| Lifetime Maximum |
| Unlimited |
Annual Out-of-Pocket Maximum
(includes deductible) |
| $3,000/single (2-member maximum) |
| Annual Deductible |
|
$1,500/member
Inpatient hospital services, outpatient
Ambulatory Surgical Centers only |
| Office Visits |
| You pay $10 |
Professional Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
|
Unlimited office visits:
you pay $10 per visit
Inpatient hospital - no charge |
| Hospital Inpatient/Outpatient |
|
Inpatient - no charge after
$1,500 deductible for non-emergency services
Outpatient - you pay 20% of negotiated fee after $1,500 deductible
for non-emergency services
(for non-emergency services) |
| Emergency Services |
|
Inpatient and professional
services - no
charge when authorized by a medical group
within 48 hours of emergency care
Outpatient - you pay $100 emergency room
co payment plus 20% |
Maternity
|
|
Professional Office Visit
you pay $10 co payment Hospital - no charge after $1,500 deductible
Outpatient Hospital - 20% after $1,500 deductible. |
| Preventive Care |
|
You pay a $10 co payment
for specific health
maintenance services |
| Ambulance |
|
You pay a $50 co payment
unless admitted to
the hospital |
| Physical and Occupational Therapy; Chiropractic Services |
| You pay $10 per visit; limited to 60 consecutive days following illness or injury; no charge for inpatient services Chiropractic benefits with medical group referral |
Drug Benefits
(retail or mail order: 30-day supply) |
Participating Provider
|
You pay $10 for generic
and $30 for Brand drugs, plus a $250 deductible for Brand
drugs
Non-Formulary:
Participating Provider: Generic 50%; Brand 100% of negotiated Fee Rate for Brand Name Drugs until the Brand Name Prescription Drug Deductible is |
Non-participating Provider
| You pay a $250 Brand deductible; then 50% of drug Limited Fee Schedule within California |
HMO Saver 
