• 15% - 25% lower premiums over comparable plans*
• Four office visits a year. Since most people visit the doctor fewer than four times a year, why pay for a plan that covers more? Each visit has an affordable $25 copay, or $40 for specialists.
• Personalized wellness programs encourage and reward the insured for reaching their health goals.
• Award-winning support tools. Employees will have 24/7 access to tools like myregence.com, where they can view claims, research treatments and medications, and find resources to improve their well-being.
• Broad network with 94% of providers across Idaho covered in our PPO network.
• Revive is a limited benefit plan that covers your employees' basic health needs and encourages their ongoing wellness.

* Pricing comparison versus an Innova benefit with the same deductible, in-network coinsurance percentage and maternity coverage.

Type of Plan:		Maternity No Referrals Office Visits Prescriptions Preventive Care Wellness Programs
Deductible:	$1000 - $5,000 individual
Annual Max:	$2,000,000
Coinsurance Max:	$2,500 / $3,500 individual
Copay:	$25 physician / $40 specialist
Coinsurance:	80% preferred providers / 50% non-preferred providers
Providers:	Preferred and Non-Preferred

Effective Date January 1, 2011 and Beyond

• Summary of Benefits for Groups of 2-99 (PDF)

Round out your medical coverage with a pharmacy benefit that best meets the needs of your group.

Package Options	Option 1	Option 2	Option 3
Deductible (does not apply to generics)	$0	$5000	Pharmacy coverage waived
Generic	$10 copay	$5 copay
Brand (formulary)	35% coinsurance	30% coinsurance
Brand (non-formulary)	50% coinsurance	50% coinsurance
Out-of-pocket maximum:	$5000	$3500
If an equivalent generic medication is available and a brand-name medication is chosen, the member is responsible for paying the applicable brand-name copay/coinsurance plus the difference in price between the equivalent generic medication and the brand-name medication not to exceed total retail cost.

Our health-focused plans come with comprehensive wellness resources. These programs are not insurance, but they are offered in addition to your medical plan to help your employees get information and support when they need it.

Integrated Care Management

Integrated Care Management provides specialized, targeted attention and support for employees who need assistance in managing their care. A Personal Care Team of clinical experts is ready to assist employees and their families with an ongoing medical condition, or serious illness or injury. The program provides easy access to one-on-one support focused on closing care gaps. Learn more about the program.

CareEnhance^®

A 24-hour nurse hotline staffed by registered nurses. CareEnhance is a great way for members to get medical questions answered without having to make an appointment with a doctor or visit an urgent care clinic. By explaining symptoms or concerns, members can get advice on what they can do on their own—or get a nurse’s opinion on whether they should see a doctor right away.

Regence Rare Disease Condition Management Program

The Regence Rare Disease Condition Management Program, in collaboration with Accordant®, is a valuable service that provides a personal health care support system to members with rare, complex, chronic conditions. Members who are affected by select conditions have 24/7 access to specially trained nurses who can answer questions and make recommendations for care.

This program is designed to meet unique health care needs and help coordinate care by working with you, your doctors and designated family members to obtain the best possible care in the most efficient manner.

Regence Advantages

Members-only discount program offers your employees savings from a number of nationally recognized, health-related companis. Learn more about Regence Advantages.

You can round out the benefits your employees will enjoy by adding optional plan benefits.

Vision

• 100% coverage for annual eye exam
• Vision Hardware - four hardware options available
• Not subject to deductible

Package Options	Option I	Option II	Option III	Option IV
Frames	$20	$25	$30	$25
Single Vision Lenses (ea.)	$12	$15	$18	$15
Bi-Focal Lenses (ea.)	$21	$26	$30	$26
Tri-Focal Lenses (ea.)	$27	$33	$40	$33
Lenticular	$52	$64	$68	$64
Contacts (Pair)	$65	$80	$95	$80

Dental Options

Three plans that offer something for everyone. Available as stand-alone, or paired with Revive.

