|
Benefit |
In-Network |
Out-of-Network |
 |
| Annual Deductible |
$1,000 Per member
(Once 2 members each reach the deductible,
the deductible
is satisfied for the entire family.) |
| Lifetime Maximum |
$5,000,000 |
Annual Out-of-Pocket Maximum
(includes deductible)
Participating & non-participating provider covered services combined
|
$5,000 per member
(Once 2 members each reach the maximum, the maximum is satisfired for the entire family) |
| Doctors' Office Visits |
30% of negotiated fee
(deductible waived) |
50% of negotiated
fee plus all excess charges
(deductible waived ) |
Professional Services
(X-ray, lab, anesthesia, surgeon, etc.) |
30% of negotiated fee |
50% of negotiated
fee plus excess charges |
Hospital Inpatient
(Overnight Hospital Stays) |
30% of negotiated fee2 |
All Charges except $650 per day |
Hospital Outpatient
(If You Don't Stay Overnight) |
30% of negotiated fee2 |
All Charges except $380 per day |
| Emergency Room Services |
30% of negotiated fee |
30% of customary and reasonable fees plus excess charges |
| Maternity |
30% of negotiated fee |
50% of negotiated fee plus excess charges |
| Preventive Care |
Annual physical exam(s): 30% of negotiated fee*
(deductible waived)
or
HealthyCheckSM Centers5: $25/$75 copay for basic/premium screening (deductible waived)
Routine mmamogram, Pap and PSA tests4: 30% of negotiated fee (deductible waived)
Well Baby and Well Child (through age 6): 40% of negotiated fee (deductible waived) |
Annual phyical exam(s): 50% of negotiated fee* plus all exess charges (deductible waived)
Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges (deductible waived)
Well Baby and Well Child (through age 6): 50% of negotieated fee plus all excess charges (deductible waived) |
| Ambulance |
30% of negotiated fee |
50% of negotiated fee plus excess charges |
| Physical & Occupational Therapy; Chiropractic Services |
30% of negotiated fee |
All charges except $25 per visit, up to 12 visits per year6 |
| Accupunture/Accupressure |
All Charges except $25 per visit, up to 24 visits per year (deductible waived) |
Prescription Drugs
(Blue Cross Formulary7)
Amounts shown are for each 30-day retail or in-network mail order supply |
$10 copay genric; $30 copay brand-name8 after $250 brand-name prescription drug deductible (2-member maximum); 30% of negotiated fee for self administered injectables, except insulin |
50% of drug limited fee schedule and all excess charges plus the copay / coinsurance as stated for in-network benfits; subject to the annual $250 brand-name prescription drug deductible. |
Other Blue Cross PPO Plan Links |
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