Plan Features Provider choice: Members have direct access to their choice of providers. Coinsurance levels are lowest for In- Network providers. If a member chooses an Out-of-Network provider, the member may be required to pay costs above the Out-of-Network allowed amount. Ambulatory Surgical Center: While many surgical procedures are best performed in a hospital setting, many can be safely and effectively performed in an Ambulatory Surgery Center (ASC) at a lower cost. A member may pay less outof-pocket if a surgical procedure is performed at an In-Network ASC. For more information, or a list of services that can be performed at an ASC, contact Regence customer service. Telehealth visits (conducted via phone, secure online video, mobile app or web) for primary care services are available from an In-Network provider, usually with lower out-of-pocket expense. Retail clinic visits are available, usually with lower out-of-pocket expense. Calendar Year Deductible to all covered expenses except where noted In-Network and Out-of-Network Deductible is combined Family deductible is two times the individual amount for the $5,000 deductible plan, otherwise family amounts are three times individual amounts. Individual In-Network deductible options per calendar year 20% and 30% Plans $250, $500, $750, $1,000, $1,500, $2,000, $3,000, $4,000, or $5,000 Calendar Year Out-of-Pocket Maximums to all covered expenses, including prescription medications, except where noted When the out-of-pocket maximum is reached, this plan provides benefits at 100% of the allowed amount for the remainder of the calendar year Family out-of-pocket maximum is two times the individual amount Deductible Option $250 $500 $750 $1,000 $1,500 $2,000 $3,000 $4,000, $5,000 Individual coverage out-of-pocket maximum $3,500, $4,500, or $7,150 $3,000, $4,000, $5,000, or $7,150 $3,000, $4,000, $5,000, or $7,150 $3,500, $4,500, $5,500, or $7,150 $4,000, $5,000, $6,000 or $7,150 $4,500, $5,500, or $7,150 $5,500 or $7,150 $7,150 Member Coinsurance Options In-Network: 20% / Out-of-Network: 40% In-Network: 30% / Out-of-Network: 50% Regence BlueShield 1
MEMBER RESPONSIBILITY Covered Services In-Network Out-of-Network Office Visits Copay Options: $20/$25/$30/$35 Professional Services/ Outpatient Radiology and Laboratory Office and inpatient services and supplies In-Network deductible waived Covered after copay Ambulatory Surgical Center 10% / 20% Hospital Services Inpatient and outpatient services and supplies Maternity Preventive Care and Immunizations In-Network not subject to deductible Emergency Room Services $100 copay per ER visit (waived if directly admitted) Rehabilitation Services Inpatient: 30 days per calendar year Outpatient: 25 visits per calendar year Acupuncture 12 visits per calendar year Spinal Manipulations 10 spinal manipulations per calendar year Home Health 130 visits per calendar year Hospice Respite care limited to 14 days inpatient/outpatient per lifetime Skilled Nursing Facility 60 inpatient days per calendar year Substance Use Disorder Services/Mental Health No benefit maximum Inpatient Outpatient Outpatient office / psychotherapy visits Other outpatient services 0% Out-of-Network Benefits Apply In-Network deductible, In-Network coinsurance and In-Network out-of-pocket maximum apply In-Network Copay (deductible waived) 0% Member may be responsible for any provider costs above the Out-of-Network allowed amount Regence BlueShield 2
Prescription Medication Coverage Prescription medication deductible options per calendar year: $0, $250, $500 Retail or Mail Order: Up to 90-day supply (one copay per 30-day supply) Specialty medications covered at participating retail pharmacies for first fill only. After first fill members use specialty pharmacies. Up to 30-day supply per fill. Deductible, copays and coinsurance apply to the out-of-pocket maximum Member may be balance billed when a nonparticipating pharmacy is used If an equivalent generic medication is available and a brand-name medication is chosen, the member is responsible for paying the applicable brand-name copay/coinsurance plus the difference in price between the equivalent generic medication and the brand-name medication not to exceed total retail cost Three Tier Option - Retail Generics: not subject to deductible $5 generic $25 preferred brand $50 brand Six Tier Option - Retail Preferred Generics: not subject to deductible $5 preferred generic / 25% generic $25 preferred brand / $50 brand $150 preferred specialty / 50% specialty $10 generic $35 preferred brand $75 brand $10 preferred generic / 25% generic $35 preferred brand / $75 brand $150 preferred specialty / 50% specialty $7 generic 25% preferred brand 50% brand $7 preferred generic / 25% generic 25% preferred brand / 50% preferred brand 25% preferred specialty / 50% specialty $10 generic 35% preferred brand 50% brand $10 preferred generic / 25% generic 35% preferred brand / 50% brand 40% preferred specialty / 50% specialty Regence BlueShield 3
MEMBER RESPONSIBILITY Optional Benefits Available With All Plans In-Network Out-of-Network Spinal Manipulations Option with no benefit maximum Pre-Deductible Spinal Manipulations 10 spinal manipulations per calendar year Not subject to deductible Vision One routine eye exam per calendar year Hardware: Maximum benefit per calendar year - $150 for VSP provider; $80 for VPSapproved wholesale vendor Not subject to deductible 0% 0% Separate Cost Share Accumulations In-Network In-Network Out-of-Network In-Network Deductible / Out-of-Pocket Maximum options $750 / $3,500 $1,000 / $4,000 $2,000 / $4,500 $3,000 / $5,000 Family deductible and family out-of-pocket maximum are two times the individual amount Out-of-Network Deductible / Out-of-Pocket Maximum: two times the In-Network amounts Member may be responsible for any provider costs above the Out-of-Network allowed amount Regence BlueShield 4
