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HomeDental Plans Short Term PPO Saver Plans BC Life & Health PPO Saver (NM31) 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 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 hospital, $5,000 other covered services (2-member maximum) All covered benefits Non-participating Provider $500 hospital, $5,000 other covered services (2-member maximum) All covered benefits Office Visits Participating Provider Well-child, 50% of negotiated fee; 2-adult, 4-child office visits, $30 copay/visit (deductible waived) Non-participating Provider Well-child, 50% of negotiated fee (deductible waived); all other visits subject to deductible Professional Services (other office visits, X-ray, lab, anesthesia, surgeon, etc.) Participating Provider 20% of negotiated fee for hospital services only. All other covered services after out-of-pocket maximum is met, then covered at 100% of negotiated fee Non-participating Provider 50% of negotiated fee plus 100% of excess Hospital Inpatient/Outpatient Participating Provider 20% 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 20% of negotiated fee3 after $500 deductible is met Non-participating Provider 20% 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 (after deductible) Participating Provider Not covered Non-participating Provider Not covered 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 (deductible waived) Non-participating Provider Routine mammogram, PSA and cancer screening, ordered by physician: 50% of negotiated fee plus 100% of excess Ambulance Participating Provider 20% of negotiated fee ($750/trip maximum paid by BC Life & Health Insurance Company) Non-participating Provider 50% of customary & reasonable plus 100% of excess Physical and Occupational Therapy; Chiropractic Services Participating Provider 20% 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 Non-participating Provider All charges except $25/visit; limited to 24 visits/year, participating and non-participating combined Drug Benefits (retail or mail order: 30-day supply) Participating Provider $10 generic4; $30 brand copay plus $500 brand deductible5 (2 Member Maximum); 30% of negotiated fee for self-administered injectables except insulin Non-Formulary: Participating Provider: Generic4 50%; Brand 100% of negotiated Fee Rate for Br Non-participating Provider 50% of the drug limited-fee schedule plus 100% of excess; $500 brand deductible6 (2-member maximum)   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 and do not apply to the out-of-pocket maximum. 2 Additional $500 admission charge at Participating Hospitals (no additional for Preferred Participating Hospitals) is for surgery or infusion therapy. This charge is not required for Ambulatory Surgical Centers or medical emergencies. 3 Additional $30 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient). 4 Generic drugs are based upon the Blue Cross drug formulary 5 Brand drug deductible does not apply to out-of-pocket maximum

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