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Blue SelectionsSM PPO - $2,500 Deductible

Oregon Health Plan

    • Office visits for a $20 copay, with no restrictions on providers.
    • No limits for prescriptions: a copay for generics and coverage for all other medications.
    • Vision care: $20 copay for an exam every 24 months. Includes glasses or contacts up to a specified amount.

Coverage at a Glance


Deductible:
Annual OOP Max: Not applicable on this plan
Lifetime Max: $2 million per member
Copay: $20
Coinsurance: 20% preferred providers, 40% non-preferred
Coinsurance Max: $4,000 preferred providers, $8,000 non-preferred (per member)
Network(s): Preferred Network

Find a Doctor
Yes Prescription benefits
Yes Dental
Yes Vision
Yes No Referrals
Yes Maternity
Yes Preventive Care
Yes Alternative Care
Yes Mental Health
 

Basic Features

Cost Sharing
Deductibles:
  • $2,500 per member
  • Family maximum of three individual deductibles
Annual OOP Max: Not applicable on this plan
Coinsurance Max:
  • You pay $0 after reaching $4,000 coinsurance maximum per member using preferred providers
  • You pay $0 after reaching $8,000 coinsurance maximum per member using non-preferred providers
  • Family coinsurance maximum of three individual maximums
Lifetime Max: $2 million paid by Regence per member
Copay: You pay $20 when using preferred or non-preferred providers
Coinsurance:
  • You pay 20% when using preferred providers
  • You pay 40% when using non-preferred providers
Everyday Needs
Prescriptions:
  • You pay 50% for all medications
  • Mail order not available
  • No deductible
  • No annual limits
Preventive Care:
  • You pay $20 copay
  • No deductible
  • Limited to women's exam, well-baby to age 2, and immunizations only
Vision:
  • One routine eye exam every 24 months
  • You pay $20 copay using preferred providers
  • You pay deductible and coinusrance using non-preferred providers
  • Limited to $85 on frames, $96 on lenses, and $181 on contacts
Office Visits:
  • You pay $20 copay using preferred or non-preferred providers
  • No deductible
Diagnostic x-ray services: Deductible and coinsurance
Outpatient Laboratory services: Deductible and coinsurance
Special Needs
Alternative care: Covered as any other condition
Maternity: Deductible and coinsurance
Mental Health:
  • Covered as any other condition
  • Inpatient: 30 days per calendar year
  • Outpatient: 7 outpatient visits per calendar year
Other considerations
Network(s): Preferred Providers
  • Preferred Provider Plan (PPP) Network (most medical services)
  • Participating (PAR) Vision Network (vision only)
  • Washington Supplemental Providers (alternative care only)

Non-Preferred Providers
  • Providers outside of the preferred network

Benefit Summary

Rates

Optional Benefits

Complete your health care plan with Dental coverage: Individual Dentacare
  • No deductibles, no annual maximums
  • $15 per visit copay for basic dental services
Learn more about Individual Dentacare »

Medical Exclusions and Limitations

Acupuncture Not limited
Alcoholism Limited to $4,500 in any 24-month period, 9-month waiting period
Ambulance $5,000 annual limit for non-emergencies, ground or air
Cosmetic/Reconstructive Surgery Not covered
Custodial Care and Rest Cures Not covered
Drug Abuse/Addiction Treatment Not covered
Durable Medical Equipment No annual limit
Family Planning Not covered
Growth Hormone Benefit Not covered
Hearing Aids Not covered
Home Health Care 180 days per calendar year
Maternity 9-month waiting period for labor & delivery
Mental Health Treatment Inpatient: 30 days per calendar year
Outpatient: 77 outpatient visits per calendar year
Obesity or Weight Control Not covered
Orthognathic Surgery Not covered
Rehabilitative Care (inpatient) 30 days per calendar year
Rehabilitative Care (outpatient) 30 sessions per calendar year
Skilled Nursing Facility 100 days per stay
Spinal Manipulation No annual limit
Temporomandibular Joint Disorder No annual limit
Transplants
  • $250,000 lifetime maximum
  • 12-month waiting period
Tobacco Addiction Treatment Not covered
Vision One exam every 24-months
You must be covered for at least 9 months before we pay for any of the following
Allergies Not covered
Ear Infections (otitis media) Not covered
Pre-existing conditions 9-month waiting period
Removal of Tonsils and Adenoids 9-month waiting period
Sterilization 9-month waiting period
This does not include all benefits, limitations, exclusions and other terms of coverage (such as eligibility and cancellation provisions) applicable to this plan. Please refer to your contract of a complete list and more in-depth explanation of benefits and the limitations and exclusions that apply.

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