Annual
deductible
$500 Annual deductible for hospital inpatient facility and professional
services, hospital outpatient surgery, medical emergency, radiation
therapy, hemodialysis treatment, infusion therapy, acupuncture/acupressure,
professional services related to covered hospital outpatient services |
In-Network
|
$500
per member; two-member maximum |
Out-Of-Network
|
$500
per member; two-member maximum |
| Lifetime
covered charges paid by Blue Cross, in-network and out-of-network
combined |
In-Network
|
$5,000,000 |
Out-Of-Network
|
$5,000,000 |
Annual
out-of-pocket maximum
In-network and out-of-network combined. Out-of-pocket maximum is
in addition to coinsurance maximum. |
In-Network
|
$5,000
out-of-pocket maximum per member. Two member maximum. The $5,000
out-of-pocket maximum accrues at the same time as the $5,000 deductible. |
Out-Of-Network
|
$5,000
out-of-pocket maximum per member. Two member maximum. The $5,000
out-of-pocket maximum accrues at the same time as the $5,000 deductible. |
Initial
office visits
Each year, the first 2 visits per adult and first 4 visits per child
(in-network and out-of-network combined) are not subject to a deductible |
In-Network
|
$20
co pay |
Out-Of-Network
|
50%
of the negotiated fee, plus 100% of charges in excess of the negotiated
fee |
Initial
diagnostic lab and x-ray
Each year, the first $500 of eligible charges per member (in-network
and out-of-network combined) is not subject to a deductible |
In-Network
|
20%
of the negotiated fee |
Out-Of-Network
|
50%
of the negotiated fee, plus 100% of charges in excess of the negotiated
fee |
Additional
office visits, diagnostic lab and x-ray and certain hospital outpatient
services**
A $5,000 deductible begins to accumulate after annual initial office
visits of 2 per adult/4per child are used, and after annual initial
diagnostic lab and x-ray benefits of $500 are paid by Blue Cross.
The $5,000 deductible also accumulates when other certain hospital
outpatient expenses are submitted |
In-Network
|
100%
of the negotiated fee up to a $5,000 deductible per member, two-member
maximum. Then Blue Cross pays 100% of eligible charges. |
Out-Of-Network
|
100%
of billed charges up to a $5,000 deductible per member, two-member
maximum. Then Blue Cross pays 100% of the eligible charges, and
member is responsible for any excess amounts. |
Hospital
inpatient facility services
Pre service Review required |
In-Network
|
PREFERRED
PARTICIPATING HOSPITALS:
20% of the negotiated fee after $500 deductible
PARTICIPATING HOSPITALS:
20% of the negotiated fee after $500 deductible |
Out-Of-Network
|
Member
pays all charges except $650 per day after $500 deductible |
| Hospital
inpatient professional services |
In-Network
|
20%
of the negotiated fee after $500 deductible |
Out-Of-Network
|
50%
of the negotiated fee, plus 100% of charges in excess of the negotiated
fee after $500 deductible |
Hospital
outpatient services
Including surgery, medical emergency, radiation therapy, hemodialysis
treatment and infusion therapy
Pre service review required
|
In-Network
|
PREFERRED
PARTICIPATING HOSPITALS:
20% of the negotiated fee after $500 deductible
PARTICIPATING HOSPITALS:
20% of the negotiated fee plus $500 admission charge for surgeries
or infusion therapy after $500 deductible |
Out-Of-Network
|
Member
pays all charges except $380 per day after $500 deductible |
| Outpatient
professional services related to covered hospital charges |
In-Network
|
20%
of the negotiated fee after $500 deductible |
Out-Of-Network
|
50%
of the negotiated fee, plus 100% of charges in excess of the negotiated
fee after $500 deductible |
| Ambulatory
Surgical Centers |
In-Network
|
20%
of the negotiated fee after $500 deductible |
Out-Of-Network
|
Member
pays all charges except $380 per day after $500 deductible |
Prescription
Drugs
30-day supply retail; Up to a 60-day supply available through mail
order. Maximum Blue Cross payment $500 per member in-network and
out-of-network combined |
In-Network
|
NOT
SUBJECT TO DEDUCTIBLE
$10 co pay generic (for each 30-day supply), $25 co pay brand (for
each 30-day supply) Self-administered injectable drugs except Insulin,
30% of negotiated fee for self-administered injectables, except
insulin. $500 maximum drug benefit
If you select a brand-name drug when a generic equivalent drug is
