First Dollar Coverage
In-network and out-of-network combined for covered medical expenses except prescription drugs
Amounts paid will not apply toward annual deductible or maximum
co pay limits |
In-Network
| Single member: $750 limit
Two-party and Family contract:
$1,500 aggregate limit |
Out-Network
| Single member: $750 limit
Two-party and Family contract:
$1,500 aggregate limit |
Annual Deductible
In-network and out-of-network combined, deductible accrues after First Dollar Coverage is exhausted |
In-Network
| Single member:
$500
Two-party & family:
$1000 aggregate |
Out-Network
| Single member:
$500
Two-party & family:
$1000 aggregate |
Annual Out-of-Pocket Maximum
Certain payments do not apply* |
In-Network
| Single member: $5,000
Two-party & family: $10,000
Co payments made to Non-Participating Providers will not apply
to annual out-of-pocket maximum for in-network providers |
Out-Network
| Once BCL&H has paid $10,000 for single party or $20,000 for two-party and family, member pays nothing for covered expenses for the remainder of the year.
Co payments made to Participating Providers will not apply to
annual out-of-pocket maximum for out-of-network providers or Family
aggregate for two-party and family contracts |
Lifetime Maximum
In-network and out-of-network combined |
In-Network
| $5,000,000 |
Out-Network
| $5,000,000 |
Office Visits
Co payments do not apply to deductible |
In-Network
|
$35 co pay
|
Out-Network
| 50% of negotiated fee plus 100% of charges in excess of negotiated fee |
Other Professional Services
Includes surgery, anesthesia, radiation therapy, in-hospital doctor visits, diagnostic x-ray and lab work |
In-Network
| 25% of negotiated fee |
Out-Network
| 50% of the negotiated fee, plus 100% of charges in excess of the negotiated fee |
Hospital Inpatient Facility Services
(Includes organ and tissue transplants)
$250 co pay if required Pre service Review not obtained |
In-Network
| 25% of negotiated fee
|
Out-Network
| Member pays all charges except
$650 per day |
Hospital Inpatient Professional Services
(Includes lab work, physician and anesthesia)
Preserve Review Required |
In-Network
| 25% of negotiated fee |
Out-Network
| 50% of negotiated fee plus 100% of charges in excess of the negotiated fee |
Hospital Outpatient Services
Pre service Review required for certain surgical services and
diagnostic procedures |
In-Network
| 25% of negotiated fee |
Out-Network
| Member pays all charges except
$380 per day |
Ambulatory Surgical Centers
Pre service Review required
|
In-Network
| 25% of negotiated fee |
Out-Network
| Member pays all charges except
$380 per day |
Prescription Drugs
Retail: 30 day supply
Mail Service: 60 day supply available for 2 co payments
Infertility drug lifetime maximum benefit $1,500 in-network and out-of-network combined |
In-Network
|
$10 co pay generic (for each 30 day
supply)
$30 co pay brand-name (for each 30 day supply) after annual $250
brand-name prescription drug deductible, in-network and out-of-network
combined, per member. Self-administered injectable drugs, except
Insulin, 30% of the negotiated fee (subject to brand-name prescription
drug deductible if applicable) |
Out-Network
|
After annual $250 brand-name prescription
deductible per member, in-network and out-of-network combined,
for brand-name prescription drugs, 50% of Drug Limited Fee Schedule
(DLFS) if filled within California, 50% of DLFS minus the co payment
if filled out-of-state. |
Health
Check(SM) screenings, Ages 7-adult
Including certain lab tests, immunizations and health education information |
In-Network
| Not subject to annual deductible
$25 or $75 co pay health screening options |
Out-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
|
$35 co pay for office visit, 25% of
the
negotiated fee for all other covered services
after annual deductible |
Out-Network
| 50% of negotiated fee, plus 100% of charges in excess of the negotiated fee after annual deductible |
Emergency Care
$100 co pay for each visit - waived if admitted |
In-Network
| 25% of the negotiated fee |
Out-Network
| 25% of customary and reasonable charges, plus 100% of excess for first 48 hours. After 48 hours, all charges in excess of $650 per day. |
| Ambulance |
In-Network
| 25% of negotiated fee |
Out-Network
| 50% of the negotiated fee, plus 100% of charges in excess of the negotiated fee |
Skilled Nursing Facility
100 days per year, in-network and out-of-network combined,
Pre service Review required |
In-Network
| 25% of negotiated fee |
Out-Network
| All charges except $150 per day |
Home Health Care
Limited to 100 visits per year, up to four hours each visit, in and out-of network combined; Preserve Review Required |
In-Network
| 25% of negotiated fee |
Out-Network
| All charges except $75 per day
|
Physical/Occupational Therapy, Chiropractic Care
12 visits per year, in-network and out-of-network combined |
In-Network
| 25% after deductible
|
Out-Network
| All charges except $25 per visit
|
Acupuncture/Acupressure
12 visits per year, in-network and out-of-network combined, does not apply to out-of-pocket maximum |
In-Network
| All charges except $25 |
Out-Network
| All charges except $25 per visit |
Mental
or Nervous Disorders and Substance Au se:
Includes chemical dependency
Inpatient
30 days per year, in-network and out-of-network combined, co payments
do not apply to out-of-pocket maximum |
In-Network
| a. All charges except $175 per day
b. All charges except $25 per visit |
Out-Network
| a. All charges except $175 per day
b. All charges except $25 per visit |
Infusion Therapy
Combined in-network and out-of-network payment will not exceed $500 per day
Pre service Review required |
In-Network
| 25% of negotiated fee |
Out-Network
| All charges except $50 per day w/o drugs |
Infertility Services
Maximum lifetime benefit $2,000 in-network and out-of-network combined
Separate $1500 Lifetime Maximum for Infertility drugs |
In-Network
|
$500 co pay, plus 25% of the balance
of the negotiated fee
$500 co pay continues after out-of-pocket maximum has been met |
Out-Network
|
$500 co pay, plus 50% of the balance
of the negotiated fee, plus 100% of charges in excess of the negotiated
fee
$500 copay continues after out-of-pocket maximum has been met |
PHF 750 (P942) 
