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Coverage Increases with PPO Saver Plan |
Similar to many other PPO plans, the PPO Saver offers modest benefit coverage at moderate premium rates. It includes benefits for prescriptions as well as doctor’s office visits.
As with all plans issued by Blue Cross of California, fees are negotiated with health care providers to assure members receive the best cost for health care service available. Network members accept the negotiated price from the plan as payment in full for rendered services.
The PPO Saver plan features two separate deductibles including a $500 deductible for each member for emergency and hospital inpatient and outpatient services. There as also a $5,000 annual deduction per member for other covered services. However, once two members have each reached either deductible, the deductible reach is satisfied for all other enrolled family members.
There is a $5,000 per member maximum out-of-pocket expense with the PPO Saver plan and once two members reach the maximum the maximum for all other family members is satisfied. Expenses incurred while paying the annual deductible do apply towards the annual out-of-pocket maximum expense.
During the years, visits to the doctor’s office the deductible is waived and children have four visits to the doctor with a $30 copay. Adults have two visits with a $40 copay and, as with the visits by the children, the deductible is waived.
Patients being recommended for professional services by their physician, mammograms, Pap tests and PSA, for instance, are charged at 20 percent of the negotiated fees for inpatient or surgical procedures. Members pay for all other covered services until the annual maximum out-of-pocket expense has been paid and then the plan pays 100 percent of the covered costs.
For inpatient or outpatient services at hospitals the member pays 20 percent of the negotiated fee after a $500 deductible. This is an admission charge at participating hospitals and does not apply at preferred participating facilities. It is for inpatient stays, outpatient surgery or infusion therapy. This is not required for services at ambulatory surgical centers or for medical emergencies.
Emergency room services are charged to the member at 20 percent of the negotiated cost and a $100 copay. This copay is waived if the visit results in the patient being admitted by the attending physician.
Basic screenings at a HealthyCheck center requires a $25 copay and a premium screening is also available with a $75 copay. Routine tests ordered by a physician cost 20 percent of the negotiated price.
Prescription coverage has a $1- copay for generic drugs and a $30 copay for brand name drugs, once the $500 brand name deductible is met. There is a 30 percent charge of the negotiated fee for self-administered injectable drugs, except insulin.
A member choosing a brand name drub when a generic equivalent is available is responsible for the $10 generic copay along with the difference in the costs of the generic drug and the brand name drug. This is in force even if the doctor writes do not substitute or dispense as written on the prescription.
Learn more at: www.baahealth.com
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