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Catastrophic Plan Option (PPO)
Providing Catastrophic benefits, the Blue Cross Prudent Buyer or Arizona Foundation for Medical Care (depending on which network you chose at open enrollment) provider networks reward insureds for utilizing in-network services. Insureds may select either a primary care physician or specialist without a "gatekeeper" referral.
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2007 Preferred Drug List
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BENEFITS |
NETWORK |
NON NETWORK |
Lifetime Maximum Benefit |
$5,000,000 |
Coinsurance Limit
(excludes copays & deductibles) |
$5,000 |
$10,000
|
Calendar Year Deductible |
$1,000 Individual
$3,000 Family |
$5,000 Individual
$15,000 Family |
Coinsurance |
70% |
50% |
Doctor's Office Visit |
Primary Care Physician |
$15 copay |
50% after deductible |
Specialty Care Physician |
$30 copay |
50% after deductible |
Outpatient Therapy |
Physical, occupational, speech or hearing |
$30 copay |
50% after deductible |
Chiropractic Care -
up to $1500 per year |
$30 copay |
50% after deductible |
Preventive Care
including routine exams on an age and gender appropriate basis |
$15 copay |
Not Covered |
Diagnostic X-Ray and Lab Tests
(in free standing facility) |
$15 copay |
50% after deductible |
Emergency Care (waived if admitted) |
Emergency Room Visits |
$75 copay |
50% after deductible |
Other Urgent Care Facilities |
$30 copay |
50% after deductible |
Emergency Ambulance Services: |
Local |
70% after deductible |
70% after deductible |
Air Ambulance
up to $18,000 per period of confinement |
70% after deductible |
70% after deductible |
Inpatient Facility Services |
Hospital Facility OR Convolescent Care Facility -
50% of semi-private room rate up to 90 days per confinement period |
70% after deductible |
$500 per confinement deductible, then 50% |
Physician Visits |
70% after deductible |
50% after deductible |
Hospital Based Anesthesia, Pathology, Radiology
(payable at network coinsurance if performed ata network facility) |
70% after deductible |
50% after deductible |
Physician's Surgical Services |
Office |
70% after copay |
50% after deductible |
Hospital (inpatientt) |
70% after deductible |
50% after deductible |
Free standing surgical center |
70% after deductible |
50% after deductible |
Outpatient Facility Services
including birthing center, free standing facility |
70% after deductible |
50% after deductible |
Private Duty Nursing -
up to $125 per day |
70% after deductible |
50% after deductible |
Podiatric Services
up to a $2,000 maximum benefit/year |
70% after deductible |
50% after deductible |
Other Health Care |
Durable Medical Equipment
up to a $10,000 lifetime benefit |
70% after deductible |
50% after deductible |
Prosthetic Medical Appliances |
70% after deductible |
50% after deductible |
Home Health Care -
home health aide up to 20 hours per week |
70% after deductible |
50% after deductible |
Hospice Care |
70% after deductible |
50% after deductible |
Hospice Lifetime Maximum |
$10,000 |
Bereavement Counseling
up to $200 per family |
70% after deductible |
50% after deductible |
Prescription Drugs: |
Prescription Drugs are not Covered |
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