Asuris NW Health
| Individual | Family | What you should know | |
|---|---|---|---|
| Annual Deductible (choose one; based on calendar year) |
$5,000 | $10,000 no one family member is eligible for benefits until the entire family deductible is met. | 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 | $5,000 Out of pocket maximum | $10,000 Out of pocket maximum | For the Regence Evolve HSA Plans, the out of pocket maximum includes the deductible. |
| 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 (100% coverage) |
Category 2 & 3 (100% coverage) |
||
| Office Visits | 0% after deductible is met | 0% after deductible is met | 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 only; 0% after medical deductible is met. 0% after medical deductible is met for generics only except for brand medications required by law. Retail or Mail Order: Up to 90 day supply for covered prescription medications. | You continue to receive discounts off the full retail price of medications through the RegenceRx discount program. Just show your member card at your pharmacy. We cover certain preventive medications according to United States Preventive Services Task Force (USPSTF) guidelines at 100%, no deductible, no copay at participating pharmacies only. Member must have a prescription. | |
| Preventive Care and Immunizations (not subject to deductible) |
Category 1 and 2: 0% Category 3: Regular plan benefits and deductible apply | Covered according to federal preventive guidelines. | |
| Outpatient Radiology and Laboratory (limit does not apply to preventive care or complex outpatient imaging) |
0% after deductible is met | 0% after deductible is met | |
| Vision Care | Excluded | Excluded | |
| Spinal Manipulations | 0% after deductible is met | 0% after deductible is met | 10 spinal manipulations per calendar year |
| Acupuncture | 0% | 0% | 6 visits per calendar year |
| Ambulance | 0% after deductible is met | 0% after deductible is met | |
| Emergency Room | |||
| Complex Outpatient Imaging | |||
| Maternity Care | Excluded | Excluded | |
| Durable Medical Equipment | 0% after deductible is met | 0% after deductible is met | |
| Hospitalization | 0% after deductible is met | 0% after deductible is met | |
| Mental Health Treatment | 0% after deductible is met | 0% after deductible is met | |
Asuris NW Health
| Optional Benefits Available (Optional benefits that are not elected are excluded from coverage) |
|
|---|---|
| Asuris Emerge Dental Rewards Option 1 | |
| Deductible per calendar year | $50 per insured $150 per family (3 times the insured amount) |
| Maximum benefit per calendar year | $750 per insured |
| Important note: The dental deductible is calculated separately from any other deductible of the policy. | |
| Understanding your dental benefits | |
We will begin to pay benefits for covered services in any calendar year only after your deductible is satisfied unless otherwise specified. Once you have satisfied any applicable deductible, we pay a percentage of the allowed amount for covered services up to the maximum benefit. When our payment is less than 100%, you pay the remaining percentage. This is your coinsurance (insured responsibility). Under the policy, you have the opportunity to qualify for a reward increase and add certain unused portions of the maximum benefit for the current calendar year to the maximum benefit for the following calendar year. For more information please refer to the policy. We do not reimburse dentists for charges above the allowed amount. A participating dentist will not charge you for any balances for covered services beyond your deductible and/or coinsurance amount. Nonparticipating dentists, however, may bill you for any balances over our payment level in addition to any deductible and/or coinsurance amount. You can find a list of providers at our Web site or by calling Customer Service. |
|
| Covered dental services (per insured) | Insured responsibility |
Preventive dental services Complete intra-oral mouth X-rays: Once in a 3-year period Cleanings: 2 per calendar year (including periodontal maintenance) Oral examinations: 2 per calendar year Panoramic mouth X-rays: Once in a 3-year period Sealants (permanent bicuspids and molars only): Under 18 years of age Space maintainers: Under 12 years of age Topical fluoride application: Under 18 years of age, 2 treatments per calendar year |
0% deductible waived |
Basic dental services (six-month waiting period) Emergency treatment for pain relief Fillings consisting of composite and amalgam restorations General dental anesthesia Uncomplicated and complex oral surgery procedures Periodontal maintenance: 2 per calendar year (including prophylaxis) Periodontal debridement: Once in a 3-year period Periodontal scaling and root planing: Once per quadrant in a 2-year period |
20% |
Major dental services (12-month waiting period) Crowns, inlays and onlays: Except no benefits are provided for replacement made fewer than seven-years after placement Dentures (full and partial): Except no benefits are provided for replacement made fewer than seven-years after placement Implants (endosteal): 4 per insured lifetime |
50% |
| Asuris Emerge Dental Option 2 | |
| Deductible per calendar year | N/A |
| Maximum benefit per calendar | $750 per insured |
| Important note: You will not be eligible for any dental benefits until the first day of the seventh month of continuous coverage under the policy. | |
| Understanding your dental benefits | |
We pay a percentage of the allowed amount for covered services up to the maximum benefit. When our payment is less than 100%, you pay the remaining percentage. This is your coinsurance (insured responsibility). We do not reimburse dentists for charges above the allowed amount. A participating dentist will not charge you for any balances for covered services beyond your deductible and/or coinsurance amount. Nonparticipating dentists, however, may bill you for any balances over our payment level in addition to any deductible and/or coinsurance amount. You can find a list of providers at our Web site or by calling Customer Service. There are no age limits or frequency limits for Dental Option 2. |
|
| Covered dental services (per insured) | Insured responsibility |
Preventive, basic and major dental services |
0% |
Preventive, basic and major dental services |
50% |
