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Blue SelectionsSM Premier - $5,000 Deductible

Oregon Health Plan | Blue Selections Premier - $5,000 deductible

    • Lowest copays for office visits, which are unlimited.
    • No limits for prescriptions: copay for generics and coverage for all other medications.
    • Deductible is waived for 90 days if you have an accidental injury.

Coverage at a Glance


Deductible:
Annual OOP Max: Not applicable on this plan
Lifetime Max: $2 million per member
Copay: $20-$40
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
No Alternative Care
Yes Mental Health
 

Basic Features

Cost Sharing
Deductibles:
  • $5,000 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 using preferred providers
Lifetime Max: $2 million paid by Regence per member
Copay:
  • You pay $20 when using preferred providers
  • You pay $40 when using non-preferred providers
Coinsurance:
  • You pay 20% when using preferred providers
  • You pay 40% when using non-preferred providers
Everyday Needs
Prescriptions:
  • $10 copay (no limits) for generic medications purchased at the pharmacy
  • You pay 50% for all medications
  • Mail order not available
  • No deductible
  • No annual limit
Preventive Care:
  • You pay $20 copay when using preferred providers
  • You pay $40 copay when using non-preferred providers
  • No deductible
  • Some limits may apply
Vision:
  • One routine eye exam per calendar year
  • You pay $20 copay when using preferred providers
  • You pay coinsurance when using non-preferred providers
  • You pay $0 up to $250 per calendar year on vision hardware
Office Visits:
  • You pay $20 copay when using preferred providers
  • You pay $40 copay when using non-preferred providers
  • No deductible
Diagnostic x-ray services: Deductible and coinsurance
Outpatient Laboratory services: Deductible and coinsurance
Special Needs
Alternative care: Not covered
Maternity: Deductible and coinsurance
Mental Health:
  • Inpatient: deductible and coinsurance, 30 day maximum
  • Outpatient: not covered
Other considerations
Network(s): Preferred Providers
  • Preferred Provider Plan (PPP) Network (most medical services)
  • Participating (PAR) Vision Network (vision only)

Non-Preferred Providers
  • Providers outside our Preferred network

Benefit Summary

Rates



Fourth quarter rates are effective 10/1/2009 through 12/31/2009.

First quarter rates are effective 1/1/2010 through 3/31/2009.

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 covered
Alcoholism Limited to $4,500 in any 24-month period
Ambulance Not liited
Cosmetic/Reconstructive Surgery Not covered
Custodial Care and Rest Cures Not covered
Dental Injury Not covered
Drug Abuse/Addiction Treatment Not covered
Durable Medical Equipment Not limited
Family Planning Not covered
Growth Hormone Benefit Must be preauthorized
Hearing Aids Not covered
Home Health Care 130 visits per calendar year
Mental Health Treatment Inpatient covered only, 30 day maximum per calendar year
Obesity or Weight Control Not covered
Orthognathic Surgery Not covered
Outpatient Counseling Not covered
Preventive Care
  • Well-Baby-Care up to 2 years
  • Well-Child one exam per calendar year
  • Adult Routine Physical one exam per calendar year
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 Not covered
Temporomandibular Joint Disorder $1,000 per calendar year
Transplants
  • $250,000 livetime maximum
  • 24-month waiting period
Tobacco Addiction Treatment Not covered
You must be covered for at least 12 months before we pay for any of the following
Allergies 12-month waiting period
Sterilization 12-month waiting period
Elective Procedures 12-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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