| 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 Co payment,
No charge for office visit related services |
| Hospital Inpatient/Outpatient |
|
Inpatient - $250 per day
Co payment, four (4) day Co payment 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 co payment plus 20%
of the negotiated fee rate (waived if admitted into the hospital)
Inpatient - $250 per day Co payment, four (4) day Co payment
maximum per admission. |
| Maternity |
|
Professional Services:
$25 office visits Inpatient Services: $250 per day Co payment,
four (4) day Co payment maximum per admission |
| Preventive Care |
|
You pay a $25 co payment
for specific health maintenance services |
| Ambulance |
|
You pay a $50 Co payment
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
Co payment 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 Co payment/Coinsurance
stated for participating pharmacies |
HMO
