On This Page: Physician Services, Hospital Services, Vision, Wellness, Mental and Substance Abuse, Prescription Drugs
Blue Cross
provides the California Hospital and Physician network effective 01/01/2004. |
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| PPO
Provider | Non-PPO
Provider
|
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|
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| LIFETIME MAXIMUM
| $5,000,000
| $5,000,000
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| CALENDAR YEAR DEDUCTIBLE
| $300/ person
$900/ family
| $300/ person
$900/ family
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OUT-OF-POCKET EXPENSE
LIMITATIONS (after deductible) 1 | $1,000 2
|
$2,500 2 |
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| PHYSICIAN SERVICES
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| Office Visit (including x-ray & laboratory)
| 85%
| 70%
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| Periodic Health Assessment 3 | Refer to wellness benefit | Refer to wellness benefit |
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| Well Baby Care 3 | Refer to wellness benefit | Refer to wellness benefit |
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| Immunizations3 | Refer to wellness benefit | Refer to wellness benefit |
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| In-Hospital Visits Maternity Care (Pre-natal, delivery, post-natal) | 85% | 70% |
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HOME HEALTH CARE
HOME INFUSION THERAPY
& SKILLED HOME NURSING
(All treatment must be reviewed for medical necessity through case-management .)
|
| Mandatory Case
Management
Authorization
| Mandatory
Case
Management
Authorization
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HOSPICE CARE
All treatment must be reviewed for medical necessity through case-management .
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|
Mandatory
Case
Management
Authorization
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Mandatory
Case
Management
Authorization
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HEARING AIDS
|
One device per ear every three years, reimbursed @ 50% up to an allowable charge of $2,000 per device, after satisfaction of plan deductible.
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One device per ear every three years, reimbursed @ 50% up to an allowable charge of $2,000 per device, after satisfaction of plan deductible.
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| HOSPITAL SERVICES
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REGULAR PLAN
|
NON-PPO PROVIDER
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Inpatient (Room and Board, within Plan limits, and Ancillary Services)
| 85% after a $100 per admission co-pay | 70% after a $100 per admission co-pay |
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|
Outpatient
Outpatient Surgery
| 85%
85% | 70%
70% |
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| Outpatient Lab or X-Ray | 85% | 70% |
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| Emergency Room | 85% after $50 co-pay (waived if admitted) | 70% after $50 co-pay (waived if admitted) |
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| Ambulatory Surgery Center | 85% | $1,500 incident maximum |
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| ACUPUNCTURE, BIOFEEDBACK, MANIPULATIONS OF THE MUSCULOSKELETAL SYSTEM,
OCCUPATIONAL THERAPY, OSTEOPATHIC MANIPULATIVE TREATMENT AND OUTPATIENT
PHYSICAL THERAPY
| 85% of up to $60 per visit, to a maximum of 50 visits per Calendar Year | 70% of up to $60 per visit, to a maximum of 50 visits per Calendar Year |
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INFERTILITY
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Not Covered
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Not Covered
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CHILD IMMUNIZATION & ALL ASSOCIATED
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VISION PLAN
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85% for exam, lenses and frames, following satisfaction of Calendar Year deductible up to a maximum payment of $200 per participant per Calendar Year
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85% for exam, lenses and frames, following satisfaction of Calendar Year deductible up to a maximum payment of $200 per participant per Calendar Year
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WELLNESS PLAN
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$500 per person/
$1,500 per family
per Calendar
Year, for specific
Wellness or preventive care expenses
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$500 per person/
$1,500 per family
per Calendar
Year, for specific
Wellness or preventive care expenses
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| MENTAL AND NERVOUS AND SUBSTANCE ABUSE 4
PBH and Non-PBH provider visits are integrated for purposes of the annual visit limits, meaning they cross accumulate. |
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| Non-PBH Provider |
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| Inpatient | 70% of reasonable and customary charges after a $200 inpatient co-payment per admission, up to a maximum of 14 days per lifetime. Regular plan deductible applies.
|
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| Outpatient | 70% of reasonable & customary up to a maximum of 20 visits per Calendar Year
(Regular plan deductible applies.) |
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| PBH PROVIDER
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| Inpatient | 100% after a $200 inpatient co-pay per confinement for a maximum of 45 days
per Calendar Year |
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| Outpatient | 100% after a $15 co-pay up to a maximum of 45 visits/ year for non-SMI or
70 visits/ year for SMI (Serious Mental Illness) |
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|
PRESCRIPTION DRUGS 6
See update regarding Coordination of Benefits |
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| Generic | Preferred | Brand |
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| Retail | $10 co-pay 30-day supply | $15 co-pay 30-day supply | $25 co-pay 30-day supply |
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| Mail Order 7
See letter regarding mandatory mail order for ongoing prescriptions. | $20 co-pay up to a 90-day supply | $30 co-pay up to a 90-day supply | $36 co-pay up to a 90-day supply |
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| 1 | When reached, benefits (other than Mental and Nervous and Substance Abuse)
are payable at 100% of usual and customary allowance, for the rest of the Calendar
Year. |
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| 2 | For those Medicare Eligible Certified Retirees and their Medicare eligible
dependents/same-sex domestic partners having benefits paid on a "carve-out"
basis, in the Out-of-Pocket Expense Benefit (after deductible) is $400 for PPO
providers and $600 for non-PPO providers. |
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| 3 |
Limited coverage as defined in SPD is
extended for dependents age 6 and under.
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| 4 |
PBH and Non-PBH provider visits are integrated for purposes of the annual visit
limits, meaning they cross accumulate.
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| 6 |
Brand name drugs will be covered at the generic co-pay level if a generic equivalent
is available, even when prescribed as DAW (Dispense as Written). If Brand name
drug is elected you must pay the generic co-pay plus the difference in cost between
the brand and generic medications.
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| 7 |
All maintenance medications must be filled through the mail order program. Effective 7/1/2004 the pharmacy provider is Medco. Prior to this, AdvancePCS was the pharmacy provider.
Retail coverage is available for original plus one refill of this medication.
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| Disclaimer | NOTE: This is only a brief summary of your benefits. All benefit descriptions contained herein are governed by the limitations and other information contained in your SPD.
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