|
Selections
Medical
Plan - Regence BlueShield
November
1, 2008 - October 31, 2009 |
|
Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
|
|
|
In-Network |
Out-Of-Network |
|
PPO
Network |
Regence
BlueShield
Selections
Network
|
Extended
Network |
|
Deductible |
None |
$200 per person/$600 per family |
|
Out-of-Pocket Max |
$2,500 per person |
$10,000
per person |
|
Maximum
Benefit |
$2,000,000 |
|
Professional
Services |
$20 copay,
then 90% |
$20 copay,
then 60% after deductible |
|
Preventive
Care |
$20 copay,
then 90% |
Not covered
except for mammograms at 60% |
|
Lab
Work |
90% |
60% after deductible |
|
Ambulance
- ground services up to $2,000 max/yr |
80% |
80% after deductible |
|
Hospital
Inpatient |
$200 copay
per admission, then 90% |
$200 copay
per admission, then 60% after deductible |
|
Emergency
Room |
$75
copay per visit; waived if admitted |
|
Maternity |
Same as any other condition;
provided for subscriber or spouse |
|
Spinal
Manipulations - 20 visits/yr max |
90% up to $25 per visit |
60% after deductible up
to $25 per visit |
|
Rehabilitation Services: |
|
|
Inpatient -
$30,000max/condition
|
90%
|
60% after deductible |
|
Outpatient
-
$1,500max/yr |
$20 copay,
then 90% |
$20 copay,
then 60% after deductible |
|
Mental
Disorders: |
|
|
Inpatient
|
90%; 12 days per year |
60% after deductible;
6 days per year |
|
Outpatient
|
$20 copay,
then 90%;
15 visits per year |
$20 copay,
then 60% after deductible;
12 visits per year |
|
Chemical
Dependency -
$13,500
every 2 years max
|
90%
|
60%
|
|
Prescription
Drugs
(Par
Pharmacies)
RX
Dosages |
Generic: $10 copay
Brand
Name: $20 copay
Non-Formulary:
$40 copay
34-day
supply or 100 tablets or capsules, whichever is
greater |
|
Mail
Order Prescriptions
RX
Dosages
|
Generic: $20 copay
Brand
Name: $40 copay
Non-Formulary:
$80 copay
90-day supply |
|
Drug
Formulary |
Click Here
to find out which prescription drugs are covered |
|
Vision
Exam - 1 every calendar year |
$20 copay,
then 90% |
Not Covered |
|
Vision
Hardware - every 2 calendar years |
Frames,
lenses and contacts will
be paid at 80% up to $400
To include Lasik Surgery |
