Regence Evolve HSA PlanSM 80/60/60 |
| |
Individual |
Family |
What you should know |
Annual Deductible
Deductible does not apply to certain benefits |
$2,000 or $3,500 |
$4,000 or $7,000 |
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 out-of-pocket maximum |
$5,000 |
$10,000 |
Once you reach this amount, Regence pays 100% |
| 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) |
Professional Services
Deductible applies after upfront benefit limits are met. Office and inpatient services and supplies
|
20% |
40% |
40% |
Hospital Services/Ambulatory Surgical Center
Inpatient and outpatient services and supplies |
20% |
40% |
40% |
Complex Outpatient Imaging (CT Scan, MRI, PET, MRA, SPECT, Bone Density)
|
50% |
50% |
50% |
| Emergency Room Services |
20% |
20% |
20% |
Ambulance Services
Air and ground ambulance to nearest facility |
Preventive Care and Immunizations
Not subject to the deductible |
0% |
0% |
40% |
Genetic Testing
$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing). Deductible applies after upfront benefit limits are met |
20% |
40% |
40% |
Home Health
130 visits per calendar year |
20% |
40% |
40% |
Hospice
Respite care limited to 14 days inpatient/outpatient per lifetime |
20% |
40% |
40% |
| Mental Health Treatment |
20% |
40% |
40% |
Acupuncture
Six visits per calendar year maximum benefit |
20% |
40% |
40% |
Spinal Manipulations
10 spinal manipulations per calendar year maximum benefit |
20% |
40% |
40% |
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) |
20% |
40% |
40% |
Prostheses
$2,500 per calendar year maximum benefit (this limit does not apply to surgically implanted and external breast prostheses) |
20% |
40% |
40% |
Rehabilitation Services
Inpatient: $8,000 per calendar year maximum benefit
Outpatient: $1,500 per calendar year maximum benefit |
20% |
40% |
40% |
Skilled Nursing Facility
30 inpatient days per calendar year |
20% |
40% |
40% |
Transplants
$350,000 lifetime maximum benefit; includes donor costs |
20% |
40% |
40% |
Prescription Medications
Generics only (including generic contraceptives and generic diabetic drugs and supplies); subject to medical deductible. Brand formulary diabetic drugs and supplies covered. 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. |
20% |
20% |
20% |
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 HSA Plan
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 |
| Preventive Care |
Preventive services and immunizations are covered according to guidelines set forth by the United States Preventive Services Task Force (USPSTF), Centers for Disease
Control and Prevention (CDC) and Health Resources and Services Administration (HRSA). Standard plan benefits apply for any service that does not meet these guidelines. |
| 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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