Your Regence Breakthru 70 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 Participating (PAR) Vision Network is the panel of providers
for your vision examination benefit and the Supplemental Provider Listing
is the panel of providers for your acupuncture and spinal manipulation benefit.
| |
Breakthru 70 Plan |
|
Lifetime maximum benefit |
$2,000,000 per individual |
| Calendar year deductible
options per individual |
$1,000 or $3,000 |
| 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 |
$5,000 |
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%, copays, prescription medications, preventive care,
and vision services do not accumulate toward the deductible. Covered expenses
paid at 100%, deductibles, copays, prescription medications, and vision
services do not apply to the coinsurance maximum. |
| Office Visits and Preventive
Care Services |
Deductible Waived - We Pay |
| Office visits |
100% after $30 copay |
100% after $40 copay |
| Immunizations all ages* |
70% |
50% |
| Well-baby exam to age 2* |
70% |
50% |
| Annual women's examination
including Pap test* |
70% |
50% |
| Mammograms that accompany
the annual women's exam |
70% |
50% |
| Adult and child routine physical
examinations* |
70% |
50% |
| *All preventive care services
including related laboratory tests, screening procedures, and X-rays are
limited to $200 per calendar year. |
| Other Professional Services |
After Deductible - We Pay |
| Office procedures |
70% |
50% |
| Diagnostic radiology
and lab |
70% |
50% |
| Therapeutic injections
including allergy shots |
70% |
50% |
| Surgery |
70% |
50% |
| Maternity care
including newborn care |
70% |
50% |
| Hospital Services |
After Deductible - We Pay |
| Emergency room care for medical
emergency |
70% after $100 copay (copay waived if admitted) |
| Emergency room care for non-emergency |
70% after $100 copay |
50% after $100 copay |
| Inpatient hospital stay |
70% |
50% |
| Inpatient rehabilitation |
70% |
50% |
| Outpatient hospital services |
70% |
50% |
| Other Services |
After Deductible - We Pay |
| Ambulance |
70% |
| Rehabilitation including occupational,
speech, and physical therapy |
70% |
50% |
| Acupuncture and spinal manipulations |
70% |
50% |
| Skilled nursing facility,
home health, and hospice care |
70% |
50% |
| Durable medical equipment
and supplies |
70% |
50% |
| Vision Services |
No Deductible - We Pay |
| Routine eye examination once
per calendar year |
100% after $30 copay |
50% |
| Vision hardware (includes
frames, lenses, and contact lenses) |
100% up to $150 calendar year maximum |
| Prescription Medications
- We Pay |
Generic |
Formulary |
Non-Formulary |
| Pharmacy purchased medications |
100% after $10 copay |
70% |
50% |
| Mail order purchased medications |
100% after $30 copay |
70% |
70% |
| Please note: There
is a separate $3,000 annual limit for all prescription medications however,
once this limit is reached, the Regence Rx Discount Program applies. Find
a Participating Pharmacy and the Preferred Medication List/Formulary at
www.regencerx.com. |
|
Additional Benefits |
| 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
