Benefit

PPO Plan

Choice of Provider

Your choice of doctor/hospital

Your choice of doctor/hospital

Must use Kaiser provider & facility

Annual Deductible
(per calendar year)

$100 Person
$300 Family

$500 Person
$1,500 Family

No deductible

Major Medical Benefits
(per calendar year)

After deductible, all eligible services paid at 80% of 1st $5,000, then 100%

After deductible, all eligible services paid at 80% of 1st $5,000, then 100%

Paid in full after applicable co-payment

Lifetime Maximum

$2,000,000

$2,000,000

No limit

Hospital Services:
Inpatient Semi-private room
(Visit website or see booklet
for Outpatient Benefits)

 Paid at 90%

80% after deductible

Paid in full

80% after deductible

80% after deductible

80% after deductible

Prescription Drugs

Generic medications:
$10 Copay
(retail)/$30 Copay (mail order)
Preferred Brand Medications:
80% (retail and mail order
Non-preferred Brand medications:
50% (retail and mail order)
Individual prescription medication out-of-pocket limit per calendar year $1,000 (separate from medical). After your maximum out-of-pocket is met each calendar year, we pay 100%.
(See CHOICES list on website http://www.regence.com)

Generic medications:
$10 Copay
(retail)/$30 Copay (mail order)
Preferred Brand Medications:
80% (retail and mail order
Non-preferred Brand medications:
50% (retail and mail order)
Individual prescription medication out-of-pocket limit per calendar year $1,000 (separate from medical). After your maximum out-of-pocket is met each calendar year, we pay 100%.
(See CHOICES list on website http://www.regence.com)

Paid in full after $10 co-pay for up to 30 day supply
Paid in full after $10 co-pay 90 day supply via mail order for maintenance drugs

Ambulance

Paid at 80%

80% after deductible

Paid in full after $50 co-pay per trip

Emergency Room Care

$100 co-pay then 90% (waived if admitted)

$100 co-pay (waived if admitted) then 80%

$50 + $10 co-pay

Additional Accident

80% after deductible

80% after deductible

Paid as regular benefit

Maternity Care

90% after deductible

80% after deductible

Inpatient prenatal & postnatal paid in full; outpatient paid in full after $10 co-pay

Preventive Care

Paid at 100%

Paid at 100%

Paid in full after $10 co-pay - all members

Periodic Health Plan

Not covered

Not covered

Not covered

Chiropractic Care

80% after $100 deductible

See Alternative Care

Alternative Care

Not covered

Not covered

Member pays $10 co-pay for Naturopathic, Chiropractic, and/or Acupuncture care.  Member pays $25 co-pay for Massage Therapy.  Massage Therapy is limited to 12 one-hour visits per calendar year.