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Breakthru Plan Benefits
Breakthru 70 and Breakthru 50
$1,000 to $5,000 Deductible
This
is a Preferred Provider (PPO) plan that does not require a
referral to see another doctor.
The Breakthru 70 plan covers prescription
drugs, maternity, preventive care and vision care expenses. The
Breakthru 50 plan does not cover these expenses.
Chances are excellent that your doctor is a Regence BlueShield PPO
plan provider.
Click
here to find out if your doctor belongs to the "Preferred"
network (in the "Plan:" drop-down box, choose "Preferred").
The percentages shown below are the amounts paid by Regence
BlueShield.
To download
and/or print a summary
of Breakthru benefits,
click on one of the
following plan names:
Breakthru 70 or
Breakthru 50. |
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|
Plan Name |
Breakthru
70 |
Breakthru
50 |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating Provider |
Preferred Plan Provider |
Participating
Provider |
Annual Deductible
Per
individual PCY; choose one of the deductibles shown;
the maximum deductible per family equals 3 times the individual
amount; the deductible applies to all expenses unless otherwise
specified |
$1,000
or
$3,000 |
$2,500
or
$5,000 |
|
Lifetime Maximum |
$2 million per individual |
Annual Coinsurance Maximum
Per
individual PCY;
the maximum coinsurance per family
equals 3 times the individual
amount; once the coinsurance is met,
Preferred Plan Providers are covered
in full |
$5,000 |
Unlimited |
$10,000 |
Unlimited |
Preventive Care
No deductible
Routine exams, immunizations, well child care, and routine cancer
screenings including preventive surgeries, such as colonoscopies |
$200 maximum benefit
per person
per calendar year |
Not covered |
|
70% |
50% |
|
Immunizations |
Included in
Preventive Care
shown above |
Not covered |
Office, Home & Outpatient Hospital Visits
No deductible
(Clarity 80 and 70 plans only;
deductible applies to Clarity 50 plan) |
100%
after $30
per-visit
copay |
100%
after $40
per-visit
copay |
50% |
|
Other Outpatient Professional Services & Inpatient Professional Care |
70% |
50% |
50% |
|
|
 |
|
Plan Name |
Breakthru
70 |
Breakthru 50 |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating Provider |
Preferred Plan Provider |
Participating
Provider |
Prescription Drugs***
No
deductible
$3,000
maximum benefit PCY; prescriptions limited to 34-day supply per prescription at a retail
pharmacy or 90-day supply by
mail order |
Generic
Formulary:
100% after $10 retail copay
100% after $20 mail order copay
Brand-Name Formulary: 70%
Non-Formulary: 50% |
Not covered |
Routine Vision Exam
No
deductible
One
exam PCY |
100%
after $30 copay |
100%
after $40 copay |
Not covered |
Vision Hardware
No
deductible
Frames,
lenses and contact lenses |
100%* to $200
maximum benefit
per person PCY |
Not covered |
|
Outpatient Diagnostic Imaging (X-Ray) & Lab Services |
70% |
50% |
50% |
Mammography
No deductible for
routine mammograms
(Clarity 80 and 70 plans only;
deductible applies to Clarity 50 plan) |
70% |
50% |
50% |
|
Cholesterol Screening |
Included in
Preventive Care
shown above |
Not covered |
|
Prostate Cancer Screening |
70% |
50% |
50% |
|
Facility Care (Hospital) Inpatient & Outpatient |
70% |
50% |
50% |
Skilled Nursing Facility
30 days maximum per
calendar year |
70%* |
50%* |
Emergency Room Care
$100 copay
per emergency room
visit; waived if directly admitted
to an inpatient facility (see the
Emergency Care
paragraph
shown toward the bottom of this page) |
70% |
50% |
50% |
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|
Plan Name |
Breakthru
70 |
Breakthru 50 |
|
PCY = per calendar year |
Preferred Plan Provider |
Participating Provider |
Preferred Plan Provider |
Participating
Provider |
Ambulance Services**
$2,000
maximum benefit
PCY for ground services |
70% |
50% |
Maternity Care
Including
prenatal care |
70% |
50% |
Not covered |
Spinal and Other Manipulations
10 visits
limit PCY |
70% |
50% |
50% |
Acupuncture Services
12 visits limit
PCY |
70% |
50% |
50% |
|
Naturopathic Services |
70% |
50% |
50% |
Home Medical Equipment
$2,500 maximum PCY |
70% |
50% |
50% |
|
Prostheses and Orthotics |
70% |
50% |
50% |
|
Special Equipment and Supplies |
70% |
50% |
Home Health Care
130 visits limit PCY |
70% |
50% |
Hospice Care
6-month benefit maximum |
70% |
50% |
Mental Disorders
Inpatient - 8 days limit PCY
Outpatient - 12 visits limit PCY |
70% |
50% |
50% |
Rehabilitation
Including physical,
occupational, speech and massage therapy
Maximum benefit PCY:
Inpatient - $4,000
Outpatient - $2,000 |
70% |
50% |
50% |
Transplants
12-month waiting period
$250,000 lifetime maximum;
$50,000 per transplant donor
organ procurement maximum; $2,500 per
transplant travel
and lodging maximum |
70% |
50% |
50% |
Occupational Injury
or Disease |
Covered as for any
other condition (limited to partners, proprietors or corporate
officers who are not covered by a Workers' Compensation Act or other
similar law) |
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Pre-Existing Conditions |
A pre-existing
condition is one for which there has been
diagnosis, treatment (including the use of prescribed drugs), or
medical advice within the six month period prior to the effective date
of coverage or a condition for which symptoms existed within the six
month period prior to the date of coverage and for which a prudent
person would have ordinarily sought treatment.
