Your Regence HSA (Health Savings Account) Healthplan provides coverage for services provided by In-Network and Out-Of-Network
physicians and other professional providers as listed below. Once enrolled, the Participating Network is the panel of providers for
which you will receive the greatest benefits.
|
HSA Healthplan |
| Lifetime benefit maximum |
$2 million per individual |
| Benefit Features |
In-Network Benefit |
Out-Of-Network Benefit |
| Deductibles |
Single - $1,500, $2,500, $3,500
Family - $3,00, $5,000, $7,000 |
| Out-of-pocket maximum amount
per calendar year including deductible |
Single - $5,000
Family - $10,000 |
None |
| After your maximum coinsurance
is met each calendar year, we pay |
100% |
N/A |
Preventive Care Services
|
Deductible Waived - We Pay |
Immunizations for adults and children |
80% |
60% |
Well-baby exam and well child care
(including related lab & x-ray services) |
80% |
60% |
Annual women's exams including Pap tests & mammograms |
80% |
60% |
Adult routine physical exams including related lab & x-ray services |
80% |
60% |
| Professional Services |
After Deductible We Pay |
Office visits and other office procedures |
80% |
60% |
Therapeutic injections and allergy shots |
80% |
60% |
Maternity care |
80% |
60% |
Surgery |
80% |
60% |
Diagnostic radiology and lab |
80% |
60% |
| Hospital Services |
After Deductible We Pay |
Emergency room care for medical emergency |
80% |
Emergency room card for non-emergency |
80% |
60% |
Inpatient stay
(including surgery, rehabilitation and mental illness) |
80% |
60% |
Outpatient services
( including surgery, diagnostic radiology, and
lab) |
80% |
60% |
| Other Services |
After Deductible We Pay |
Ambulance |
80% |
Alcoholism treatment |
80% |
60% |
Outpatient Rehabilitation
(physical, speech, and occupational therapy) |
80% |
60% |
Skilled nursing facility, home health, and hospice care |
80% |
60% |
Durable medical equipment and supplies |
80% |
60% |
| Prescription Benefits |
After Deductible We Pay |
Pharmacy purchased prescription medications (30-day supply) |
50% |
Oral or self-administered prescription medications for chemotherapy |
80% |
Additional Benefits |
Accidental death |
Provides $25,000 for an adult enrollee and $5,000 for an enrollee under the age of 18. |
| BlueCard ® program |
Provides savings
nationwide. To receive the best benefit, please use BlueCard
PPO providers of the Blue Cross and/or Blue Shield Plan in the area where
you receive the service. Using providers outside of the Blue Cross and/or Blue Shield Plan may likely result in
greater out of pocket expenses. Find a provider near you at www.bcbs.com. |
| Please note: Single coverage deductible and out-of-pocket maximum applies when an individual is enrolled without dependents.
Family coverage deductible and out-of-pocket maximum applies when an individual and one or more dependents are enrolled.
Prior to benefits being paid, the entire family deductible must be met. |
Plan Updates 