• Dental Plan Information: Encore^SM, Expressions^SM & Radiance^SM

These exclusions apply to the medical plans only (including chemical dependency/mental health, complementary care, and vision) and do not apply to the wellness programs, dental options and EAP.

PREEXISTING CONDITION EXCLUSION

Exclusion Period for Preexisting Conditions: 12 months (credit may be given for prior qualifying previous coverage). Exclusion Period does not apply to Insureds enrolled prior to reaching nineteen (19) years of age.

Important note: Preexisting condition means a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six (6) month period immediately preceding the effective date of coverage.

Qualifying Previous Coverage means with respect to an individual, health benefits or coverage provided under any of the following: Group health benefit plan; Health insurance coverage without regard to whether the coverage is offered in the group market, individual market or otherwise; Medicare; Medicaid; medical and dental care for members and certain former members of the uniformed services and their dependents (?uniformed services? means the armed forces, the Commissioned Corps of the National Oceanic and Atmospheric Administration and the Public Health Service); a medical care program of the Indian Health Services or of a tribal organization; a state high-risk pool coverage; Federal Employees Health Benefits Program (FEHBP); a public health plan (a plan established or maintained by a state, a foreign country, the U.S. government, or other political subdivision of a state, the U.S. government or foreign country that provides health insurance coverage to individuals enrolled in the plan); or a health plan issued under the Peace Corps Act. A state Children?s Health Insurance Program (CHIP), is creditable coverage, whether it is a stand-alone separate program, a CHIP Medicaid expansion program, or a combination program, and whether it is provided through a group health plan, health insurance, or any other mechanism.

Outside the Service Area

Members have the security of knowing they can access Blue Cross and/or Blue Shield (Blue Plan) providers across the country and worldwide through the BlueCard® Program. Plan benefits apply as described in the Contract, and members may receive discounts on their services.

Exclusions

Benefits will not be provided in any of the following circumstances or for any of the following conditions under the terms of the policy. However, these exclusions shall not apply with regard to an otherwise Covered Service 1) an Injury, if the Injury results from an act of domestic violence or a medical condition (including physical and mental) and regardless of whether such condition was diagnosed before the Injury, as required by federal law; or 2) a preventive service as specified under the Preventive Care benefit of the policy.

