| Lifetime
Maximum |
In-Network
|
$5,000,000.00 |
Out-of-Network
|
$5,000,000.00 |
| Out
of Pocket Maximum |
In-Network
|
$7,500.00
In and Out of Network Combined |
Out-of-Network
|
$7,500.00
In and Out of Network Combined |
| Annual
Deductible |
In-Network
|
$0 |
Out-of-Network
|
$0 |
| Office
Visits |
In-Network
|
$40
Copay |
Out-of-Network
|
50%
of negotiated fee plus 100% of charges in excess of negotiated
fee 1 |
Professional
Services
|
In-Network
|
40%
of negotiated fee |
Out-of-Network
|
50%
of negotiated fee plus 100% of charges in excess of of negotiated
fee |
| Inpatient
Hospital Services (Includes organ and tissue transplants) |
In-Network
|
40%
of negotiated fee plus $400 copay per day/4 day max per admission
2,4,5 |
Out-of-Network
|
All
charges except $650 per day |
| Outpatient
Hospital Services/Ambulatory Surgical Center |
In-Network
|
40%
of negotiated fee plus $400 copay per outpatient surgery admit
4,5 |
Out-of-Network
|
All
charges except $380 per day |
| Emergency
Care |
In-Network
|
40%
of negotiated fee 3 |
Out-of-Network
|
40%
of C&R for first 48 hours plus 100% of charges in excess of
C&R. After 48 hours all charges in excess of $650 per day
3 |
| Maternity |
In-Network
|
Not
Covered |
Out-of-Network
|
Not
Covered |
| Preventive
Care/Healthy Check Center |
In-Network
|
$25
or $75 option |
Out-of-Network
|
Not
covered |
Preventive
Care
|
In-Network
|
$40
office visit plus 40% of negotiated fee for well-baby and
well-child thru age 6 $40 office visit plus 40% of negotiated
fee for Covered Services other than the Office Visit for Annual
Pap exam Breast exams Mammogram testing and appropriate screening
for breast cancer Cervical and Ovarian cancer screening tests
Prostatic Specific Antigen(PSA) study |
Out-of-Network
|
All
charges in excess of 50% of negotiated fee for well-baby and
well-child thru age 6
All Charges in excess of 50% of negotiated fee |
| Ambulance
Service |
In-Network
|
40%
of negotiated fee |
Out-of-Network
|
All
charges in excess of 50% of negotiated fee |
| Physical
Therapy, Occupational Therapy/Chiro |
In-Network
|
40%
of negotiated fee; limited to 12 visits/year, participating
and non-participating combined |
Out-of-Network
|
All
charges except $25 per visit |
| Acupuncture/Acupressure |
In-Network
|
All
charges except $25 per visit; limited to 24 visits/year, participating
and non-participating combined |
Out-of-Network
|
All
charges except $25 per visit; limited to 24 visits/year, participating
and non-participating combined |
| Prescription
Drug Benefit |
In-Network
|
$500
Brand Name Deductible
$10 Generic Copay $30 Brand Name Copay 30% Self administered
injectable 6
If you select a Brand Name Drug when a generic equivalent
is available even if a physician writes a "dispense as written"
or "do not substitute" prescription you pay the generic
drug copayment plus the cost between the Brand Name drug
and the generic equivalent drug. None of the amount paid
applies toward your Brand Name Drug Deductible
Click here to view the Blue Cross of California drug formulary |
Out-of-Network
|
50%
of Drug Limited Fee schedule less the copay as stated for
participating pharmacies
|
