Short Term PPO Generic Plans, PPO plans

Short Term PPO Generic Plans

BC Life & Health Right Plan PPO 40 with generic prescription drug coverage (PE48)

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	$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 ^2,4,5
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 ^3,7
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
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	$10 Generic CoPay, Right Plan Generic Prescription Formulary ⁶ Click here to view the Right Plan generic prescription formulary
Out-of-Network	50% of Drug Limited Fee schedule less the copay as stated for participation pharmacies

	Please Note: When locating a provider, PPO plans are also referred to as Prudent Buyer
1	Non-participating charges in excess of the negotiated fee will not be paid.
2	$500 admission charge for admit to Participating (tier II) Hospital Same benefits for Blue Card providers
3	Additional $100 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
4	Once OOP max is met, $400 copayment will not be required to remainder of that Year
5	$400 CoPay as explained in Hospital In-Network inpatient/outpatient benefits
6	Members on Right Plan PPO 40 with No Prescription Drug Coverage and Right Plan PPO 40 with Generic Only Prescription Drug Coverage can access Anthem blue cross Pharmacy discounts when filling a prescription for a non-covered drug. Members must present the Anthem blue cross member ID card when they have their prescription filled.

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