• To the extent benefits are provided or covered by any governmental agency, except as otherwise provided by law.
• Expenses for services incurred as a result of any work related injury or illness, including any claims that are resolved pursuant to a disputed claim settlement for which the Insured has or had a right to compensation.
• Any injury or illness resulting from any act of war or from explosion of atomic or similar fissionable materials in war (declared or undeclared) or any illness or injury contracted or incurred during military service, including any complications or recurrences thereof, or national disaster.
• Any situation in which no specific medical treatment plan or psychiatric plan is furnished, including but not limited to rest cure, detoxification setup, custodial care, etc.
• Home infusion therapy.
• Hospital benefits when hospitalization is primarily for diagnostic studies or physical therapy when such procedures could have been done adequately and safely on an outpatient basis.
• Pregnancy tests unless provided by a physician and administered in the physician's office or in the hospital.
• Maternity and/or conditions due to pregnancy (including involuntary complications of pregnancy), unless benefits are provided by an endorsement to the policy.
• Maternity benefits (including involuntary complications of pregnancy) for dependent children.
• Adult immunizations required for travel abroad, including but not limited to cholera, plague, typhoid, typhus, and yellow fever when services are provided by a Non-Preferred Provider.
• Laetrile (amygdalin); acupuncture; chelation therapy (except for lead poisoning); homeopathic services; naturopathic services; thermography; massage therapy.
• Routine eye refraction; eye glasses; visual therapy or training.
• Radial keratotomy (refractive keratoplasty or other surgical procedures to correct refractive errors/astigmatism).
• Routine hearing examinations; hearing aids.
• Humidifiers; vaporizers; air conditioners; or any other air filtration or purification unit or system.
• Physical fitness or physical therapy equipment including, but not limited to, whirlpools, spas, hot tubs; weight lifting equipment; charges in or by health spas; weight reduction programs.
• Cosmetic and/or reconstructive services and supplies, including services and supplies related to a previous cosmetic procedure or complications of a previous cosmetic procedure, except as follows:
  • Related to breast reconstruction following a mastectomy to the extent required by law (refer to the Women's Health and Cancer Rights provision for additional information);
  • Due to a trauma, infection, or other disease of the involved part; or
  • Due to a congenital disease or anomaly for an insured dependent child.
  • For the purposes of this exclusion, cosmetic means a procedure that primarily improves or changes appearance and does not primarily restore an impaired function of the body.
• Investigative treatment as determined by Regence BSI.
• Benefits which are payable under any automobile medical, personal injury protection ("PIP"), automobile no-fault, underinsured or uninsured, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance is issued to or makes benefits available to the Insured, whether or not application is duly made therefore.
• Procedures related to sex transformations.
• Services and supplies for or in connection with: (1) infertility treatment, except to the extent covered services are required to diagnose such a condition, (2) reversal of sterilization; (3) surrogate pregnancy; (4) assisted reproductive technology (ART) procedures; and (5) fertility drugs and medications (Pergonal, etc.).
• Vasectomies (male sterilization) will be covered for physician services only.
• Treatment of sexual dysfunction or sexual inadequacy, including erectile dysfunction and impotence; and medications for impotency (Viagra, etc.).
• Outpatient rehabilitation services and supplies, including but not limited to physical, occupational, respiratory, or speech therapy.
• Outpatient cardiac and pulmonary rehabilitation therapies.
• Medical or surgical treatment for obesity and manifestations thereof, or for reversal or revisions of surgery for obesity.
• Benefits in connection with transplants, except as set forth in human organ and tissue transplants of the policy.
• Benefits in connection with harvesting and reinfusion of bone marrow for the treatment of any illness, except as set forth in the human organ and tissue transplants of the policy.
• Any services, chemotherapy, radiation therapy (or any therapy that damages the bone marrow), supplies, drugs, and aftercare for or related to bone marrow transplant, stem cell support or peripheral stem cell support procedures for a condition not set forth in the human organ and tissue transplants of the policy.
• Birth control devices and/or birth control prescription drugs, unless benefits are provided by an endorsement to the policy.
• Outpatient prescription drugs, unless benefits are provided by an endorsement to the policy.
• Prescription drugs and medicines for smoking cessation.
• Human Growth Hormone therapy.
• Services and supplies provided by a chiropractor.
• Services and supplies for the treatment of mental or neuropsychiatric conditions, chemical dependency, alcoholism and/or drug addiction. Prescription medications for the treatment of mental or neuropsychiatric conditions, chemical dependency, alcoholism and/or drug addiction, unless prescription drug benefits are provided by an endorsement to the policy.
• Services connected with nonemergency, nonmaternity hospital admissions on Fridays or Saturdays, unless surgery is performed the day of admission or the day following admission.
• Termination of pregnancy (elective abortion), except when performed to preserve the life of the enrolled female Insured.
• Services and supplies related to dentistry, temporomandibular joint (TMJ) disorders, dental implants, orthodontic treatment, oral surgery (except for the treatment of a jaw fracture), orthognathic conditions, or orthognathic surgery, whether necessary due to an accident, disease, deformity, or dental treatment.
• Orthodontic bracing for treatment of temporomandibular joint (TMJ) disorders.
• Charges for services and supplies: (1) for which an Insured is not required to make payment, (2) that are made only because benefits are available under the Policy, or (3) for which an insured would have no legal obligation to pay in the absence of this or any similar coverage
• Expenses for services furnished by a provider who is related to the Insured by blood or marriage or who resides in the Insured's household.
• Charges for telephone or internet consultations; missed appointments; claim form completion; interest charges; legal services; obtaining medical records; or provider travel and/or lodging expenses.
• Durable medical equipment, including but not limited to accessories and supplies used in conjunction with durable medical equipment, heating pads, contour chairs, therapeutic beds, hospital beds, setup and delivery of durable medical equipment, except as provided in the policy.
• Routine foot care (including removal of corns or calluses or trimming of nails); foot impression casting including x-rays incidental to casting; orthopedic shoes; arch supports and other supportive devices for the feet; and off-the-shelf shoe inserts.
• Orthotic devices, including but not limited to braces, splints, orthopedic appliances, and other orthotic supplies.
• Prosthetic devices, except for necessary prostheses following a mastectomy. See the prosthetic devices and Women's Health and Cancer Right sections of the policy.
• Convenience items such as telephones; television; guest trays or meals; personal hygiene items or services; or homemaker or housekeeping services, except by home health aides as ordered in a hospice treatment plan.
• Drugs and supplies not requiring a prescription order, including but not limited to aspirin, antacid, benzyl peroxide preparations, cosmetics, medicated soaps, food supplements, syringes, and bandages; Antabuse, Methadone, Minoxidil, or Rogaine hair preparations; experimental drugs including those labeled, "Caution-Limited by Federal Law to Investigational Use;" and prescription medications related to health care services which are not covered under the policy. Notwithstanding this exclusion, Regence BSI may choose to cover certain over-the-counter medications when prescription drug benefits are provided under the policy. Such approved over-the-counter medications must be identified by Regence BSI in writing and will specify the procedures for obtaining benefits for such approved over-the-counter medications. Please note that the fact a particular over-the-counter drug or medication is covered does not require Regence BSI to cover or otherwise pay or reimburse the Insured for any other over-the-counter drug or medication.
• Diet and weight monitoring, and educational services.
• Special foods or diets, vitamins, minerals, dietary and nutritional supplements, and nutritional therapy. See the Phenylketonuria Formulas section for PKU formulas benefits.
• Biofeedback.
• Wigs and artificial hair pieces.
• Any services, supplies, or charges which result from the treatment of any direct or indirect complication of any illness or condition for which coverage is not or was not provided.

