| Copay |
$35 |
50% |
| OfficeVisit |
$35 |
50% |
| Deductible |
|
|
| Coinsurance |
30% with preferred providers |
50% with non-preferred providers |
| Coinsurance Limit |
|
|
| Out-of-Pocket Maximum |
|
|
| Lifetime Maximum |
No Limit |
No Limit |
| Prescription Drugs |
Prescription drug coverage (outpatient; subject to the plan medical deductible) -- At Participating Pharmacies (Up to a 30-day supply)(outpatient; subject to the plan medical deductible) -
- Generic Formulary Drugs: $10/prescription
- Formulary Brand-Name Drugs: $35/prescription
- Non-Formulary Brand-Name Drugs: $50 or 50%/prescription whichever is greater (Maximum of $150/Rx)
- Mail Service Prescriptions (Up to a 60-day supply)(outpatient; subject to the plan medical deductible):
- Generic Formulary Drugs: $20/prescription
- Formulary Brand-Name Drugs: $70/prescription
- Non-Formulary Brand-Name Drugs: $100 or 50%/prescription, whichever is greater (maximum of $300/Rx)
|
Prescription drug coverage (outpatient; subject to the plan medical deductible) -- At Participating Pharmacies (Up to a 30-day supply)(outpatient; subject to the plan medical deductible) -
- Generic Formulary Drugs: $10/prescription
- Formulary Brand-Name Drugs: $35/prescription
- Non-Formulary Brand-Name Drugs: $50 or 50%/prescription whichever is greater (Maximum of $150/Rx)
- Mail Service Prescriptions (Up to a 60-day supply)(outpatient; subject to the plan medical deductible):
- Generic Formulary Drugs: $20/prescription
- Formulary Brand-Name Drugs: $70/prescription
- Non-Formulary Brand-Name Drugs: $100 or 50%/prescription, whichever is greater (maximum of $300/Rx)
|
| Emergency Room |
Emergency Health Coverage -- Emergency Room Services ($75 or $100 copayment/visit is waived if the member is admitted directly to the hospital as an inpatient): $75/visit + 30%
- ER Physician Visits: 30%
- Ambulance Services (Surface or air): 30%
|
Emergency Health Coverage -- Emergency Room Services ($75 or $100 copayment/visit is waived if the member is admitted directly to the hospital as an inpatient): Covered at same level as preferred provider
- ER Physician Visits: Covered at same level as preferred provider
- Ambulance Services (Surface or air): Covered at same level as preferred provider
|
| Adult Preventative Care |
Annual Routine Physical Exam and Gynecological Exam (Includes Pap test or other approved cervical cancer screening tests and routine mammography when received as part of the annual exam or preventive care exam): $0 |
Annual Routine Physical Exam and Gynecological Exam (Includes Pap test or other approved cervical cancer screening tests and routine mammography when received as part of the annual exam or preventive care exam): 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 X-ray and Laboratory: 30% |
Outpatient X-ray and Laboratory: 50% |
| Maternity |
Not Covered |
Not Covered |
| Physical Therapy |
Rehabilitation Services -- Provided in the Office of a Physician or Physical Therapist (Up to 20 visits per calendar year): 30% (visit limit combined with physical, occupational, respiratory, and speech therapy visits)
Chiropractic Services (Blue Shield's payment is limited to $25/visit): 50% (Up to 12 visits per calendar year) |
Rehabilitation Services -- Provided in the Office of a Physician or Physical Therapist (Up to 20 visits per calendar year): 50%
Chiropractic Services (Blue Shield's payment is limited to $25/visit): Not covered |
| Home Health Care |
Home Health Services (Up to 90 pre-authorized visits per calendar year): 30% |
Home Health Services (Up to 90 pre-authorized visits per calendar year): Not covered |
| Mental Health |
Mental Health Services -- Inpatient Hospital Facility Services: 30%
- Inpatient Physician Services: 30%
- Outpatient Visits for Severe Mental Health Conditions: $35
- Outpatient Visits for Non-Severe Mental Health Conditions (Up to 20 visits per calendar year combined with chemical dependency visits): 30%
Chemical Dependency Services (Substance abuse) -- Inpatient Hospital Facility Services for Medical Acute Detoxification: 30%
- Inpatient Physician Services for Medical Acute Detoxification: 30%
- Outpatient Visits (Up to 20 visits per calendar year combined with non-severe mental health visits): 30%
|
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%
- 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: 30%
- Inpatient Semiprivate Room and Board, Services and Supplies, and Subacute Care: 30%
- Bariatric Surgery Inpatient Services (Pre-authorization required: medically necessary surgery for weight loss, only for morbid obesity): 30%
Outpatient Services -- Non-emergency Services and Procedures, Outpatient Surgery in a Hospital: 30%
- Outpatient Surgery Performed in an Ambulatory Surgery Center (ASC): 30%
- Outpatient X-ray and Laboratory: 30%
|
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, Outpatient Surgery in a Hospital: 50%
- Outpatient Surgery Performed in an Ambulatory Surgery Center (ASC): 50%
- Outpatient X-ray and Laboratory: 50%
|
