| Lifetime Maximum |
Participating Provider
|
$5,000,000/member |
Non-participating Provider
|
$5,000,000/member |
Annual Out-of-Pocket Maximum
(includes deductible) |
Participating Provider
|
$5,000/single (2-member maximum) Participating and non-participating combined1 |
Non-participating Provider
|
$5,000/single (2-member maximum) Participating and non-participating combined1 |
| Annual Deductible |
Participating Provider
|
$2,500/member (2-member maximum) All covered benefits |
Non-participating Provider
|
$2,500/member (2-member maximum) All covered benefits |
| Office Visits |
Participating Provider
|
No office visit benefit until out-of-pocket maximum met, then 100% of negotiated fee |
Non-participating Provider
|
No office visit benefit until out-of-pocket maximum met, then 100% of negotiated fee |
Professional Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.) |
Participating Provider
|
20% of negotiated fee, hospital only. No office visit benefits until out-of-pocket maximum met, then covered at 100% of negotiated fee |
Non-participating Provider
|
Covered expenses paid at 50% of the limited-fee schedule plus 100% of excess |
| Hospital Inpatient/Outpatient |
Participating Provider
|
20% of negotiated fee |
Non-participating Provider
|
All charges except: $650/day inpatient, $380/day outpatient |
| Hospice |
Participating Provider
|
$10,000 lifetime maximum, participating and non-participating providers combined |
Non-participating Provider
|
$10,000 lifetime maximum, participating and non-participating providers combined |
| Emergency Services |
Participating Provider
|
20% of negotiated fee3 |
Non-participating Provider
|
20% of customary & reasonable for the first 48 hours plus 100% of excess; after 48 hours, you pay all charges except $650/day for
covered services3 |
Maternity
(after deductible) |
Participating Provider
|
Not covered |
Non-participating Provider
|
Not covered |
| Preventive Care |
Participating Provider
|
HealthyCheck Centers: $25 or $75 copay for basic screenings; routine mammogram, PSA and cancer screening, ordered by physician: 20% of negotiated
fee (deductible waived) |
Non-participating Provider
|
Outside California, 50% of customary & reasonable to maximum of $250/year; routine mammogram, PSA and cancer screening, ordered by physician:
50% of customary & reasonable plus 100% of excess |
| Ambulance |
Participating Provider
|
20% of negotiated fee ($750/trip maximum
paid by BC Life & Health Insurance Company) |
Non-participating Provider
|
50% of customary & reasonable plus 100% of excess |
| Physical and Occupational Therapy; Chiropractic Services |
Participating Provider
|
Not covered unless during inpatient admission |
Non-participating Provider
|
Not covered unless during inpatient admission |
| Acupuncture/Acupressure |
Participating Provider
|
Not covered |
Non-participating Provider
|
Not covered |
Drug Benefits
(retail or mail order: 30-day supply) |
Participating Provider
|
Not covered |
Non-participating Provider
|
Not covered |
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Santa Barbara Health Insurance Services