| Lifetime
Maximum |
In-Network
|
$3,000,000/member |
Out-of-Network
|
$3,000,000/member |
Annual
out-of-pocket Maximum
|
In-Network
|
$1,000 plus the medical deductible
per Insured per policy* |
Out-of-Network
|
$1,000 plus the medical deductible
per Insured per policy* |
| Annual
Deductible |
In-Network
|
$250 per Insured per policy (waived
for accidents) |
Out-of-Network
|
$250 per Insured per policy (waived
for accidents) |
| Office
Visits |
In-Network
|
20% of Negotiated Fee Rate |
Out-of-Network
|
20% of Negotiated Fee Rate |
Professional
Services
(X-ray, lab, anesthesia, surgeon, etc.) |
In-Network
|
20% of Negotiated Fee Rate |
Out-of-Network
|
20% of Negotiated Fee Rate (NFR)
plus all charges in excess of NFR unless Special Circumstances
apply |
| Hospital
Inpatient/Outpatient |
In-Network
|
20% of Negotiated Fee Rate ** |
Out-of-Network
|
Insured pays all charges except:
$650/day inpatient, $380/day outpatient |
| Emergency
Services |
In-Network
|
20% of Negotiated Fee Rate ** |
Out-of-Network
|
Within California: Physician: 20% of
Customary and Reasonable (C&R) charges or billed charges
plus all charges in excess of C&R
Hospital: 20% of C&R charges or billed charges, whichever is
less plus all charges in excess of C&R for the first 48 hour |
| Maternity |
In-Network
|
No benefits |
Out-of-Network
|
No benefits |
| Home
Health Care |
In-Network
|
20% of Negotiated Fee Rate (NFR) -
limited to 30 visits per policy term |
Out-of-Network
|
20% of Negotiated Fee Rate (NFR) -
limited to 30 visits per policy term |
| Skilled
Nursing Facilities |
In-Network
|
No Benefits |
Out-of-Network
|
No Benefits |
| Hospice |
In-Network
|
No Benefits |
Out-of-Network
|
No Benefits |
| Preventive
Care |
In-Network
|
HealthyCheck Centers: $25 or $75
copay for basic screenings (deducible-free); Routine Pap smears,
annual mammograms, PSA and cancer screening, as ordered by
physician including the related office visit: 20% of Negotiated
Fee Rate, subject to the deductibl |
Out-of-Network
|
Routine Pap smears, annual
mammograms, PSA and cancer screening, ordered by physician
including the related office visit: 20% of Negotiated Fee Rate,
subject to the deductible |
| Infusion
Therapy |
In-Network
|
20% of Negotiated Fee Rate – Up to
$2000 maximum per person during the policy term |
Out-of-Network
|
20% of Negotiated Fee Rate – Up to
$2000 maximum per person during the policy term |
| Ambulance |
In-Network
|
20% of Negotiated Fee Rate –
Maximum payment of $1000 per person during policy term |
Out-of-Network
|
20% of Negotiated Fee Rate –
Maximum payment of $1000 per person during policy term |
| Physical
and Occupational Therapy; Chiropractic Services |
In-Network
|
20% of Negotiated Fee Rate; In an
outpatient facility, limited to a combined maximum of $1000 per
person during policy term |
Out-of-Network
|
20% of Negotiated Fee Rate; In an
outpatient facility, limited to a combined maximum of $1000 per
person during policy term |
| Acupuncture/Acupressure |
In-Network
|
Insured pays all of the NFR except
$25; 12 visit maximum. Subject to the deductible |
Out-of-Network
|
Insured pays all charges except $25
per visit; 12 visit maximum. Subject to the deductible |
Mental,
Emotional or Functional Nervous Disorders
(Inpatient Hospital Charges)
|
In-Network
|
50% up to the semi-private room rate
- Up to a combined maximum of $5,000 during policy term |
Out-of-Network
|
50% up to the semi-private room rate
- Up to a combined maximum of $5,000 during policy term |
Mental,
Emotional or Functional Nervous Disorders
(In or Outpatient Professional Charges)
|
In-Network
|
50% Outpatient; $40 per visit max
but no more than one visit per week for outpatient treatment –
Up to a combined maximum of $5000 during Policy term. |
Out-of-Network
|
50% Outpatient; $40 per visit max
but no more than one visit per week for outpatient treatment –
Up to a combined maximum of $5000 during Policy term. |
| Speech
Therapy |
In-Network
|
No Benefits |
Out-of-Network
|
No Benefits |
Drug
Benefits
(retail or mail order: 30-day supply)
|
In-Network
|
$10 generic***; $30 brand copay.
Brand drug maximum of $500 per Insured per policy. 30% of
Negotiated Fee Rate for self-administered injectables |
Out-of-Network
|
Copayment as stated for
Participating Pharmacies plus 50% of the Drug Limited Fee
Schedule (DLFS) and all charges in excess of the DLFS |
| AD
& D |
In-Network
|
50000 |
Out-of-Network
|
50000 |
