Step 1 of 2: Medical profile   Gender Date of birth Height Weight Smoker? Applicant* M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Spouse -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children 0  1 2 3 4 5 6         Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Children -- M F   / / Ft 4 5 6 7 In 0 1 2 3 4 5 6 7 8 9 10 11 Currently Insured?* Yes No Have conditions?* yes   no Please specify  Take medications?* yes   no Please specify  Step 2 of 2: Tell us about yourself First Name* Last Name* Address* City* State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip* Day Phone* Evening Phone* Contact Time* Morning Afternoon Evening Email* By submitting this form, you agree to be legally bound to, and abide by, the Privacy Policy.

PPO (Preferred Provider Organization)

A PPO is somewhat similar to an indemnity plan in that you still have the freedom to go to the doctor of your choice. Costs, however, are lower if you stay within the network of providers.

If you stay within the network, you will pay a copayment, or a fixed amount for services (like $10 for an office visit or prescription). This copayment is based on lower charges for PPO members.

If you go outside the network, you will pay a copayment based on higher charges and you will need to meet the deductible. You may also have to pay the difference between the actual fee and the amount covered by your plan.

Providers:

BLUE SHIELD (CA)

Deductible Plans
Blue Shield offers four affordable Deductible Plan options - $500, $750, $1,500 and $2,000 - fixed copays and percentage copayments vary based on the plan.

Features-

• For people who visit the doctor less frequently
• Members pay 25 or 30 percent for many covered services within the network after meeting the deductible
• Preventive care benefits for a fixed copay before meeting the deductible
• Prescription generic drug benefits at participating pharmacies before meeting the deductible

Rates-

Deductible Plan Options:	$500 Deductible Plan	$750 Deductible Plan	$1,500 Deductible Plan	$2,000 Deductible Plan
Percentage Copayments - Services w/ Preferred Providers - Services w/ Non-Preferred Providers	25% 50%	30% 50%	30% 50%	30% 50%
Physician Services (i.e. office visits)	$30 Copay w/ Choice Provider	$35 Copay w/ Choice Provider	$40 Copay w/ Choice Provider	$45 Copay w/ Choice Provider
Prescription Drugs (at participating pharmacies) - Generic formulary drugs - Brand-name formulary drugs	$7/prescription $25/prescription	$10/prescription $30/prescription	$7/prescription $25 + 10% / prescription	$10/prescription $30 + 10% / prescription
Monthly Rates	Individual - $166 Two-Party - $323 Family - $532	Individual - $107 Two-Party - $210 Family- $346	Individual - $98 Two-Party - $189 Family- $311	Individual - $68 Two-Party - $133 Family - $219

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