| 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 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 |
| Maternity |
In-Network
|
Not Covered |
Out-of-Network
|
Not Covered |
| Preventive
Care/HealthyCheck 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 for breast cancer
Cervical and Ovarian cancer screening tests Prostatic Specific
Antigen(PSA) study |
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
|
$500 Brand Name Deductible
$10 Generic Copay $30 Brand Name Copay 30% Self administered
injectable 6
If you select a Brand Name Drug when a generic equivalent is
available even if a physician writes a “dispense as written”
or “do not substitute” prescription you pay the generic drug
copayment plus the cost between the Brand Name drug and the
generic equivalent drug. None of the amount paid applies toward
your Brand Name Drug Deductible
Click
here to view the Blue Cross of California drug formulary |
Out-of-Network
|
50% of Drug Limited Fee schedule
less the copay as stated for participating pharmacies
|
