| 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
|
$1,000/member
(2-member maximum) All covered benefits |
Non-participating
Provider
|
$1,000/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 |
| 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: 25% of negotiated fee;
well-baby and well-child, 40% of
negotiated fee; Annual Physical
Exam 30% of negotiated fee (deductible |
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 services
(deductible waived)4 |
| 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
(2 Member Maximum); 30% of negotiated
fee for self-administered injectables
except insulin
Non-Formulary:
Participating Provider: Generic5
50%; Brand 100% of negotiated Fee
Rate for Br |
Non-participating
Provider
|
50%
generic5 or 50% of brand
drug limited-fee schedule within
California; $250 brand deductible6 |
