| Calendar
year deductible (combined for all providers) |
In-Network
|
$3,500/member; 2 family member max |
Out-of-Network[1]
|
$3,500/member; 2 family member max |
| Lifetime
Maximum (combined for all providers) |
In-Network
|
$5,000,000/member |
| Annual
Out-of-Pocket Maximum |
In-Network
|
Member must meet Yearly deductible
only (2 family member max) |
Out-of-Network
|
$10,000/member; 2 family member max |
| 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 (including x-ray) 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 Cove |
| 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 24 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
Retail and Mail order combined (Subject to $500 brand name drug
deductible )6
|
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 |
