Silver 4500 Legacy LHP

77969OR5280015
Silver
EPO

Silver 4500 Legacy LHP is a Silver EPO plan by Regence BlueCross BlueShield of Oregon.

IMPORTANT: You are viewing the 2023 version of Silver 4500 Legacy LHP 77969OR5280015. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Silver 4500 Legacy LHP is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Silver 4500 Legacy LHP 77969OR5280015.
Insurer: Regence BlueCross BlueShield of Oregon
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 77969OR5280015

Cost-Sharing Overview

Silver 4500 Legacy LHP offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Silver 4500 Legacy LHP?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Silver 4500 Legacy LHP offers the following features and referral requirements.

Wellness Program: No
Disease Program:
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Silver 4500 Legacy LHP covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Silver 4500 Legacy LHP includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Prenatal and Postnatal Care
Covered
30.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
30.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$20.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$20.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$10.00 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Preferred Brand Drugs
Covered
30.00% Coinsurance after deductible 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Specialty Drugs
Covered
40.00% Coinsurance after deductible 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Outpatient Rehabilitation Services
Covered
30.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Combined limit of 30 visits for OT, ST, and PT. Visit limit does not apply to treatment of mental health conditions.
Habilitation Services
Covered
30.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions.
Chiropractic Care
Covered
$20.00 100.00%20 Visit(s) per Year
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 100.00% Hardware to correct visual defect due to severe medical or surgical problem such as stroke, neurological disease, trauma or eye surgery other than refractive procedures limited to one pair of glasses (frames and lenses) or contact lenses per calendar year.
Hearing Aids
Covered
30.00% Coinsurance after deductible 100.00% Hearing assistance coverage complies with state and federal law
Imaging (CT/PET Scans, MRIs)
Covered
30.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Covered
30.00% Coinsurance after deductible 100.00% Covered when medically necessary.
Acupuncture
Covered
$20.00 100.00%12 Visit(s) per Year
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year One pair of lenses and one frame per year (contacts in lieu of glasses)
Dental Check-Up for Children
Covered
0.00% 100.00%
Rehabilitative Speech Therapy
Covered
30.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
30.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
30.00% Coinsurance after deductible 100.00%
Primary Care Visit to Treat an Injury or Illness
Covered
$20.00 100.00%
Specialist Visit
Covered
$85.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$20.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
30.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
30.00% Coinsurance after deductible 100.00% Respite care – max of 5 consecutive days; lifetime max of 30 days
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$85.00 $85.00 Out of service area coverage is available
Home Health Care Services
Covered
30.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible Out of service area coverage is available
Emergency Transportation/Ambulance
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible Out of service area coverage is available
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
30.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Covered
30.00% Coinsurance after deductible 100.00% one attempt to correct a scar or defect that resulted from an accidental injury or treatment for an accidental injury or one attempt to correct a scar or defect on the head or neck that resulted from a surgery (more than one attempt is covered if medically necessary)
Skilled Nursing Facility
Covered
30.00% Coinsurance after deductible 100.00%60 Days per Year
X-rays and Diagnostic Imaging
Covered
30.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Covered
20.00% 100.00%
Orthodontia – Child
Covered
50.00% 100.00%
Major Dental Care – Child
Covered
50.00% 100.00%
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Covered
No Charge 100.00%
Transplant
Covered
30.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
30.00% Coinsurance after deductible 100.00%
Dialysis
Covered
30.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
30.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
30.00% Coinsurance after deductible 100.00%
Radiation
Covered
30.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
30.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
30.00% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
30.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
100.00% Information about gender affirming care can be found in plan documents.
Tier 1-Zero Cost-Share Preventive Drugs
Covered
$0.00 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Tier 2-Preferred Generic Drugs
Covered
$10.00 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Tier 3-Non-Preferred Generic Drugs
Covered
20.00% 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Tier 4-Preferred Brand Drugs
Covered
30.00% Coinsurance after deductible 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Tier 5-Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Tier 6-Preferred Specialty Drugs
Covered
40.00% Coinsurance after deductible 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Tier 7-Non-Preferred Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00% Insulin: $80 max out of pocket for 30 day supply prior to deductible
Telehealth-Primary Care Visit
Covered
$10.00 100.00%
Telehealth-Specialist Visit
Covered
$85.00 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver 4500 Legacy LHP preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Silver 4500 Legacy LHP including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Silver 4500 Legacy LHP?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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