|
|
BlueSelections Plus
|
| Lifetime benefit maximum |
$2 million per individual
|
| Deductibles |
-
$500 per person
-
$1,000 per person
-
$2,500 per person
-
$5,000 per person
|
-
$1,500 family
-
$3,000 family
-
$7,500 family
-
$15,000 family
|
Annual Maximum Coinsurance
(maximum of three coinsurance maximums per contract) |
In-Network:
$6,000
|
Out-Of-Network:
$10,000
|
| Preventative Care Services |
| Adult and Child Immunizations |
100% after $30 copay, not subject to the deductible
|
100% after $40 copay, not subject to the deductible
|
| Annual Women's Exams includes PAP smear and mammogram |
100% after $30 copay, not subject to the deductible
|
100% after $40 copay, not subject to the deductible
|
| Annual Men's Exams includes PSA test |
100% after $30 copay, not subject to the deductible
|
100% after $40 copay, not subject to the deductible
|
| Well-baby exam to age 2 |
100% after $30 copay, not subject to the deductible
|
100% after $40 copay, not subject to the deductible
|
| Well Child |
100% after $30 copay, not subject to the deductible
|
100% after $40 copay, not subject to the deductible
|
| |
| Dental Services |
Individual Dentacare (optional)
|
Office Visit
Physician services |
In-Network:
We pay 100% after $30 copay
not subject to deductible
|
Out-Of-Network:
We pay 100% after $40 copay
not subject to deductible
|
Hospitalizations
Hospital Facility
(Inpatient & Outpatient) |
In-Network:
We pay 70%
|
Out-Of-Network:
We pay 50%
|
| Emergency Room |
We pay 70% after $100 copay
|
| Laboratory and Radiology Services |
In-Network:
We pay 70%
|
Out-Of-Network:
We pay 50%
|
| Maternity |
In-Network:
We pay 70%
|
Out-Of-Network:
We pay 50%
|
Vision
Eye Exam (Refractions) |
IN-NETWORK:
We pay 100% after $30 copay. Limited to one eye exam (refraction) per
calendar year. Not subject to deductible.
|
OUT-OF-NETWORK:
We pay 50%. Limited to one eye exam (refraction) per calendar year. Not
subject to deductible.
|
| Hardware (Glasses, Lenses, Contacts) |
We pay 100%; Hardware limited to $150 per calendar year.
Not subject to deductible.
|
| Prescription Drugs |
Generic: We pay 100% after $10 copay
We pay 50% for all other charges,
$5,000 annual limit
Regence Rx discount available after limit is reached.
|
|
Additional Benefits
|
| Accidental death |
Provide $15,000 for you and your enrolled
adult spouse, $4,000 for each enrolled dependent or child subscriber |
| |