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BLUE SHIELD OF CALIFORNIA PPO

Blue Shield of California PPO members can select doctors and hospitals within the PPO network, or they can pay more and go outside of the network for care.  Unlike the HMO, you do not need to pre-select a primary care physician.  You may see any physician in the Preferred Provider Network.  You do not need to be referred to see a specialist.  Contracted doctors and hospitals in the preferred provider network render covered services to PPO plan members at contracted rates.  Preferred providers will accept Blue Shield’s payment as payment in full after you cover the required deductibles, copayments and coinsurance amounts. 

Providers who have not contracted with Blue Shield to be part of our preferred provider network often charge members more than Blue Shield allowable amounts.  You are responsible for the difference between the amount the non-preferred provider bills and any amount that Blue Shield pays.  Some PPO plan benefits, such as certain preventive care and office visits, are not covered when accessed from a non-contracted provider. 

PPO Plan Summary

• Annual calendar year deductible: $100/individual; $300/family
• $10 office visit copay; out of network 10% coinsurance*
• Prescription drug benefit: up to a 30 day supply through retail $3 generic, $15 brand name at participating pharmacies; also benefits at non participating pharmacies are 25% of allowable amount plus copay; up to 90 day supply through mail service at $3 generic and $35 brand name; 30% up to $150 max copay for specialty medication
• Up to 20 chiropractic visits per calendar year, $25 copay
• Up to 12 acupuncture visits per calendar year, $25 copay
• Emergency room facility services $100 copay; emergency room physician visits 10% coinsurance
• Hospital services 10% coinsurance; non-preferred hospital services 10% copay up to $600 per day maximum payment
• Annual copay calendar year maximum: $300/individual; $900/per family
• No Lifetime maximum benefit (effective 10/1/10)

*Coinsurance is the percentage of the allowable amount or billed charges that you pay for covered services after meeting any applicable plan deductible.

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