Microsoft word - plan v-b ppp.doc

Your Preferred Provider Plan provides coverage for services provided by Preferred and Non-Preferred physicians and other professional providers as
listed below. For assistance in locating a Preferred Provider Plan Network physician or other professional provider please visit our Web site at
www.myregence.com.
Please note: This benefit summary provides a brief description of your health care plan benefits and is not a guarantee of payment. Please refer to
your benefits booklet for a complete list of benefits and the limitations and exclusions that apply.
Preferred
Non-Preferred
Benefit Features
Provider Benefit
Provider Benefit
Maximum family deductible per calendar year We pay a percentage of covered expenses up to this amount After $5,000 of covered expenses each calendar year, we pay Maximum amount you pay each calendar year per person including deductible Important note: Covered expenses paid at 100% and copayments do not accumulate toward your deductible or out-of-pocket maximum.
Copayments will continue to be collected after your out-of-pocket maximum has been met. If two family members have met the out-of-pocket
maximum, other enrolled family members need only meet any remaining family deductible to have covered expenses paid at 100% for the remainder
of the calendar year.
Preventive Care Services (see schedule on back)
Deductible Waived - We Pay
Annual women's exam including Pap and mammogram Routine physical exams including related lab and X-ray Routine immunizations age 19+ (deductible applies) Professional Services
After Deductible - We Pay
Office visits including mental health/chemical dependency Therapeutic injections including allergy shots Chiropractic care (12 visit allowance per calendar year) Hospital Services
After Deductible - We Pay
Inpatient stay including maternity, mental health, chemical dependency and Emergency room care (copay waived if admitted to hospital or other facility on an Other Services
After Deductible - We Pay
Rehabilitation including occupational, speech, and physical therapy Additional accident (deductible waived for 90 days from injury date) Pharmacy Purchased
Mail Order
Prescription Medications
(90-day supply)
(90-day supply)
Out-of-pocket maximum per person per calendar year Additional Benefits
Provides savings nationwide by using physicians and other professional providers of the Blue Cross and/or Blue Shield Plan in the area where you receive the service. Using providers outside of the Blue Cross and/or Blue Shield Plan may likely result in greater out of pocket expenses. Find a provider near you at
www.bcbs.com.
Limitations and Exclusions
This benefit summary provides a brief description of your health care plan benefits and is not a guarantee of payment. Please refer to your benefits booklet for a complete list of benefits and the limitations and exclusions that apply. Once enrolled, your benefits booklet can be viewed online at our Web site, www.or.regence.com.
Preventive Care Schedule*
These Pharmacy Benefits Are Not Covered
¾
Immunizations
Impotence, infertility, and experimental/investigational medications. Medications prescribed for cosmetic purposes (including, but not limited to Retin-A for anyone 26 years of age or over, Renova, Well-baby care
Lamisil, Sporanox, and topical minoxidil). Services And Supplies Not Covered
Women’s exam
Services provided by a member of the patient’s immediate family. Charges in excess of the amount allowed according to the terms of Services or supplies that are not medically necessary. Services related to or supporting infertility and reversal of Routine physical exam including related lab and X-ray
Custodial care, personal hygiene, and other forms of supervised Services and supplies provided for obesity or weight reduction, including complications arising from such treatment. *Not covered for travel or employment purposes Mental health treatment for conditions and diagnosis that describe Prostate and Colorectal Cancer Screening
relational problems, problems related to abuse or neglect or other issues that may be the focus of assessment or treatment. This Covered services include medically necessary prostate and colorectal would include, but is not limited to, such issues as occupational or cancer screenings. Please refer to your benefits booklet for how cancer Services and supplies (including medications) for or in connection These Pharmacy Benefits Are Limited
with sexual dysfunction regardless of cause, except for counseling The maximum quantity for pharmacy purchased medications is a 90- services provided by covered, licensed mental health practitioners. day supply. The maximum quantity for mail order purchased Treatment, surgery, or counseling services for sexual reassignment. medications is a 90-day supply. Some medications may be limited by Mental health treatment for paraphilia for all ages. quantity rather than day supply or may require preauthorization by the Developmental learning disabilities for age 18 and older. Compound medications are only covered when one ingredient is a complications arising from such services. federal legend or state restricted medication. Experimental and investigational treatment, procedures, equipment, These Benefits Are Limited
Residential care treatment for mental health conditions is limited to Treatment for addiction to tobacco, tobacco products, nicotine Mental health treatment for parent-child relational problems, neglect Appliances or equipment primarily for personal comfort or or abuse of child, and bereavement is limited to children five years convenience, and therapeutic devices including eyeglasses and hearing aids (except as specified in the benefits booklet). We provide transplant coverage only to those who have been covered by us, or another insurer with similar transplant coverage, Surgery to alter the refractive character of the eye. for a total of at least 24 months (or since birth), providing there is no Self-help training, instructional programs, and physical exercise lapse between the two coverages. Benefits are based on the programs (except where specifically listed). recipient’s eligibility, not the donor’s. Below are services not covered by this medical plan unless your Inpatient rehabilitation benefits are limited to 30 inpatient days per employer purchased them as part of your benefit package. Check calendar year. Benefits are increased to 60 days per calendar year for head and spinal cord injuries or stroke. Neurodevelopmental therapy is limited to children age 17 and under. Outpatient rehabilitation benefits are limited to 30 sessions per calendar year. Benefits are increased to 60 sessions per calendar year for head and spinal cord injuries or stroke. Neurodevelopmental therapy is limited to children age 17 and Skilled Nursing Facility care is limited to 100 days per stay. Home health care is limited to 180 visits per calendar year. Dental care is limited to the treatment of an accidental injury to natural teeth or a fractured jaw. Diagnosis must be made within 6 months and treatment within 12 months of the injury. Ground ambulance is limited to 500 miles per calendar year. Chiropractic care is limited to 12 visits per calendar year and to the treatment of musculoskeletal disorders only. TDD Line for people with hearing impairments 1 (800) 382-1003 www.myregence.com
Smoking Cessation: Oregon Quit Line 1 (877) 270-STOP www.cisbenefits.org

Source: http://www.occma.org/Portals/29/HR/Regence%20PPP.pdf