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Oregon Medical Insurance > Regence BlueCross BlueShield of Oregon > Blue Selections Premier Benefits

Providence Health Plans

 
BlueSelections Premier
Lifetime benefit maximum
$2 million per individual
Deductibles
  • $500 per person
  • $1,000 per person
  • $2,500 per person
  • $5,000 per person
  • $7,500 per person
  • $1,500 family
  • $3,000 family
  • $7,500 family
  • $15,000 family
  • $22,500 family
Annual Maximum Coinsurance
(maximum of three coinsurance maximums per contract)
In-Network:
$4,000
Out-Of-Network:
$8,000
Preventative Care Services
Adult and Child Immunizations
100% after $20 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 $20 copay, not subject to the deductible
100% after $40 copay, not subject to the deductible
Annual Men's Exams includes PSA test
100% after $20 copay, not subject to the deductible
100% after $40 copay, not subject to the deductible
Well-baby exam to age 2
100% after $20 copay, not subject to the deductible
100% after $40 copay, not subject to the deductible
Well Child
100% after $20 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 $20 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 80%
Out-Of-Network:
We pay 60%
Emergency Room
We pay 80% after $100 copay
Laboratory and Radiology Services
In-Network:
We pay 80%
Out-Of-Network:
We pay 60%
Maternity
In-Network:
We pay 80%
Out-Of-Network:
We pay 60%
Vision
Eye Exam (Refractions)
IN-NETWORK:
We pay 100% after $20 copay. Limited to one eye exam (refraction) per calendar year. Not subject to deductible.
OUT-OF-NETWORK:
We pay 60%. Limited to one eye exam (refraction) per calendar year. Not subject to deductible.
Hardware (Glasses, Lenses, Contacts)
We pay 100%; Hardware limited to $250 per calendar year. Not subject to deductible.
Prescription Drugs
Generic: We pay 100% after $10 copay
We pay 50% for all other charges,
No annual limit
Additional Benefits
Additional Accident Coverage Deductible waived for accidental injuries treated within 90 days of injury date
Accidental death Provide $25,000 for you and your enrolled adult spouse, $5,000 for each enrolled dependent or child subscriber
 

 
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