| Lifetime
Maximum |
|
|
Unlimited |
Annual
Out-of-Pocket Maximum
(includes deductible) |
|
$3,000/single
(2-member maximum) |
| Annual
Deductible |
|
No
deductible |
| Office
Visits |
|
You
pay $25 |
Professional
Services
(X-ray, lab, anesthesia, surgeon,
etc.) |
|
$25
office visit Copayment,
No charge for office visit
related services |
| Hospital
Inpatient/Outpatient |
|
Inpatient
— $250 per day Copayment,
four (4) day Copayment maximum
per admission
Outpatient — you pay 20% of
negotiated fee (for non-emergency
services) |
| Emergency
Services |
|
Professional
services — no charge when
authorized by a medical group
within 48 hours of emergency
care
Outpatient — you pay $100
emergency room copayment plus
20% of the negotiated fee
rate (waived if admitted into
the hospital)
Inpatient - $250 per day Copayment,
four (4) day Copayment maximum
per admission. |
| Maternity |
|
Professional
Services: $25 office visitsInpatient
Services: $250 per day Copayment,
four (4) day Copayment maximum
per admission |
| Preventive
Care |
|
You
pay a $25 copayment for specific
health maintenance services |
| Ambulance |
|
You
pay a $50 Copayment unless
admitted to the hospital |
| Physical
and Occupational Therapy;
Chiropractic Services |
|
You
pay $25 per visit; limited
to 60 consecutive days following
illness or injury; no charge
for inpatient services Chiropractic
benefits with medical group
referral |
Drug
Benefits
(retail or mail order: 30-day
supply) |
Participating
Provider
|
You
pay $10 for generic and $30
for Brand drugs, after a $250
deductible for Brand drugs
Non-Formulary:Participating
Provider: Generic 50%; Brand
100% of negotiated Fee Rate
for Brand Name Drugs until
the Brand Name Prescription
Drug Deductible is satisfied.
After the Brand Name $250
Drug Deductible is satisfied,
50% of the Negotiated Fee
Rate for Brand Name Drugs
if no Generic Equivalent is
available.
If you select a Brand Name
Drug when a generic equivalent
is available even if a physician
writes a “dispense as written”
or “do no substitute” prescription
you pay the generic drug Copayment
plus the cost between the
Brand Name drug and the generic
drug. None of the amount paid
applies toward your Brand
Name Drug Deductible.
|
Non-participating
Provider
|
50%
of drug Limited Fee Schedule
within California less the
Copayment/Coinsurance stated
for participating pharmacies |
