Health and Welfare Summary Plan Description
8.2 Blue Shield California PPO Network.
A "Preferred Provider" is a Physician, Hospital, ambulatory surgery center, certified registered nurse anesthetist, participating dialysis center, home health care agency or home infusion agency (including hospice services in accordance with Medicare Guidelines) that has contracted with the Plan or its delegate (in the Plan's case, Blue Shield) to furnish services and to accept the Plan's payment, along with any deductibles and coinsurance, as full payment for covered services. The Plan's major California medical Preferred Provider organization network (or "PPO") is the Blue Shield Shared Advantage Program. It provides for the payment of Covered Charges rendered by in-network providers at predetermined fees. Neither the Participant nor the Plan is responsible for any charges in excess of the contracted amount. Some services not normally covered under the Plan may be included at no charge at a PPO network facility. Information regarding the Self-Funded PPO program, and a schedule of Preferred Providers, is available by contacting the Plan Office or through Blue Shield's web-site at blueshieldca.com. With the exception of certain charges identified as subject to the No Surprises Act, described below in Section 8.4 below, when you use out-of-network providers, payment is limited to Reasonable and Customary Covered Charges, and you must pay any charges that exceed the Reasonable and Customary amount in addition to the annual deductible and any coinsurance. Therefore, you may have substantially higher out-of-pocket expenses when you use out-of-network providers. Charges that exceed the Reasonable and Customary amount will not be applied to the deductible, any coinsurance, or the out-of-pocket maximum.