Regence BlueShield - Online Application

Breakthru 80 Plan Benefits

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.

	Breakthru 80 Plan
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	$500 per individual/$1,500 per family or $1,500 per individual/$4,500 per family
Lifetime maximum:	$2,000,000 per individual
Benefits	Preferred Plan Provider	Participating  Provider
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	$2,500 per person $7,500 per family	No out-of-pocket maximum
Professional Services	(unless specified otherwise)
Office, home, and outpatient hospital visits; not subject to deductible	100% after $20 per-visit copay	100% after $40 per-visit copay
Outpatient diagnostic x-ray and laboratory services; and other professional services; subject to deductible	80%	50%
Coverage includes the services of physicians, osteopaths, naturopaths, and other eligible health care professional providers	80%	50%
Hospital Facility (Inpatient & Outpatient) Including diagnostic x-ray and laboratory $100 copay per emergency room visit (waived if admitted)	80%	50%
Acupuncture 12 visits per calendar year maximum	80%	50%
Ambulance Services** Ground services: $2,000 per calendar year	80%	80%
Blood Bank**	80%	80%
Home Health and Hospice Home Health – 130 visits per calendar year maximum Hospice – 6 months maximum	80%	80%
Home Medical Equipment $2,500 per calendar year maximum	80%	50%
Home Phototherapy	80%	80%
Infusion Therapy Growth hormone only treatment is limited to $25,000 per calendar year	80%	50%
Mammography	80%	50%
Maternity	80%	50%
Mental Disorders Inpatient – 8 days per calendar year Outpatient – 12 visits per calendar year	80%	50%
Occupational Injury Provided for subscriber only	same as any condition
Phenylketonuria (PKU) Formulas Not subject to waiting periods	80%	80%
Prescription Drugs	$3,000 per calendar year maximum; not subject to deductible
Generic Formulary	100% after $10 Retail copay/100% after $20 Mail Order copay
Brand-Name Formulary	70%
Non-Formulary	50%
Preventive Care $400 per calendar year maximum; not subject to deductible. Routine exams, immunizations, well child care, routine cancer screenings.	100%	50%
Prostate Cancer Screening	80%	50%
Prostheses and Orthotics	80%	50%
Rehabilitative Care Inpatient – $4,000 per calendar year maximum Outpatient – $2,000 per calendar year maximum	80%	50%
Skilled Nursing Facility 30 days per calendar year maximum	*	80%
Special Equipment and Supplies	80%	80%
Spinal Manipulations 10 visits per calendar year maximum	80%	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	80%	50%
Vision Care
One routine eye exam per calendar year; not subject to deductible	100% after $20 copay	100% after $40 copay
Vision hardware: $400 per calendar year maximum	***	100%

*At this time, these services are provided only by Participating Providers.
**At this time, these services are provided only by Recognized Providers.
***At this time, these services are provided only by Participating orRecognized Optical 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.

Copay: There is a per-visit copay for each office call/home visit billed as such by a provider in the office, home, or hospital outpatient department (waived for surgery, for radiation and chemotherapy, for spinal manipulations, or if you are directly admitted to the hospital as an inpatient).  Copays do not apply toward the deductible or the out-of-pocket coinsurance amount

Care Outside the Service Area: All care received outside the service area will be paid the same as in the service area if you use a Preferred Plan or participating provider. Payment will be based on the allowed amount. To receive the highest benefit level, you must receive services from a Preferred Plan provider. Benefits will be provided for care received from a recognized provider at the level specified for Preferred Plan providers if there is no local Blue Cross and/or Blue Shield participating provider network in a particular area. If there is no Preferred Plan provider network in an area, benefits will be provided for care received from a participating provider at the level specified for Preferred Plan providers. Call 1-800-810-BLUE (2583) for names of Preferred Plan or participating providers with the local Blue Cross and/or Blue Shield plan. When you need health care outside of the U.S. or its territories, call the BlueCard Worldwide Center at 1-800-810-BLUE or call collect at 1-804-673-1177. If you are admitted to a hospital while traveling outside the service area, you must contact the Company within 24 hours to receive full plan benefits. If you meet all requirements, inpatient benefits will be provided at the level specified for Preferred Plan providers for like services and supplies.

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 (Regence BlueShield) 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.