| Calendar
year deductible (In and Out of Network
Combined) |
In-Network
|
$3,500/member;
$7,000/family aggregate |
|
Out-of-Network
|
$3,500/member;
$7,000/family aggregate 1 |
| Lifetime
Maximum (combined for all providers) |
In-Network
|
$5,000,000/member |
| Annual
Out-of-Pocket Maximum (In and Out of Network
Combined) |
In-Network
|
Single
member $5,000; Family aggregate $10,000 |
| Office
Visits |
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
50%
of negotiated fee plus excess of negotiated
fee after deductible met |
Professional
Services
(X-ray, lab, anesthesia, surgeon, etc) |
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
50%
of negotiated fee plus excess of negotiated
fee after deductible met |
| Inpatient
Hospital Services |
In-Network
|
Covered
in full after deductible met2 |
Out-of-Network
|
All
charges except $650/day after deductible
met |
| Outpatient
Hospital Services |
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
All
charges except $380/day after deductible
met |
| Emergency
Care |
In-Network
|
Covered
in full after deductible met3 |
Out-of-Network
|
1st
48 hours: all charges in excess of 100%
of C & R after deductible met; after
48 hours, all charges except $650/day |
| Pregnancy
& Maternity Services |
In-Network
|
Not
Covered |
Out-of-Network
|
Not
Covered |
| Preventive
Care |
In-Network
|
Routine
mammogram, PSA and Pap test: Covered in
full after deductible met4;
Well Baby & Well Child (through age
6): Covered in full after deductible met;
HealthyCheck Centers5: $25
or $75 copay |
Out-of-Network
|
Routine
mammogram, PSA and Pap test: 50% of negotiated
fee plus excess of negotiated fee after
deductible met; Well Baby & Well Child
(through age 6): 50% of negotiated fee
plus excess of negotiated fee after deductible
met; HealthyCheck Centers: Not Covered. |
| Ambulance
Service |
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
50%
of negotiated fee plus excess of negotiated
fee after deductible met |
Physical
Therapy, Physical Medicine & Occupational
Therapy, including Chiropractic Services
limited to 12 visits/calendar year; additional
visits may be authorized) |
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
All
charges except $25/visit after deductible
met |
Acupunture
/ Acupressure
(limited to maximum Blue Cross payment
of $25/visit; limited to 24 visits/calendar
year in & out-of-network combined) |
In-Network
|
All
charges except $25/visit after deductible
met |
Out-of-Network
|
All
charges except $25/visit after deductible
met |
Outpatient
Speech Therapy
When following surgery, injury or non-congenital
organic disease excess of C& R (limited
to 50 visits/year in and out-of-network
combined) |
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
50%
of C&R plus excess of C&R after
deductible met |
Skilled
Nursing Facility
Semi-private room, services & supplies
(limited to 100 days per calendar year
in and out-of-network combined) |
In-Network
|
Covered
in full after deductible met |
Out-Network
|
All
charges except $150/day after deductible
met |
Home
Health Care
Services & supplies from a home health
agency (limited to 60 visits/calendar
year, one visit by a home health aide
equals four hours or less; not covered
while member receives hospice care) |
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
All
charges except $75/day after deductible
met |
Infusion
Therapy
Combined admin, prof and drug for out-of-network
will not exceed $500/day
Includes medication, caregiver training
& visits by provider to monitor therapy;
durable medical equipment |
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
Admin
& Prof. Srvcs: All charges in excess
of $50/day after deductible met
Drugs: All charges in excess of Drug AWP
after deductible met |
Medical
Supplies, Equipment & Footwear
Footwear limited to $400 per year maximum
combined for $400/calendar year in and
out-of-network combined
|
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
50%
of negotiated fee plus excess of negotiated
fee after deductible met |
Mental
or Nervous Disorders
Inpatient Hospital & Day Treatment
Programs (limited to 30 days/year in &
out-of network combined)
Professional Services (Inpatient or Outpatient
physician charges except services (limited
to 1 visit/day; 20 visits/year) |
In-Network
|
Inpatient
Hospital & Day Treatment Programs
(limited to 30 days/year in & out-of
network combined): All charges except
$175/day after deductible met; Professional
Services (Inpatient or Outpatient physician
charges except services (limited to 1
visit/day; |
Out-of-Network
|
Inpatient
Hospital & Day Treatment Programs
(limited to 30 days/year in & out-of
network combined): All charges except
$175/day after deductible met; Professional
Services (Inpatient or Outpatient physician
charges except services (limited to 1
visit/day; |
Severe
Mental Illness and serious Emotional Disturbances
of a Child
(Services provided as any other medical
condition)
|
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
50%
of negotiated fee plus excess of negotiated
fee after deductible met |
Hospice
(limited to a lifetime maximum BC Life
benefit of $10,000 in and out of network
combined)
|
In-Network
|
Covered
in full after deductible met |
Out-of-Network
|
50%
of negotiated fee plus excess of negotiated
fee after deductible met |
Prescription
Drug Coverage 6
Retail and Mail order combined (Subject
to combined deductible w/ Medical
|
In-Network
|
Generic:
$10 copay Brand: $30 copay Non-formulary:
50% of negotiated fee Self Admin Injectibles:
30% of negotiated fee |
Out-of-Network
|
50%
of Drug Limited Fee Schedule plus excess |
