Blue Cross PPO Saver & Share 2500 PPO

     
     
BLUE CROSS PLANS Blue Cross Blue Cross
EFFECTIVE January 1, 2001 PPO Saver Plan PPO Share 2500 Plan
Deductible per Person $500 hospital & $5,000 other services $2,500
Deductible Maximum per Family Two Deductible Maxium/Family Two Deductible Maxium/Family
Coinsurance Paid after Deductible 80% 75%
Your Coinsurance Percentage 20% 25%
NOTE: YOUR COINSURANCE PERCENTAGE IS BASED ON THE BLUE CROSS NEGOTIATED DISCOUNT, NOT THE PROVIDER'S BILLED CHARGES.    
Your Maximum Out of Pocket Costs $5,000 per Person/2 per Family $5,000 per Person/2 per Family
Lifetime Benefit $5,000,000 $5,000,000
Pre-existing Conditions 6 month waiting period 6 month waiting period
(Credit is given on pre-existing condition waiting period if you had recent prior health coverage)    
Office Visits-Adults $30 Copay - 2 visit maxium/yr 25% of negotiated fee - No Ded.
Office Visits-Well-Child Visits 50% - 4 visit maximum/yr 50% of negotiated fee - No Ded.
Hospitalization-your portion 20% after Ded. 25% after Ded.
Maternity Not Covered $1,000 CoPay + 30% after Ded.
Outpatient Surgery 20% after Ded. 25% after Ded.
Laboratory & X-Ray 20% after Ded. 25% after Ded.
Ambulance 20% after Ded; $750 max/trip 25% after Ded.
Emergency Room 20% after $500 Deductible $30 + 25% after Ded. - In Network
(CoPay waived if admitted Out of Network 25%+ any excess Out of Network: 25%+ any excess
as an inpatient) charges. After 48 hours, BC limits charges. After 48 hours, BC limits
  payment to $650 per day. payment to $650 per day.
Acupuncture BC pays $25 per visit/24 visits/yr BC pays $25 per visit/24 visits/yr
(Deductible Waived) (Deductible Waived)
Chiropractic Care/ Physical Therapy 20% after Ded; 12 visits/yr 25% after Ded; 12 visits/yr
PREVENTIVE CARE    
Well Baby Care See Office Visits above 50% of negotiated
Check Ups Use Check Up Center for basic discount-No Deductible
Check Ups screening - $25 or $75 CoPay Use Check Up Center for basic
  Deductible Waived screening - $25 or $75 CoPay
Mammogram, Cancer Screening 20% - No Ded. 25% - No Ded.
     
     
OUT PATIENT Rx COPAYS $10 Generic / *$30 Brand Name $10 Generic / *$30 Brand Name
(Retail or Mail Order) *(Brand Name CoPay applies *(Brand Name CoPay applies
after a $500 Deductible) after a $500 Deductible)
  (2 Deductible max. per family) (2 Deductible max. per family)
     
NOTE: This summary shows CoPays & Co-Insurance Percentages that apply when you use Blue Cross' PPO Providers, (In-Network) . When you use Providers who do not contract with Blue Cross, the Co-Insurance is usually 50% / 50%, and some services like Preventive Care are Not Covered Out-of-Network.