Applications Provider Finder Members PlanScape Blue Cross of California The RightPlan PPO 40 Individual Health Plan Low Premium, No Medical Deductible PPO Plan Want to know what benefits come with the RightPlan PPO 40 health insurance plan? Below you'll find the answer. If you have any questions, or would like more info on RightPlan PPO 40 health plan benefits, call your agent (818)987-5000 More Blue Cross PPO Plans Get A Quote Apply now     Download the Appication Benefit Participating Provider Non-Participating Partner Annual Deductible $0 Lifetime Maximum $5,000,000 Annual Out-of-Pocket Maximum $7,500 Participating and Non-Participating Provider combined 1 Office Visits $40 copay 50% of negotiated fee plus 100% of excess Professional Services (x-ray, lab, anesthesia, surgery, etc.) 40% of negotiated fee 50% of negotiated fee plus 100% of excess Hospital Inpatient 40% of negotiated fee plus $400 copay per day/4-day max copay per admission 2 All charges except $650 per day Hospital Outpatient 40% of negotiated fee plus $400 copay per outpatient surgery admission 2 All charges except for $380 per day Emergency Services 40% of negotiated fee 3 40% of customary & reasonable for first 48 hours plus 100% of excess. After 48 hours, all charges in excess of $650 per day 3 Preventative Care Routine mammogram, PSA and PAP tests 4: $40 office visit plus 40% of negotiated fee Well Baby & Well Child (through age 6): $40 office visit plus 40% of negotiated fee HealthyCheck Centers 5: $25 and $75 copay for basic screenings Routine mammogram, PSA and PAP tests 4: 50% of negotiated fee plus excess Well Baby & Well Child (through age 6): 50% of negotiated fee plus excess Ambulance 40% of negotiated fee 50% of negotiated fee plus 100% of excess Physical and Occupational Therapy; Chiropractic Service 40% of negotiated fee, up to 12 visits per year 6 All charges except $25 per visit, up to 12 visits per year Acupuncture/Acupressure All charges except $25 per visit, up to 24 visits per year 6 Maternity Not covered Prescription Coverage Options Prescription Drug Benefits Retail or Mail Order: 30-day supply Participating Provider Non-Participating Provider RightPlan PPO 40 with No Prescription Drug Coverage (P958) No Prescription Coverage No Prescription Coverage RightPlan PPO 40 with Generic Prescription Drug Coverage (PE48) $10 copay generic (for drugs on RightPlan Generic Prescription Drug Formulary only) 50% of Drug Limited Fee Schedule within California (for drugs on RightPlan Generic Prescription Drug Formulary only) RightPlan PPO 40 with Comprehensive Prescription Drug Coverage (PE49) $10 copay generic, $30 copay brand after calendar year $500 brand name prescription drug deductible 7; 30% of negotiated fee for self-administered injectibles, except insulin 50% of Drug Limited Fee Schedule within California after calendar year $500 brand name prescription drug deductible 7 Note: Benefits for cancer clinical trials in accordance with Health and Safety Code Section 1370.6 will be available administratively. 1 Excludes non-participating charges in excess of the Blue Cross negotiated fee and non-participating charges in excess of customary and reasonable fees for emergency care. Copayments to participating and non-participating providers apply to out-of-pocket maximum except where specifically noted. 2 Additional $500 admission charge at Participating Hospitals (no additional charge for Preferred Participating) is for inpatient stays or outpatient surgery or infusion therapy. The charge is not required for Ambulatory Surgical Centers or medical emergencies. 3 Additional $30 copay applies for each Emergency Room visit. Waived if admitted as inpatient. 4 Tests ordered by a physician are covered, including appropriate screening for breast, cervical and ovarian cancer. 5 One HealthyCheck visit at a HealthyCheck Center only allowed for each 12-month period. HealthyCheck applies only to adults and children age 7 and above. 6 Benefits include visits to Participating and Non-Participating Providers combined. 7 If a member selects a brand-name drug when a generic equivalent drug is available, even if the physician writes a "dispense as written" or "do not substitute" prescription, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug.The amount paid does not apply to the member's brand-name deductible.

Common Accidents and What They Cost You
Scenario #1. Cleaning the garage. The garage finally looks good but you stepped on a rusty nail. Charge for an office visit and Tetanus shot:
	RightPlan PPO 40 Participating Provider	No Health Coverage
Total Charges	$220	$220
Blue Cross Discount	-88	----
Blue Cross negotiated fee	$132
Blue Cross Payment	-88
You Pay	$44	$220
Scenario #2. Ski slope. Your ski went one way and your leg went another. Emergency Room charges only for a brocken leg:
	RightPlan PPO 40 Participating Provider	No Health Coverage
Total charges	$1,900	$1,900
Blue Cross discount	$-410	---
Blue Cross negotiated fee	$1,490
Member's ER copay	$-30
Sub total	$1,460
Blue Cross payment	$876
You pay 40%	$584
Plus ER copay	+30
You Pay	$614*	$1,900
* Assuming you have RightPlan PPO 40 coverage and you have not yet reached your annual out-of-pocket maximum. Charges may be higher ifyou receive services from a non-participating provider.