Your Regence Breakthru 50 Plan provides coverage
for services provided by In-Network and Out-Of-Network physicians and other
professional providers as listed below. Once enrolled, the Preferred Provider
Plan Network is the panel of providers for which you will receive the greatest
benefits. The Supplemental Provider Listing is the panel of providers for your
acupuncture and spinal manipulation benefit.
| |
Breakthru 50 Plan |
|
Lifetime maximum benefit |
$2,000,000 per individual |
| Calendar year deductible
options per individual |
$2,500 or $5,000 |
| Calendar year deductible
per family |
Maximum of 3 individual deductibles |
Benefit Features |
In-Network Provider Benefit |
Out-of-Network Provider Benefit |
| Maximum coinsurance per
individual per calendar year |
$10,000 |
None |
| Maximum coinsurance per
family per calendar year |
Maximum of 3 individual coinsurance maximums |
None |
| After the maximum coinsurance
is met each calendar year, we pay |
100% |
N/A |
| Please note: Covered
expenses paid at 100% and copays do not accumulate toward the deductible.
Covered expenses paid at 100%, copays, and deductibles do not apply to the
out-of-pocket maximum. |
| Professional Services |
After Deductible - We Pay |
| Office visits and other office
procedures |
50% |
50% |
| Diagnostic radiology and lab |
50% |
50% |
| Therapeutic injections including
allergy shots |
50% |
50% |
| Surgery |
50% |
50% |
| Hospital Services |
After Deductible - We Pay |
| Emergency room care for medical
emergency |
50% after $100 copay (copay waived if admitted) |
| Emergency room care for non-emergency |
50% after $100 copay |
50% after $100 copay |
| Inpatient hospital stay |
50% |
50% |
| Inpatient rehabilitation |
50% |
50% |
| Outpatient hospital services |
50% |
50% |
| Other Services |
After Deductible - We Pay |
| Ambulance |
50% |
| Rehabilitation including occupational,
speech, and physical therapy |
50% |
50% |
| Acupuncture and spinal manipulations |
50% |
50% |
| Skilled nursing facility,
home health, and hospice care |
50% |
50% |
| Durable medical equipment
and supplies |
50% |
50% |
|
Additional Benefits |
| Regence Rx Discount program |
Provides a discount program
for prescriptions. All you need to do is show your member ID card at any
participating pharmacy. |
| Special Beginnings® |
Provides a maternity program
designed to promote healthy prenatal care through education and support. |
| BlueCard® program |
Provides savings nationwide
by using Participating providers of the Blue Cross and/or Blue Shield Plan
in the area where you receive the service. Find a provider near you at www.bcbs.com. |
Asuris
NW Health
