| Lifetime Maximum |
Participating Provider
| $5,000,000/member |
Non-participating Provider
| $5,000,000/member |
Annual Out-of-Pocket Maximum
(includes deductible) |
Participating Provider
| $7,500/single (2-member maximum) Participating and non-participating combined1 |
Non-participating Provider
| $7,500/single (2-member maximum) Participating and non-participating combined1 |
| Annual Deductible |
Participating Provider
| $5000/member (2-member maximum) All covered benefits |
Non-participating Provider
| $5000/member (2-member maximum) All covered benefits |
| Office Visits |
Participating Provider
| Well-child, 40% of negotiated fee; 30% of negotiated fee for other services (deductible waived) |
Non-participating Provider
| 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
|
Healthy Check 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 (deductible
waived) |
Non-participating Provider
| Routine mammogram, PSA and cancer screening, ordered by physician: 50% of negotiated fee plus 100% of excess |
| 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 generic4;
$35 brand copay plus $750 brand deductible5 (2
Member Maximum); 30% of negotiated fee for self-administered
injectables except insulin
Non-Formulary:
Participating Provider: Generic4 50%; Brand 100% of negotiated Fee Rate for Br |
Non-participating Provider
| 50% generic4 or 50% of brand drug limited-fee schedule within California; $750 brand deductible5 (2-member maximum) |
