Regence BlueShield   Comprehensive Plans     Breakthru 80     Breakthru 70   Catastrophic Plans     Preferred Plan     Selections     Breakthru 50   HSA Plans     HSA Comprehensive     HSA HealthPlan   Plan Rates   Apply Now!   Provider Directory   Waiting Period     & Exclusions   FAQ's   LifeWise of WA   HSA Plans   Individual Dental   Group Medical   Group Dental   Grp Life & Disability   About the Plan   Premiums   Application   US Citizens   Foreign Nationals   Long Term		(Available to Washington State Residents Only) SUMMARY OF BENEFITS INDIVIDUAL SELECTIONS® CATASTROPHIC PLAN The benefits of this plan, for medically necessary services, will be provided at the percentage specified below, after the deductible and any applicable copays heve been met. Unless otherwise specified, all benefits are subject to the annual deductible in addition to any copays and coinsurance. The Selections network offers you the most complete coverage. To be eligible you must choose a Personal Care Provider (PCP) from our list of Selections providers, except for self-referral benefits specified in your contract. Your PCP will manage your care; however when you need more specialized care, your PCP will refer you to a Selections specialist or extended network provider. The extended network offers you the freedom to choose from many of the providers who participate with the Company (Regence BlueShield). You may use these providers without a referral if you are willing to pay a greater share of the cost. Deductible, coinsurance and copay represent WHAT YOU PAY. Benefits Selections® Network Extended Network Annual Deductible Copays 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 $1,750 per individual $5,250 per family 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 equivalent of three individual out-of-pocket coinsurance amount in a calendar year $3,500 per person $10,500 per family No out-of-pocket maximum Professional Services $15 professional copay in office, home, or hospital outpatient department. Coverage includes the services of physicians, osteopaths, naturopaths, and other eligible health care providers 20% 50% (unless specified otherwise) Hospital Facility (Inpatient & Outpatient)* Including diagnostic x-ray and laboratory $75 copay per emergency room visit (waived if admitted) 20% 50% Acupuncture $15 professional copay 12 visits per calendar year maximum 20% 50% Ambulance Services Ground services provided to $2,000 per calendar year maximum 20% 20% Blood Bank 20% 20% Home Health and Hospice Home Health - 130 visits per calendar year maximum Hospice - 6 months maximum 20% 50% Home Medical Equipment $5,000 per calendar year maximum 20% 50% Home Phototherapy 20% 50% Infusion Therapy Growth hormone treatment is limited to $25,000 per calendar year 20% 50% Mammography 20% 50% Mental Disorders Inpatient Outpatient 20% 8 days per calendar year 12 visits per calendar year 50% 6 days per calendar year 10 visits per calendar year Outpatient Rehabilitation $15 professional copay $1,500 per calendar year maximum 20% 50% Phenylketonuria (PKU) Formulas Not subject to waiting periods 20% 50% Prostate Cancer Screening 20% 50% Prosthetics and Orthotics 20% 50% Skilled Nursing Facility 30 days per calendar year maximum 20% 50% Smoking Cessation $500 lifetime maximum 20% 20% Special Equipment and Supplies 20% 20% Spinal Manipulations $15 professional copay 10 manipulations per calendar year maximum 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 20% see contract for criteria * Services and supplies required to treat a medical emergency, inside the service area, will be provided at the Selections network payment level of 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 directly admitted to the hospital as an inpatient). Copays do not apply toward the deductible or to the out-of-pocket coinsurance amount. Annual Out-of-Pocket Coinsurance Amount: Benefits will be provided at the percentage specified until the annual out-of-pocket Coinsurance (stoploss) maximum has been reached for the Selections network. When your eligible out-of-pocket coinsurance expenses for the Selections network have reached $3,500 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. Any balances of charges not covered by this plan will be your responsibility to pay. The annual deductible, copays, outpatient rehabilitation, and smoking cessation do not apply to the maximum stoploss amount. The maximum stoploss 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 our 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 the Company within 24 hours to receive full plan benefits. You must also agree to comply with the Company'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. When you need health care outside of the United States or its territories, call the BlueCard Worldwide Service Center at 1-800-810-BLUE(2583) 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 the Company for 12 consecutive months. No benefits will be provided for preexisting conditions 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. 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. Copyright© 1998-2008, Maddock & Associates  |  Privacy Statement Problems viewing this page? Contact the webmaster.