| BC Life & Health PPO Share 1000 (1930)
Some counties have special rates by Zip code | |
| 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) |
Monthly rates, subject to change / Click here to Apply Now
/ Call 1-800-655-9525 /
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