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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| Open Access Provider
| Non-Open Access Provider
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| LIFETIME MAXIMUM
| $5,000,000
| $5,000,000
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| CALENDAR YEAR DEDUCTIBLE
| None
| $300/ person
$900/ family
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OUT-OF-POCKET EXPENSE
LIMITATIONS (after deductible) 1 |
Not Applicable
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$10,000
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| PHYSICIAN SERVICES
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| Office Visit (including x-ray & laboratory)
| 100% after $10 co-pay | 60% |
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| Periodic Health Assessment 2 | 100% after $10 co-pay | Not Covered |
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| Well Baby Care 2 | 100% after $10 co-pay | Not Covered |
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| Immunizations 2 | 100% after $10 co-pay | Not Covered |
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| In-Hospital Visits Maternity Care (Pre-natal, delivery, post-natal) | 100% | 60% |
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HOME HEALTH CARE
HOME INFUSION THERAPY
& SKILLED HOME NURSING
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All treatment must be reviewed for medical necessity through case-management .
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| 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
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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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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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Open Access
Provider
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Non-Open Access
Provider
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Inpatient (Room and Board, within Plan limits, and Ancillary Services)
| 100% after a $100 per admission co-pay | 60% after a $100 per admission co-pay |
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Outpatient Hospital Services | 100% | 60% |
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| Outpatient Surgery | 100% after $25 co-pay | 60% |
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| Outpatient Lab or X-Ray | 100% after $25 co-pay | 60% |
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| Emergency Room | 100% after $50 co-pay | 60% after a $50 co-pay (waived if admitted) |
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| Ambulatory Surgery Center | 100% | $1,500 incident maximum |
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| ACUPUNCTURE, BIOFEEDBACK, MANIPULATIONS OF THE MUSCULOSKELETAL SYSTEM,
OCCUPATIONAL THERAPY, OSTEOPATHIC MANIPULATIVE TREATMENT AND OUTPATIENT
PHYSICAL THERAPY
| 100% of up to $60 per visit, to a maximum of 50 visits per Calendar Year | 60% 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 SERVICES | | | |
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| Through age 6 |
100% after
$10 co-pay | 60% |
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| Age 7 and above (see Wellness Plan) | Not Covered | Not Covered |
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VISION PLAN
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85% for exam, lenses and frames, 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 3
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 | No coverage. A PBH provider must be used to receive benefits.
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| Outpatient | No coverage. A PBH provider must be used to receive benefits. |
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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 4
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 5 | $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 other than Open Access Provider plan, limited coverage as defined in SPD is
extended for dependents age 6 and under.
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| 3 |
PBH and Non-PBH provider visits are integrated for purposes of the annual visit
limits, meaning they cross accumulate.
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| 4 |
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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| 5 | All maintenance medications must be filed 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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