BENEFIT
DESCRIPTION |
NETWORK
PROVIDER |
NON-NETWORK
PROVIDER |
|
Lifetime Maximum Benefit (LTM): |
$5,000,000.00 per person |
|
Contract Allowance: |
Based on PPO
fee schedule |
Based on MAP
allowance |
|
Calendar Year Deductible
(CYD) |
|
|
|
Individual Maximum |
$250 |
|
Family Maximum |
$700 |
|
Physician Expenses: |
|
|
|
Office visits |
$15 copay* |
70% of allowance,
after CYD |
|
Adult Wellness (routine
physical including related testing) |
$15 copay* (max $250 per
CY) |
70% of allowance,
deductible waived
(max $250 per CY) |
|
Maternity-office visits &
delivery |
$15 copay* first visit,
then 90% fee schedule |
70% of allowance,
after CYD |
|
Well child care (birth to
age 16, 18 visits) |
$15 copay* |
70% of allowance,
deductible waived
|
|
Lab, X-Ray & Diagnostic
Testing: |
90% fee schedule, after CYD
Deductible Waived - Laboratory tests |
70% of allowance,
after CYD |
|
Hospital Expenses
(including maternity) |
|
|
|
Inpatient - including
physician visits |
90% fee schedule,
after CYD |
70% of allowance,
after CYD and PAD |
|
Nursery Care for
Well Newborns |
90% fee schedule,
after CYD |
70% of allowance,
after CYD |
|
Outpatient Surgury
(Hospital or Surgical Center) |
90% fee schedule,
after CYD |
70% of allowance,
after CYD |
|
Per Admission Deductible
(PAD) |
None |
$300 per admission |
|
Emergency Room/
Hospital care: |
90% fee schedule,
after CYD |
70% of allowance,
after CYD; PAD
applies if admitted |
|
Other Expenses |
|
|
|
Home HealthCare |
90% of fee schedule, after
CYD
($5,000 CY max) |
70% of allowance,
after CYD
($5,000 CY max) |
|
DME |
90% fee schedule, after CYD |
70% of allowance,
after CYD |
|
Physical, Speech, Cardiac,
Occupational Therapy |
90% of fee schedule, after
CYD
($10,000 CY max) |
70% of allowance,
after CYD
($10,000 CY max) |
|
Ambulance Services
(Deductible waived for accident related services) |
90% of allowance,
deductible waived |
90% of allowance,
deductible waived |
|
Skilled Nursing Facility |
90% of fee schedule, after
CYD
(120 days per CY) |
70% of allowance,
after CYD
(120 days per CY) |
|
Hospice |
100% of fee schedule,
deductible waived (10,000, LTM) |
100% of fee schedule,
deductible waived (10,000, LTM) |
|
Mental and Nervous |
|
|
|
Inpatient |
90% of fee schedule, after
CYD
(30 days/visits per CY) |
70% of allowance,
after CYD and PAD
(30 days/visits per CY) |
|
Outpatient |
$15 copay*
(45 visits per CY) |
70% of allowance,
after CYD
(45 visits per CY) |
|
Alcohol and Drugs: |
|
|
|
Inpatient |
90% of fee schedule, after
CYD to LTM |
70% of allowance,
after CYD and
PAD to LTM |
|
Outpatient |
$15 copay* |
70% of allowance,
after CYD to LTM |
|
|
$25,000 LTM (inpatient and
outpatient combined; based on services paid by BCBSF) |
|
Out of Pocket Coinsurance
Maximums**: |
Excludes Deductibles and
Copayments |
|
Individual |
$1500 |
|
Family - Aggregate |
$4500 |
|
Prescription Drugs: |
|
|
|
Up to a one month supply |
$10 copay* -
Generic
$20 copay* -
Preferred Brand
$30 copay*-
Non Preferred Brand |
Not Covered |
|
Mail-order-90 days supply
maintenance medication |
$20 copay* -
Generic
$40 copay* -
Preferred Brand
$60 copay*-
Non Preferred Brand |
|
|
Organ Transplant |
|
|
|
Covered for heart,
heart-lung, liver lung, kidney, cornea and bone marrow transplants |
80% of fee schedule, after
CYD |
50% of allowance, after CTD
and PAD |
|
Dependent Children: |
|
Pre-existing Conditions: |
|
(Applies to All Plans) |
|
(Applies to All Plans) |
