| 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
|
HealthyCheck 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 w |
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) |