Optional Program Available With All Plans Employee Assistance Program (EAP) No cost to the member for: Up to four face-to-face sessions per incident to manage stress or work-life balance situations Legal and financial assistance 24/7 crisis line Additional Information Outside the Service Area Members have the security of knowing they can access Blue Cross and/or Blue Shield (Blue Plan) providers across the country through the BlueCard Program and worldwide through the BlueCross BlueShield Global Core Program. Plan benefits apply as described within this document, and members may receive discounts on their services. Regence BlueShield 5
General Medical Exclusions Coverage is not provided for any of the following, including direct complications or consequences that arise from: Cosmetic/Reconstructive Services and Supplies except for reconstruction for functional injury and disease, to treat a congenital anomaly, and for breast reconstruction following a medically necessary mastectomy to the extent required by law Counseling in the absence of illness is excluded unless required by law Custodial Care: Non-skilled care and helping with activities of daily living unless member is eligible for Palliative Care benefits Dental Examinations and Treatments Fees, Taxes, Interest: Charges for shipping and handling, postage, interest, or finance charges that a provider might bill; except sales taxes for durable medical equipment and mobility enhancing equipment Government Programs: Benefits that are covered, or would be covered in the absence of this plan, by any federal, state or governmental program Hearing Aids and Other Hearing Devices: Hearing aids (externally worn or surgically implanted) and other hearing devices are excluded. This exclusion does not apply to cochlear implants. Immunizations, if the Insured receives them only for purposes of travel, occupation, or residency in a foreign country Infertility: Except to the extent covered services are required to diagnose such condition, treatment of infertility, including, but not limited to surgery and fertility drugs and medications is excluded Investigational Services: Treatment or procedures (health interventions) and services, supplies and accommodations provided in connection with investigational treatments or procedures Military Service Related Conditions: The treatment of any condition caused by or arising out of a member's active participation in a war or insurrection or conditions incurred in or aggravated during performance in the Uniformed Services Motor Vehicle Coverage and Other Insurance Liability Non-Direct Patient Care including appointments scheduled and not kept, charges for preparing medical reports, itemized bills or claim forms, and visits or consultations that are not in person (except as specifically allowed under the telemedicine and telehealth medical benefits). Obesity or Weight Reduction/Control: Treatment, medications, surgeries (including revisions, reversals, and treatment of complications), programs or supplies intended to result in or relate to weight reduction, regardless of diagnosis, unless required by law Orthognathic Surgery except for congenital conditions, temporomandibular joint disorder, injury, and sleep apnea Personal Comfort Items: Appliances or equipment primarily for comfort, convenience, cosmetics, environmental control, education or general physical fitness (e.g. televisions, telephones, air conditioners, air filters, humidifiers, whirlpools, heat lamps, weight lifting equipment, physical fitness programs, and therapy or service animals, including the cost of training and maintenance.) Physical Exercise Programs and Equipment including hot tubs or membership fees at spas, health clubs, or other facilities; applies even if the program, equipment, or membership is recommended by the member s provider Private Duty Nursing including ongoing shift care in the home Riot, Rebellion and Illegal Acts: Services and supplies for treatment of an illness, injury or condition caused by a member s voluntary participation in a riot, armed invasion or aggression, insurrection or rebellion, sustained by a member while committing an illegal act Routine Foot Care Routine Hearing Exams Regence BlueShield 6
Self-Help, Self-Care, Training, or Instructional Programs including childbirth classes including infant care; and instruction programs, including those programs that teach a person how to use durable medical equipment or how to care for a family member Services and Supplies Provided by a Member of Member s Family Services and Supplies That Are Not Medically Necessary Services for Administrative or Qualification Purposes: Physical or mental examinations and associated services (such as laboratory or similar tests) primarily for administrative or qualification purposes Services to Alter Refractive Character of the Eye Sexual Dysfunction: Treatment of sexual dysfunction, regardless of cause, including but not limited to devices, implants, and surgical procedures, and medications except for covered mental health services Third-Party Liability: Services and supplies for treatment of illness or injury for which a third party is or may be responsible Travel and Transportation Expenses other than covered ambulance services Work-Related Conditions except for subscribers and their dependents who are owners, partners, or corporate officers and are exempt from state or federal workers' compensation law This is a brief summary of benefits; it is not a certificate of coverage. All benefits must be medically necessary. For full coverage provisions, refer to the contract. Regence BlueShield 7