|
WEA
Select Plan
2 - Premera Blue Cross
October 1, 2003
- September 30, 2004 |
|
Information provided is in summary
format. Any difference between the summary provided and
actual contract will be settled in favor of the contract.
|
|
Policy
Number |
8000207 |
|
|
In-Network |
Out-Of-Network* |
|
Heritage
Network |
Premera Blue Cross
Heritage Providers |
Out-of-Network Providers |
|
Deductible |
None |
|
Coinsurance |
80% |
60% |
|
Out-of-Pocket
Limit |
$5,500/Individual |
|
Maximum
Benefit |
$5,000,000 |
|
Office
Visits |
$25 copay |
$30 copay |
|
Preventive
Care
-
$200 limit per year with $500 limit for well baby care
through age 3 |
100% |
80% |
|
Lab
Work |
80% |
60% |
|
Ambulance |
80% |
60% |
|
Hospital Inpatient
|
$150 copay per day;
$450 maximum per year, then 80% |
$150 copay per day;
$450 maximum per year, then 60% |
|
Emergency
Room |
$75 copay, waived if
admitted |
|
Maternity |
Paid
as illness |
|
Rehabilitative Therapy |
|
|
Inpatient
- 120 day limit
per year
|
$150 copay per day;
$450 maximum per year, then 80% |
$150 copay per day;
$450 maximum per year, then 60% |
Outpatient - 45 visit limit
per year |
$25 copay |
$30 copay |
|
Chiropractic |
$25 copay |
$30 copay |
|
Mental
Health: |
|
|
Inpatient
|
$150 copay per day;
$450 maximum per year, then 80% |
$150 copay per day;
$450 maximum per year, then 80% |
|
Outpatient -
50 visit limit per year
|
70% |
50% |
|
Chemical Dependency:
$11,285
maximum in a 24 month period
|
|
|
Inpatient
|
$150 copay per day;
$450 maximum per year, then 80% |
$150 copay per day;
$450 maximum per year, then 60% |
|
Outpatient
|
80% |
60% |
|
Retail Prescriptions
(Participating Pharmacies)
|
Generic:
$7 copay
Preferred Brand: $20 copay
Non-Preferred Brand:
$30 copay
|
Generic:
$7 copay, plus 25%
Preferred Brand: $20 copay,
plus 25%
Non-Preferred Brand:
$30 copay, plus 25%
|
|
Supply Limit |
Per Copay
Acute: Up to 34 days |
|
Mail Order Prescriptions
|
Generic:
$10 copay
Preferred Brand: $15 copay
Non-Preferred Brand:
$25 copay
|
|
Supply Limit |
Up to 100 day supply |
|
Vision
Benefit |
None. See the self-funded NBN
Vision Plan Summary offered by the
Seattle
Public Schools to all eligible employees. |
|
Hearing/Audio
Benefit |
Hardware - 80% coverage, $400
limit each 3 years |
|
Notes |
*You may also incur
"balance billing" from out-of-network providers for
charged amounts above the contracted Heritage
provider rates. |
