 Blue
Cross Blue Shield
Century Preferred PPO
|
| |
|
|
| No
referrals needed to see specialists in the Century Preferred
PPO. |
| |
|
|
| Medical
Care |
In-Network |
Out-of-Network |
| Office
Visit Copay |
$15 |
Deductible
& Coinsurance |
| Hospital
Visit Copay |
$250
per admission |
Deductible
& Coinsurance |
| Urgent
Care Copay |
$50 |
Not
Covered |
Emergency
Room Copay
(waived if admitted) |
$75 |
$75 |
| Outpatient
Surgery Copay |
$100 |
Deductible
& Coinsurance |
Annual
Deductible
(Individual/2 person/3+ person) |
Not
applicable |
$400/$800/$1200 |
| Coinsurance |
Not
applicable |
30%
to a
maximum of
$2000/$4000/$6000 |
Lifetime Maximum
|
Unlimited |
$1,000,000 |
| |
|
|
| View
the entire list: |
Summary
of covered services |
| |
|
|
| Prescriptions |
Copay
(30 day supply) |
By
mail
(31+ day supply) |
| Tier
1: Generic |
$5 |
$10 |
| Tier
2: Listed brand name |
$15 |
$30 |
| Tier
3: Non-listed brand name |
$25 |
$50 |
| Annual
Maximum |
Unlimited |
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|
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| Important
Information/Web Links |
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|
|
| Provider
Directories: |
|
|
| California |
Directory
Select PrudentBuyer PPO/Hospital |
| Connecticut |
Directory
Select Connecticut |
| Out-of-State
(BlueCard) |
Directory Search
the PPO Network |
|
BlueCard
Worldwide |
Directory
Must
have ID number to search |
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|
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