Regence Evolve Plus SM |
| |
Individual |
Family |
What you should know |
Annual Deductible
(choose one; based on calendar year) |
$1,000, $2,500, $5,000, or $7,500 |
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 Maximums |
$5,500 coinsurance maximum |
Family coinsurance maximum is three times the individual maximum |
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 |
$2,000,000 per individual member |
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 With Preferred providers, you’ll generally have lower out-of-pocket costs.
Category 2 With Participating providers, you’ll generally pay more out of pocket than with providers
in Category 1.
Category 3 With Non-contracted providers, you’ll have the highest out-of-pocket costs and they may bill you for the balance over our payment of the claim. |
Category 1 |
Category 2 & 3 |
Upfront Office Visits
(Injury and Illness) |
$25 per visit for first four visits per person.
After four, then subject to deductible and coinsurance. |
Copay applies only to the office exam. All other services provided during the visit are subject to the applicable deductible and coinsurance |
| Prescription Medication |
Generics - $10 copay
Brand formulary - $500 deductible, 50% coinsurance |
$2,500 per calendar year maximum for all drugs (including contraceptives); RegenceRx discount available |
| Preventive Care |
30%; No deductible or age or annual limits |
50%; No deductible or age or annual limits |
Routine office visits including well-baby care and routine physical exams
Routine laboratory, radiology and diagnostic procedures including mammography and prostate screenings
Routine procedures including routine colonoscopies
Immunizations for adults and children |
Immunizations
|
0% coinsurance; no deductible |
0% coinsurance; no deductible |
(adult and child) No benefit limit |
Upfront Outpatient Radiology and Laboratory
|
First $400 per calendar year, not subject to deductible |
(limit does not apply to preventive care or complex outpatient imaging). |
| Vision Care |
20%; Routine eye exam and hardware covered to a combined $150 per calendar year maximum; not subject to deductible or coinsurance maximum |
Refraction and hardware |
| Emergency Room Services |
$150 copay per ER visit
(waived if admitted), then 20% |
|
Other Professional Service
|
20% |
50% |
Deductible applies after upfront benefit limits are met. Office and inpatient services and supplies |
Upfront Outpatient Radiology and Laboratory
|
0% for first $400 per year; then subject to deductible and coinsurance |
Limit does not apply to preventive care or complex outpatient imaging |
Other Outpatient Radiology and Laboratory
|
20% |
50% |
Deductible applies after upfront benefit limits are met |
Complex Outpatient Imaging
|
50%; $1,500 per year maximum. |
50%; $1,500 per year maximum. |
(CT Scan, MRI, PET, MRA, SPECT, Bone Density) |
| Hospital Services/Ambulatory Surgical Center
|
20% |
50% |
Inpatient and outpatient services and supplies |
| Maternity Care |
20% |
50% |
Separate $7,500 deductible per pregnancy |
| Ambulance Services |
20% |
20% |
Air and ground ambulance to nearest facility |
| Genetic Testing |
20% |
50% |
$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing) |
| Home Health |
20% |
50% |
130 visits per calendar year |
| Hospice |
20% |
50% |
Respite care limited to 14 days inpatient/outpatient per lifetime |
| Mental Health Treatment |
20% |
50% |
|
| Acupuncture |
20% |
50% |
Six visits per calendar year maximum benefit |
| Spinal Manipulations |
20% |
50% |
10 spinal manipulations per calendar year maximum benefit |
| Durable Medical Equipment |
20% |
50% |
$2,500 per calendar year maximum benefit (limit does not apply to insulin pumps/supplies and lifesaving equipment such as oxygen and ventilators) |
| Orthotics |
20% |
50% |
$500 per calendar year maximum benefit (limit does not apply to diabetic orthotics) |
| Prostheses |
20% |
50% |
$2,500 per calendar year maximum benefit (limit does not apply to surgically implanted and external breast prostheses) |
| Rehabilitation Services |
20% |
50% |
Inpatient: $8,000 per calendar year maximum benefit
Outpatient: $1,500 per calendar year maximum benefit |
| Skilled Nursing Facility |
20% |
50% |
30 inpatient days per calendar year |
| Transplant |
20% |
50% |
$350,000 life time maximum including donor cost |
| Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery |
50% |
50% |
$2,500 per lifetime maximum benefit |
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 Plus
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 |
Assurant Health
