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 PREFERRED CATASTROPHIC PLAN 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, outpatient rehabilitation, smoking cessation, and most participating provider services do not apply to the annual out-of-pocket coinsurance amount. Deductible, coinsurance and copay represent WHAT YOU PAY. Benefits Preferred Plan Provider Participating Provider 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 amounts in a calendar year $3,500 per person $10,500 per family No out-of-pocket maximum Professional Services Including diagnostic x-ray and laboratory. Coverage includes the services of physicians, osteopaths, naturopaths, and other eligible health care professional providers 20% 50% (unless specified otherwise) Hospital Facility (Inpatient & Outpatient)*** Including diagnostic x-ray and laboratory $100 copay per emergency room visit (waived if admitted) 20% 50% Acupuncture 12 visits per calendar year maximum 20% 50% Ambulance Services** Ground services: $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% 20% Home Medical Equipment $2,500 per calendar year maximum 20% 50% Home Phototherapy 20% 20% Infusion Therapy Growth hormone treatment is limited to $25,000 per calendar year 20% 50% Mammography 20% 50% Mental Disorders Inpatient - 8 days per calendar year Outpatient - 12 visits per calendar year 20% 50% Phenylketonuria (PKU) Formulas Not subject to waiting periods Covered in full Covered in full Prostate Cancer Screening 20% 50% Prosthetics and Orthotics 20% 50% Rehabilition Inpatient - $4,000 per calendar year maximum Outpatient - $2,000 per calendar year maximum 20% 50% Skilled Nursing Facility 30 days per calendar year maximum * 20% Smoking Cessation $500 lifetime maximum 20% 20% Special Equipment and Supplies 20% 20% Spinal Manipulations 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% 50% * At this time, this service is provided only by participating providers. ** At this time, these services are provided only by recognized 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 Blue Cross and/or Blue Shield plan, except for emergency services. 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 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 requirements, 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 BlueShield) 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.