View Benefit Details First Lastname (Certificate #: 123456789)

View Contract Information      Benefits/Deductibles Used

Plan Name: Blue Cross HMO Cc01
Summary of Benefits Effective: 6/19/2002

Benefit Applicable Provider Network Benefit Level
General Provisions 
    General 
    Eligibility 
            Dependent Eligibility To  All 19 years
            Dependent Maximum Age Limit  All 24 years
    Maximum Copayments 
            Single Party Copayment Maximum  HMO $1,500
            Two Party Copayment Maximum  HMO $3,000
            Family Copayment Maximum  HMO $4,500
HMO Benefits 
    Inpatient Hospital-Medical 
            Blood Copayment  HMO $0
    Skilled Nursing Facilities 
            Skilled Nursing Facility Med/Rtc Ab88 Calendar Year Maximum Comb  HMO 100 days
    Emergency Room And Emergency Diagnosis Benef 
            Emergency Room In Area Copayment  HMO $50
            Emergency Room Out Of Area Copayment  HMO $50
    Preventive Care Benefits 
            Routine Exam Copayment  HMO $10
            Well Baby Exam Copayment  HMO $10
            Eye Exam Copayment  HMO $10
            Hearing Copayment  HMO $10
    Physician Home/Office Benefits 
            Home/Office Visit Copayment  HMO $10
            Specialist Copayment  HMO $10
            Allergy Serum Copayment  HMO $10
    Physician Home Office Consultations 
            Consultation Copayment  HMO $10
    Diagnostic X-Ray & Lab 
            Allergy Testing Copayment  HMO $10
    Post Surgical Vision 
            Glasses/Contacts Following Surgery  HMO 1 occurrence
    Physical Therapy 
            Physical Therapy Copayment  HMO $10
            Physical Therapy Maximum Per Illness  HMO 60 days
            Physical Therapy Maximum Per Injury  HMO 60 days
    Rehabilitation Therapies 
            Speech Therapy Copayment  HMO $10
            Speech Therapy Maximum Per Illness/Injury  HMO 60 days
            Occupational Therapy Copayment  HMO $10
            Occupational Therapy Maximum Per Illness/Injury  HMO 60 days
    Durable Medical Equipment 
            Durable Medical Equipment Calendar Year Maximum  HMO $2,000
    Obstetrical Benefits 
            Obstetrical Copayment  HMO $10
            Obstetrical Consultation Copayment  HMO $10
            Obstetrical Counseling Copayment  HMO $10
            Family Planning Copayment  HMO $10
            Abortion Copayment  HMO $150
    Sterilization/Infertility 
            Tubal Ligation Copayment  HMO $150
            Vasectomy Copayment  HMO $100
            Infertility Treatment Copayment  HMO 50%
    Home Health Care Benefits 
            Home Health Per Visit Copayment  HMO $10
    Hospice Care Benefits 
            Hospice Life Maximum  HMO $5,000
    Mental Health Parity 
    Inpatient Hospital-Nervous/Menta 
            Inpatient Copayment Per Day  HMO $100
            Inpatient Psychiatric Calendar Year Maximum  HMO 30 days
    Outpatient Nervous/Mental 
            Outpatient Nervous/Mental Copayment  HMO $35
            Outpatient Nervous/Mental Calendar Year Maximum  HMO 20 visits
    Professional Nervous/Mental 
            Nervous/Mental Medical While Hospitalized Copayment  HMO $35
            Nervous/Mental Medical While Hospitalized Maximum Per Day  HMO 1 visit
            Nervous/Mental Medical While Hospitalized Maximum Per Calendar Year  HMO 30 visits
    Inpatient Substance Abuse 
            Inpatient Substance Abuse Per Day Copayment  HMO $100
Drug Rider Benefits 
    Drug Rider Coverage 
            Brand Name Retail Copayment  All $15
            Brand Name Mail Order Copayment  All $30
            Generic Retail Copayment  All $7
            Generic Mail Order Copayment  All $14
            Rx Mail Order Supply Maximum  All 90 days
            Rx Retail Supply Maximum  All 30 days