| 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
|
$2,500/member
(2-member maximum) All covered benefits |
Non-participating
Provider
|
$2,500/member
(2-member maximum) All covered benefits |
| Office
Visits |
Participating
Provider
|
No
office visit benefit until out-of-pocket maximum met, then
100% of negotiated fee |
Non-participating
Provider
|
No
office visit benefit until out-of-pocket maximum met, then
100% of negotiated fee |
Professional
Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
Participating
Provider
|
20%
of negotiated fee, hospital only. No office visit benefits
until out-of-pocket maximum met, then covered at 100% of negotiated
fee |
Non-participating
Provider
|
Covered
expenses paid at 50% of the limited-fee schedule plus 100%
of excess |
| Hospital
Inpatient/Outpatient |
Participating
Provider
|
20%
of negotiated fee |
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 |
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
|
Healthy
Check Centers: $25 or $75 copay for basic screenings; routine
mammogram, PSA and cancer screening, ordered by physician:
30% of negotiated fee; well-baby and well-child, 40% of negotiated
fee (deductible waived) |
Non-participating
Provider
|
Outside
California, 50% of customary & reasonable to maximum of $250/year;
routine mammogram, PSA and cancer screening, ordered by physician:
50% of customary & reasonable 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
|
Not
covered unless during inpatient admission |
Non-participating
Provider
|
Not
covered unless during inpatient admission |
| Acupuncture/Acupressure |
Participating
Provider
|
Not
covered |
Non-participating
Provider
|
Not
covered |
Drug Benefits
(retail or mail order: 30-day supply) |
Participating
Provider
|
Not
covered |
Non-participating
Provider
|
Not
covered |
