|
|
Lifetime
Maximum
- Unlimited |
Annual
Out-of-Pocket Maximum
(includes deductible) |
|
$3,000/single (2-member maximum) |
| Annual
Deductible |
|
No deductible |
| Office
Visits |
|
You pay $10 |
Professional
Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
|
Unlimited office
visits: you pay $10 per visit
Inpatient hospital — no charge |
| Hospital
Inpatient/Outpatient |
|
Inpatient — no charge
Outpatient — you pay 20% of negotiated fee
(for non-emergency services) |
| Emergency
Services |
|
Inpatient and professional services
— no
harge when authorized by a medical group
wthin 48 hours of emergency care
Outpatient — you pay $100 emergency room
copayment plus 20% Office Visit you pay $10 Inpatient Hospital
no charge Outpatient Hospital you pay 20% of Negotiated Fee |
Maternity
|
|
You pay 20% of the Negotiated Fee |
| Preventive
Care |
|
You pay a $10 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 $10 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, plus 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 s |
Non-participating
Provider
|
You pay a $250 Brand deductible;
then 50% of drug Limited Fee Schedule within California |
