Medical-Option VII

Other Benefit Summaries:

MEDICAL DENTAL VISION LIFE/AD&D LTD VOL. STD VOL. ACCIDENT EAP SECTION 125

Option VII Regence K-12 BlueShield Low Option October 1, 2005 - September 30, 2006
Information provided is in summary format. Any difference between the summary provided and actual contract will be settled in favor of the contract.
	In-Network	Out-Of-Network
PPO Network	Regence BlueShield Preferred Providers	Participating Providers
Deductible	$500 Individual/$1,500 Family
Coinsurance*	80%	50%
Out-of-Pocket Max	$2,500 Individual/$7,500 Family**
Maximum Benefit	$2,000,000
Office Visits	$20 copay, then 80% after deductible	$20 copay, then 50% after deductible
Preventive Care - 1 exam per year - $500 max per year	$20 copay, then 80%	$20 copay, then 50%
Diagnostic Lab & X-rays	80% after deductible	50% after deductible
Ambulance	80% after deductible
Hospital Inpatient***	80% after deductible	50% after deductible
Emergency Room	$75 copay (waived if admitted)
Surgery:
Inpatient/Outpatient	80% after deductible	50% after deductible
Chiropractic - 10 visits/yr	$20 copay, then 80%	$20 copay, then 50%
Psychiatric:
Inpatient* -** 8 days/yr	80% after deductible	50% after deductible
Outpatient - 12 visits/yr	$20 copay; then 50% after deductible	$20 copay; then 50% of allowable charges
Chemical Dependency:	$12,500 maximum every two years
Inpatient***	80% after deductible	50% after deductible
Outpatient	80% after deductible	50% after deductible
Prescription Drugs - Retail (Participating Pharmacies)	Generic: $5 copay Brand Name: $20 copay Non-Formulary: $40 copay
RX Dosages - Retail	Up to 34-day supply
Mail Order Prescription Drugs	Generic: $10 copay Brand Name: $40 copay Non-Formulary: $80 copay
RX Dosages - Mail Order	Up to 90-day supply
Vision Care	Not covered

*Coinsurance percentage stated is paid on eligible and allowable charges.

**Your out-of-pocket amount does not include deductible or copays.

***Prior authorization is required for hospital admissions.