| Lifetime
Maximum |
Participating
Provider
|
$5,000,000/member |
Non-participating
Provider
|
$5,000,000/member |
Annual
Out-of-Pocket Maximum
(includes deductible) |
Participating
Provider
|
$3,500/single (2-member maximum)
Participating and non-participating combined1 |
Non-participating
Provider
|
$3,500/single (2-member maximum)
Participating and non-participating combined1 |
| Annual
Deductible |
Participating
Provider
|
$1,000/member (2-member maximum) All
covered benefits |
Non-participating
Provider
|
$1,000/member (2-member maximum) All
covered benefits |
| Office
Visits |
Participating
Provider
|
No office visit benefit until
out-of-pocket maximum met, then 100% of negotiated fee |
Non-participating
Provider
|
No office visit benefit
until out-of-pocket maximum met, then
100% of negotiated fee |
Professional
Services
(other office visits, X-ray, lab, anesthesia,
surgeon, etc.) |
Participating
Provider
|
20% of negotiated fee, hospital
only. No office visit benefits until out-of-pocket maximum met,
then covered at 100% of negotiated fee |
Non-participating
Provider
|
Covered expenses paid at 50% of the
limited-fee schedule plus 100% of excess |
| Hospital
Inpatient/Outpatient |
Participating
Provider
|
20% of negotiated fee |
Non-participating
Provider
|
All charges except: $650/day
inpatient, $380/day outpatient |
| Hospice |
Participating
Provider
|
$10,000 lifetime
maximum, participating and non-participating
providers combined |
Non-participating
Provider
|
$10,000 lifetime maximum,
participating and non-participating providers combined |
| Emergency
Services |
Participating
Provider
|
20% of negotiated fee3 |
Non-participating
Provider
|
20% of customary & reasonable
for the first 48 hours plus 100% of excess; after 48 hours, you
pay all charges except $650/day for
covered services3 |
Maternity
(after deductible) |
Participating
Provider
|
Not covered |
Non-participating
Provider
|
Not covered |
| Preventive
Care |
Participating
Provider
|
HealthyCheck Centers: $25 or $75
copay for basic screenings; routine mammogram, PSA and cancer
screening, ordered by physician: 20% of negotiated fee
(deductible waived) |
Non-participating
Provider
|
Outside California, 50% of customary
& reasonable to maximum of $250/year; routine mammogram, PSA
and cancer screening, ordered by physician: 50% of customary
& reasonable plus 100% of excess |
| Ambulance |
Participating
Provider
|
20% of negotiated fee ($750/trip
maximum
paid by BC Life & Health Insurance Company) |
Non-participating
Provider
|
50% of customary & reasonable
plus 100% of excess |
| Physical
and Occupational Therapy; Chiropractic
Services |
Participating
Provider
|
Not covered unless during inpatient
admission |
Non-participating
Provider
|
Not covered unless during inpatient
admission |
| Acupuncture/Acupressure |
Participating
Provider
|
Not covered |
Non-participating
Provider
|
Not covered |
Drug
Benefits
(retail or mail order: 30-day supply) |
Participating
Provider
|
Not covered |
Non-participating
Provider
|
Not covered |
