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Blue Shield Spectrum PPO Plan 750
Oleg Skurskiy An Authorized Agent of Blue Shield of California Call : (818) 987-5000
 

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We offer five deductible levels that make it easy and affordable to get the health care you need. You'll enjoy a wide range of benefits, your choice of providers and many fixed copayments before meeting your deductible.

Plan Features

-Coverage for preventive care, prescription drugs, hospitalization and more


- A range of deductible options


-Preventive care benefits for a fixed copayment before you meet your health plan deductible


-Prescription generic drug benefits at participating pharmacies before you meet your brand-name drug deductible


-Pay 25% or 30% for many covered services (depending on deductible level) after meeting the deductible for preferred providers


-Choice of providers every time you seek covered services. There are lower out-of-pocket costs when you choose from over 45,000 preferred providers.


-Chiropractic care benefits1 before you meet your deductible


-Injectable contraceptives benefits before you meet your deductible

Get complete details for: Shield Spectrum PPO Plan 750(PDF, 114 KB).
DEDUCTIBLE

$750 ($1,500 family)
FIXED DOLLAR COPAYMENTS

$35 with Preferred Choice providers,
$45 with Affiliated providers
PERCENTAGE COPAYMENTS

30% with Preferred Choice providers
40% with Affiliated providers
CALENDAR-YEARCOPAYMENT MAXIMUM (Does not include the plan deductible)

$4,000 ($8,000 family) This copayment maximum also includes copayments from preferred providers when there is no designation of “Choice provider” and “Affiliated provider.”
LIFETIME MAXIMUM

$6,000,000
TOTAL OUT-OF-POCKET COSTS

Deductible + copayment maximum
PROFESSIONAL SERVICES
Physician Services
– Office visits, consultations, OB/GYN and specialist visits and second surgical opinions

$35 with Preferred Choice providers
$45 with Affiliated providers (Deductible Waived)
– Allergy testing and treatment

30% with Preferred Choice providers
40% with Affiliated providers
PREVENTIVE CARE
Annual routine physical exam (office visit) (one per calendar year, age three and over)

$35 with Preferred Choice providers
$45 with Affiliated providers (Deductible Waived)
Annual routine gynecological exam (office visit) (one per calendar year)

$35 with Preferred Choice providers
$45 with Affiliated providers (Deductible Waived)
Well-baby care office visits (from birth through and including age two)

$35 with Preferred Choice providers
$45 with Affiliated providers (Deductible Waived)
Immunizations

No charge (Deductible Waived)
Annual pap test or other approved cervical cancer screening tests and routine mammography (if part of the Annual Routine Physical or Gynecological Exam)

No charge
Routine screening laboratory and other services ordered during preventive care office visits (per facility, per date of service)

30%
OUTPATIENT SERVICES
– Non-Emergency services and procedures

30% with Preferred Choice providers
40% with Affiliated providers
– Surgery services received in an outpatient department of a hospital

30% with Preferred Choice providers
40% with Affiliated providers
– Surgery services received in an ambulatory surgery center (ASC)

30%
– Radiological procedure requiring prior authorization (such as CT scans, MRIs, and MRAs)

30%
– Outpatient or out-of-hospital X-ray and laboratory (per facility, per date of service)

30%
HOSPITALIZATION SERVICES
– Inpatient physician visits and consultations, surgeons and assistants, anesthesiologists, pathologists, radiologists

30% with Preferred Choice providers
40% with Affiliated providers
– Inpatient semiprivate room and board, services and supplies, and subacute care

30% with Preferred Choice providers
40% with Affiliated providers
EMERGENCY HEALTH COVERAGE
– Emergency room facility services

30%
– Inpatient physician visits and consultations, surgeons and assistants, anesthesiologists, pathologists, radiologists

30%
– Inpatient semiprivate room and board, services and supplies, and subacute care

30%
AMBULANCE SERVICES
– Surface or Air

30%
PRESCRIPTION DRUG COVERAGE6
At Participating Pharmacies (up to a 30-day supply)
– Generic formulary drugs

$10/prescription (Deductible Waived)
– Brand-name formulary drugs

$30/prescription
– Non-formulary brand-name drugs

$45+10% (maximum copayment of $100 per prescription)
– Home self-administered injectables

30%
Mail Service Prescription (up to a 60-day supply)
– Generic formulary drugs

$10/prescription (Deductible Waived)
– Brand-name formulary drugs

$30/prescription
– Non-formulary brand-name drugs

$75+10% (maximum copayment of $150 per prescription)
– Home self-administered injectables

Not covered
DURABLE MEDICAL EQUIPMENT
– Prosthetic appliances and home medical equipment

30%
MENTAL HEALTH SERVICES9
– Inpatient hospital facility services

30%
– Inpatient physician services

30%
– Outpatient visits for severe mental health conditions

$35 copayment (Deductible Waived)
– Outpatient visits for non-severe mental health conditions (up to 20 visits per calendar year combined with chemical dependency visits)

30%
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)
– Inpatient hospital facility services for medical acute detoxification

