| Annual
deductible |
In-Network
|
$1,000 per member; two-member maximum |
Out-Of-Network
|
$1,000 per member; two-member maximum |
| Lifetime
covered charges paid by Blue Cross, in-network and out-of-network
combined |
In-Network
|
$5,000,000 |
Out-Of-Network
|
$5,000,000 |
Annual
out-of-pocket maximum
In-network and out-of-network combined. Certain payments do not
apply |
In-Network
|
Deductible plus $2,000 per member,
Two-member family maximum |
Out-Of-Network
|
Deductible plus $2,000 per member,
Two-member family maximum |
| Office
visits |
In-Network
|
Not covered |
Out-Of-Network
|
Not covered |
Hospital
inpatient facility services
Pre service Review required |
In-Network
|
PREFERRED PARTICIPATING HOSPITALS:
20% of the negotiated fee after deductible PARTICIPATING HOSPITALS:
20% of the negotiated fee plus $500 admission charge after deductible |
Out-Of-Network
|
Member pays all charges except $650
per day after deductible |
| Hospital
inpatient professional services |
In-Network
|
20% of the negotiated fee after deductible |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of the negotiated fee after deductible |
Hospital
outpatient services
Limited to surgery, medical emergency, radiation therapy, hemodialysis
treatment and infusion therapy. Pre service Review required |
In-Network
|
PREFERRED PARTICIPATING HOSPITALS:
20% of the negotiated fee after deductible
PARTICIPATING HOSPITALS:
20% of the negotiated fee plus $500
admission charge for surgeries or infusion therapy after deductible |
Out-Of-Network
|
Member pays all charges except $380
per day after deductible |
Outpatient
professional services related to covered hospital charges
Limited professional services covered |
In-Network
|
20% of the negotiated fee after deductible |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of the negotiated fee after deductible |
Ambulatory
Surgical Centers
Pre service Review Required |
In-Network
|
20% of the negotiated fee after deductible |
Out-Of-Network
|
Member pays all charges except $380
per day after deductible |
Prescription
Drugs
30-day supply retail; up to a 60-day supply available through
mail order. Maximum Blue Cross payment $500 per member, in-network
and out-of-network combined |
In-Network
|
NOT SUBJECT TO DEDUCTIBLE
$10 copay generic (for each 30-day supply), $25 copay brand
(for each 30-day supply); self-administered injectable drugs,
except Insulin, 30% of negotiated fee for self-administered injectables,
except insulin. $500 maximum drug benefit
If you select a brand-name drug when a generic equivalent drug
is available, even if the physician writes a "dispense as written"
or "do not substitute" prescription, the member will be responsible
for the generic copay plus the difference in cost between the
brand-name and the generic equivalent drug. * |
Out-Of-Network
|
NOT SUBJECT TO DEDUCTIBLE
50% of Drug Limited Fee Schedule, plus 100% of charges in excess
of drug limited fee |
Healthy
Check screenings, Ages 7-adult
Includes certain lab tests, immunizations and health education
information |
In-Network
|
NOT SUBJECT TO DEDUCTIBLE
$25 or $75 copay health screening options. |
Out-Of-Network
|
Not Available |
Well-baby
immunizations and adult screening tests
Children through age 6: Regular check-up and immunizations
Ages 7-adult: Limited to annual pap, breast exam, and mammogram
for women and Prostate Specific Antigen (PSA) study for men |
In-Network
|
20% of the negotiated fee after deductible |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of the negotiated fee after deductible |
Emergency
Care
$100 copay for each visit - waived if admitted |
In-Network
|
PREFERRED PARTICIPATING HOSPITALS
AND PARTICIPATING HOSPITALS:
20% of the negotiated fee after deductible |
Out-Of-Network
|
20% of customary and reasonable charges,
plus 100% of excess for first 48 hours; after 48 hours, all charges
in excess of $650 per day after deductible |
Ambulance
$750 per trip maximum Blue Cross payment |
In-Network
|
20% of the negotiated fee, plus 100%
of charges in excess of $750 per trip maximum up to the negotiated
amount after deductible |
Out-Of-Network
|
50% of customary and reasonable charges,
plus 100% of charges in excess of customary and reasonable charges
after deductible |
Skilled
Nursing Facility
100 days per year, in-network and out-of-network combined
$540 per day maximum Blue Cross payment Pre service Review required. |
In-Network
|
20% of the negotiated fee, plus 100%
of charges in excess of $540 per day maximum up to the negotiated
amount after deductible |
Out-Of-Network
|
Member pays all charges except $380
per day after deductible |
Home
Health Care
90 four-hour visits per year, in-network and out-of-network combined
$137.50 per visit maximum Blue Cross payment Pre service Review
required |
In-Network
|
20% of the negotiated fee, plus 100%
of charges in excess of $137.50 per visit maximum up to the negotiated
amount after deductible |
Out-Of-Network
|
50% of customary and reasonable charges,
plus 100% of charges in excess of customary and reasonable charges
after deductible |
| Physical/Occupational
Therapy, Chiropractic Care |
In-Network
|
Not covered |
Out-Of-Network
|
Not covered |
Acupuncture/Acupressure
12 visits per year, in-network and out-of-network combined |
In-Network
|
All charges except $25 per visit after
deductible |
Out-Of-Network
|
All charges except $25 per visit after
deductible |
Mental
Health*, including Chemical Dependency, inpatient:
30 days per year, in-network and out-of-network combined |
In-Network
|
All of the negotiated fee except $175
per day after deductible |
Out-Of-Network
|
All charges except $175 per day after
deductible |
| Mental
Health*, including Chemical Dependency, outpatient professional
services |
In-Network
|
Not covered |
Out-Of-Network
|
Not covered |
Infusion
Therapy, including Chemotherapy
Pre service Review required |
In-Network
|
20% of the negotiated fee after deductible |
Out-Of-Network
|
50% of the negotiated fee, plus 100%
of charges in excess of $50 per day for all infusion therapy expenses
except drugs; all charges in excess of the average wholesale price
for all infusion therapy drugs; all charges in excess of the combined
maximum Blue Cross payment of $500 per day after deductible |
Infertility
Services
Lifetime maximum $2,000 in-network and out-of-network combined |
In-Network
|
20% of the negotiated fee after deductible |
Out-Of-Network
|
INPATIENT FACILITY SERVICES: Member
pays all charges except $650 per day after deductible
OUTPATIENT FACILITY SERVICES: Member pays all charges except $380
per day after deductible
PROFESSIONAL SERVICES RELATED TO COVERED HOSPITAL CHARGES: 50%
of the negotiated fee, plus 100% of charges in excess of the negotiated
fee after deductible |
