Annual Out-of-Pocket Maximum
(includes deductible)
Participating Provider
$3,000/single, $5,500/family All covered benefits for medical and drug combined
Non-participating Provider
$3,000/single, $5,500/family All covered benefits for medical and drug combined
Annual Deductible
Participating Provider
$2,400/single, $4,500/family All covered benefits for medical and drug combined
Non-participating Provider
$2,400/single, $4,500/family All covered benefits for medical and drug combined
Office Visits
Participating Provider
After deductible, 50% of negotiated fee
Non-participating Provider
Not covered
Professional Services
(other office visits, X-ray, lab, anesthesia, surgeon, etc.)
Participating Provider
50% of negotiated fee
Non-participating Provider
Not covered
Hospital Inpatient/Outpatient
Participating Provider
50% of negotiated fee
Non-participating Provider
Not covered
Emergency Services
Participating Provider
50% of negotiated fee3
Non-participating Provider
50% of customary & reasonable for first 48 hours plus 100% of excess; no coverage after 48 hours
Maternity
(after deductible)
Participating Provider
50% of negotiated fee
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: 50% of negotiated
fee; well-child, 50% of negotiated fee (deductible waived)
Non-participating Provider
Not covered
Ambulance
Participating Provider
50% of negotiated fee
Non-participating Provider
Emergency only, then 50% of customary & reasonable
Physical and Occupational Therapy; Chiropractic Services
Participating Provider
50% of negotiated fee limited to 12 visits/year
Non-participating Provider
Not covered
Acupuncture/Acupressure
Participating Provider
All charges except $25/visit; limited to 12 visits/year combined
Non-participating Provider
Not covered
Drug Benefits
(retail or mail order: 30-day supply)
Participating Provider
Combined with medical deductible. 15% of negotiated fee, generic; 35% of negotiated fee, brand; 30% of negotiated fee, self-administered injectables
except insulin
Non-participating Provider
Not covered
Notes:
Please Note: When locating a provider, PPO plans are also referred to as Prudent Buyer
1
Non-participating charges in excess of the negotiated fee will not be paid and do not apply to the out-of-pocket maximum.
2
Additional $30 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
3
Maternity copay is per pregnancy and does not apply to out-of-pocket maximum.
4
Generic drugs are based upon the Blue Cross drug formulary.
5
Brand drug deductible does not apply to out-of-pocket maximum.
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can substitute for courteous service from an experienced professional. Our staff
is always happy to help with your California health insurance, California dental
insurance, or term life insurance needs. Feel free to call us any time at (800)
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