|
| 3500
PPO HSA Plan at a Glance: |
|
|
Benefit
|
Participating
Provider
|
Non-Participating
Provider
|
| |
Annual
Deductible (Medical/Pharmacycombined
In-
and out-of-network combined) |
|
|
|
| |
Lifetime
Covered Charges Paid by BCL&H |
|
$5,000,000
per member
|
$5,000,000
per member
|
| |
Annual
Out-of-Pocket Maximum
(Medical/Pharmacy combined
In-
and out-of-network combined) |
|
Single
member: $5,000
Families: $10,000 aggregate
|
Single
member: $5,000
Families: $10,000 aggregate
|
|
|
After
deductible,
0% of the negotiated fee
|
After
deductible, 50% of negotiated fee plus 100% of
charges in excess of the negotiated fee
|
| |
Professional
Services
(x-ray, lab,
anesthesia, surgery, etc.) |
|
After
deductible,
0% of the negotiated fee
|
After
deductible, 50% of negotiated fee plus 100% of
charges in excess of the negotiated fee
|
| |
Hospital
Inpatient
Facility Services |
|
After
deductible,
0% of the negotiated fee
|
After
deductible,
all charges except $650 per day
|
| |
Hospital
Outpatient
Services |
|
After
deductible,
0% of the negotiated fee
|
After
deductible,
all charges except $380 per day
|
| |
Emergency
Services
($100 copay
for each visit – waived if admitted) |
|
After
deductible, $100 copay
plus 0% of the negotiated fee
|
After
deductible,
all charges in excess of 100% of customary and
reasonable for the first 48 hours. After 48 hours:
All charges except $650 per day
|
| |
Preventive
Care
| - |
Routine
Mammogram, Pap and PSA tests |
| - |
Well
Baby & Well Child
(through age 6)
|
|
|
| |
|
After
deductible,
$0 of the negotiated fee
|
|
After
deductible,
$0 of the negotiated fee
|
|
$25
and $75 copay for basic screenings
(deductible waived)
|
|
|
| |
|
After
deductible, 50% of negotiated fee
plus 100% of charges in excess of
the negotiated fee
|
|
After
deductible, 50% of negotiated fee
plus 100% of charges in excess of
the negotiated fee
|
|
|
|
|
After
deductible,
0% of the negotiated fee
|
After
deductible, 50% of negotiated fee plus 100% of
charges in excess of the negotiated fee
|
| |
Physical
and Occumational Therapy;
Chiropractic Services |
|
After
deductible,
0% of the negotiated fee
|
After
deductible,
all charges except $25 per visit
|
| |
Acupuncture
and
Acupressure |
|
After
deductible,
all charges except $25 per visit
|
After
deductible,
all charges except $25 per visit
|
|
|
Not
Covered
|
Not
Covered
|
| |
Prescription
Drugs
(30-day supply retail; up to 60-day supply
available through mail order. Subject to annual
deductible.) |
|
Blue
Cross Formulary Drugs: $10 copay generic copay;
$30 copay brand-name copay after annual deductible;
50% coinsurance for non-formulary drugs; 30% of
negotiated fee for self-administered injectable
drugs, except insulin
|
50%
of the Drug Limited
Fee Schedule within California
|
|
This
information is presented only as a very brief overview of
some of the benefits of this plan, and is intended only
for general education. The amount of benefits provided
depends on the plan selected. Premium will vary with the
type of benefits selected. These plans contain exclusions
from and limitations of coverage. Please see the product
brochure for more complete information, as well as information
about terms of renew ability, preexisting conditions, out-of-network
penalties, and notification requirements. Plans are
subject to health underwriting. To be considered for
reimbursement, expenses must qualify as covered expenses.
Expenses are also subject to reasonable and customary limits,
unless you use a network, and all other policy provisions,
including determinations of medical necessity.
Coverage
Synopsis:
Blue
Cross generally offers the best value for full
coverage. They cover doctor visits, prescription drugs,
vision, accident benefit, and of course, hospitalization.
The coverage and rates are excellent, and they have
what is probably the widest PPO network in the state of
California. Complete details can be seen by opening
the"Outline of Coverage"
brochure for the plan you are interested in:
You
can also refer to the chart above for
a coverage overview.
Notes
on Blue Cross of California HMO plan:
A Health
Maintenance Organization (HMO) is a plan that provides health
care from specific doctors and hospitals that contract with
the plan. While the plans comes with low co-payments
for Doctor Visits ($10) and coverage for maternity benefits,
your geographical service area is often limited, and you
have no coverage if seen by a doctor or hospital that does
not participate with the plan.
With
an HMO, you must first chose a Primary Care Physician (PCP),
from whom you must obtain a referral prior to seeking care
from a specialist. You will not receive coverage for
any (non-emergency) care not authorized by your Primary
Care Physician at your Participating Medical Group.
Rates:
Rates
vary based upon zip code, age, and effective date. You
can get an instant
quote online.
PPO
Network:
Blue
Cross of California gives you access to one of the largest
networks in California, with thousands of health care providers
throughout the state. Having access to the PPO network
can mean substantial discounts in what you pay for your
health care, even before you meet your deductible.
The large list of doctors and hospitals can be viewed at
their online
directory.
Underwriting:
Blue
Cross has one of the easiest, most efficient underwriting
teams in the industry. The process is very fast if
no medical records are needed. While it is always
a good idea to apply at least three weeks prior to the time
you need your new coverage to take effect, some applications
that are done online are approved by Blue Cross within 24
hours.
The
company does have the right to accept or decline any individual
or family application. Certain conditions may be waivered
with a temporary rider (usually for one to two years), or
an indefinite rider. If you are currently being treated
for depression, anxiety, or high cholesterol, please let
us know before you apply so we can make sure there are no
delays in getting you covered.
Effective
dates:
The
coverage can go into effect in as quickly as 24 hours, though
you risk being declined if claims are submitted before the
underwriting process is completed. You may request
an effective date any time the date after you sign the application
and 60 days later. Please note that you will be billed
starting on your requested effective date, even if you have
not yet been notified that you have been approved. This
is very good for someone who does not have any present coverage
and would like for their benefits to begin right away. For
those who are already covered, it is suggested that you
maintain your current coverage in force until you have received
notice from either HSA
for America
or directly
from Blue Cross that your coverage has been approved and
is in force.
Your
earliest possible effective date will be the day after Blue
Cross has received all the necessary documents and information
needed to process your application.
HSA Administrator:
Your
health savings account is totally separate from your health
insurance, and you may use any approved bank or trustee
as your HSA administrator. We recommend that you choose
one from our HSA administrator
page, where you can compare rates and features.
About
Blue Cross of
California:
Blue
Cross of California has been serving the health
care needs of Californians since 1937. Blue Cross
of California, together with its branded affiliates, provides
health care services to more than 6.8 million members.
Blue
Cross of California has been assigned a rating
of "A" (Excellent) from the A.M.
Best Company, an independent insurance rating organization.
HSA
for America is an independent authorized
Blue Cross of CA agent.
CA License
#: 0E39302
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