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Benefits Summary

Personal Choice® PPO

General Information Personal Choice
High Option		 Personal Choice Standard Option
(Calendar Year Benefit Period) In-Network Out-of-Network1 In-Network Out-of-Network1
Annual Deductible
Individual/Family		 $300/$600 $1000/$2000 $500/$1000 $1500/$3000
After Deductible, Plan Pays 100% 70% 80% 60%
Out-of-Pocket Maximum Individual/Family* $0/$0 $4,000/$8,000 $2,000/4,000 $5,000/$10,000
Lifetime Maximum
$50,000 Lifetime Maximum for Mental Health3		 Unlimited $500,000 Unlimited $500,000
Annual Inpatient Hospital Days 365 70 365 70
Annual Inpatient Mental Health Days 30 20 30 20
Benefits  
Office Visits $10 copay, No Deductible 70% $15 copay, No Deductible 60%
Preventive Care for Adults and Children $10 copay, No Deductible 70% $15 copay, No Deductible 60%
Pediatric Immunizations 100%2, No Deductible 70%, No Deductible 100%2, No Deductible 60%, No Deductible
Routine Gynecological Exam/Pap (1 per calendar year3) 100%, No Deductible 70%, No Deductible 100%, No Deductible 60%, No Deductible
Mammogram 100%, No Deductible 70%, No Deductible 100%, No Deductible 60%, No Deductible
Nutrition Counseling (6 visits per calendar year3) 100%, No Deductible 70% 100%, No Deductible 60%
Outpatient Therapies
– Physical, Speech, Occupational, Restorative Services, including spinal manipulation
– Cardiac Rehabilitation (36 visits per calendar year3)
– Respiratory Therapy
– Pulmonary Rehabilitation (12 visits per calendar year3)		 $15 copay, No Deductible 70% $15 copay, No Deductible 60%
Outpatient Mental Health Care**
– Visits 1-9
– Visits 10+		 30 Visits per calendar year
– $20 copay, No Deductible
– $30 copay, No Deductible		 20 Visits per calendar year3
– 50%
– 50%		 30 Visits per calendar year
– $20 copay, No Deductible
– $30 copay, No Deductible		 20 Visits per calendar year3
– 50%
– 50%
Emergency Room $40 copay, No Deductible
(copay waived if admitted)		 $40 copay, No Deductible
(copay waived if admitted)		 $40 copay, No Deductible
(copay waived if admitted)		 $40 copay, No Deductible
(copay waived if admitted)
Outpatient Laboratory/Pathology 100%, No Deductible 70% 100%, No Deductible 60%
Inpatient Hospital Services
Outpatient Surgery
Maternity and Newborn Care
Skilled Nursing Facility (90 days per calendar year3)
Chemo/Radiation/Dialysis
Hospice/Home Health Care
Outpatient X-Ray/Radiology
Durable Medical Equipment and Prosthetics 		100%
100%
100%
100%
100%
100%
100%
100% 		70%
70%
70%
70%
70%
70%
70%
70%
 80%
80%
80%
80%
80%
80%
80%
80%
 60%
60%
60%
60%
60%
60%
60%
60%
Substance Abuse Treatment**
– Detoxification: 7 days per adm3; 4 adm lifetime maximum3
– Rehabilitation: 30 days per calendar year3; 90 days lifetime maximum3
- Outpatient/Partial Facility Visits: 60 visits per calendar year3; 120 visits lifetime maximum3
100%

100%

100%
70%

70%

70%
80%

80%

80%
60%

60%

60%
Prescription Drugs Generic 80%/Brand 50%*** Generic 80%/Brand 50%*** Generic 60%/Brand 40%*** Generic 60%/Brand 40%***

What’s Not Covered?

  • Cosmetic surgery, supplies or treatment
  • Routine foot care
  • Supportive devices for the foot (orthotics), except for podiatric appliances for the prevention of complications associated with diabetes
  • Dental and vision care
  • Military, occupational injuries or illness
  • Benefits payable by the government, Medicare or through motor vehicle insurance
  • Services determined not to be medically appropriate or medically necessary
  • Expenses in excess of the allowable charge for covered services as determined by Independence Blue Cross
  • Experimental or investigative services
  • Inpatient private duty nursing
  • Acupuncture
  • Assisted fertilization techniques, such as but not limited to, in-vitro fertilization, artificial insemination, GIFT, ZIFT
  • Coverage for any preexisting condition, illness, or injury for which medical advice was recommended or received within a twelve-month period preceding the effective date of coverage is excluded for the first 12 months.

NOTE: Eligible unmarried dependent children are generally covered to age 19 regardless of student status. (See contract for additional details)

1 Out-of-network, non-participating providers may bill you for differences between the Plan allowance, which is the amount paid by Personal Choice, and the provider's actual charge. This amount may be significant. Claims payments for out-of-network professional providers (physicians) are based on IBC's own fee schedule. For services rendered by hospitals and other facility providers, the allowance may not refer to the actual amount paid by Personal Choice to the provider. Under Independence Blue Cross (IBC) contracts with hospitals and other facility providers, IBC pays using bulk purchasing arrangements that save money at the end of the year but do not produce a uniform discount for each individual claim. Therefore, the amount paid by IBC at the time of any given claim may be more or it may be less than the amount used to calculate your liability. It is important to note that all percentages for out-of-network services are percentages of the Plan allowance, not the provider's actual charge

2 Office visit may be subject to copayment

3 Combined in/out-of-network

* Out-of-pocket maximum does not include any expense incurred for prescription drugs, outpatient mental health services, and deductible, penalty, or copayment amounts

** Additional days/visits may be available; please refer to your contract for details

*** Even when there is no generic equivalent.

This summary represents only a partial listing of the benefits and exclusions of the Personal Choice program described in this summary. Benefits and exclusions may be further defined by medical policy. As a result, this managed care plan may not cover all of your health care expenses. Read your contract carefully for a complete listing of the terms, limitations and exclusions of the program. If you need more information, please call 215-557-7577.

Benefits underwritten or administered by QCC Insurance Company, a subsidiary of Independence Blue Cross – independent licensees of the Blue Cross and Blue Shield Association.