
30% Coinsurance after deductible 
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
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Exclusions and Limitations
Exclusions and Limitations
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Company
Blue Cross of California
Plan Name
PPO Share 2500
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