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