Blue Shield of California PPO

Overview

Blue Shield of California Network (PPO) covers most forms of medically necessary care subject to various limits.  After you satisfy the annual deductible of $1,000, the Plan pays 70% of covered charges (or 90% if you use the PPO).

Annual Deductible

Before any payments are made by the plan you must satisfy the annual deductible.

Individual - $1,000 per calendar year

Family - $3,000 per calendar year.
This is the maximum total deductible for all family members combined.

Hospital Deductible

For each hospitalization

PPO - 10% co-payment

Non-PPO - 30% co-payment. Additional $200 Deductible for non-Blue Shield PPO Hospital or Residential Treatment Center. Hospital precertification is required.

Coinsurance

The portion (percentage) of the charges that the plan pays after all deductibles have been satisfied.

For most services the following schedule applies until you reach the maximum amount of charges. Please see the Schedule of Benefits for a complete list of schedules and coinsurance rates.

After the maximum of $12,500 in covered charges has been reached for a family member in a calendar year, subsequent charges for that family member are paid at 100%.

Important: Only charges of PPO Providers are automatically considered "covered" for the purpose of the annual out-of-pocket maximum. Charges from other providers may exceed the amount allowed so you will have to pay the excess out-of-pocket, and these excess charges will not count towards the $12,500 maximum.

Other Out-of-Pocket Expenses

Are those which are not covered by the plan and for which you are responsible. These do not count towards your coinsurance maximum.

• Non-PPO providers may charge amounts in excess of the UCR (usual, customary and reasonable) amounts allowed by the plan.
• Charges for services that exceed your annual maximum or a specific maximum or limit.
• Charges which are not medically necessary including care not approved through the medical review process.

Lifetime Maximum

No plan maximum

Blue Shield
PPO

You are encouraged to receive all of your medical care from providers who are members of the plan's PPO network. Some of benefits you receive for using the Blue Shield PPO are:

• Copayments for some types of care are less.
• Your coinsurance will be lower as shown above.
• PPO provider must directly bill the Plan, rather than making you pay and then request reimbursement.

Click here to locate PPO providers.

Medical Review

The set of programs to help ensure that you receive appropriate care. Penalties will apply if you neglect to use the medical review required by the plan.

• Preadmission certification is mandatory for all non-emergency admissions.
• For emergency hospitalization, Blue Shield must be notified within 1 day of admission.

Coinsurance and Limitations for Some Common Types of Coverage

Consult the Blue Shield's Evidence of Coverage.

Prescription

BIN/PCN/Submitted Group
BIN: 004336
PCN: G77993333
GRP: W3000011

Additional Info:

Phone: 1-855-599-2650
Web Site: www.blueshieldca.com

Summary Schedule of Benefits
Group #: W3000011

Blue Shield – Access at your fingertips, register through the app.
Sign up for your Digital ID Card