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HomeDental Plans Short Term PPO Generic Plans BC Life & Health Right Plan PPO 40 with generic prescription drug coverage (PE48) Select Another Plan Determine the rates for the medical plan you selected and other available plans by clicking on the Get a Personalized Quote link on the left. Lifetime Maximum In-Network $5,000,000.00 Out-of-Network $5,000,000.00 Out of Pocket Maximum In-Network $7,500.00 In and Out of Network Combined Out-of-Network $7,500.00 In and Out of Network Combined Annual Deductible In-Network $0 Out-of-Network $0 Office Visits In-Network $40 CoPay Out-of-Network 50% of negotiated fee plus 100% of charges in excess of negotiated fee 1 Professional Services In-Network 40% of negotiated fee Out-of-Network 50% of negotiated fee plus 100% of charges in excess of of negotiated fee Inpatient Hospital Services (Includes organ and tissue transplants) In-Network 40% of negotiated fee plus $400 copay per day/4 day max per admission 2,4,5 Out-of-Network All charges except $650 per day Outpatient Hospital Services/Ambulatory Surgical Center In-Network 40% of negotiated fee plus $400 copay per outpatient surgery admit 2,4,5 Out-of-Network All charges except $380 per day Emergency Care In-Network 40% of negotiated fee 3 Out-of-Network 40% of C&R for first 48 hours plus 100% of charges in excess of C&R. After 48 hours all charges in excess of $650 per day 3,7 Maternity In-Network Not Covered Out-of-Network Not Covered Preventive Care/Healthy Check Center In-Network $25 or $75 option Out-of-Network Not covered Preventive Care In-Network $40 office visit plus 40% of negotiated fee for well-baby and well-child thru age 6 $40 office visit plus 40% of negotiated fee for Covered Services other than the Office Visit for Annual Pap exam Breast exams Mammogram testing and appropriate screening Out-of-Network All charges in excess of 50% of negotiated fee for well-baby and well-child thru age 6 All Charges in excess of 50% of negotiated fee Ambulance Service In-Network 40% of negotiated fee Out-of-Network All charges in excess of 50% of negotiated fee Physical Therapy, Occupational Therapy/Chiro In-Network 40% of negotiated fee; limited to 12 visits/year, participating and non-participating combined Out-of-Network All charges except $25 per visit Acupuncture/Acupressure In-Network All charges except $25 per visit; limited to 24 visits/year, participating and non-participating combined Out-of-Network All charges except $25 per visit; limited to 24 visits/year, participating and non-participating combined Prescription Drug Benefit In-Network $10 Generic CoPay, Right Plan Generic Prescription Formulary 6 Click here to view the Right Plan generic prescription formulary Out-of-Network 50% of Drug Limited Fee schedule less the copay as stated for participation pharmacies   Please Note: When locating a provider, PPO plans are also referred to as Prudent Buyer 1 Non-participating charges in excess of the negotiated fee will not be paid. 2 $500 admission charge for admit to Participating (tier II) Hospital Same benefits for Blue Card providers 3 Additional $100 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient). 4 Once OOP max is met, $400 copayment will not be required to remainder of that Year 5 $400 CoPay as explained in Hospital In-Network inpatient/outpatient benefits 6 Members on Right Plan PPO 40 with No Prescription Drug Coverage and Right Plan PPO 40 with Generic Only Prescription Drug Coverage can access Blue Cross Pharmacy discounts when filling a prescription for a non-covered drug. Members must present the Blue Cross member ID card when they have their prescription filled.

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