Limitations

• Total benefits paid for office, home, and outpatient hospital visits, including second and third surgical consultative opinions shall be limited to a combined maximum of four (4) visits per Insured each calendar year for services provided by a preferred provider and non-preferred provider.
• Total benefits paid for Inpatient rehabilitation services shall be limited to a maximum of fifteen (15) days per Insured each calendar year.
• Total benefits paid for home health care visits shall be limited to a maximum of sixty (60) visits per Insured each calendar year.
• Total benefits paid for hospice care services shall be limited to a maximum of fourteen (14) days during an Insured's lifetime.
• Total benefits paid for extended care in a skilled nursing facility shall be limited to a maximum of thirty (30) days per Insured each calendar year.
• Claims submitted to Regence BSI more than twelve (12) months after the last day on which covered services were rendered shall be ineligible for payment, unless it can be shown to the satisfaction of Regence BSI that there was unusual and justifiable cause for such late submission.

Vision Exclusions

Benefits will not be provided in any of the following circumstances or for any of the following conditions under the terms of the policy:

• Routine examination required by an employer as a condition of employment.
• Any condition covered by Worker's Compensation or similar law.
• Sunglasses or safety glasses, either prescription or nonprescription.
• Services or supplies primarily for beautification, cosmetic, or aesthetic purposes.
• Special procedures such as orthoptics and visual training.
• Contact fittings.
• Lens service agreement.
• Scratch resistant coating.
• Tint or color coating.

 

This is a brief summary of benefits; it is not a certificate of coverage. All benefits must be medically necessary. For full coverage provisions, refer to the contract.

* Pricing comparison versus an Innova benefit with the same deductible, in-network coinsurance percentage and maternity coverage.

Revive-1-2011-Policy; Revive-SG-$1000-1-2011-BK; Revive-SG-$2000-1-2011-BK; Revive-SG-$3000-1-2011-BK; Revive-SG-$5000-1-2011-BK; Revive-51+-$1000-1-2011-BK; Revive-51+-$2000-1-2011-BK; Revive-51+-$3000-1-2011-BK; Revive-51+-$5000-1-2011-BK