Regence BlueCross BlueShield of Oregon

Regence Evolve Plus Plan Benefits for Clark County, Washington
	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 Coinsurance Maximums	$5,500 per member	$16,500 per family	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 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 20%)	Category 2 & 3 (You pay 50%)
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	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
Immunizations	0% coinsurance; no deductible	0% coinsurance; no deductible	(adult and child) No benefit limit
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	$100 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%	Diagnosis, prenatal care, labor and delivery
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: 10 days per calendar year Outpatient: 25 visits per calendar year
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
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 ($25 copy per visit) Vision exam and hardware each year $150 per calendar year maximum, covered before you meet your deductible. First $400 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 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