| Lifetime
Maximum |
Participating
Provider
|
$5,000,000/member |
Non-participating
Provider
|
$5,000,000/member |
Annual
Out-of-Pocket Maximum
(includes deductible) |
Participating
Provider
|
$5,000/single
(2-member maximum) Participating and non-participating combined1
|
Non-participating
Provider
|
$5,000/single
(2-member maximum) Participating and non-participating combined1
|
| Annual
Deductible |
Participating
Provider
|
$500
hospital, $5,000 other covered services (2-member maximum)
All covered benefits |
Non-participating
Provider
|
$500
hospital, $5,000 other covered services (2-member maximum)
All covered benefits |
| Office
Visits |
Participating
Provider
|
Well-child,
50% of negotiated fee; 2-adult, 4-child office visits, $30
copay/visit (deductible waived) |
Non-participating
Provider
|
Well-child,
50% of negotiated fee (deductible waived); all other visits
subject to deductible |
Professional
Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
Participating
Provider
|
20%
of negotiated fee for hospital services only. All other covered
services after out-of-pocket maximum is met, then covered
at 100% of negotiated fee |
Non-participating
Provider
|
50%
of negotiated fee plus 100% of excess |
| Hospital
Inpatient/Outpatient |
Participating
Provider
|
20%
of negotiated fee2 |
Non-participating
Provider
|
All
charges except: $650/day inpatient, $380/day outpatient |
| Hospice |
Participating
Provider
|
$10,000
lifetime maximum, participating and non-participating providers
combined |
Non-participating
Provider
|
$10,000
lifetime maximum, participating and non-participating providers
combined |
| Emergency
Services |
Participating
Provider
|
20%
of negotiated fee3 after $500 deductible is met
|
Non-participating
Provider
|
20%
of customary & reasonable for the first
48 hours plus 100% of excess; after 48 hours,
you pay all charges except $650/day for
covered services3 |
Maternity
(after deductible) |
Participating
Provider
|
Not
covered |
Non-participating
Provider
|
Not
covered |
| Preventive
Care |
Participating
Provider
|
Healthy
Check Centers: $25 or $75 copay for basic screenings; routine
mammogram, PSA and cancer screening, ordered by physician:
30% of negotiated fee (deductible waived) |
Non-participating
Provider
|
Routine
mammogram, PSA and cancer
screening, ordered by physician: 50% of
negotiated fee plus 100% of excess |
| Ambulance |
Participating
Provider
|
20%
of negotiated fee ($750/trip maximum
paid by BC Life & Health Insurance Company) |
Non-participating
Provider
|
50%
of customary & reasonable plus 100% of excess |
| Physical
and Occupational Therapy; Chiropractic Services |
Participating
Provider
|
20%
of negotiated fee; limited to 12 visits/year, participating
and non-participating combined |
Non-participating
Provider
|
All
charges except $25/visit; limited to 12 visits/year, participating
and non-participating combined |
| Acupuncture/Acupressure |
Participating
Provider
|
All
charges except $25/visit; limited to 24 visits/year, participating
and non-participating combined |
Non-participating
Provider
|
All
charges except $25/visit; limited to 24 visits/year, participating
and non-participating combined |
Drug
Benefits
(retail or mail order: 30-day supply) |
Participating
Provider
|
$10
generic4; $30 brand copay plus $500 brand deductible5
(2 Member Maximum); 30% of negotiated fee for self-administered
injectables except insulin
Non-Formulary:
Participating Provider: Generic4 50%; Brand 100%
of negotiated Fee Rate for Br |
Non-participating
Provider
|
50%
of the drug limited-fee schedule plus 100% of excess; $500
brand deductible6 (2-member maximum) |
