This is a Self Funded PPO Plan with coverage worldwide for medically necessary treatments,

Choose any physician or hospital. Reduced charges are available from the Preferred Provider hospital and physician networks that have a contract with the Plan. Your out-of-pocket expenses will be higher when you use a provider or facility that is not a Preferred Provider.

Please note: Prior to 11/1/08, the Preferred Provider Organization Network was provided through First Health

The Plan now contracts with the Blue Shield Shared Advantage Program for its Preferred Provider Organization (PPO) and medical case management services.

• Using a provider from the PPO network saves both you and the Plan money. To find a PPO provider, access www.blueshieldca.com
• Prior Authorization/Pre-Admission Review: Before any non-emergency hospitalization, you should call 800-343-1691 to determine whether a procedure or treatment program is covered, or if an alternative service is recommended.
• Case Management services assist you in obtaining medical services from the most appropriate source for certain complex medical conditions.

$750,000 per calendar year per family member.
$2,000,000 lifetime maximum per family member

After satisfying the deductible, most benefits are paid at 80% for services provided by a PPO Provider and 60% for services proved by a non-PPO provider. For each covered person, there is a $1,000 out-of-pocket maximum per calendar year. After this has been met, covered charges are paid at 100% for that person.

PPO Provider -
Plan Pays:

Non-PPO Provider -
Plan Pays:

The first $5,000 of covered charges are paid at 100%, and are not subject to the deductible.

The first $5,000 of covered charges are paid at 80%, and are not subject to the deductible.

80% after deductible

60% after deductible.

80% after deductible

60% after deductible

80% after deductible

60% after deductible

Pays 80% after deductible for:
Annual Physical - up to $300 maximum
Immunization Inoculations
Preventive care and immunizations.

Pays 60% after deductible for:
Annual Physical - up to $300 maximum
Immunization Inoculations
Preventive care and immunizations.

100% reimbursement of reasonable and customary charges for:
Fecal occult blood test
Flexible Sigmoidoscopy
Colonoscopy
Pap smears and Pelvic Exams
Prostate Cancer Screenings
Mammogram Screenings (some age based limitations)

Pays 80% after the deductible has been satisfied if required to move patient from place of injury or illness to nearest hospital equipped to provide necessary care.

Pays 60% after the deductible has been satisfied if required to move patient from place of injury or illness to nearest hospital equipped to provide necessary care.

Members & Spouses/Domestic Partners only Same as hospital confinement shown above for 48 hours following vaginal delivery and 96 hours following delivery by caesarian section.

Pays 80% after deductible
Covered while mother is confined.

Pays 60% after deductible
Covered while mother is confined.

These servces will each be limited to a maximum of 30 visits per calendar year effective January 1, 2009.