Small Group Plan Designs

OPEN ACCESS POS
Page 1
click here for page 2 (more BC Open Access POS plan options)

Description of Benefits

Small Group Open Access POS Plan Options

2005AX

2006AX

2505AX

2007AX

2506AX

 2010AX
Lifetime Maximum  In-Network Unlimited Unlimited Unlimited Unlimited Unlimited  Unlimited
Out-of-Network  $5,000,000  $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 $0 $0 $0 $500 $500  $1,000
Out-of-Network $300 $500 $1000 $1,000 $1,000 $2000
Coinsurance  In-Network

100%

100%

80%

100%

80%
 100%
Out-of-Network

70%

60%

60%

60%

60%
 60%
Out-of-Pocket Maximum for Calendar Year - Includes Deductible
(per member-max 3 members)		  In-Network $0 $0 $1000 $0 $1,000 $0
Out-of-Network $1,500 $4,000 $4,000 $4,000 $4,000 $4,000
Physicians Office Visit PCP/Specialist
(includes x-ray and lab work done and billed by Drs. office)		  In-Network $25/$35 $25/$35 $25/$35 $25/$35 $25/$35  $25/$35
Out-of-Network
Plan pays after deductible		 70% 60% 60% 60% 60%  60%
Outpatient Diagnostic X-ray/Lab
(Plan pays after deductible)		  In-Network 100% 100% 80% 100% 80%  100%
Out-of-Network 70% 60% 60% 60% 60%  60%
Outpatient Surgery Facility includes x-ray and lab
(Plan pays after deductible)		  In-Network $100 Copay $100 Copay 80% $100 Copay 80%  100%
Out-of-Network 70% 60% 60% 60% 60%  60%
Physician Outpatient Services (surgeon, radiologist, anesthesiologist, etc)
(Plan pays after deductible)		  In-Network 100% 100% 100% 100% 100%  100%
Out-of-Network 70% 60% 60% 60% 60%  60%
Maternity
(physician fee only)		  In-Network
(1st visit only)		 $35 $100 $100 $100 $100  $100
Out-of-Network
Plan pays after deductible		 70% 60% 60% 60% 60%  60%
Inpatient Hospital
(Plan pays after deductible)		  In-Network 100% 100% 80% 100% 80%  100%
Out-of-Network 70% 60% 60% 60% 60%  60%
Physician Inpatient Services (surgeon, radiologist, anesthesiologist, etc)
(Plan pays after deductible)		  In-Network 100% 100% 100% 100% 100%  100%
Out-of-Network 70% 60% 60% 60% 60%  60%
Physical and Occupational Therapy,
Chiropractic, Athletic Trainers
(Plan pays after deductible)		  In-Network $35 $35 $35 $35 $35  $35
Out-of-Network 70% 60% 60% 60% 60%  60%
Visits per year 20 20 20 20 20  20
Inpatient Behavioral Health/Substance Abuse
30 Day calendar year max
(Plan pays after deductible)		  In-Network 100% 100% 80% 100% 80%  100%
Out-of-Network Not Covered Not Covered Not Covered Not Covered Not Covered  Not Covered
Outpatient Behavioral Health/Substance Abuse
20 Visit calendar year max		  In-Network $35  $35  $35  $35  $35  $35
Out-of-Network
Plan pays after deductible		 Not Covered  Not Covered Not Covered  Not Covered  Not Covered  Not Covered

Emergency Room Copay
(waived if admitted)

 In or Out
of Network		 $100 $100 $100 $100 $100  $100
Prescription Drug
Copays

Prescription deductible per member (calendar yr)

 $0 $0 $0 $0 $0  $0

Generic/Formulary

 $20 $20 $20 $20 $20  $15

Brand/Formulary

 $35 $35 $35 $35 $35  $30

Non-Formulary

 $60 $60 $60 $60 $60  $60

Mail Order

 $60/$60 $60/$60 $60/$60 $60/$60 $60/$60  $30/$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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