No Annual or Lifetime Dollar Limit. Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services California Prenatal Screening Program $0 $0 Not covered $0 Primary care office visit 20% ✔ 40% ✔ Specialist care office visit 20% ✔ 40% ✔ Physician home visit 20% ✔ 40% ✔ Physician or surgeon services in an Outpatient Facility 20% ✔ 40% ✔ Physician or surgeon services in an inpatient facility 20% ✔ 40% ✔ Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 20 visits per Member, per Calendar Year. Teladoc consultation Family planning • Counseling, consulting, and education • Injectable contraceptive, diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. • Tubal ligation • Vasectomy Podiatric services 20% 20% 20% $0 $0 $0 $0 20% 20% ✔ 40% ✔ ✔ 40% ✔ ✔ 40% ✔ ✔ Not covered Not covered Not covered Not covered ✔ Not covered ✔ 40% ✔ Pregnancy and maternity care 40% 40% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 20% 20% ✔✔ ✔✔ Emergency Services Emergency room services If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services $150/visit plus 20% 20% ✔ ✔ $150/visit plus 20% 20% ✔ ✔ When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 20% ✔ 40% ✔ Ambulance services This payment is for emergency or authorized transport. 20% ✔ 20% ✔ Outpatient Facility services 40% Ambulatory Surgery Center 10% ✔ Subject to a Benefit maximum ✔ of $350/day 40% Outpatient Department of a Hospital: surgery 20% ✔ Subject to a Benefit maximum ✔ of $350/day Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 20% ✔ 40% Subject to a Benefit maximum of $350/day ✔ Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant servic...
No Annual or Lifetime Dollar Limit. When using a Participating Provider3 When using a Non- Participating Provider4 Individual coverage $3,425 Family coverage $3,425: individual $6,850: Family $12,000 $12,000: individual $24,000: Family Under this Plan there is no annual or lifetime dollar limit on the amount Blue Shield will pay for Covered Services. When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Preventive Health Services7 Preventive Health Services $0 30% California Prenatal Screening Program $0 $0 Primary care office visit 10% 30% Specialist care office visit 10% 30% Physician home visit 10% 30% Physician or surgeon services in an outpatient facility 10% 30% Physician or surgeon services in an inpatient facility 10% 30% Other professional services Other practitioner office visit Includes nurse practitioners, physician assistants, and therapists. Acupuncture services Up to 20 visits per Member, per Calendar Year. Chiropractic services Up to 30 visits per Member, per Calendar Year. Teladoc consultation Family planning Counseling, consulting, and education Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. Tubal ligation Vasectomy Podiatric services 10% 30% 10% 30% 10% 30% $0 Not covered $0 30% $0 30% $0 30% 10% Not covered 10% 30% Pregnancy and maternity care 30% 30% Physician office visits: prenatal and postnatal Physician services for pregnancy termination 10% 10%
