| Lifetime Maximum |
In-Network
| $3,000,000/member |
Out-of-Network
| $3,000,000/member |
Annual Out-of-Pocket Maximum
|
In-Network
| $1,000 plus the medical deductible per Insured per policy * |
Out-of-Network
| $1,000 plus the medical deductible per Insured per policy * |
| Annual Deductible |
In-Network
| $1000 per Insured per policy (waived for accidents) |
Out-of-Network
| $1000 per Insured per policy (waived for accidents) |
| Office Visits |
In-Network
| 20% of Negotiated Fee Rate |
Out-of-Network
| 20% of Negotiated Fee Rate |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
In-Network
| 20% of Negotiated Fee Rate |
Out-of-Network
| 20% of Negotiated Fee Rate (NFR) plus all charges in excess of NFR unless Special Circumstances apply |
| Hospital Inpatient/Outpatient |
In-Network
| 20% of Negotiated Fee Rate ** |
Out-of-Network
| Insured pays all charges except: $650/day inpatient, $380/day outpatient |
| Emergency Services |
In-Network
| 20% of Negotiated Fee Rate ** |
Out-of-Network
|
Within California: Physician:
20% of Customary and Reasonable (C&R) charges or billed charges
plus all charges in excess of C&R
Hospital: 20% of C&R charges or billed charges, whichever is less plus all charges in excess of C&R for the first 48 hour |
| Maternity |
In-Network
| No benefits |
Out-of-Network
| No benefits |
| Home Health Care |
In-Network
| 20% of Negotiated Fee Rate (NFR) - limited to 30 visits per policy term |
Out-of-Network
| 20% of Negotiated Fee Rate (NFR) - limited to 30 visits per policy term |
| Skilled Nursing Facilities |
In-Network
| No Benefits |
Out-of-Network
| No Benefits |
| Hospice |
In-Network
| No Benefits |
Out-of-Network
| No Benefits |
| Preventive Care |
In-Network
|
Healthy Check Centers:
$25 or $75 copay for basic screenings (deducible-free); Routine
Pap smears, annual mammogram's, PSA and cancer screening,
as ordered by physician including the related office visit:
20% of Negotiated Fee Rate, subject to the deductible |
Out-of-Network
|
Routine Pap smears, annual
mammogram, PSA and cancer screening, ordered by physician
including the related office visit: 20% of Negotiated Fee
Rate, subject to the deductible |
| Infusion Therapy |
In-Network
|
20% of Negotiated Fee Rate
– Up to $2000
maximum per person during the policy term |
Out-of-Network
|
20% of Negotiated Fee Rate
– Up to $2000
maximum per person during the policy term |
| Ambulance |
In-Network
| 20% of Negotiated Fee Rate – Maximum payment of $1000 per person during policy term |
Out-of-Network
| 20% of Negotiated Fee Rate – Maximum payment of $1000 per person during policy term |
| Physical and Occupational Therapy; Chiropractic Services |
In-Network
| 20% of Negotiated Fee Rate; In an outpatient facility, limited to a combined maximum of $1000 per person during policy term |
Out-of-Network
| 20% of Negotiated Fee Rate; In an outpatient facility, limited to a combined maximum of $1000 per person during policy term |
| Acupuncture/Acupressure |
In-Network
| Insured pays all of the NFR except $25; 12 visit maximum. Subject to the deductible |
Out-of-Network
| Insured pays all charges except $25 per visit; 12 visit maximum. Subject to the deductible |
Mental, Emotional or Functional Nervous Disorders
(Inpatient Hospital Charges) |
In-Network
| 50% up to the semi-private room rate - Up to a combined maximum of $5,000 during policy term. |
Out-of-Network
| 50% up to the semi-private room rate - Up to a combined maximum of $5,000 during policy term. |
Mental, Emotional or Functional Nervous Disorders
(In or Outpatient Professional Charges) |
In-Network
| 50% Outpatient; $40 per visit max but no more than one visit per week for outpatient treatment – Up to a combined maximum of $5000 during Policy term. |
Out-of-Network
| 50% Outpatient; $40 per visit max but no more than one visit per week for outpatient treatment – Up to a combined maximum of $5000 during Policy term. |
| Speech Therapy |
In-Network
| No Benefits |
Out-of-Network
| No Benefits |
Drug Benefits
(retail or mail order: 30-day supply) |
In-Network
|
$10 generic***; $30 brand
copay. Brand drug maximum of $500 per Insured per policy.
30% of Negotiated Fee Rate for self-administered injectables |
Out-of-Network
|
copayment as stated for
Participating Pharmacies plus 50% of the Drug Limited Fee
Schedule (DLFS) and all charges in excess of the DLFS |
| AD & D |
In-Network
| 50000 |
Out-of-Network
| 50000 |
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