| Active Members |
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| Under the Blue Cross PPO Prudent Buyer Plan, you have the greatest choice of healthcare professionals because you may receive healthcare services from any licensed healthcare professional for your covered services. You may choose between a Blue Cross PPO provider and a non-PPO provider (a provider who does not belong to the Blue Cross PPO network). However, you may receive significant cost reductions and a higher level of benefit coverage when you visit Blue Cross PPO network healthcare professionals for covered services. When you use a non-PPO provider, you may be required to pay for the service at the time services are rendered and to submit your own claim forms to Blue Cross. |
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| PPO PLAN RATES - MEMBER COST PER PAY PERIOD |
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| Member Only |
$0.00 |
| Two Party |
$25.04 |
| Family |
$61.29 |
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| PPO PLAN BENEFIT OVERVIEW - EFFECTIVE 7/1/10 |
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| CALENDAR YEAR DEDUCTIBLE |
$250 per individual / $500 maximum per family |
| OUT OF POCKET MAXIMUM (Excluding Routine co-pay and ER co-pay) |
$1,500 per individual In-network; and
$1,500 per individual Out-of-Network
(excludes deductible & co-payments) |
| LIFETIME MAXIMUM |
$5,000,000 per covered person |
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| HOSPITAL SERVICES |
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| EMERGENCY ROOM |
$75 co-pay; waived if admitted
(Co-pay is in addition to the deductible) |
| URGENT CARE VISITS |
For Visits at an urgent care facility:
90% In-Network (1) / 70% Out-of-Network (2) |
| INPATIENT (Room, Board and Support Services) |
90% In-Network (1) / 70% Out-of-Network (2)
(Failure to obtain pre-authorization of
services will result in a 20% penalty) |
| INPATIENT MATERNITY CARE |
90% In-Network (1) / 70% Out-of-Network (2) |
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| PHYSICIAN SERVICES |
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| OFFICE VISITS |
90% In-Network (1) / 70% Out-of-Network (2) |
| SPEECH THERAPY (outpatient speech therapy following injury or organic disease) |
90% In-Network / 90% Out-of-Network |
| PHYSICAL THERAPY, Physical Medicine, Occupational Therapy, Chiropractic Services (limited to 24 visits/cal yr) |
90% In-Network (1) / 70% Out-of-Network (2)
(Out-of-Network Services are limited
to a maximum benefit of $25 per visit) |
| ACUPUNCTURE (limited to 24 visits/cal yr) |
90% In-Network (1) / 70% Out-of-Network (2)
(Services are limited to a maximum benefit of
$30 per visit) |
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| HEALTH MAINTENANCE |
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| ROUTINE PHYSICAL EXAMINATIONS FOR SUBSCRIBERS AND DEPENDENTS |
At In-Network Providers Only: |
| $25 co-payment; 100% up to $250 calendar year maximum. Not subject to the deductible. |
| WELL WOMAN CARE |
90% In-Network (1) / 70% Out-of-Network (2)
1 routine gynecology physical exam per calendar year. Includes breast and pelvic exams, mammogram & pap smears. |
| WELL BABY AND WELL CHILD CARE, Up to Age 19 |
90% In-Network (1) / 70% Out-of-Network (2) |
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| CHEMICAL DEPENDENCY AND SUBSTANCE ABUSE |
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| INPATIENT |
90% In-Network (1) / 70% Out-of-Network (2) |
| OUTPATIENT |
90% In-Network (1) / 70% Out-of-Network (2) |
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| MENTAL OR NERVOUS DISORDER |
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| INPATIENT |
90% In-Network (1) / 70% Out-of-Network (2) |
| OUTPATIENT |
90% In-Network (1) / 70% Out-of-Network (2) |
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| OTHER COVERED EXPENSES |
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| HEARING AID BENEFIT |
90% In-Network (1) / 80% Out-of-Network (2)
up to $1,500 for both ears every 3 years;
deductible waived |
| PRESCRIPTION DRUGS - RETAIL PHARMACY (30 day supply) |
$15 for Generic - $25 for Brand3 |
| 20% (to a maximum of $100 co-pay per prescription) for injectables5 |
| PRESCRIPTION DRUGS - MAIL ORDER (90 day supply) |
$15 for Generic - $25 for Brand |
| 20% (to a maximum of $100 co-pay per prescription) for injectables5 |
| VISION CARE |
$20 co-pay every 12 months for eye exams, lenses and frames. Vision care provided by Vision Service Plan (VSP). |
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| 1. In-Network refers to Participating Blue Cross Provider. For Outside California, it is a Blue Cross/Blue Shield Provider. There are substantial savings when you use a Network Provider. Subject to the deductible. |
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| 2. Out-of-Network is a Non-Participating Provider. Out-of-Pocket costs are higher when you choose to use an Out-of-Network Provider. Subject to the deductible. |
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| 3. Participating Blue Cross Pharmacy: When a generic equivalent is available, you will pay the brand co-pay plus the difference of prescription drug covered expense between the generic and the brand name drug. |
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| 4. Co-pay maximum does not apply to infertility treatment under the CaliforniaCare "Plus" Plan. |
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| 5. The 20% co-pay does not apply to insulin. The standard co-pays of $15 Generic and $25 brand name apply to insulin. |
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| 6. Professional services that may be available from Blue Cross In-Network (PPO) providers, but would usually be available from providers whose specialities are not represented in the Blue Cross PPO network, are payable at the higher reimbursement level of the plan. |
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| The foregoing brief description of benefits is provided for your convenience and is subject to all terms, conditions, limitations and exclusions of the Blue Cross contract. Please refer to the Blue Cross evidence of coverage for details on benefits. |
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| All members and their families are encouraged to utilize the Los Angeles Police Protective League’s Employee Assistance Program (EAP) prior to accessing your selected medical plan. The EAP provides 10 sessions covered at no cost to the family. |