Pre-existing
conditions will not be
covered until a member has been continuously enrolled under this plan
for 9 (nine) months. In some cases, Regence BlueShield will apply
credit for pre-existing conditions if the person enrolling has been
covered by a prior group or individual health benefit plan that is
considered "creditable" coverage, at any time during the 63
(sixty-three) day period immediately preceding the receipt date of the
application. |
* At this time, this
service is provided only by participating providers.
** At this time, this service is provided only by recognized providers.
*** At this time, this service is provided only by participating or
recognized optical providers.
Copay: (applies to Breakthru 70 plan) There is a
per-visit copay for each office call/home visit billed as such by a
provider in the office, home, or hospital outpatient department (waived
for surgery, for radiation and chemotherapy, for spinal manipulations, or
if you are directly admitted to the hospital as an inpatient). Copays do
not apply toward the deductible or to the coinsurance
maximum.
Cost
Containment Provisions: All hospital and skilled nursing
facility admissions must be medically necessary. Preadmission approval
is required for all inpatient admissions outside the service area if
you seek care from providers who have not contracted with a Blue Cross
and/or Blue Shield plan, except for emergency services or maternity
admissions.
Emergency Care: Emergency benefits will be provided at
the level specified for a Preferred Plan provider. In the event of a
medical emergency, treatment by a provider not normally covered under
this plan will be recognized for a 24-hour period or for such
additional time as is reasonably required to come under the care of a
Preferred Plan provider. Benefits will be based on the recognized
provider's actual charge for the service.
Care Outside the Service Area:
All care received outside the
service area will be paid the same as in the service area if you use a
Preferred Plan or participating provider. Payment will be based on the
allowed amount. To receive the highest benefit level, you must receive
services from a Preferred Plan provider. If there is no Preferred Plan
provider network in an area, benefits will be provided for care received
from a participating provider at the level specified for Preferred Plan
providers. Benefits will be provided for
care received from a recognized provider at the level specified for
Preferred Plan providers only, if there is no local Blue Cross and/or Blue
Shield participating provider network in a particular area and for
medical emergencies. Call 1-800-810-BLUE (2583) for
names of Preferred Plan or participating providers with the local Blue
Cross and/or Blue Shield plan. When you need health care outside the
United States or its territories, call the BlueCard Worldwide Service Center at
1-800-810-BLUE or call collect at 1-804-673-1177. If you are admitted
to a hospital while traveling outside the service area, you must
contact Regence BlueShield within 24 hours to receive full plan
benefits. If you meet all requirements, inpatient benefits will be
provided at the level specified for Preferred Plan providers for like
services and supplies.
Annual Coinsurance Maximum: Benefits will be provided at the
percentages specified above until the annual coinsurance maximum has been
reached for the Preferred Plan network. When you have reached the
coinsurance maximum, this plan will provide benefits at 100% of the allowed amount for the
remainder of the calendar year for the services of Preferred Plan
providers only, unless otherwise specified. Any balances of charges not covered by
this plan will be your responsibility to pay.
The annual deductible, copays, prescription
drugs, outpatient rehabilitation, vision hardware, and most participating
provider services do not apply to the annual
coinsurance maximum.
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 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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