| Copay |
$25 with preferred providers |
50% |
| OfficeVisit |
Office Visits: $25 |
Office Visits: 50% |
| Deductible |
|
|
| Coinsurance |
40% with preferred providers |
50% with non-preferred providers |
| Coinsurance Limit |
Services with preferred providers: $6,000 Services with all providers: $8,000 |
Services with preferred providers: $6,000 Services with all providers: $8,000 |
| Out-of-Pocket Maximum |
N/A |
N/A |
| Lifetime Maximum |
No Limit |
No Limit |
| Prescription Drugs |
Prescription Drug Coverage (outpatient):- Brand-name drug deductible (brand-name drugs are subject to a brand-name drug deductible per person, per calendar year): $500
At Participating Pharmacies (up to a 30-day supply):- Generic formulary drugs: $10/prescription
- Formulary brand-name drugs: $35/prescription
- Non-formulary brand-name drugs: $50 or 50%/prescription (whichever is greater)
Mail Service Participants (up to a 60-day supply):- Generic formulary drugs: $20/prescription
- Formulary brand-name drugs: $70/prescription
- Non-formulary brand-name drugs: $100 or 50%/prescription (whichever is greater)
|
Prescription Drug Coverage (outpatient):- Brand-name drug deductible (brand-name drugs are subject to a brand-name drug deductible per person, per calendar year): $500
At Participating Pharmacies (up to a 30-day supply):- Generic formulary drugs: $10/prescription
- Formulary brand-name drugs: $35/prescription
- Non-formulary brand-name drugs: $50 or 50%/prescription (whichever is greater)
Mail Service Participants (up to a 60-day supply):- Generic formulary drugs: $20/prescription
- Formulary brand-name drugs: $70/prescription
- Non-formulary brand-name drugs: $100 or 50%/prescription (whichever is greater)
|
| Emergency Room |
Emergency Health Coverage:- Emergency room services ($100 copayment/visit waived if the member is admitted directly to the hospital as an inpatient): $100/visit + 40%
- ER physician visits: $25
- Ambulance services (surface or air): 40%
|
Emergency Health Coverage: - Emergency room services ($100 copayment/visit waived if the member is admitted directly to the hospital as an inpatient): Covered at the same level as preferred provider
- ER physician visits: Covered at the same level as preferred provider
- Ambulance services (surface or air): 40%
|
| Adult Preventative Care |
Annual routine physical exam and gynecological exam office visit (includes Pap test or other approved cervical cancer screening tests, routine mammography, and immunizations when received as part of the annual exam or preventive care visits): $0 |
Annual routine physical exam and gynecological exam office visit (includes Pap test or other approved cervical cancer screening tests, routine mammography, and immunizations when received as part of the annual exam or preventive care visits): Not covered |
| Child Preventative Care |
Annual routine physical exam and well-baby care office visits: $0 |
Annual routine physical exam and well-baby care office visits: Not covered |
| Lab / X-Ray |
Outpatient or out-of-hospital X-ray and laboratory: 40% |
Outpatient or out-of-hospital X-ray and laboratory: 50% |
| Maternity |
Pregnancy and Maternity Care:- Outpatient prenatal and postnatal care: Not covered
- Delivery and all necessary inpatient hospital services: Not covered
Family planning-- Consultations, tubal ligation, vasectomy, elective abortion: 40%
|
Pregnancy and Maternity Care:- Outpatient prenatal and postnatal care: Not covered
- Delivery and all necessary inpatient hospital services: Not covered
Family planning-- Consultations, tubal ligation, vasectomy, elective abortion: Not covered
|
| Physical Therapy |
Rehabilitation Services: (up to 12 visits per calendar year combined with chiropractic and speech therapy visits - Blue Shield's payment is limited to $25/visit with non-preferred providers)- Provided in the office of a physician or physical therapist: 40%
Chiropractic services (up to 12 visits per calendar year combined with rehabilitation services and speech therapy visits): 40% |
Rehabilitation Services: (up to 12 visits per calendar year combined with chiropractic and speech therapy visits - Blue Shield's payment is limited to $25/visit with non-preferred providers)- Provided in the office of a physician or physical therapist: 50%
Chiropractic services (up to 12 visits per calendar year combined with rehabilitation services and speech therapy visits): Not covered |
| Home Health Care |
Home Health Services (up to 90 pre-authorized visits per calendar year): 40% |
Home Health Services (up to 90 pre-authorized visits per calendar year): Not covered |
| Mental Health |
Mental Health Services:- Inpatient hospital facility services: $500/admit + 40%
- Inpatient physician services: 40%
- Outpatient visits for severe mental health conditions: $25
- Outpatient visits for non-severe mental health conditions (up to 20 visits per calendar year combined with chemical dependency visits): 40%
Chemical Dependency Services (substance abuse):- Inpatient hospital facility services for medical acute detoxification: $500/admit + 40%
- Inpatient physician services for medical acute detoxification: 40%
- Outpatient visits (up to 20 visits per calendar year combined with non-severe mental health visits): 40%
|
Mental Health Services:- Inpatient hospital facility services: 50%
- Inpatient physician services: 50%
- Outpatient visits for severe mental health conditions: 50%
- Outpatient visits for non-severe mental health conditions (up to 20 visits per calendar year combined with chemical dependency visits): Not covered
Chemical Dependency Services (substance abuse):- Inpatient hospital facility services for medical acute detoxification: 50%
- Inpatient physician services for medical acute detoxification: 50% up to $500 per day
- Outpatient visits (up to 20 visits per calendar year combined with non-severe mental health visits): Not covered
|
| Hospital Care |
Hospitalization Services:- Inpatient physician visits and consultations, surgeons and assistants, and anesthesiologists: 40%
- Inpatient semiprivate room and board, services and supplies, and subacute care: $500/admit + 40%
- Bariatric surgery inpatient services (pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity): $500/admit + 40%
Outpatient Services:- Non-emergency services and procedures: 40%
- Outpatient surgery in hospital: $500/admit + 40%
- Outpatient surgery performed in an ambulatory surgery center (ASC): 40%
|
Hospitalization Services:- Inpatient physician visits and consultations, surgeons and assistants, and anesthesiologists: 50%
- Inpatient semiprivate room and board, services and supplies, and subacute care: 50%
- Bariatric surgery inpatient services (pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity): 50%
Outpatient Services:- Non-emergency services and procedures: 50%
- Outpatient surgery in hospital: 50%
- Outpatient surgery performed in an ambulatory surgery center (ASC): 50%
|
