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Selections®
Comprehensive Benefits
$500 or $1,000 Deductible
The
Selections® Comprehensive plan is available
with your choice of either a $500 or $1,000 deductible. This is the only
$500 deductible individual health plan offered by Regence BlueShield.
Selections® is a
POS
(Point of Service)
type of managed-care plan.
When you enroll, you must choose a
PCP who will
manage your medical care. This is sometimes referred to as a "gatekeeper"
arrangement. PCPs are usually family practice, general practice, internal
medicine, and pediatrics physicians. A different PCP can be chosen for
each member of your family. When you need medical care, you must first
contact and/or visit your PCP. As long as you do this, you'll receive the
highest benefits of the plan (80%). If the PCP cannot treat your condition
and refers you to a specialist within the
Selections®
network, you’ll still receive the highest benefits (80%). If you seek
treatment without first contacting and/or visiting your PCP, a
benefit will be paid at the “Extended Network” level (50%), except for an
emergency in which case the higher benefit will be paid.
The most important thing to remember about this plan is that you always
need to contact and/or visit your PCP first to receive the highest
“Selections® Network” benefit.
Click
here to find if your doctor or practitioner belongs to the "Selections®"
network. Be sure to check the box "Search for PCPs Only" when looking to
see if your family doctor is a
Selections® PCP.
The plan covers maternity, preventive care and
prescription drugs as specified below. However, vision care is not
a covered benefit.
Click here
for Important Information About This Benefit Summary.
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Selections® Comprehensive Plan
For medically necessary services rendered by your Selections network
Personal Care Provider (PCP) or an Extended Network provider, the benefits
of this plan will be provided at the percentage specified below after
the deductible and any applicable copays have been met. |
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Benefits |
Regence BlueShield
Selections® Comprehensive Plan |
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Selections Network |
Extended Network |
Annual Deductible (per calendar year)*
Copays, prescription drugs and preventive
care do not count toward the
deductible. Family deductible is met when three or more covered family
members incur the equivalent of three individual deductible amounts |
$500 per individual ($1,500 per family)
or
$1,000 per individual ($3,000 per family) |
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Lifetime Maximum |
$1,000,000 per individual |
Annual Out-of-Pocket Coinsurance Amount
Family out-of-pocket coinsurance amount
is met when three or more covered family members reach the "per
person" out-of-pocket coinsurance amount in a calendar year,
not including the
deductible |
$2,000 per person
$6,000 per family |
No out-of-pocket maximum |
Professional Services
Including diagnostic x-ray and laboratory. $15 professional copay* in
office, home or hospital outpatient department. Coverage includes the
services of physicians, osteopaths, naturopaths and other eligible
health care professional providers. |
80% (unless
specified otherwise) |
50% (unless
specified otherwise) |
Hospital Facility
(Inpatient & Outpatient)
Including diagnostic x-ray and laboratory. $75 copay per emergency
room visit (waived if admitted)* |
80% |
50% |
Acupuncture
$15
professional copay*
12
visits per calendar year maximum |
80% |
50% |
Ambulance Services
Ground
services provided to $2,000 per calendar year
Air ambulance must be approved by Regence BlueShield |
80% |
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Blood Bank |
80% |
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Benefits |
Regence BlueShield
Selections® Comprehensive Plan |
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Selections Network |
Extended Network |
Home Health and Hospice
Home
Health - 130 visits per calendar year maximum
Hospice - 6 months maximum |
80% |
50% |
Home Medical Equipment
$5,000 per calendar year maximum |
80% |
50% |
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Home Phototherapy |
80% |
50% |
Infusion Therapy
Growth
hormone treatment is limited to $25,000
per calendar year |
80% |
50% |
Mammography
Routine
mammograms not subject to deductible |
80% |
50% |
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Maternity |
80% |
50% |
Outpatient
Rehabilitation**
$15
professional copay*
$1,500 per calendar year maximum |
80% |
50% |
Prescription Drugs**
$2,000 per calendar year maximum; closed formulary; not subject to
deductible |
50% |
Preventive Care
$200 per calendar year maximum; not subject to deductible
Routine exams, immunizations, well child care, cancer screenings |
100% |
Not covered except
for mammograms at 50% |
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Prostheses and Orthotics |
80% |
50% |
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Benefits |
Regence BlueShield
Selections® Comprehensive Plan |
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Selections Network |
Extended Network |
Skilled Nursing Facility
30 days
per calendar year maximum |
80% |
50% |
Smoking Cessation**
$500
lifetime maximum |
80% |
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Special Equipment and Supplies |
80% |
Spinal Manipulations
$15
professional copay*
10
visits per calendar year maximum |
80% |
50% |
Transplants
$250,000
lifetime maximum; $50,000 per transplant donor organ procurement
maximum; $2,500 per transplant travel and lodging maximum;
12-month waiting period |
80% |
see contract |
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Vision Care - Eye Exam |
Not covered |
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Vision Care - Hardware |
Not covered |
*
Member copays do not apply to the out-of-pocket coinsurance amount.
