|
Anthem Blue Cross
Short Term Health Insurance
PPO $500 Deductible Plan |
| |
 BC Life & Health Short Term PPO $500
Determine the rates for the medical plan you selected and other available plans.
View another Plan: $250, $500, $1,000, $2,000
Members share of costs (after deductible if any). This is an overview of coverage. A comprehensive description of coverage, benefits and limitations is contained in the Certificate of Coverage. |
Lifetime Maximum |
| In-Network |
$3,000,000/member |
| Out-of-Network |
$3,000,000/member |
| Annual out-of-pocket Maximum |
| In-Network |
$1,000 plus the medical deductible per Insured per policy* |
| Out-of-Network |
$1,000 plus the medical deductible per Insured per policy* |
| Annual Deductible |
| In-Network |
$500 per Insured per policy (waived for accidents) |
| Out-of-Network |
$500 per Insured per policy (waived for accidents) |
| Office Visits |
| In-Network |
20% of Negotiated Fee Rate |
| Out-of-Network |
20% of Negotiated Fee Rate |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
| In-Network |
20% of Negotiated Fee Rate |
| Out-of-Network |
20% of Negotiated Fee Rate (NFR) plus all charges in excess of NFR unless Special Circumstances apply |
| Hospital Inpatient/Outpatient |
| In-Network |
20% of Negotiated Fee Rate ** |
| Out-of-Network |
Insured pays all charges except: $650/day inpatient, $380/day outpatient |
| Emergency Services |
| In-Network |
20% of Negotiated Fee Rate ** |
| Out-of-Network |
Within California: Physician: 20% of Customary and Reasonable (C&R) charges or billed charges plus all charges in excess of C&R
Hospital: 20% of C&R charges or billed charges, whichever is less plus all charges in excess of C&R for the first 48 hours
Ambulatory Surgical Center (ASC): 80% of C&R charges plus all charges in excess of C&R |
| Maternity |
| In-Network |
No benefits |
| Out-of-Network |
No benefits |
| Home Health Care |
| In-Network |
20% of Negotiated Fee Rate (NFR) - limited to 30 visits per policy term |
| Out-of-Network |
20% of Negotiated Fee Rate (NFR) - limited to 30 visits per policy term |
| Skilled Nursing Facilities |
| In-Network |
No Benefits |
| Out-of-Network |
No Benefits |
| Hospice |
| In-Network |
No Benefits |
| Out-of-Network |
No Benefits |
| Preventive Care |
| In-Network |
HealthyCheck Centers: $25 or $75 copay for basic screenings (deducible-free); Routine Pap smears, annual mammograms, PSA and cancer screening, as ordered by physician including the related office visit: 20% of Negotiated Fee Rate, subject to the deductible |
| Out-of-Network |
Routine Pap smears, annual mammograms, PSA and cancer screening, ordered by physician including the related office visit: 20% of Negotiated Fee Rate, subject to the deductible |
| Infusion Therapy |
| In-Network |
20% of Negotiated Fee Rate – Up to $2000 maximum per person during the policy term |
| Out-of-Network |
20% of Negotiated Fee Rate – Up to $2000 maximum per person during the policy term |
| Ambulance |
| In-Network |
20% of Negotiated Fee Rate – Maximum payment of $1000 per person during policy term |
| Out-of-Network |
20% of Negotiated Fee Rate – Maximum payment of $1000 per person during policy term |
| Physical and Occupational Therapy; Chiropractic Services |
| In-Network |
20% of Negotiated Fee Rate; In an outpatient facility, limited to a combined maximum of $1000 per person during policy term |
| Out-of-Network |
20% of Negotiated Fee Rate; In an outpatient facility, limited to a combined maximum of $1000 per person during policy term |
| Acupuncture/Acupressure |
| In-Network |
Insured pays all of the NFR except $25; 12 visit maximum. Subject to the deductible |
| Out-of-Network |
Insured pays all charges except $25 per visit; 12 visit maximum. Subject to the deductible |
Mental, Emotional or Functional Nervous Disorders
(Inpatient Hospital Charges) |
| In-Network |
50% up to the semi-private room rate - Up to a combined maximum of $5,000 during policy term |
| Out-of-Network |
50% up to the semi-private room rate - Up to a combined maximum of $5,000 during policy term |
Mental, Emotional or Functional Nervous Disorders
(In or Outpatient Professional Charges) |
| In-Network |
50% Outpatient; $40 per visit max but no more than one visit per week for outpatient treatment – Up to a combined maximum of $5000 during Policy term. |
| Out-of-Network |
50% Outpatient; $40 per visit max but no more than one visit per week for outpatient treatment – Up to a combined maximum of $5000 during Policy term. |
| Speech Therapy |
| In-Network |
No Benefits |
| Out-of-Network |
No Benefits |
Drug Benefits
(retail or mail order: 30-day supply) |
| In-Network |
$10 generic***; $30 brand copay. Brand drug maximum of $500 per Insured per policy. 30% of Negotiated Fee Rate for self-administered injectables |
| Out-of-Network |
Copayment as stated for Participating Pharmacies plus 50% of the Drug Limited Fee Schedule (DLFS) and all charges in excess of the DLFS |
| AD & D |
| In-Network |
$50,000 |
| Out-of-Network |
$50,000 |
