Medical PPO
| Network Benefit | Non-Network Benefit | ||
Your copay : Your deductible : Your coinsurance : Out-of-Pocket Maximum : |
$10 $0 90% $1,500 Single $3,000 Family |
70% | |
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| PHYSICIAN SERVICES | |||
Office Visits Hospital Visits X-ray and lab tests |
$10 90% 90% |
70% 70% 70% | |
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| PREVENTIVE CARE | |||
Well-baby immunizations Routine physical exams Annual Pap smears Mammograms Prostate exam for men |
$10 and 90%, up to $200 maximum $10 and 90%, up to $200 maximum $10 and 90%, up to $200 maximum $10 and 90%, up to $200 maximum $10 and 90%, up to $200 maximum |
70% 70% 70% 70% 70% | |
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| HOSPITAL | |||
Inpatient facility charges Outpatient facility charges (Including facility X-ray & lab tests) Emergency room Urgent care centers |
90% 90% 90% 90% |
70% 70% 70% 70% | |
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| MATERNITY | |||
Professional Services |
90% |
70% | |
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| PRESCRIPTION DRUG | |||
30-day supply for one copay | Covered expenses are payable at 100% after $10 generic / $15 brand |
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(This chart is only a summary. Please see the evidence of coverage or disclosure form for the selected plan for a thorough description of its benefits, limitations, exclusions and conditions of coverage.) | |||
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| Customer Service Information | |
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| CARRIER INFORMATION | |
Carrier website Provider Finder Customer Service Forms |
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| CLAIMS INFORMATION | |
Claims address Claims phone number |
Blue Cross of California P.O. Box 9062 Oxnard, CA 93031-9062 800-627-8797 |
| BROKER INFORMATION | |
Broker phone number Broker email address |
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 FAQs - Frequently Asked Questions :Refer to your Combined Evidence of Coverage and Disclosure Form or Plan Agreement for a more detailed listing of benefits and coverage, including exclusions, limitations and conditions applicable. |
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Q : I misplaced my ID card, how can I request another ? A : Contact the Customer Service Department to order a new ID card. Q : I recently moved, how can I change my address ? A : Submit a request to change your address in writing, or contact the Customer Service Department. Q : How can I add a newborn to my contract ? A : You must submit a request to add a newborn to your contract in writing. Blue Cross of California must receive this form within 31 days from the date of birth. If Blue Cross receives this request on the day following the 31st day of life, you must complete the 1-50 Small Group Employee Application and send it to Blue Cross. The effective date of coverage will be delayed for 12 months. The application is subject to medical review by an underwriter for approval. *Your employer must be notified of any change to your coverage before sending this application to Blue Cross. Q : How long can my children remain on my contract ? A : An existing dependent child may remain on the Subscriber contract if one of the following conditions are met : Unmarried Children to the 19th birthday. Unmarried Children from the 19th to the 24th birthday who qualify as dependents for federal income tax purposes and who are full time students with verification of student enrollment from the registrar's office of a college with a seal. Requires written verification of enrollment annually for approval of continued coverage. Unmarried Children enrolled before age 24 who, upon reaching age 24, depend on the Subscriber for support and are unable to work due to mental retardation or physical handicap. A Physician must certify this disability in writing. This certification must be received by Blue Cross within 31 days of the Child's 24th birthday. After the Child's 26th birthday, Blue Cross may request proof of continuing dependency and disability, but not more often than yearly. Q : Where can I get a list of physicians or hospitals that participate in the Prudent Buyer (PPO) network ? A : This information is available in the Provider Search or you can contact the Customer Service Department to request a provider directory. Q : Where can I get a list of medical groups that participate in the CaliforniaCare (HMO) network ? A : This information is available in the Provider Search or you can contact the Customer Service Department to request a provider directory. Q : How can I change my Primary Care Physician ? A : If you are a CaliforniaCare (HMO) Plan Member, you can contact the Customer Service Department to request to change your CaliforniaCare provider. Q : How can I get referred to a specialist ? A : For Prudent Buyer (PPO) Members : If you select a specialist that participates in the Prudent Buyer Network, a referral is not required. If you select a specialist that does not participate in the Prudent Buyer Provider Network, your personal financial costs will be considerably higher than when you use participating providers. You will have to pay any part of a provider's bill which is over what we allow in benefits for non-participating providers. For CaliforniaCare (HMO) Members : If you need specialty care which cannot be provided by your Primary Care Physician at your Medical Group, your Primary Care Physician will arrange to send you to a specialist (within your Medical Group whenever possible) or to a facility outside of your Medical Group. Female CaliforniaCare members may self-refer to an OB/GYN within their Participating Medical Group (PMG) or Independent Physicians Association (IPA) without first obtaining a referral from their Primary Care Physician. If you are referred, your Primary Care Physician will give you a completed "Authorization for Referral Services" form which specifies what treatment or services your physician authorizes. Take this form to the health care provider to whom you have been referred on the appointment date indicated on the authorization form, and that provider will fill in the appropriate parts and will send it back to your Medical Group. If you do not receive the authorization form, please ask for it from your Primary Care Physician or CaliforniaCare Coordinator. Remember : payment will only be made for the number of visits and the medical care that is specifically authorized by your Primary Care Physician. Before obtaining any other care, be sure to check with your Primary Care Physician to make sure that such additional care will be authorized. You are responsible for paying for services rendered that are not authorized by your Primary Care Physician. Q : How can I get a claim form so I can submit my doctor's bill to Blue Cross ? A : Open the Patient Claim Form. Print this form on your printer. Follow the instruction on the form and send it to Blue Cross or contact the Customer Service Department to have a claim form mailed to you. Q : What address do I send medical claim forms to ? A : See the Customer Service Directory. Q : How long do I have to submit a claim for a medical service or a purchase of a prescription drug ? A : You have 15 months from the date you received medical services or purchased a prescription drug to submit the claim. Q : Has Blue Cross received my medical claim ? A : You can contact the Customer Service Department to verify if your claim has been received. Q : What is the status of my medical claims ? A : You can contact the Customer Service Department for status of your claims. |
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