| Lifetime
Maximum |
Participating
Provider
|
$5,000,000/member |
Non-participating
Provider
|
$5,000,000/member |
Annual
Out-of-Pocket Maximum
(includes deductible) |
Participating
Provider
|
$5,000/single (2-member maximum)
Participating and non-participating combined1 |
Non-participating
Provider
|
$5,000/single (2-member maximum)
Participating and non-participating combined1 |
| Annual
Deductible |
Participating
Provider
|
$500 hospital, $5,000 other covered
services (2-member maximum) All covered benefits |
Non-participating
Provider
|
$500 hospital, $5,000 other covered
services (2-member maximum) All covered benefits |
| Office
Visits |
Participating
Provider
|
Well-child, 50% of negotiated fee;
2-adult, 4-child office visits, $30 copay/visit (deductible
waived) |
Non-participating
Provider
|
Well-child, 50% of negotiated fee
(deductible waived); all other visits subject to deductible |
Professional
Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
Participating
Provider
|
20% of negotiated fee for hospital
services only. All other covered services after out-of-pocket
maximum is met, then covered at 100% of negotiated fee |
Non-participating
Provider
|
50% of negotiated fee plus 100% of
excess |
| Hospital
Inpatient/Outpatient |
Participating
Provider
|
20% of negotiated fee2 |
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
after $500 deductible is met |
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
|
Routine mammogram, PSA and cancer
screening, ordered by physician: 50% of
negotiated fee 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
|
20% of negotiated fee; limited to 12
visits/year, participating and non-participating combined |
Non-participating
Provider
|
All charges except $25/visit;
limited to 12 visits/year, participating and non-participating
combined |
| Acupuncture/Acupressure |
Participating
Provider
|
All charges except $25/visit;
limited to 24 visits/year, participating and non-participating
combined |
Non-participating
Provider
|
All charges except $25/visit;
limited to 24 visits/year, participating and non-participating
combined |
Drug
Benefits
(retail or mail order: 30-day supply) |
Participating
Provider
|
$10 generic4; $30 brand
copay plus $500 brand deductible5 (2 Member Maximum);
30% of negotiated fee for self-administered injectables except
insulin
Non-Formulary:
Participating Provider: Generic4 50%; Brand 100% of
negotiated Fee Rate for Br |
Non-participating
Provider
|
50% of the drug limited-fee schedule
plus 100% of excess; $500 brand deductible6 (2-member
maximum) |
