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(Available to Washington State Residents Only)
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SUMMARY OF BENEFITS
BREAKTHRU 80 PREFERRED PLAN
FOR INDIVIDUALS & FAMILIES
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For medically necessary services rendered by a Preferred Plan, participating, or recognized provider, the benefits of this plan will be provided at the percentage of the allowed amount as specified below after the deductible has been met. Unless otherwise specified, all benefits are subject to the annual deductible in addition to any copays and coinsurance.
When you have reached the annual out-of-pocket 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 rehabilitative care, vision hardware, and most participating provider services do not apply to the annual out-of-pocket coinsurance amount.
Deductible, coinsurance and copay represent WHAT YOU PAY.
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Benefits |
Preferred Plan
Provider |
Participating
Provider |
Annual Deductible
Copays, prescription drugs, preventive care and the routine eye exam do not count toward the deductible. Family deductible is met when three or more covered family members reach the equivalent of three individual deductible amounts in a calendar year
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$500 per individual/$1,500 per family
or
$1,500 per individual/$4,500 per family
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Lifetime maximum: |
$2,000,000 per individual
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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 |
$2,500 per person
$7,500 per family |
No out-of-pocket maximum |
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Professional Services |
(unless specified otherwise) |
Office, home, and outpatient hospital visits; not subject to deductible
Outpatient diagnostic x-ray and laboratory services; and other professional services; subject to deductible
Coverge includes the services of physicians, osteopaths, naturopaths, and other eligible health care professional providers
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$20 per-visit copay
20%
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$40 per-visit copay
50%
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Hospital Facility
(Inpatient & Outpatient)****
Including diagnostic x-ray and laboratory
$100 copay per emergency room visit (waived if admitted)
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20% |
50% |
Acupuncture
12 visits per calendar year maximum
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20% |
50% |
Ambulance Services**
Ground services: $2,000 per calendar year maximum
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20% |
20% |
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Blood Bank**
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20% |
20% |
Home Health and Hospice
Home health - 130 visits per calendar year maximum
Hospice - 6 months maximum
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20% |
20% |
Home Medical Equipment
$2,500 per calendar year maximum
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20% |
50% |
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Home Phototherapy
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20% |
20% |
Infusion Therapy
Growth hormone treatment is limited to $25,000 per calendar year
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20% |
50% |
Mammography
Routine mammograms not subject to deductible
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20% |
50% |
Maternity
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20% |
50% |
Mental Disorders
Inpatient - 8 days per calendar year
Outpatient - 12 visits per calendar year
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20% |
50% |
Occupational Injury
(provided for the subscriber only)
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Same as any other condition |
Phenylketonuria (PKU) Formulas
Not subject to waiting periods
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20% |
20% |
Prescription Drugs
$3,000 per calendar year maximum;
not subject to deductible
Generic Formulary
Brand-Name Formulary
Non-Formulary
more info
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$10 Retail copay
$20 Mail Order copay
30%
50%
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Preventive Care
$400 per calendar year maximum;
not subject to deductible
Routine exams, immunizations, well child care, routine cancer screenings including preventive surgeries, such as colonoscopies
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Covered in full |
50% |
Prostate Cancer Screening
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20% |
50% |
Prosthetics and Orthotics
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20% |
50% |
Rehabilitative Care
Inpatient -- $4,000 per calendar year maximum
Outpatient -- $2,000 per calendar year maximum
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20% |
50% |
Skilled Nursing Facility
30 days per calendar year maximum
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* |
20% |
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Special Equipment and Supplies
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20% |
20% |
Spinal Manipulations
10 visits per calendar year maximum
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20% |
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
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20% |
50% |
Vision Care (not subject to deductible)
One routine eye exam per calendar year
Vision hardware: $400 per calendar year maximum
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$20 copay
*** |
$40 copay
Covered in full |
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* At this time, this service is provided only by participating providers.
** At this time, these services are provided only by recognized providers.
*** At this time, this service is provided only by participating or recognized optical providers.
**** Services and supplies required to treat a medical emergency will be provided at the Preferred Plan payment level of benefits.
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 BlueCross 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.
Copay: 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 out-of-pocket coinsurance amount.
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. Benefits will be provided for care received from a recognized provider at the level specified for Preferred Plan providers if there is no local Blue Cross and/or Blue Shield participating provider network in a particular area. 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. 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 of 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 the Company within 24 hours to receive full plan benefits. If you meet all requirments, inpatient benefits will be provided at the level specified for Preferred Plan providers for like services and supplies.
Waiting Periods: No benefits are provided for treatment relating to a transplant until you have been covered under this or a prior plan with the Company (Regence Blue Shield) 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.
This is a brief summary of benefits; it is not a certificate of coverage. For full coverage provisions, including a description of waiting periods, limitations, and exclusions, refer to the plan contract.
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E-mail us for more information and a free quote or CALL TOLL FREE
1-800-875-4490 (in the U.S.)
or 1-253-854-0199 (outside the U.S.)
Fax: 1-253-896-9411
Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424
Serving all of Washington at 800-875-4490, Seattle at 206-682-1628,
Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291.
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