** Benefits do not apply to the out-of-pocket coinsurance amount.
Selections Network Benefits: After the deductible has been met,
the Selections network benefits are provided when you choose a
Personal Care Provider (PCP) who will manage your care. When more
specialized care is necessary, your PCP will refer you to a Selections
specialist or extended network provider. A copay is required at the
time most outpatient services are received.
Extended Network Benefits: The extended network offers
you the freedom to choose from many of the providers who participate
with Regence BlueShield. You may use these providers without a
referral if you are willing to pay a greater share of the cost. As in
the Selections network, a deductible applies and you pay a copay at
the time you receive most outpatient services.
Self-Referral Care: You may self-refer to an approved
smoking cessation provider. You may also self-refer to an approved
chiropractor for covered chiropractic services and receive the
Selections network benefit level. A female subscriber or dependent may
refer herself for covered women's health care services to a Selections
provider including physicians, advanced registered nurse practitioners
in women's
health and midwifery, physician's assistants, or midwives and receive
the Selections network benefit level. A female subscriber or dependent
may also refer herself to the specified above Selections or extended
network providers for maternity benefits.
Copays: Each covered person will be required to pay a $15
copay for certain services such as outpatient professional services
performed in the office, home, hospital outpatient department, or
other facility, and a $75 copay for each visit to a hospital emergency
room for illness, injury, or surgery (waived if admitted directly to
the hospital as an inpatient).
Stoploss Limits: Benefits will be provided at the
percentage specified until the annual stoploss (out-of-pocket
coinsurance) amount maximum has been reached for the Selections
network. When your eligible out-of-pocket coinsurance expenses for the
Selections network have reached $2,000 per person per calendar year,
the payment level for most benefits within the Selections
network only will increase to 100% of the allowed amount for the
remainder of the calendar year. The maximum stoploss (out-of-pocket
coinsurance) amount per family is three times the individual stoploss
amount. There is no stoploss maximum on extended network benefits.
Emergency Care: Inside the service area, your plan will cover
treatment by a network or
non-network physician or hospital. You will receive the higher level
of benefits only if you notify us within 24 hours or as soon as is
reasonably possible, and you agree to follow our managed care
guidelines. Otherwise, you will receive the lower level of benefits.
Benefits will be based on the recognized provider's actual charge for
the service.
Care
Outside the Service Area:
You have the same coverage and
limitations for care outside the service area as you do within the
extended network. However, any benefit payable at 50% will be paid at
80%. Any additional charges will be your responsibility and you may
have to submit your own claims. If you live in the service area and
are admitted to a hospital while traveling outside the service area,
you must contact Regence BlueShield within 24 hours to receive full
plan benefits. You must also agree to comply with Regence BlueShield's
managed care guidelines, which may require you to move under the care
of a Selections provider in the service area as soon as feasible. If
you meet all requirements, inpatient benefits will be provided at the
Selections network level. Preadmission approval is required for all
inpatient admissions outside the service area if you seek care from
providers that have not contracted with a Blue Cross and/or Blue
Shield plan, except for emergency services or maternity admissions.
When you need health care outside the U.S. or its territories, call
the BlueCard Worldwide Service Center at 1-800-810-BLUE or call
collect at 1-804-673-1177.
Waiting Periods: No benefits are provided for treatment relating
to a transplant until you have been covered under this or a prior plan
with Regence BlueShield or Regence BlueShield's HMO subsidiary
(RegenceCare) for 12 consecutive months. No benefits will be provided
for preexisting conditions, including maternity, 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.
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Important
Information About This Benefit Summary |
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This
is a brief summary of benefits; it is not a contract or a certificate of
coverage. The complete terms of coverage are determined by the carrier's
contract. While we have accurately represented the information in this
Benefit Summary as of the time it was published, should any discrepancies
exist between this Benefit Summary and the carrier's contract, the carrier's
contract shall prevail. Please refer to the carrier's contract for a
complete statement of benefits including waiting periods, limitations and
exclusions.
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