Regence Blue Shield

Gold Benefits
  PCY = per calendar year   Regence providers
  Plan Type Describes how you can use your plan PPO
  Schedule of Benefits Benefits, exclusions and definitions Click here to view
  Provider network Regence Search Providers
Locate Pharmacies
  Annual Deductible PCY (choose one)
Family = 2x individual (In-network only)
$1,000
  Coinsurance Amount you pay after your deductible is met 20%
  Out-of-pocket maximum Includes deductible, coinsurance & copays
Family = 2x individual (In-network only)
$3,300
  Office Visits PCP office visit 20% (deductible waived)
  10 Essential Benefits Covered Services  
1 Ambulatory Patient Services Outpatient Deductible, then 20%
Spinal manipulation (10 visits PCY);
Acupuncture (12 visits PCY)
Deductible, then 20%
2 Emergency Services Emergency Room - Copay waived if directly admitted to an inpatient facility $200 copay, then deductible, then 20%
Urgent care Deductible, then 20%
Ambulance Deductible, then 20%
3 Hospitalization Inpatient Deductible, then 20%
Organ and tissue transplants Deductible, then 20%
Hospice: unlimited. Respite care: 14 days lifetime Deductible, then 20%
4 Maternity & Newborn Care Prenatal, delivery, postnatal Deductible, then 20%
5 Mental Health & Substance Use Disorder Services, including Behavioral Health Treatment Office visit Deductible, then 20%
Inpatient hospital: mental/behavioral health Deductible, then 20%
Outpatient services Deductible, then 20%
6 Prescription Drugs Tier 1 (generic) $10 copay 3
Tier 2 (category 1 formulary brand) Deductible, then 30% 3
Tier 3 (category 2 formulary brand) Deductible, then 50% 3
Tier 4 (specialty) Deductible, then 50% 1
Tier 5 (self–administrable cancer chemotherapy drugs) $10 copay 2,4
Deductible, then 20% 2
7 Rehabilitative & Habilitative Services & Devices Therapy Inpatient rehabilitation: 30 days PCY Deductible, then 20%
Physical, speech, occupational, massage therapy: 25 visits PCY Deductible, then 20%
Durable medical equipment Deductible, then 20%
Skilled nursing facility: 60 days PCY Deductible, then 20%
8 Laboratory Services Includes X-ray, pathology, imaging/diagnostic, MRI, CT, PET Deductible, then 20%
9 Preventive/Wellness Services & Chronic Disease Management Screenings
Covered in full
Exams and immunizations Covered in full
10 Pediatric Services, including Oral & Vision Care
Under 19 years of age
Eye exam: 1 PCY Covered in full
Eyewear: 1 pair lenses/contacts and 1 pair frames PCY Covered in full
Dental: preventive/basic/major 0% / 20% / 50% (deductible waived)
  Optional Benefits Available  
i Adult Dental, Adult Vision and IAP
Covered for members age 19 and older

Adult Dental6

  • No deductible and 0% for Preventive care $50 deductible per calendar year for Basic and Major Care
  • 20% for Basic care
  • 50% for Major care
  • Adult dental waiting periods for enrollees with no prior coverage: 6 months for Basic Services and 12 months for Major Services.
  • $750 annual maximum (When services incurred are less than $750, an additional benefit of $250 may be rewarded the following year, not to exceed a total benefit of $1,500)

Adult Vision

  • No deductible
  • One routine exam, per calendar year no member responsibility
  • Lenses and frames: $150 limit per calendar year

Individual Assistance Program (IAP)

  • Eight sessions no member responsibility
  • Reliant Behavioral Health Network
 

Prescription benefit details:

  1. First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy.
  2. Must be provided at a specialty pharmacy.
  3. Benefit illustrated is for purchases at a retail pharmacy.
  4. Prescription for generic drugs
  5. Prescription formulary brand and specialty drugs.
  6. Adult dental waiting periods: 6 months for Basic Services and 12 months for Major Services.
  • Coverage is limited to a 30-day supply retail or 90-day supply mail order; and a 30-day supply retail / mail order for injectable medications.
  • Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy.
  • Deductible waived for generic drugs.
  • You are responsible for the difference in cost between a dispensed brand-name drug and the equivalent generic drug, in addition to the copayment and/or coinsurance.

Note: This is a benefit summary only. For a complete description of benefits, refer to your Policy.