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Blue Shield Active Choice Plan 750
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Blue Shield of California
Plan Name Active Choice Plan 750
Plan Type PPO
Deductible None
Out of Pocket Limit $3,000 Individual/$6,000 Family for Preferred Providers
$10,000 Individual/$20,000 Family for Non-Preferred Providers
Lifetime Maximum $6,000,000
Primary Benefits


Category One
Preventive Care
• Routine physical exams, Well-baby care Immunizations, and other services as recommended by the U.S. Preventive Services Task Force

Outpatient Professional & Diagnostic
• Office visits, Diagnostic testing
First Dollar Services Coverage: $750 Individual/$1,500 Family Then the member is responsible for charges up to the calendar- year copayment maximum
Category Two
Outpatient & Inpatient Services
• Surgeries, Emergency room visits, Renal dialysis, Chemotherapy
80/60% coinsurance (some copays apply)
Category Three
Prescription Drugs
• Generic
$10 copayment
• Brand-name drugs
– Calendar-year deductible
$250 per member
– Copayment for formulary
$30 copayment after deductible is met
– Copayment for non-formulary
$45 copayment or 50% of Blue Shield contracted rate, whichever is greater after the deductible is met
– Home self-administered injectable drugs 30% after deductible is met


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