| Calendar year deductible (In and Out of Network Combined) |
In-Network
| $3,500/member; $7,000/family aggregate |
Out-of-Network
| $3,500/member; $7,000/family aggregate 1 |
| Lifetime Maximum (combined for all providers) |
In-Network
| $5,000,000/member |
| Annual Out-of-Pocket Maximum (In and Out of Network Combined) |
In-Network
| Single member $5,000; Family aggregate $10,000 |
| Office Visits |
In-Network
| Covered in full after deductible met |
Out-of-Network
| 50% of negotiated fee plus excess of negotiated fee after deductible met |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc) |
In-Network
| Covered in full after deductible met |
Out-of-Network
| 50% of negotiated fee plus excess of negotiated fee after deductible met |
| Inpatient Hospital Services |
In-Network
| Covered in full after deductible met2 |
Out-of-Network
| All charges except $650/day after deductible met |
| Outpatient Hospital Services |
In-Network
| Covered in full after deductible met |
Out-of-Network
| All charges except $380/day after deductible met |
| Emergency Care |
In-Network
| Covered in full after deductible met3 |
Out-of-Network
| 1st 48 hours: all charges in excess of 100% of C & R after deductible met; after 48 hours, all charges except $650/day |
| Pregnancy & Maternity Services |
In-Network
| Not Covered |
Out-of-Network
| Not Covered |
| Preventive Care |
In-Network
|
Routine mammogram, PSA
and Pap test: Covered in full after deductible met4;
Well Baby & Well Child (through age 6): Covered in full after
deductible met; Healthy Check Centers5: $25 or
$75 co pay |
Out-of-Network
|
Routine mammogram, PSA
and Pap test: 50% of negotiated fee plus excess of negotiated
fee after deductible met; Well Baby & Well Child (through
age 6): 50% of negotiated fee plus excess of negotiated fee
after deductible met; Healthy Check Centers: Not Covered. |
| Ambulance Service |
In-Network
| Covered in full after deductible met |
Out-of-Network
| 50% of negotiated fee plus excess of negotiated fee after deductible met |
Physical Therapy, Physical Medicine & Occupational Therapy, including Chiropractic Services
limited to 12 visits/calendar year; additional visits may
be authorized) |
In-Network
| Covered in full after deductible met |
Out-of-Network
| All charges except $25/visit after deductible met |
Acupuncture
/ Acupressure
(limited to maximum Anthem blue cross payment of $25/visit; limited
to 24 visits/calendar year in & out-of-network combined) |
In-Network
| All charges except $25/visit after deductible met |
Out-of-Network
| All charges except $25/visit after deductible met |
Outpatient Speech Therapy
When following surgery, injury or non-congenital organic disease
excess of C& R (limited to 50 visits/year in and out-of-network
combined) |
In-Network
| Covered in full after deductible met |
Out-of-Network
| 50% of C&R plus excess of C&R after deductible met |
Skilled Nursing Facility
Semi-private room, services & supplies (limited to 100 days
per calendar year in and out-of-network combined) |
In-Network
| Covered in full after deductible met |
Out-Network
| All charges except $150/day after deductible met |
Home Health Care
Services & supplies from a home health agency (limited to
60 visits/calendar year, one visit by a home health aide equals
four hours or less; not covered while member receives hospice
care) |
In-Network
| Covered in full after deductible met |
Out-of-Network
| All charges except $75/day after deductible met |
Infusion Therapy
Combined admin, prof and drug for out-of-network will not
exceed $500/day
Includes medication, caregiver training & visits by provider
to monitor therapy; durable medical equipment |
In-Network
| Covered in full after deductible met |
Out-of-Network
|
Admin & Prof. Services:
All charges in excess of $50/day after deductible met
Drugs: All charges in excess of Drug AWP after deductible met |
Medical Supplies, Equipment & Footwear
Footwear limited to $400 per year maximum combined for $400/calendar
year in and out-of-network combined
|
In-Network
| Covered in full after deductible met |
Out-of-Network
| 50% of negotiated fee plus excess of negotiated fee after deductible met |
Mental or Nervous Disorders
Inpatient Hospital & Day Treatment Programs (limited to 30
days/year in & out-of network combined)
Professional Services (Inpatient or Outpatient physician charges
except services (limited to 1 visit/day; 20 visits/year) |
In-Network
| Inpatient Hospital & Day Treatment Programs (limited to 30 days/year in & out-of network combined): All charges except $175/day after deductible met; Professional Services (Inpatient or Outpatient physician charges except services (limited to 1 visit/day; |
Out-of-Network
| Inpatient Hospital & Day Treatment Programs (limited to 30 days/year in & out-of network combined): All charges except $175/day after deductible met; Professional Services (Inpatient or Outpatient physician charges except services (limited to 1 visit/day; |
Severe Mental Illness and serious Emotional Disturbances of a Child
(Services provided as any other medical condition)
|
In-Network
| Covered in full after deductible met |
Out-of-Network
| 50% of negotiated fee plus excess of negotiated fee after deductible met |
Hospice
(limited to a lifetime maximum BC Life benefit of $10,000
in and out of network combined)
|
In-Network
| Covered in full after deductible met |
Out-of-Network
| 50% of negotiated fee plus excess of negotiated fee after deductible met |
Prescription Drug Coverage 6
Retail and Mail order combined (Subject to combined deductible
w/ Medical
|
In-Network
|
Generic: $10 co pay Brand:
$30 co pay Non-formulary: 50% of negotiated fee Self Admin
Injectibles: 30% of negotiated fee |
Out-of-Network
| 50% of Drug Limited Fee Schedule plus excess |
