For medically necessary services rendered
by a Preferred Plan, participating or recognized provider, the benefits of this
plan will be provided at the percentage of the allowed amount specified below
after the deductible has been met. Unless otherwised specified, all benefits
are subject to the annual deductible in addition to any copays and coinsurance.
When you have reached the annual out-of-pocket coinsurance maximum, this plan
will provide benefits at 100% of the allowed amount for the remainder of the
calendar year for the services of Preferred Plan providers only, unless otherwise
specified. The annual deductible, copays, outpatient rehabilitative care, and
most participating provider services do not apply to the annual out-of-pocket
coinsurance amount.
Benefits
Preferred Plan
Provider
Participating/Recognized
Provider
Annual Deductible
Copays do not count toward the deductible.
Family deductible is met when three or more covered
family members incur the equivalent of three individual deductible amounts
in a calendar year
$2,500 per individual/$7,500 per family
or
$5,000 per individual/$15,000 per family
Lifetime maximum:
$2,000,000 per individual
Annual Out-of-Pocket Coinsurance Amount
Family out-of-pocket coinsurance amount is met
when three or more covered family members reach the equivalent of three
individual out-of-pocket coinsurance amounts in a calendar year
$10,000 per person
$30,000 per family
No out-of-pocket
maximum
Professional Services
Including diagnostic x-ray and laboratory. Coverage
includes the services of physicians, osteopaths, naturopathsic providers,
and other eligible health care professional providers
50%
(unless specified otherwise)
50%
(unless specified otherwise)
Hospital Facility (Inpatient & Outpatient)
Including diagnostic x-ray and laboratory
$100 copay per emergency room visit (waived if admitted)
50%
50%
Acupuncture
12 visits per calendar year maximum
50%
50%
Ambulance Services**
Ground services: $2,000 per calendar
year
50%
50%
Blood Bank**
50%
50%
Home Health and Hospice
Home Health–
130 visits per calendar year maximum
Hospice – 6 months maximum
50%
50%
Home Medical Equipment
$2,500 per calendar year maximum
50%
50%
Home Phototherapy
50%
50%
Infusion Therapy
Growth hormone only treatment is limited to $25,000
per calendar year
50%
50%
Mammography
50%
50%
Occupational Injury
(provided for subscriber only)
same as any condition
Phenylketonuria (PKU) Formulas
Not subject to waiting periods
50%
50%
Prostheses and Orthotics
50%
50%
Rehabilitative Care
Inpatient – $4,000 per calendar year maximum Outpatient – $2,000 per calendar year maximum
50%
50%
Skilled Nursing Facility
30 days per calendar year maximum
*
50%
Special Equipment and Supplies
50%
50%
Spinal Manipulations
10 visits per calendar year maximum
50%
50%
Transplants
$250,000 lifetime maximum; $50,000 per transplant donor
organ procurement maximum; $2,500 per transplant travel and lodging
maximum; 12-month waiting period
50%
50%
*At this time, these services are provided only by Participating
Providers.
**At this time, these services are provided only by Recognized
Providers.
Cost Containment Provisions: All
hospital and skilled nursing facility admissions must be medically necessary.
Preadmission approval is required for all inpatient admissions outside the service
area if you seek care from providers who have not contracted with a Blue Cross
and/or Blue Shield plan, except for emergency services.
Emergency Care: Emergency benefits will
be provided at the level specified for a Preferred Plan provider. In the event
of a medical emergency, treatment by a provider not normally covered under this
plan will be recognized for a 24-hour period or for such additional time as
is reasonably required to come under the care of a Preferred Plan provider.
Benefits will be based on the recognized provider’s actual charge for the service.
Care Outside the Service Area: All care
received outside the service area, whether or not a medical emergency, will
be covered at 50% of the allowed amount. Any balances of charges not covered
by this plan will be your responsibility.
Waiting Periods: No benefits are provided
for treatment relating to a transplant until you have been covered under this
or a prior plan with the Company (Asuris Northwest Health) for 12 consecutive
months. No benefits will be provided for preexisting conditions until you have
been covered under this plan for nine consecutive months, unless you were continuously
covered for at least nine months under the immediately preceding creditable
plan.
This is a brief summary of benefits, it is
not a certificate of coverage. For full coverage provisions, including a description
of waiting periods, limitations, and exclusions, refer to the plan contract.
Asuris
NW Health