available, even if the physician writes a "dispense as written"
or "do not substitute" prescription, the member will be responsible
for the generic co pay plus the difference in cost between the brand-name
and the generic equivalent drug. * |
Out-Of-Network
|
NOT
SUBJECT TO DEDUCTIBLE
50% of Drug Limited Fee Schedule, plus 100% of charges in excess
of drug limited fee. |
Healthy
Check screenings, Ages 7-adult
Includes certain lab tests, immunizations and health education information |
In-Network
|
NOT
SUBJECT TO DEDUCTIBLE
$25 or $75 co pay health screening options. |
Out-Of-Network
|
Not
available |
Well-baby
immunizations and adult screening tests
CHILDREN THROUGH AGE 6: Regular check-up and immunizations
AGES 7-ADULT: limited to annual pap, breast exam, and mammogram
for women and Prostate Specific Antigen (PSA) study for men. |
In-Network
|
NOT
SUBJECT TO DEDUCTIBLE
20% of the negotiated fee |
Out-Of-Network
|
NOT
SUBJECT TO DEDUCTIBLE
50% of the negotiated fee, plus 100% of charges in excess of the
negotiated fee. |
Emergency
Care
$100 co pay for each visit - waived if admitted |
In-Network
|
PREFERRED
PARTICIPATING HOSPITALS AND PARTICIPATING HOSPITALS: 20% of the
negotiated fee after $500 deductible |
Out-Of-Network
|
20%
of customary and reasonable charges, plus 100% of excess for first
48 hours; after 48 hours, all charges in excess of $650 per day
after $500 deductible |
Ambulance
$750 per trip maximum Blue Cross payment |
In-Network
|
20%
of negotiated fee, plus 100% of charges in excess of $750 per trip
maximum up to the negotiated amount after $500 deductible |
Out-Of-Network
|
50%
of customary and reasonable charges, plus 100% of charges in excess
of customary and reasonable charges after $500 deductible |
Skilled
Nursing Facility
100 days per year, in-network and out-of-network combined
$540 per day maximum Blue Cross payment Pre service Review required |
In-Network
|
20%
of negotiated fee, plus 100% of charges in excess of $540 per day
maximum up to the negotiated amount after $500 deductible |
Out-Of-Network
|
All
charges except $380 per day after $500 deductible |
Home
Health Care
90 four-hour visits per year, in-network and out-of-network combined
$137.50 per visit maximum Blue Cross payment Pre service Review
required |
In-Network
|
20%
of negotiated fee, plus 100% of charges in excess of $137.50 per
day maximum up to the negotiated amount after $500 deductible |
Out-Of-Network
|
50%
of customary and reasonable charges, plus 100% of charges in excess
of customary and reasonable charges after $500 deductible |
| Physical/Occupational
Therapy, Chiropractic Care |
In-Network
|
Not
covered |
Out-Of-Network
|
Not
covered |
Acupuncture/Acupressure
12 visits per year, in-network and out-of-network combined |
In-Network
|
All
charges except $25 per visit after $500 deductible |
Out-Of-Network
|
All
charges except $25 per visit after $500 deductible |
Mental
Health*, including Chemical Dependency, inpatient:
30 days per year in-network and out-of-network combined |
In-Network
|
All
of the negotiated fee except $175 per day after $500 deductible |
Out-Of-Network
|
All
charges except $175 per day after $500 deductible |
| Mental
Health*, including Chemical Dependency, outpatient professional
services |
In-Network
|
Not
covered |
Out-Of-Network
|
Not
covered |
Infusion
Therapy, including Chemotherapy
Pre service Review required |
In-Network
|
20%
of the negotiated fee after $500 deductible |
Out-Of-Network
|
50%
of the negotiated fee, plus 100% of charges in excess of $50 per
day for all infusion therapy expenses except drugs; all charges
in excess of the average wholesale price for all infusion therapy
drugs; all charges in excess of the combined maximum $500 Blue Cross
payment per day after $500 deductible |
Infertility
Services
Lifetime maximum $2,000 in-network and out-of-network combined |
In-Network
|
20%
of the negotiated fee after $500 deductible |
Out-Of-Network
|
INPATIENT
FACILITY SERVICES: Member pays all charges except $650 per day after
$500 deductible
OUTPATIENT FACILITY SERVICES: Member pays all charges except $380
per day after $500 deductible
PROFESSIONAL SERVICES RELATED TO COVERED HOSPITAL CHARGES:
50% of the negotiated fee, plus 100% of charges in excess of the
negotiated fee after $500 deductible |
