|
Traditional
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.
|
|
Network |
Regence
BlueShield Participating Providers
|
|
Deductible* |
$200 per
person/$600 per family |
|
Out-of-Pocket Max |
$1,250 per person |
|
Maximum
Benefit |
$2,000,000 |
|
Professional
Services |
$20 copay,
then 80% |
|
Preventive
Care |
$20 copay,
then 80% (no annual maximum; deductible waived) |
|
Lab
Work |
80% |
|
Ambulance
|
80% |
|
Hospital
Facilities |
80% |
|
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 |
80% up to $25
per visit |
|
Rehabilitation Services: |
|
|
Inpatient
|
80%
|
|
Outpatient
|
80%
|
|
Mental
Disorders: |
|
|
Inpatient - 30 days/yr
|
80% |
|
Outpatient - 50 visits/yr
|
80% after $20 copay |
|
Chemical
Dependency -
$13,500
every 2 years max
|
80%
|
|
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 80% |
|
Vision
Hardware - every 2 calendar years |
Frames,
lenses and contacts will
be paid at 80% up to $400
To include LASIK Surgery |
