BC Life & Health PPO Share 1000

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	$1,000/member (2-member maximum) All covered benefits
Non-participating Provider	$1,000/member (2-member maximum) All covered benefits
Office Visits
Participating Provider	Well-child, 40% of negotiated fee; office visits, 30% of negotiated fee (deductible waived)
Non-participating Provider	Well-child, 50% of negotiated fee; office visits, 50% of negotiated fee (deductible waived)
Professional Services (other office visits, X-ray, lab, anesthesia, surgeon, etc.)
Participating Provider	30% of negotiated fee
Non-participating Provider	50% of negotiated fee plus 100% of excess
Hospital Inpatient/Outpatient
Participating Provider	30% of negotiated fee²
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	30% of negotiated fee³
Non-participating Provider	30% 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
Participating Provider	30% of negotiated fee
Non-participating Provider	50% of negotiated fee plus 100% of excess
Preventive Care
Participating Provider	HealthyCheck Centers: $25 or $75 copay for basic screenings; routine mammogram, PSA and cancer screening, ordered by physician: 30% of negotiated fee; well-baby and well-child, 40% of negotiated fee; Annual Physical Exam, 30% of negotiated fee (deductibl
Non-participating Provider	Routine mammogram, PSA and cancer screening, ordered by physician: 50% of negotiated fee plus 100% of excess; Annual Physical Exam, 50% of negotiated fee plus excess for covered services (deductible waived)⁴
Ambulance
Participating Provider	30% of negotiated fee
Non-participating Provider	50% of customary & reasonable plus 100% of excess
Physical and Occupational Therapy; Chiropractic Services
Participating Provider	30% of negotiated fee; limited to 12 visits/year, participating and non-participating combined
Non-participating Provider	All charges except $25/visit; limited to 12 visits/year, participating and non-participating combined
Acupuncture/Acupressure
Participating Provider	All charges except $25/visit; limited to 24 visits/year, participating and non-participating combined (deductible waived)
Non-participating Provider	All charges except $25/visit; limited to 24 visits/year, participating and non-participating combined (deductible waived)
Drug Benefits (retail or mail order: 30-day supply)
Participating Provider	$10 generic⁵; $30 brand copay plus $250 brand deductible⁶ (2 Member Maximum); 30% of negotiated fee for self-administered injectables except insulin Non-Formulary: Participating Provider: Generic⁵ 50%; Brand 100% of negotiated Fee Rate for Br
Non-participating Provider	50% generic⁵ or 50% of brand drug limited-fee schedule within California; $250 brand deductible⁶ (2-member maximum)

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 $500 admission charge at Participating Hospitals (no additional for Preferred Participating Hospitals) is for surgery or infusion therapy. This charge is not required for Ambulatory Surgical Centers or medical emergencies.
3	Additional $100 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
4	Members covered more than six (6) months, up to $200; members covered less than six (6) months, up to $100
5	Generic drugs are based upon the Anthem Blue Cross drug formulary
6	Brand drug deductible does not apply to out-of-pocket maximum.

Here at Santa Barbara Health Insurance Services we know that no web site 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) 765-1540.

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