| Lifetime
Maximum |
Participating
Provider
|
$5,000,000/member |
Non-participating
Provider
|
$5,000,000/member |
Annual
Out-of-Pocket Maximum
(includes deductible) |
Participating
Provider
|
$5,000/single
(2-member maximum)
Participating and non-participating combined1 |
Non-participating
Provider
|
$5,000/single
(2-member maximum)
Participating and non-participating combined1 |
| Annual
Deductible |
Participating
Provider
|
$500/member
(2-member maximum) All covered benefits |
Non-participating
Provider
|
$500/member
(2-member maximum) All covered benefits |
| Office
Visits |
Participating
Provider
|
Well-child,
40% of negotiated fee; office visits, 30% of negotiated fee
(deductible waived) |
Non-participating
Provider
|
Well-child,
50% of negotiated fee; office visits, 50% of negotiated fee
(deductible waived) |
Professional
Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
Participating
Provider
|
30%
of negotiated fee |
Non-participating
Provider
|
50%
of negotiated fee plus 100% of excess |
| Hospital
Inpatient/Outpatient |
Participating
Provider
|
30%
of negotiated fee2 |
Non-participating
Provider
|
All
charges except: $650/day inpatient, $380/day outpatient |
| Hospice |
Participating
Provider
|
$10,000
lifetime maximum, participating and non-participating providers
combined |
Non-participating
Provider
|
$10,000
lifetime maximum, participating and non-participating providers
combined |
| Emergency
Services |
Participating
Provider
|
30%
of negotiated fee3 |
Non-participating
Provider
|
30%
of customary & reasonable for the first 48 hours plus 100%
of excess; after 48 hours, you pay all charges except $650/day
for covered services3 |
Maternity
|
Participating
Provider
|
30%
of negotiated fee |
Non-participating
Provider
|
50%
of negotiated fee plus 100% of excess |
| Preventive
Care |
Participating
Provider
|
Healthy
Check Centers: $25 or $75 copay for basic screenings; routine
mammogram, PSA and cancer screening, ordered by physician:
30% of negotiated fee; well-baby and well-child, 40% of
negotiated fee Annual Physical Exam 30% of negotiated fee
deductible |
Non-participating
Provider
|
Routine
mammogram, PSA and cancer screening, ordered by physician:
50% of negotiated fee plus 100% of excess Annual Physical
Exam, 50% of negotiated fee plus excess for covered services4
|
| Ambulance |
Participating
Provider
|
30%
of negotiated fee |
Non-participating
Provider
|
50%
of customary & reasonable plus 100% of excess |
| Physical
and Occupational Therapy; Chiropractic Services |
Participating
Provider
|
30%
of negotiated fee; limited to 12 visits/year, participating
and non-participating combined |
Non-participating
Provider
|
All
charges except $25/visit; limited to 12 visits/year, participating
and non-participating combined |
| Acupuncture/Acupressure |
Participating
Provider
|
All
charges except $25/visit; limited to 24 visits/year, participating
and non-participating combined (deductible waived) |
Non-participating
Provider
|
All
charges except $25/visit; limited to 24 visits/year, participating
and non-participating combined (deductible waived) |
Drug
Benefits
(retail or mail order: 30-day supply) |
Participating
Provider
|
$10
generic5; $30 brand copay plus $250 brand deductible6;
30% of negotiated fee for self-administered injectables
except insulin
Non-Formulary:
Participating Provider: Generic5 50%; Brand 100%
of negotiated Fee Rate for Brand Name Drugs until |
Non-participating
Provider
|
50%
generic5 or 50% of brand drug limited-fee schedule
within California; $250 brand deductible6 (2-member
maximum) |
