BC Life & Health Basic PPO 1000 (7900)
 
  Lifetime Maximum
  Participating Provider $5,000,000/member Non-participating Provider $5,000,000/member

  Annual Out-of-Pocket Maximum
  (includes deductible) Participating Provider $3,500/single (2-member maximum) Participating and non-
  participating combined1 Non-participating Provider $3,500/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 No office visit benefit until out-of-pocket maximum met, then 100% of negotiated fee
  Non-participating Provider No office visit benefit until out-of-pocket maximum met, then 100% of negotiated fee

  Professional Services
  (other office visits, X-ray, lab, anesthesia, surgeon, etc.) Participating Provider 20% of negotiated fee, hospital
  only. No office visit benefits until out-of-pocket maximum met, then covered at 100% of negotiated fee
  Non-participating Provider Covered expenses paid at 50% of the limited-fee schedule plus 100% of excess

  Hospital Inpatient/Outpatient
  Participating Provider 20% of negotiated fee 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 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 Outside California, 50% of customary & reasonable to maximum of $250/year; routine mammogram,
  PSA and cancer screening, ordered by physician: 50% of customary & reasonable 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 Not covered unless during inpatient admission Non-participating Provider Not covered
  unless during inpatient admission

  Acupuncture/Acupressure
  Participating Provider Not covered Non-participating Provider Not covered

  Drug Benefits
  (retail or mail order: 30-day supply) Participating Provider Not covered Non-participating Provider Not covered


  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).