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Regence BlueShield - Online
Application
Index | Exclusions
& Limitations | Provider
Directory | Download Application
Benefit Schedules:
Selections® Cat | Preferred Cat | HSA
| HSA Comprehensive | Breakthru 50 | Breakthru
70 | Breakthru 80
Rate Schedules:
Selections® Cat | Preferred
Cat | HSA | HSA Comprehensive | Breakthru
50 | Breakthru 70 | Breakthru
80
Regence HSA Comprehensive Healthplan 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 as specified
below after the deductible has been met. Unless otherwise specified, all benefits
are subject to the annual deductible in addition to any coinsurance. When you
or you and your family have reached the annual out-of-pocket 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. Any balances of
charges not covered by this plan will be your responsibility to pay.
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HSA Comprehensive Healthplan |
Annual Deductible
Family deductible applies
when the subscriber and one or more dependents are enrolled. Prior to
benefits being paid for any family member, the entire family deductible
must be met. |
$1,500 single
$3,000 family |
| Lifetime maximum:
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$2,000,000 per individual |
| Benefits |
Preferred Plan Provider |
Participating Provider |
Annual Out-of-Pocket Coinsurance
Amount
The total amount
of coinsurance and deductible amount you or you and your family are responsible
to pay during a calendar year for covered services, after which the plan
will provide 100 percent of the allowed amount for the remainder of that
calendar year, unless otherwise specified. Any balances of charges not
covered by this plan will be you or your family’s responsibility
to pay. Family out-of-pocket amount applies when the subscriber and one
or more dependents are enrolled. Prior to benefits being paid at 100%
for any family member, the entire family out-of-pocket maximum must be
met. |
$5,000 member
$10,000 family |
No out-of-pocket maximum |
Professional Services
Including diagnostic x-ray
and laboratory. Coverage includes the services of physicians, osteopaths,
naturopathic providers, and other eligible health care professional providers |
80%
(unless specified otherwise) |
60%
(unless specified otherwise) |
Hospital Facility (Inpatient
& Outpatient)
Including diagnostic
x-ray and laboratory |
80% |
60% |
Acupuncture
12 visits per calendar
year maximum |
80% |
60% |
Ambulance Services**
Ground services:
$2,000 per calendar year maximum |
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% |
60% |
| Home Phototherapy |
80% |
80% |
Infusion Therapy
Growth hormone only treatment
is limited to $20,000 per calendar year |
80% |
60% |
Mammography
Routine mammograms not subject to deductible |
80% |
60% |
| Maternity |
80% |
80% |
Mental Disorders
Inpatient - 8 days per calendar year
Outpatient - 12 visits per calendar year |
80% |
60% |
| Newborn Care |
80% |
80% |
Occupational Injury (provided for the subscriber only)
Not subject to waiting
periods |
80% |
60% |
Phenylketonuria (PKU)
Formulas
Not subject to waiting
periods |
80% |
80% |
Prescription Drugs
$2,000 per calendar year maximum; closed formulary |
* |
50% |
Preventive Care
Not subject to deductible |
80% |
60% |
Prostate Cancer Screening
Routine prostate cancer screenings not subject to deductible |
80% |
60% |
| Prostheses and Orthotics |
80% |
60% |
Rehabilitation
Inpatient – $4,000 per calendar year maximum
Outpatient – $2,000 per calendar year maximum |
80% |
60% |
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% |
60% |
Transplants
$250,000 lifetime maximum; 12-month
waiting period |
80% |
60% |
*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 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.
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Asuris
NW Health