LAPRA - Blue Cross PPO

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Active Members

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.

PPO PLAN RATES - MEMBER COST PER PAY PERIOD

MEMBER ONLY	$0.00
TWO-PARTY	$32.00
FAMILY	$67.36

PPO PLAN BENEFIT OVERVIEW - EFFECTIVE 7/1/08

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 (Excludes deductible, co-payments, mental or nervous disorder and chemical and substance abuse.)
LIFETIME MAXIMUM	$5,000,000 PER COVERED PERSON

HOSPITAL SERVICES

EMERGENCY ROOM	$75 co-pay; waived if admitted (Co-pay is in addition to deductible)
URGENT CARE VISITS	For Visits at an urgent care facility 90% Par¹ 70% Non-Par²
INPATIENT (Room, Board and Support Services)	90% Par¹ 70% Non-Par² (Failure to obtain pre-authorization of services will result in a 20% penalty)
INPATIENT MATERNITY CARE	90% Par¹ 70% Non-Par²

PHYSICIAN SERVICES

OFFICE VISITS

90% Par¹ 70% Non-Par²

SPEECH THERAPY (outpatient speech therapy following injury or organic disease

90% Par 90% Non-Par⁷

PHYSICAL THERAPY, Physical Medicine, Occupational Therapy, Chiropractic Services (limited to 24 visits/cal yr)

90% Par¹ 70% Non-Par²(Non-Par Services are limited to a maximum benefit of $25 per visit)

HEALTH MAINTENANCE

ROUTINE PHYSICAL EXAMINATIONS FOR SUBSCRIBERS AND DEPENDENTS	At Participating Providers Only: $25 co-payment; 100% up to $250 calendar year maximum. Not subject to the deductible.
WELL WOMAN CARE	90% Par¹ 70% Non-Par² 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% Par¹ 70% Non-Par²

CHEMICAL DEPENDENCY AND SUBSTANCE ABUSE

INPATIENT HOSPITAL	90% Par¹ 70% Non-Par² 30-days per calendar year, except for detoxification
OUTPATIENT HOSPITAL	Par¹: 50% up to $75/visit Non-Par²: 50% up to $25/visit. Up to 50 visits per calendar year participating and non-participating providers combined.

MENTAL OR NERVOUS DISORDER

INPATIENT PROFESSIONAL³	90% Par¹ 70% Non-Par²
OUTPATIENT PHYSICIAN SERVICES³	Par¹: 50% up to $75/visit Non-Par²: 50% up to $25/visit.

OTHER COVERED EXPENSES

HEARING AID BENEFIT	Plan pays 80% up to $1,500 for both ears every 3 years; deductible waived
PRESCRIPTION DRUGS - RETAIL PHARMACY (30 day supply)	$15 for Generic -$25 for Brand⁴ 20% (to a maximum of $100 co-pay per prescription for injectables⁶
PRESCRIPTION DRUGS - MAIL ORDER (90 day supply)	$15 for Generic -$25 for Brand 20% (to a maximum of $100 co-pay per prescription for injectables⁶
VISION CARE	$20 co-pay every 12 months for eye exams, lenses and frames. Vision care provided by Vision Service Plan (VSP).

1. Par (or In-Network) refers to Participating Blue Cross Provider. For Outside California, it is a Blue Cross/Blue Shield Provider. There is substantial savings when you use a Par Provider. Subject to the deductible.

2. Non-Par (or Out-of-Network) is a Non-Participating Provider. Out-of-Pocket benefits are higher when you choose to use a Non-Par Provider. Subject to the deductible.

3. Visit or day limits do not apply to certain mental health care described in the Evidence of Coverage.

4. 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.

5. Co-pay maximum does not apply to infertility treatment under the CaliforniaCare "Plus" Plan

6. The 20% co-pay does not apply to insulin. The standard co-pays of $15 Generic and $25 brand name apply to insulin.

7. Professional services that may be available from Blue Cross 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.

Note: Covered services for the treatment of severe mental disorders will not be subject to any limitations applicable to mental or nervous disorders. Such services will be subject to all other terms, conditions, limitations and exclusions, including applicable Medical Benefit Maximums.

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.

** 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.

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