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.
2002 PORAC Benefits
(The Prudent Buyer Plan®)
|
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 |
|
Type of Services |
Description of Services |
You Pay |
||
|
|
Prudent Buyer Plan Providers |
Non-Prudent Buyer Plan Providers* |
||
|
Hospital Services Inpatient
|
Semi-private room/board, special care units, all medically necessary services & general nursing care Surgical room fee, radiation & chemotherapy treatment, renal dialysis |
10%
10% |
10%*
10%* |
|
|
Physician Care |
Office visits Allergy testing, serum injections & medication Eye exam (when required due to eye surgery) Well-child care up to $500/year (includes immunizations & inoculations) Adult annual exam up to $500/year (includes pap smears & breast exam) |
$10 copay 10% 10% 10% No charge
No charge |
10%* 10%* 10%* No charge*
No charge* |
|
|
Hearing |
Hearing exams (up to $50/exam) Hearing aids (up to $450 each year) |
20% 20% |
20%* 20% |
|
|
Diagnostic X-Ray/Lab |
Outpatient diagnostic X-ray & lab services |
10% |
10%* |
|
|
Prescription Drugs** |
Drugs prescribed by a physician (drugs include birth control pills, insulin & authorized diabetic supplies |
Retail Generic: $5 copay Brand: $20 copay Mail Order Generic: $10 copay Brand: $30 copay
|
Limited Fee Schedule Limited Fee Schedule |
|
|
Durable Medical Equipment & Supplies |
Must be 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% |
|
|
Maternity |
Room/board, delivery room, special care units, nursery care Alternative birth center Nurse midwife Natural childbirth classes |
10%
10% Not Covered |
10%*
10%* Not Covered |
|
|
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%
|
10%* 50%*
|
|
|
Ambulance |
Ground or air in- and out-of-area |
20% |
20% |
|
|
Emergency Services |
In- and out-of-area for the initial treatment of a sudden & severe illness or accidental injury; includes hospital, professional services & supplies Non-emergency use of emergency room |
10%
|
10%
|
|
|
Mental Disorders & Substance Abuse |
Please see the COMPREHENSIVE BEHAVIORAL HEALTH PROGRAM benefits below |
|||
|
Home Health Care |
100 visits/Calendar Year |
10% |
10% |
|
|
Skilled Nursing Services |
100 days/Calendar Year (not for custodial care) |
10% |
10% |
|
|
Speech Therapy |
Inpatient or outpatient treatment when following surgery, injury or for non-congenital organic disease |
10% |
10%* |
|
|
Physical Therapy & Chiropractic Care |
Outpatient office visits All other services |
$10 copay ( up to 20 visits/calendar year) 10% |
10%* (up to $35/visit) 10%* (up to $700/year) |
|
|
Occupational Therapy |
Provided under home health & skilled nursing facility benefits if therapy & agency are Blue Cross approved |
|||
|
Acupuncture |
Acupuncture |
10% |
10%* |
|
|
Biofeedback |
For conditions other than mental health |
10% |
10%* |
|
|
Hospice |
Hospice care up to a maximum lifetime payment of $5,000 in approved hospice |
10% |
10% |
|
|
Other |
Unreplaced blood Blood administration Special duty nursing care |
20% 10% 20% |
20% 10% 20% |
|
*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.
Behavioral Health Program Covered Services
Payment for Covered Expense Incurred (subject to amounts stated in Benefit Maximums)
|
Covered Services |
With Authorization |
Without Authorization |
|
|
Participating BHP Providers |
Participating
BHP |
Non-BHP Provider |
|
|
Outpatient Visits for Psychotherapy & Psychological Testing |
20% of Covered Expense up to one visit/day, & costs in excess of a combined total of 50 visits/calendar year |
50% of Covered Expense up to one visit/day, $50/visit & costs in excess of a combined total of 25 visits/calendar year |
50% of Covered Expense up to one visit/day, $25/visit; & costs in excess of Covered Expense & a combined total of 25 visits/calendar year |
|
Inpatient Services Mental Disorders & Substance Abuse
|
$150 per Course of Treatment & 20% of Covered Expense |
$300 per Course of Treatment & 50% of Covered Expense |
$500 per Course of Treatment & 50%, of Covered Expense & costs in excess of Covered Expense |
|
Outpatient Treatment Center Services Mental Disorders & Substance Abuse |
|
|
|
|
Benefit Maximums Mental Disorders (inpatient & outpatient facilities; for outpatient, two sessions at outpatient facility equal one inpatient day)
|
Combined total for all Covered Services equals maximum of 30 days/calendar year
|
||
* For BHP Providers, a Course of Treatment is limited to the number of days prescribed by the medical director of the Inpatient Treatment or Outpatient Day Treatment Center and accepted by the 8HP Care Manager.
For non-BHP Providers, a Course of Treatment is limited to a Maximum of 30 consecutive days for inpatient services at an Inpatient Treatment Facility or 60 days per year for services from an Outpatient Day Treatment Center.
PORAC's Prudent Buyer Plan Exclusions and Limitations
|
The Prudent Buyer Plan does not cover services & supplies • received before your enrollment effective date; • received during an inpatient stay that began before your enrollment effective date; • received after your plan coverage ends; • not specifically listed as covered; • for experimental or investigational services; • not Medically Necessary as defined by Blue Cross; • provided by local, state (except Medi-Cal) or federal government agencies, or to the extent covered by Medicare; • covered under Workers' Compensation laws-whether or not you apply for such benefits; • provided without charge; • for braces, other orthodontic appliances or services, or for dental care except within six months of an accidental injury occurring while covered under the plan; • for eyeglasses except after a covered eye surgery; eye examinations or eye; • eye surgery solely for correction of refractive defects of the eye such as nearsightedness & astigmatism; • for hearing aids or routine hearing tests; • for cosmetic services; trans-sexual surgery; • primarily for weight reduction or treatment of obesity; • for rest home or nursing home care; |
• for custodial care; • for in-vitro fertilization procedures, artificial insemination, gamete intrafallopian transfer & any services in connection with those procedures, or sterilization reversal; contraceptive devices; • for charges over Blue Cross' recognized amounts; • for treatment of mental disorders or chemical dependency (except as stated in the Behavioral Health Program); • for hospitalization for environmental change or diagnostic testing; • for private room charge over two-bed room rate, unless a private room is medically necessary; • for consultations by telephone or facsimile machine; personal comfort items; • for professional services provided by a family member or by a person living in your home; such benefits; a for professional services provided by a family member or by a person • for orthopedic shoes & shoe inserts; • for conditions caused by release of nuclear energy; • for pathological gambling or codependency; • for caffeine addiction; • for speech disorders; • for treatment of chronic pain, except as specifically provided under the "Hospice Care" provision in the Evidence of Coverage & Disclosure Form; • for treatment of illness, injury or condition causing member to be totally disabled, if the member was covered under a prior plan, totally disabled the date that plan terminated & entitled to an extension of benefits under that plan. |
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.
