Regence BlueCross BlueShield of Oregon

Regence Evolve Core Plan Benefits for Clark County, Washington
	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	$22,500	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.
Annual Benefit Maximum	$2,000,000		This is the highest dollar amount we will pay toward essential benefits in a calendar year - per person.
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 (You pay 30%)	Category 2 & 3 (You pay 50%)
Upfront Office Visits (Injury and Illness)	$35 per visit for first four visits per calendar year. Not subject to deductible		Copay applies only to the office exam. All other services provided during the visit are subject to the applicable deductible and coinsurance
Prescription Medication	RegenceRx discount program available for both generic and brand formulary drugs
Preventive Care	0%; 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
Upfront Outpatient Radiology and Laboratory	First $200 per calendar year, not subject to deductible		(limit does not apply to preventive care or complex outpatient imaging).
Other Professional Service	30%	50%	Deductible applies after upfront benefit limits are met. Office and inpatient services and supplies
Other Outpatient Radiology and Laboratory	30%	50%	Deductible applies after upfront benefit limits are met
Vision Care	Not covered	Not covered
Emergency Room Services	30% coinsurance and deductible; $150 copay per ER visit (waived if directly admitted)
Hospital Services/Ambulatory Surgical Center	30%	50%	Inpatient and outpatient services and supplies
Immunizations	0%; not subject to deductible	50%; not subject to deductible	(adult and child) No benefit limit
Complex Outpatient Imaging	50%	50%.	(CT Scan, MRI, PET, MRA, SPECT, Bone Density) $1,500 per calendar year maximum.
Ambulance Services	30%	30%	Air and ground ambulance to nearest facility
Maternity Care	Not covered		Diagnosis, prenatal care, labor and delivery
Genetic Testing	30%	50%	$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing)
Home Health	30%	50%	130 visits per calendar year
Hospice	30%	50%	Respite care limited to 14 days inpatient/outpatient per lifetime
Mental Health Treatment	30%	50%
Acupuncture	30%	50%	Six visits per calendar year maximum benefit
Spinal Manipulations	30%	50%	10 spinal manipulations per calendar year maximum benefit
Durable Medical Equipment	30%	50%	$2,500 per calendar year maximum benefit (limit does not apply to insulin pumps/supplies and lifesaving equipment such as oxygen and ventilators)
Prostheses	30%	50%	$2,500 per calendar year maximum benefit (limit does not apply to surgically implanted and external breast prostheses)
Rehabilitation Services	30%	50%	Inpatient: 10 days per calendar year Outpatient: 25 visits per calendar year
Skilled Nursing Facility	30%	50%	30 inpatient days per calendar year
Transplant	30%	50%	$350,000 life time maximum including donor cost
Preventive care (yearly physical, Pap, PSA, etc.) covered before you meet your deductible Four upfront office visits per member per year covered before you meet your deductible ($35 copay per visit) First $200 per member per year outpatient X-ray and lab services covered at 100% per year before you meet your deductible Optional dental benefits available!
Optional Dental Benefits Available (Optional benefits that are not elected are excluded from coverage)
Dental Rewards Option 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