2005 Small Group Plan Designs PPO Page 1 click here for page 2 (more BC PPO plan options)

Description of Benefits		2005 Small Group PPO Plan Options
		100	1200SX	1201SX	1202SX	1203SX
Lifetime Maximum (in and out-of-network combined)		$5,000,000	$5,000,000	$5,000,000	$5,000,000	$5,000,000
Calendar year Deductible (per member-max 3 members)	In-Network	$300	$300	$500	$1,000	$1,500
	Out-of-Network	$300	$600	$1,000	$2,000	$3,000
Coinsurance	In-Network	90%	90%	90%	90%	90%
	Out-of-Network	70%	70%	60%	60%	60%
Out-of-Pocket Maximum for Calendar Year - Includes Deductible (per member-max 3 members)	In-Network	$1,300	$1,300	$1,500	$2,000	$2,500
	Out-of-Network	$6,300	$3,600	$5,000	$6,000	$7,000
Physicians Office Visit PCP/Specialist (includes x-ray and lab work done and billed by Drs. office)	In-Network	$15/$15	$25/$25	$25/$25	$40/$40	$40/$40
	Out-of-Network Plan pays after deductible	70%	70%	60%	60%	60%
Outpatient Surgery Facility includes x-ray and lab (Plan pays after deductible)	In-Network	90%	90%	90%	90%	90%
	Out-of-Network	70%	70%	60%	60%	60%
Physician Outpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	90%	90%	90%	90%	90%
	Out-of-Network	70%	70%	60%	60%	60%
Maternity (physician fee only)	In-Network (1st visit only)	$100	$100	$100	$100	$100
	Out-of-Network Plan pays after deductible	70%	70%	60%	60%	60%
Inpatient Hospital (Plan pays after deductible)	In-Network	90%	90%	90%	90%	90%
	Out-of-Network	70%	60%	60%	60%	60%
Physician Inpatient Services (surgeon, radiologist, anesthesiologist, etc) (Plan pays after deductible)	In-Network	90%	80%	80%	80%	80%
	Out-of-Network	70%	60%	60%	60%	60%
Physical and Occupational Therapy, Chiropractic, Athletic Trainers (Plan pays after deductible)	In-Network	90%	90%	90%	90%	90%
	Out-of-Network	70%	60%	60%	60%	60%
	Visits per year	20	20	20	20	20
Inpatient Behavioral Health/Substance Abuse 30 Day calendar year max (Plan pays after deductible)	In-Network	80%	80%	80%	80%	80%
	Out-of-Network	60%	60%	60%	60%	60%
Outpatient Behavioral Health/Substance Abuse 20 Visit calendar year max	In-Network	$25	$25	$25	$40	$40
	Out-of-Network Plan pays after deductible	60%	60%	60%	60%	60%
Emergency Room Copay (waived if admitted)	In or Out of Network	$100	$100	$100	$100	$100
Prescription Drug Copays	Prescription deductible per member (calendar yr)	$0	$0	$0	$0	$0
	Generic/Formulary	$15	$20	$20	$20	$20
	Brand/Formulary	$25	$35	$35	$35	$35
	Non-Formulary	$40	$60	$60	$60	$60
	Mail Order	Not Covered	$60	$60	$60	$60
Note: Plan benefits listed above are intended as a summary only and do not replace benefits listed in certificate of coverage. Some specific benefits may have limitations and/or exclusions. Refer to your policy for more detail.
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