This is only a summary of your benefits. Please refer to the Evidence of Coverage & Disclosure Form for a complete description of benefits, Exclusions & Limitations, and your rights and responsibilities.
2004 Brief
Summary of PORAC Benefits
(The Prudent Buyer Plan®)
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Prudent Buyer Calendar Year Deductible: $300 per member / $900 per family Non-Prudent Buyer Calendar Year Deductible: $600 per member / $1,800 per family |
Maximum Out-of-Pocket Costs: $5,000 per member per year (does not apply to mental disorders & chemical dependency treatment, or Rx drugs |
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Type of Services |
Description of Services |
You Pay |
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Prudent Buyer Plan Providers |
Non-Prudent Buyer Plan Providers* |
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Physician Care |
Office visits Allergy testing, serum injections & medication Well-child care up to $500/year (includes immunizations & inoculations) Adult annual exam up to $500/year (includes pap smears & breast exam) |
$20 copay 10% 10% No charge
No charge |
10%* 10%* No charge*
No charge* |
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Hearing |
Hearing exams (up to $50/exam) Hearing aids (up to $450 each year) |
20% 20% |
20%* 20% |
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Maternity |
Room/board, delivery room, special care units, nursery care Alternative birth center Nurse midwife |
10%
10% |
10%*
10%* |
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Hospital Services InpatientOutpatient |
Semi-private room/board & all medically necessary care Surgical room, renal dialysis |
10%
10% |
10%*
10%* |
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Prescription Drugs** |
Drugs prescribed by a physician (drugs include birth control pills, insulin & authorized diabetic supplies |
Retail Generic: $ 5 copay Brand: $20 copay Non-Formulary: $35 copay Mail Order Generic: $10 copay Brand: $30 copay Non-Formulary $50 copay |
Retail ** Limited Fee Schedule Limited Fee Schedule Limited Fee Schedule Mail Order N/A |
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Emergency Services |
In- and out-of-area for the initial treatment of a sudden & severe illness or accidental injury; Non-emergency use of emergency room |
10%
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10%
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Ambulance |
Ground or air in- and out-of-area |
20% |
20% |
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Physical Therapy & Chiropractic Care |
All services |
10% |
10%* (up to $700/year) |
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Diagnostic X-Ray/Lab |
Outpatient diagnostic X-ray & lab services |
10% |
10%* |
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Mental Disorders & Substance Abuse |
COMPREHENSIVE BEHAVIORAL HEALTH PROGRAM |
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Family Planning |
Voluntary sterilization Infertility studies & treatment (up to $5,000/lifetime) Sterilization reversal, contraceptive devices, in-vitro fertilization, artificial insemination & gamete intra-fallopian transfer |
10% 50%
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10%* 50%*
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Durable Medical Equipment & Supplies |
Certified by a physician & required for the care of an illness or injury; Covered Expense for rental cannot exceed the usual purchase price |
20% |
20% |
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Acupuncture |
Acupuncture |
10% |
10%* |
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Biofeedback |
For conditions other than mental health |
10% |
10%* |
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Hospice |
Hospice care up to a maximum lifetime payment of $5,000 in approved hospice |
10% |
10% |
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Other |
Unreplaced blood Blood administration Special duty nursing care |
20% 10% 20% |
20% 10% 20% |
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*The member's payment for Non-Prudent Buyer Plan provider services is based on a strictly limited schedule of allowances; members must pay charges in excess of those scheduled amounts. In some instances a Non-Prudent Buyer Plan provider can be paid at Customary & Reasonable or Reasonable Charges. Refer to your Evidence of Coverage & Disclosure Form for complete benefit information. For emergency services by Non-Prudent Buyer Plan providers, the member's payment is based on Blue Cross' Customary & Reasonable Charges; the member must pay charges in excess of those allowances.
**If non-mandatory brand name drugs are purchased, the member will be responsible for the copay & the total price difference between the brand name drug & the generic drug. The Calendar Year Deductible does not apply to Prescription Drug Benefits.
This is only a summary of your benefits. Please refer to the Evidence of Coverage & Disclosure Form for a complete description of benefits, Exclusions & Limitations, and your rights and responsibilities.