30% with Preferred Choice providers
40% with Affiliated providers
– Inpatient physician services for medical acute detoxification

30% with Preferred Choice providers
40% with Affiliated providers
– Outpatient visits (up to 20 visits per calendar year combined with non-severe mental health visits)

30%
HOME HEALTH SERVICES
– Home Health Services

30%
OTHER
Pregnancy and Maternity Care (An initial $1,000 copayment per pregnancy applies to professional delivery services)
– Outpatient prenatal and postnatal care

30% with Preferred Choice providers
40% with Affiliated providers
– Delivery and all necessary inpatient hospital services

30% with Preferred Choice providers
40% with Affiliated providers
Family Planning
(no benefits are provided for infertility services; oral contraceptives are covered under the outpatient prescription drug benefit)
– Consultations

30% with Preferred Choice providers
40% with Affiliated providers
– Tubal ligation, vasectomy, elective abortion

30% with Preferred Choice providers
40% with Affiliated providers
– Injectable Contraceptives

$25 copayment (Deductible Waived)
Physical Medicine (benefits subject to periodic review for medical necessity)
– Provided by M.D. (in physician’s office or a hospital outpatient department); or in the office of a physical, occupational, or respiratory therapist

30% with Preferred Choice providers
40% with Affiliated providers
Chiropractic Services (up to 12 visits per calendar year)
– Received from a chiropractor

50% up to $25 (member responsible for all charges over $25) (Deductible Waived)
Skilled Nursing Facility (SNF) and Subacute Care (following transfer from hospital unless Blue Shield gives written authorization; up to 100 days per calendar year)
– Semiprivate accommodations in a hospital SNF unit

30%
– Semiprivate accommodations in a freestanding SNF unit

30%
Out-of-State Services (full plan benefits covered nationwide with the BlueCard program)

30% with BlueCard Participating Providers
Diabetes Care
– Diabetes care supplies (diabetic testing supplies are covered under the Outpatient Prescription Drug benefit)

30%
– Diabetes self-management training

$35 with Preferred Choice providers
$45 with Affiliated providers (Deductible Waived)
Active Start Plan 35 PPO - No Medical Deductible   Shield Spectrum PPO 5000   Access®+ Value HMO
Active Start Plan 25 PPO - No Medical Deductible   Shield Spectrum PPO 2000   Access®+ HMO
Balance Plan PPO 1000 - no Maternity   Shield Spectrum PPO 1500    
Balance Plan PPO 1700 - no Maternity   Shield Spectrum PPO 750   Blue Shield Senior
Balance Plan PPO 2500 - no Maternity   Shield Spectrum PPO 500    
Essential Plan PPO 1750 Dental & Vision Included   Blue Shield Short Term
Essential Plan PPO 3000 Dental & Vision Included HSA Savings Plan 2400 / 4800  
Essential Plan PPO 4500 Dental & Vision Included HSA Savings Plan 4000 / 8000  

Coinsurance amounts represented with a "%" are payable after the plan deductibles are reached; Co-pay amounts represented with a "$" are not subject to plan deductibles (except where noted). Refer to contract for a detailed explanation of plan benefits, features, exclusions and limitations. Benefits subject to change without notice. Co-pays, Deductibles, and Coinsurance amounts listed above are your share of the costs for covered benefits.

Do Not Cancel your current coverage until a new policy is approved and you have received written confirmation of the policy's rates and benefits from the insurance company. Rate and Benefit Disclaimer Notification! The rate and benefit information provided herein was generated by the Quotit Corporation's individual health insurance quoting system. The Quotit Corporation or It's Licensee's do not guarantee or warrant the correctness or completeness of the rate and benefit information contained herein and shall not be liable for any loss or damage arising out of use of the quoted rate and benefit information.

Additionally, information contained in this website is limited in scope, subject to change without notice, and does not contain all the terms, conditions, limitations, or exclusions of the referenced benefit plans. Only the insurance company Plan Documents and Policy's contain the exact terms and conditions of coverage. Your grant of access to the rate and benefit summaries contained herein may not be relied upon as a guarantee of your eligibility or coverage under these benefit plans.

Blue Shield of California Life & Health Insurance Company Life was formed in 1954 as a wholly owned subsidiary of Blue Shield of California to provide a full range of insurance products for their customers. With 3.3 million members and $7.5 billion in annual revenue, Blue Shield of California is the state's third largest health plan. Founded in 1939 and headquartered in San Francisco, Blue Shield is a not-for-profit corporation with approximately 4,300 employees and more than 20 offices throughout California.

Blue Shield of California Life & Health Insurance Company Life has grown by offering competitive insurance products including Group Term Life, Accidental Death & Dismemberment, Blue Shield of California Life & Health Insurance Company Life Vision Plan, Stop Loss and Exec-U-Med medical reimbursement plans in tandem with Blue Shield of California health plans or on a stand-alone basis . In the early 1980s, introduced their Short-Term Health products. The Option One and Option Twelve plans remain one of the leading products of their kind in California
 
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Copyright © 2005 Oleg Skurskiy Authorized Independent Agent, CA License 0E50389