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 Coinsurance Maximums |
$4,000 (for $1,000 deductible only) / $5,500 (for all other deductibles) coinsurance maximum |
$12,000 (for $1,000 deductible only) Family coinsurance maximum is three times the individual maximum for all other deductibles |
On Regence Evlove Core and Plus, this is the total amount you pay for coinsurance, in addition to the deductible, in a calendar year before the plan covers the full cost (100%)
of eligible expenses. |
| Annual Benefit Maximum |
$2,000,000 |
This is the highest dollar amount we will pay toward essential benefits in a calendar year. |
| 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 |
Other Professional Service
|
20% |
50% |
Deductible applies after upfront benefit limits are met. Office and inpatient services and supplies |
| Hospital Services/Ambulatory Surgical Center
|
20% |
50% |
Inpatient and outpatient services and supplies |
| Prescription Medication* |
$10 copay for generics
$500 deductible, 50% coinsurance for brand formulary only
$4,500 per year maximum for all drugs (including contraceptives). |
After you reach the annual limit, you can receive discounts off the full retail price of medications through the Regence Rx discount program. Just show your member ID card at your pharmacy. |
Preventive Care
(excludes complex imaging) No benefit limit |
0%; not subject to deductible |
50%; not subject to deductible |
Includes routine physical exams, lab and X-ray (includes PAP and PSA screening), and well-baby care. |
Immunizations
|
0%; not subject to deductible |
0%; not subject to deductible |
(adult and child) No benefit limit |
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). |
Complex Outpatient Imaging
|
50%; $1,500 per year maximum. |
50%; $1,500 per year maximum. |
(CT Scan, MRI, PET, MRA, SPECT, Bone Density) |
| Vision Care |
20%; Routine eye exam and hardware covered to a combined $150 per calendar year maximum; not subject to deductible or coinsurance maximum |
|
| Complementary Care |
20% limited to 8 visits per calendar year maximum;
not subject to deductible or coinsurance |
Complementary care includes naturopathic, chiropractic, and acupuncture services and supplies. |
| Ambulance Services |
20% |
20% |
Air and ground ambulance to nearest facility |
| Emergency Room Services |
$100 copay per ER visit
(waived if admitted), then 20% |
|
| Maternity Care |
20% |
50% |
|
| 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% |
Inpatient: 6 days per calendar yearOutpatient: 12 visits per calendar year |
| Neurodevelopmental Therapy |
20% |
50% |
For children age 17 and underInpatient and outpatient combined:$1,500 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 and Prostheses |
20% |
50% |
|
| 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% |
$250,000 life time maximum including donor cost |
| Alcoholism Treatment |
20% |
20% |
$4,500 every two calendar years maximum(inpatient and outpatient combined) |
| Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery |
50% |
50% |
$2,500 per lifetime maximum benefit |
| Hearing Aids and Evaluations |
20% |
50% |
(for dependents who meet criteria)$4,000 every four calendar years maximum |
| Tobacco Use Cessation Programs |
20% |
20% |
$500 lifetime maximum |
*Prescription Medication Coverage
|
$10 copay for generics
$500 deductible, 50% coinsurance for brand formulary only.
$4,500 per calendar year maximum for all drugs (including
contraceptives)
(On $1,000 deductible medical plan: $500 prescription medications deductible is waived and 50% coinsurance applies to brand formulary and non-formulary.)
Self administered chemotherapy drugs: self administered chemotherapy drugs will not accumulate to the Rx benefit maximum.
$10 generics, $50 brand formulary, $100 non-formulary.
Tobacco
Cessation prescription drugs: (Including generic/brand/non-formulary)
$500 lifetime maximum. Tobacco cessation drugs will not accumulate to RX benefit maximum. $10 copay for generics; 50% coinsurance
for brand formulary and non-formulary.
|
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 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 |
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