| Annual medical deductible |
In-Network
| None |
Out-Of-Network
| None |
Lifetime covered charges
paid by Blue Cross |
In-Network
| Unlimited |
Out-Of-Network
| Not applicable |
| Annual out-of-pocket maximum |
In-Network
| $1,750 per member
$3,500 per family (two or more
members-aggregate)
Certain member payments do not apply |
Out-Of-Network
| Not applicable |
Office visits,
including office visits for maternity |
In-Network
|
$20 copay |
Out-Of-Network
| Not covered |
| Other professional services, including maternity, diagnostic lab and x-ray |
In-Network
| No charge |
Out-Of-Network
| Not covered |
| Hospital inpatient facility services |
In-Network
|
$250 copay per admission |
Out-Of-Network
| Not covered, except for certain emergency services |
| Hospital inpatient professional services (lab, physician, anesthesia) |
In-Network
| No charge |
Out-Of-Network
| Not covered, except for certain emergency services |
Hospital outpatient services
(facility based services) |
In-Network
|
20% copay |
Out-Of-Network
| Not covered, except for certain emergency services |
| Ambulatory Surgical Centers |
In-Network
|
20% copay |
Out-Of-Network
| Not covered, except for certain emergency services |
Prescription Drugs
30-day supply retail; Up to a 60-day supply available through mail order |
In-Network
|
$10 copay generic (for each 30-day
supply) not subject to deductible, $25 copay brand (for each
30-day supply) after annual $150 brand name prescription drug
deductible per member, in-network and out-of-network combined,
infertility drug lifetime maximum benefit $1,500 in-network and
out-of-network combined, self-administered injectable drugs, except
Insulin, 30% of the negotiated fee (subject to brand name prescription
drug deductible if applicable).
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 once the brand deductible is satisfied. Amounts the member
pays for drugs, with a generic equivalent, will not apply toward
satisfying the member's brand name deductible. |
Out-Of-Network
| 50% of Drug Limited Fee Schedule if filled within California after annual $150 brand name prescription drug deductible per member, in-network and out-of-network combined, infertility drug lifetime maximum benefit $1,500 in-network and out-of-net-work
combined, Mail order not available |
| Well-baby immunization and adult screening tests |
In-Network
|
$20 copay per office visit |
Out-Of-Network
| Not covered |
Emergency Care
$100 copay for each visit - waived if admitted |
In-Network
| No charge |
Out-Of-Network
| No charge except 100% of amounts in excess of customary and reasonable fees |
| Ambulance |
In-Network
| No charge if ordered by the Primary Care Physician or in an emergency |
Out-Of-Network
| Not covered, except for certain emergency services |
Skilled Nursing Facility
100 days per year in a two-bed room |
In-Network
| No charge |
Out-Of-Network
| Not covered |
Home Health Care
Up to 3 two-hour visits per day |
In-Network
| No charge if ordered by the Primary Care Physician |
Out-Of-Network
| Not covered |
Physical/Occupational Therapy
Up to 60 consecutive days following an illness or injury |
In-Network
| No charge if ordered by the Primary Care Physician |
Out-Of-Network
| Not covered |
Chemical Dependency*
Inpatient: detoxification for alcohol or drug abuse (acute stage only) |
In-Network
|
$250 copay per admission for inpatient
services |
Out-Of-Network
| Not covered |
Mental Health*
Outpatient professional services:
One visit per day, 20 visits per year |
In-Network
|
$20 copay |
Out-Of-Network
| Not covered |
Infusion Therapy, including
Chemotherapy |
In-Network
| No charge |
Out-Of-Network
| Not covered |
| Infertility |
In-Network
| 50% charge |
Out-Of-Network
| Not covered |
