UC2004 查看數據表（PDF） - Unspecified
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UC2004 Datasheet PDF : 36 Pages
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Schedule of Benefits
Effective Date of this Plan
January 1, 2004
Behavioral Health Benefits for Blue Cross PLUS Members
Mental Health Member Copayments
In-Network Providers1
Out-of-Network
Providers
Office Visit Copayment
Visits 1-5: $0
Visits 6+: $10*
Not Applicable
Deductibles and Out-of-Pocket Maximum
Mental
Health/Substance Abuse
Calendar Year
Deductible
Substance Abuse
Inpatient Calendar
Year Deductible
Mental Health Out-of-
Pocket Maximum
Non- notification
Penalty
Not Applicable
$1002
$1,500 per person**
$4,500 per family**
Not Applicable
$500 per person
$1,500 per family
Not Applicable
$5,000 per person**
$15,000 per family**
$2005
Percentage Payable by the Plan after Copayments/Deductibles Satisfied
Mental Health Inpatient3
100%
70%4
Substance Abuse
Inpatient4
Mental Health
Outpatient
Substance Abuse
Outpatient
Lifetime Maximum
80% with Treatment Plan 70% with Treatment
Compliance
Plan Compliance
50% without Treatment 40% without Treatment
Plan Compliance
Plan Compliance
100% after Copayment
70%
80%
70%
None
$2,000,000
*Copayment is waived for children to age six.
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