BC Life & Health PPO Saver

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	$500 hospital, $5,000 other covered services (2-member maximum) All covered benefits
Non-participating Provider	$500 hospital, $5,000 other covered services (2-member maximum) All covered benefits
Office Visits
Participating Provider	Well-child, 50% of negotiated fee; 2-adult, 4-child office visits, $30 copay/visit (deductible waived)
Non-participating Provider	Well-child, 50% of negotiated fee (deductible waived); all other visits subject to deductible
Professional Services (other office visits, X-ray, lab, anesthesia, surgeon, etc.)
Participating Provider	20% of negotiated fee for hospital services only. All other covered services after out-of-pocket maximum is met, then covered at 100% of negotiated fee
Non-participating Provider	50% of negotiated fee plus 100% of excess
Hospital Inpatient/Outpatient
Participating Provider	20% 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	20% of negotiated fee³ after $500 deductible is met
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	Routine mammogram, PSA and cancer screening, ordered by physician: 50% of negotiated fee 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	20% 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
Non-participating Provider	All charges except $25/visit; limited to 24 visits/year, participating and non-participating combined
Drug Benefits (retail or mail order: 30-day supply)
Participating Provider	$10 generic⁴; $30 brand copay plus $500 brand deductible⁵ (2 Member Maximum); 30% of negotiated fee for self-administered injectables except insulin Non-Formulary: Participating Provider: Generic⁴ 50%; Brand 100% of negotiated Fee Rate for Br
Non-participating Provider	50% of the drug limited-fee schedule plus 100% of excess; $500 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 $30 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
4	Generic drugs are based upon the Blue Cross drug formulary
5	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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