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HomeDental Plans Short Term PPO$2000 Plans BC Life & Health Short Term PPO $2000 (NM07) Select Another Plan Determine the rates for the medical plan you selected and other available plans by clicking on the Get a Personalized Quote link on the left. 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 $2000 per Insured per policy (waived for accidents) Out-of-Network $2000 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 co pay 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 of the NFR except $25; 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 co pay. Brand drug maximum of $500 per Insured per policy. 30% of Negotiated Fee Rate for self-administered injectables Out-of-Network Co payment 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 --- Please Note: When locating a provider, PPO plans are also referred to as Prudent Buyer * Non-participating charges in excess of the negotiated fee will not be paid and do not apply to the out-of-pocket maximum. ** Additional $50 co pay applies for each emergency room visit (waived if admitted as inpatient). *** Generic drugs are based upon the Blue Cross drug formulary.

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