Annual Deductible
Medical/Pharmacy combined: In and Out of Network Combined |
In-Network
| Single Member: $3500
Family Contract: $7000 aggregate |
Lifetime Covered Charges Paid by BCL&H
In-Network and Out-of-Network Combined |
In-Network
| $5,000,000 |
Annual out-of-pocket maximum
In and Out of Network Combined
The member is stil responsible for all charges over the allowable amount when usin a non-participating provider. |
In-Network
| Single Member: $4000
Family Contract: $7,500 aggregate |
Out-Network
| Once the Out-of-pocket maximum has been met, member pays nothing for covered expenses for the remainder of the year. |
| Office Visits |
In-Network
| After deductible Insured pays $35 Co-pay |
Out-Network
| After deductible Insured pays 50% of negotiated fee plus 100% of charges in excess of negotiated fee |
Other professional services, includes maternity, diagnostic lab and x-rays
|
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays 50% of negotiated fee plus 100% of charges in excess of negotiated fee |
Hospital Inpatient Facility Services
(Includes organ and tissue transplants)
Pre-service Review Required |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays all charges except $650 per day |
Hospital Inpatient Professional Services
Includes lab work, physician and anesthesia |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays 50% of negotiated fee plus 100% of charges in excess of negotiated fee |
Hospital Outpatient Services
Pre-Service Review required for certain surgical services and diagnostic procedures |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays all charges except $380 per day |
Ambulatory Surgical Centers
Preservice Review required
|
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays all charges except $380 per day |
Infertility benefit
Lifetime infertility medical benefit $2000 (par and non par providers combined)
Lifetime infertility pharmacy benefit $1500 (par and non par providers combined) |
In-Network
| After deductible Insured pays a $500 copayment plus 0% of any balance of the negotiated fee remaining after the $500 copayment |
Out-Network
| After deductible Insured pays a $500 copayment plus 50% of any balance remaining after the $500 copayment plus any charges in excess of the negotiated fee |
Prescription Drugs
30-day supply retail; up to a 60-day supply available through mail-order Subject to combined deductilble DAW override allowed.
Lifetime maximum infertility benefit $1500
MPTD amount goes toward deductible and OOP |
In-Network
| $10 co-pay generic formulary (for each 30-day supply)
$25 co-pay brand formulary name (for each 30-day supply) after combined deductible is met
Self-administered injectable drugs, except insulin, 30% of the negotiated fee. 50% Co-Insurance for Non-Formulary drugs.
Multisource Brand name drugs are MPTD. When a brand name drug is requested by a Member and a generic exists, the Member pays the difference in cost between brand name drugs and generic equivalent, plus the brand name co-pay. |
Out-Network
| Drug Limited Fee Schedule after annual deductible, in-network and out-of-network combined; |
HealthyChek Screenings
Ages 7-Adult
Includes certain lab tests, immunizations and health education information |
In-Network
| Deductible waived
$25 or $75 co-pay health screening options |
Out-Network
| Not Available |
Preventive Care:
Well Baby Immunizations and Adult Screening Tests
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
| Deductible waived
Well Baby, Well Child, Adult Screenings: $35 co-pay plus 0% co-insurance on any excess charges |
Out-Network
| Deductible waived
Well Child: 50% of negotiated fee plus 100% of charges in excess of the negotiated fee
Adult: 50% of negotiated fee plus 100% of the charges in excess of the negotiated fee |
Physical Exam:
One exam allowed annually par and non par providers combined |
In-Network
| Deductible waived
Insured pays $35 for the office visit plus 100% of the negotiated fee rate for all other covered services beyond that related office visit, and any charges in excess of the benefit limit stated in the note below.
Insured pays all charges except $100 within first 6 months of enrollment.
Insured pays all charges except $200 after first 6 months of enrollment
|
Out-Network
| Deductible waived
Insured pays 50% of the negotiated fee rate plus any charges in excess of the negotiated fee rate for the office visit and all other covered services related to the office visit, and any charges in excess of the benefit limit stated below.
Insured pays all charges except $100 within first 6 months of enrollment.
Insured pays all charges except $200 after first 6 months of enrollment
|
Emergency Care
$100 co pay for each visit - waived if admitted |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible
Non Par Physician: Insured pays all charges in excess of C&R
Non Par Hospital or ASC: Insured pays all charges in excess of C&R for the first 48 hours. After 48 hours, the Insured pays all charges except $650 per day. |
| Ambulance |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays 0% of negotiated fee plus 100% of charges in excess of negotiated fee |
Skilled Nursing Facility
100 days per year, in-network and out-of-network combined; Preservice Review required |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays all charges except $150 per day |
Home Health Care
Limited to 100 visits per year, up to four hours each visit; in-network and out-of-network combined; Preservice Review Required |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays all charges except $75 per visit |
Physical/Occupational Therapy, Chiropractic Care
12 visits per year, in-network and out-of-network combined does not apply to out-of-pocket maximum when services are rendered by a par provider |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays all charges except $25 per visit |
Acupuncture/Acupressure
12 visits per year, in-network and out-of-network combined; does apply to out-of-pocket maximum when services are rendered by a par provider |
In-Network
| After deductible Insured pays all charges except $25 per visit |
Out-Network
| After deductible Insured pays all charges except $25 per visit |
Mental Healh
Inpatient
Includes chemical dependency
Inpatient
30 days per year, in-network and out-of-network combined; copayments do apply to out-of-pocket maximum when services are rendered by a par provider |
In-Network
| After deductible Insured pays all charges except $175 per day |
Out-Network
| After deductible Insured pays all charges except $175 per day |
Mental Healh
Outpatient Professional Services
Includes chemical dependency
Outpatient professional services
One visit per day, 20 visits per year, in-network and out-of-network combined; copayments do apply to out-o-pocket maximum when services are rendered by a par provider |
In-Network
| After deductible Insured pays all charges except $25 per day |
Out-Network
| After deductible Insured pays all charges except $25 per day |
Infusion Therapy
Includes chemotherapy
Precservice Review Required |
In-Network
| After deductible Anthem blue cross pays 100% of the negotiated fee |
Out-Network
| After deductible Insured pays all charges in excess of $50 per day for al infusion therapy expensed except drugs; all charges in excess of the average wholesale price for all infusion therapy drugs; all charges in excess of the combined maximum BCL&H payment of $500 per day |
PPO 3500 HSA Compatible Plan (V471)
