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Individual: $4500

Family: $9000

Per Person: $4500

Individual: $0

Family: $0

Per Person: $0

Individual: $10600

Family: $21200

Per Person: $10600

CoPay: $30.00

CoInsurance: Not Applicable

Covered: Covered

Benefit Explanation: Includes virtual, retail health clinic and medical evaluation at an affiliated immunization pharmacy visits. No charge for 24/7 medical virtual visits when performed through the BCN selected vendor app. Diagnostic services are not included in the office visit copayment. These services are subject to the plan's deductible and coinsurance, if applicable.

CoPay: $50.00 Copay after deductible

CoInsurance: Not Applicable

Covered: Covered

Benefit Explanation: Referral required. The penalty for not having a referral is denial of payment. Diagnostic services are not included in the office visit copayment. These services are subject to the plan's deductible and coinsurance, if applicable. No charge for 24/7 medical virtual visits when performed through the BCN selected vendor app.

CoPay: $100.00 Copay after deductible

CoInsurance: Not Applicable

Covered: Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. Preventive drugs are covered with no out-of-pocket costs when health care reform requirements are met. Any coupon, rebate, or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer’s deductible, cost-sharing or out of pocket maximum

CoPay: $150.00 Copay after deductible

CoInsurance: Not Applicable

Covered: Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. Preventive drugs are covered with no out-of-pocket costs when health care reform requirements are met. Any coupon, rebate, or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer’s deductible, cost-sharing or out of pocket maximum

CoPay: $4.00 Copay after deductible

CoInsurance: Not Applicable

Covered: Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. Preventive drugs are covered with no out-of-pocket costs when health care reform requirements are met. Any coupon, rebate, or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer’s deductible, cost-sharing or out of pocket maximum

CoPay: Not Applicable

CoInsurance: 40.00% Coinsurance after deductible

Covered: Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: Refer to drug list for quantity limits and other exclusions. BCN has contracted with an exclusive pharmacy network for specialty drugs. Call the customer service phone number on the back of your ID card for the pharmacy’s phone number or location nearest to you. If you obtain your specialty drugs from any other pharmacy, you are responsible for the total cost. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer’s deductible, cost-sharing or out of pocket maximum

CoPay: Not Applicable

CoInsurance: 20.00% Coinsurance after deductible

Covered: Covered

Benefit Explanation: Prior authorization required. The penalty for not having prior authorization is denial of payment.

CoPay: Not Applicable

CoInsurance: 20.00% Coinsurance after deductible

Covered: Covered

Benefit Explanation: Prior authorization required. The penalty for not having prior authorization is denial of payment.

CoPay: $250.00 Copay after deductible

CoInsurance: 20.00% Coinsurance after deductible

Covered: Covered

Benefit Explanation: Emergency room visits will be covered at non-participating facilities for medical emergencies and accidental injuries only. Copayment waived if admitted inpatient into the hospital.

CoPay: $40.00

CoInsurance: Not Applicable

Covered: Covered

Benefit Explanation: Urgent Care visits will be covered at non-participating providers for medical emergencies and accidental injuries only.

CoPay: Not Applicable

CoInsurance: 20.00% Coinsurance after deductible

Covered: Covered

Benefit Explanation: Prior authoriztion required. The penalty for not having prior authorization is denial of payment.

CoPay: No Charge

CoInsurance: Not Applicable

Covered: Covered

Benefit Explanation: Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance, or deductible may apply.

CoPay: No Charge

CoInsurance: Not Applicable

Covered: Covered

Limit Quantity: 1

Limit Unit: Exam(s) per Year

Benefit Explanation: Out of network is paid up to the allowed amount. A child is defined as a member up to age 19.

CoPay:

CoInsurance:

Covered: Not Covered

Limit Quantity:

Limit Unit:

CoPay:

CoInsurance:

Covered: Not Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: