Blue Cross of California Individual RightPlan PPO 40 (No Rx) California Health Insurance Plan Details

Insurance Plan Summary
Company
Blue Cross of California
Plan Name
Individual RightPlan PPO 40 (No Rx)
Plan Type
PPO
Primary Care Physician Required
No 
Specialist Referrals Required
No 
HSA Eligible
No 
Out-of-Network Coverage
Yes
In-Network Coverage
Coinsurance
40% 
Office Visit
 
Primary Doctor
$40 Copay 
Specialist
$40 Copay 
Periodic Health Exam
HealthyCheck Centers: $25 Copay for basic screenings or $75 Copay for premium screenings (ages 7 to adult) 
Periodic OB-GYN Exam
$40 Copay plus 40% Coinsurance 
Well Baby Care
$40 Copay plus 40% Coinsurance 
Chiropractic
40% Coinsurance, 12 visits Max. per year 
Mental Health
Plan pays $25 per visit, 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
40% Coinsurance 
Emergency Room
$100 Copay (waived if admitted) plus 40% Coinsurance 
Outpatient Surgery
$500 Copay Per Surgical Admission plus 40% Coinsurance 
Hospitalization
$500 Copay Per Day plus 40% Coinsurance, 4-day Maximum Copay Per Admission 
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
Individual RightPlan PPO 40 (No Rx)
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