Regence Evolve Core SM |
| |
Individual |
Family |
What you should know |
Annual Deductible
(choose one; based on calendar year) |
$2,500, $5,000, $7,500 or $10,000 |
Family deductible is three times the individual deductible |
Your deductible is the dollar amount you pay in a calendar year before the plan pays covered benefits. Not all benefits apply toward the deductible. Some benefits require a copay or other cost-sharing
amount. |
| Annual Coinsurance Maximum |
$7,500 |
Family coinsurance maximum is three times the individual maximum for all other deductibles |
Applies to all covered expenses except where noted.
When the coinsurance maximum is reached, this plan provides benefits at 100% of the allowed amount for the remainder of the calendar year. |
| Lifetime Maximum |
No Overall Lifetime Maximum |
This is the highest dollar amount we will pay toward all health care services during your lifetime under this plan. |
| Percentages and copays shown are what you pay for each covered event. The percentages shown are what you pay after you have met your deductible, unless otherwise noted. |
Provider Type |
Category 1
(Preferred) |
Category 2
(Participating) |
Category 3
(Non-contracted)
(Member may be responsible for any provider costs above the Category 3 allowed amount) |
Upfront Office Visits
(Injury and Illness)
First four per calendar year
Not subject to deductible |
$35 copay |
$35 copay |
$35 copay |
Upfront Outpatient Radiology and Laboratory
First $200 per calendar year. Not subject to deductible. |
$0 |
$0 |
$0 |
Other Professional Services
Deductible applies after upfront benefit limits are met. Office and inpatient services and supplies
|
30% |
50% |
50% |
Other Outpatient Radiology and Laboratory
Deductible applies after upfront benefit limits are met |
Complex Outpatient Imaging (CT Scan, MRI, PET, MRA, SPECT, Bone Density)
|
50% |
50% |
50% |
| Hospital Services/Ambulatory Surgical Center |
30% |
50% |
50% |
| Maternity Care |
Excluded |
Excluded |
Excluded |
Emergency Room Services
$100 copay per ER visit (waived if directly admitted) |
30% |
30% |
30% |
Ambulance Services
Air and ground ambulance to nearest facility |
Preventive Care and Immunizations
Not subject to the deductible |
0% |
0% |
Standard Category 3 Benefits Apply |
Genetic Testing
$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing). Deductible applies after upfront benefit limits are met |
30% |
50% |
50% |
Home Health
130 visits per calendar year |
30% |
50% |
50% |
Hospice
Respite care limited to 14 days inpatient/outpatient per lifetime |
30% |
50% |
50% |
| Mental Health Treatment |
30% |
50% |
50% |
Acupuncture
Six visits per calendar year maximum benefit |
30% |
50% |
50% |
Spinal Manipulations
10 spinal manipulations per calendar year maximum benefit |
30% |
50% |
50% |
Durable Medical Equipment
$2,500 per calendar year maximum benefit (limit does not apply to insulin pumps/supplies and lifesaving equipment such as oxygen and ventilators) |
30% |
50% |
50% |
Prostheses
$2,500 per calendar year maximum benefit (this limit does not apply to surgically implanted and external breast prostheses) |
30% |
50% |
50% |
Rehabilitation Services
Inpatient: $8,000 per calendar year maximum benefit
Outpatient: $1,500 per calendar year maximum benefit |
30% |
50% |
50% |
Skilled Nursing Facility
30 inpatient days per calendar year |
30% |
50% |
50% |
Transplants
$350,000 lifetime maximum benefit; includes donor costs |
30% |
50% |
50% |
*Prescription Medication Coverage
|
Rx discount program only
(includes generic & brand formulary drugs).
We cover certain preventive medications according to United States Preventive Services Task Force (USPSTF) guidelines at 100%, no deductible, no copay at participating pharmacies only. Member
must have a prescription.
|
Optional Benefits Available
(Optional benefits that are not elected are excluded from coverage) |
Dental Option I
Incentive Dental Plan
$750 per calendar year maximum benefit. When you incur services less than $500, your calendar year maximum may be increased by
$250 for the following year. |
Evolve Core
Member Responsibility |
What you should know |
No deductible and 0% for Preventive dental care
$50 deductible per calendar year for Basic and Major Care
20% for Basic care
50% for Major care |
Waiting Periods: 6 months for Basic Services and 12 months for Major Services. |
Dental Option II
Dollar-Based Dental Plan
$750 per calendar year maximum benefit (Preventive, Basic and Major services combined) |
No deductible
0% for the first $200 of covered services then 50% up to the annual maximum |
Waiting Periods: 6 months for all covered services |
Additional Information |
| Waiting Periods |
No benefits are provided for treatment relating to a transplant until the member has been covered under this or a prior plan for 12 consecutive months. There is
a nine month waiting period that must be met prior to benefits being available for pre-existing conditions. Members may receive credit from prior medical coverage. Pre-existing condition waiting
periods do not apply to Members up to age 19. |
| 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 above, and members may receive discounts on their services. |
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