The Blue Shield Preferred Provider Organization (PPO) provides you with the flexibility to go to the provider or medical facility of your choice—even if your provider or the facility is not in the Blue Shield network.
If you see providers and go to facilities within the Blue Shield network, however, your out-of-pocket costs are much lower than if you go out of network for your care.
View detailed information about the Blue Shield PPO
| Basics | |
|---|---|
|
Overview |
You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network. When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield. Group #170292 |
|
Pre-Authorization Requirement |
Pre-authorization required for all hospital stays and certain outpatient procedures. PENALTY for not pre-authorizing: benefit reduced to 50% of Blue Shield Allowed Amount. Maximum reduction of $1,000. You pay balance of all charges not covered by Blue Shield. Out-of-Pocket Maximum does not apply. Certain benefits may be denied in full for failure to pre-authrorize. |
| Office copay |
Network: $20 copay primary/$50 copay specialist Non-Network: 60% after deductible |
| Deductible |
Network: $500 per individual/$1,500 per family |
|
Out-of-Pocket Maximum |
Network: $3,500 per individual/$7,000 family A single out-of-pocket maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the out-of-pocket maximum is met.) |
| Preventative Care | |
|---|---|
|
Physical exams for adults |
Network: 100% |
|
Physical exams for children |
Network: 100% |
|
Pap smears |
Network: 100% if part of annual preventive |
|
Immunizations |
Network: 100% Non-Network: Not covered; travel immunizations not covered |
| Well-woman visits | Network: 100% Non-Network: Not covered |
| Prescription Drugs | |
|---|---|
|
Pharmacy (Retail) |
Blue Shield Network pharmacy: $10 generic; $30 brand name; $75 non-formulary -- up to a 30-day supply Non-Network pharmacy: Member pays co-payment plus 25% of billed charges Fertility drugs covered at 50% (deductible does not apply); max benefit of $5,000 per lifetime |
|
Mail order drug program |
$20 generic; $60 brand name; $150 non-formulary -- up to a 90-day supply Must use Blue Shield mail-order service |
|
Birth Control Pills |
Included in Prescription Drug benefit |
Traveling Outside the U.S.
Benefits will be provided for covered services you receive anywhere within the Blue Shield network. Blue Shield has network providers outside of California and the United States.
You can access service outside of California through the BlueCard Worldwide® Network.
If you need care while out of the country, call the toll-free BlueCard Program Access number at (800) 810-2583, or call collect at (804) 673-1177, 24 hours a day, seven days a week.
Before traveling abroad, call Blue Shield Customer Service at (800) 873-3605 to find out what you need to make your plan work for you when you travel. For more information, visit the Blue Shield’s website.
In an emergency, go directly to the nearest hospital. As soon as possible, you should call Blue Shield at (800) 343-1691 or call collect at (804)673-1177, 24 hours a day, seven days a week.
