Regence BlueShield

Regence Evolve HSA 100 Plan Benefits
  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 Category 2 & 3
Office visits 0% 0% 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 & 2; 0% Category 3; 0% after deductible Covered according to federal preventive guidelines.
Outpatient Radiology and Laboratory
0% after deductible is met 0% after deductible is met (limit does not apply to preventive care or complex outpatient imaging).
Vision Care Excluded Excluded  
Spinal Manipulations 0% after deductible is met 0% after deductible is met 10 spinal manipulations per calendar year
Acupuncture 0% after deductible is met 0% after deductible is met 6 visits per calendar year
Ambulance 0% after deductible is met 0% after deductible is met  
Emergency Room 0% after deductible is met 0% after deductible is met  
Complex Outpatient Imaging
0% after deductible is met 0% after deductible is met (CT Scan, MRI, PET, MRA, SPECT, Bone Density)
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  
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 HSA 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
50% 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