Lifetime Maximum

$2,000,000

Annual Deductible

Refer to your benefits brochure for your specific deductible amount. Family deductible applies when the subscriber and one or more dependents are enrolled.

Annual Out-of-Pocket Amount

$5,000 Member/$10,000 Family. The total amount of coinsurance and deductible amount you or you and your family are responsible to pay during a calendar year for covered services, after which the plan will provide benefits at 100 percent of the allowed amount for the remainder of that calendar year, unless otherwise specified. Any balances of charges not covered by this plan will be you or you and your family’s responsibility to pay. The family out-of-pocket amount applies when the subscriber and one or more dependents are enrolled. Prior to benefits being paid for any family member at 100%, the entire family out-of-pocket maximum must be met.

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 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 (2583) or call collect at 1-804- 673-1177.

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 or maternity admissions.

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 six consecutive months. There is a preexisting condition waiting period that must be met prior to benefits being available. Refer to your benefits brochure for details regarding this waiting period. Maternity benefits and PKU benefits are not subject to the waiting periods of this 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 your benefits brochure and the contract on file with your group.

Your feedback is important to us. If you have suggestions about the benefits covered under this plan, you may contact us at 1-800-458-3523 or complete a Suggestion Box form.

The items listed below are identical to those in our Exclusions and Limitations (PDF).

The noncovered services and supplies under our standard medical plans include, but are not limited to:

• Acupuncture for smoking cessation
• Benefits covered by government programs
• Charges for services or supplies that are above the allowed amount, except as required by law for emergencies
• Charges that in the absence of the plan there would be no obligation to pay
• Cosmetic surgery and supplies (including drugs) and the treatment of any direct or indirect complications of such surgery, except: 1) when related to an illness or injury; 2) for congenital anomalies; 3) for reconstructive breast surgery following mastectomies to the extent required under federal and state law as follows: a) reconstruction of the diseased breast; b) reconstruction of the nondiseased breast to produce a symmetrical appearance; and c) prostheses and physical complications of all stages of a mastectomy, including lymphedemas
  
• Custodial care
  
• Dental services, except as provided under the Repair of Teeth and Hospitalization for Dental Services benefits
  
• Dyslexia treatment, except as required for Neurodevelopmental Therapy
  
• Eyeglasses and contact lenses and the fitting, except for the first intraocular lenses following cataract surgery (optional Vision Hardware benefit is available)
  
• Hearing aids
  
• Hospitalization for conditions for which the member is not usually hospitalized, such as common colds, minor cuts or bruises, removal of small tumors, and similar minor conditions
  
• Injuries sustained while practicing for or competing in a professional or semiprofessional athletics contest
  
• Investigational services or supplies
  
• In-vitro fertilization, artificial insemination, embryo transfer, or other artificial means of conception, including any expenses for fertility drugs
  
• Marital counseling; family counseling, except as specified in the Mental Disorders benefit
  
• Over-the-counter contraceptive supplies and devices
  
• Physical or psychiatric exams to obtain or continue employment, licensure, legal proceedings, insurance, school admission, sports activities, or for purposes of medical research
  
• Private duty nursing or hourly nursing charges
  
• Routine eye exams, except on Selections plans (Optional Vision Care benefit including exams available on Traditional and Preferred Plans)
  
• Services or supplies payable under Medicare, when by law Medicare is primary, regardless of whether the member had properly enrolled when first eligible
  
• Services or supplies covered by auto insurance, personal injury protection insurance, homeowner insurance, or commercial premises coverage
  
• Services or supplies not medically necessary* for illness, injury, or physical disability
  
• Services provided by a family member (spouse, parent, or child), the group, or any of the group’s employees or agents
  
• Surgery (including reversals), treatment, programs, or supplies that are intended to result in weight reduction, regardless of diagnosis
  
• Surgery or treatment for sexual dysfunction/impotence or transsexualism
  
• Treatment of any condition caused by or resulting from active participation in the armed forces in a war or insurrection.
  
• Treatment of any condition that the Secretary of Veterans Affairs determines to have been incurred in, or aggravated during, performance of service in the uniformed services of the United States.
  
• Visual analysis, therapy, training, or orthoptics
  
• Visits or consultations that are not in person, including but not limited to any telephone, Internet, or other electronic communication (except tele-medicine in remote locations, as approved by the Company), whether initiated by the member or the member’s provider

*Medically Necessary: Health care services or supplies that a physician or other health care provider exercising prudent clinical judgment, would provide to you for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that are: In accordance with generally accepted standards of medical practice; clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your illness, injury or disease; and not primarily for the convenience of you, or your physician or other health care provider, and not more costly than an alternative service or sequence of services, or supply at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your illness, injury or disease. For these purposes, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Physician Specialty Society recommendations and the views of Physicians practicing in relevant clinical areas and other relevant factors.