HSA Washington: Regence Blue Shield Evolve HSA 80/60/60

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Regence Evolve HSA 80/60/60 Benefits

The Regence Evolve HSA Plan is a simple way to pay for life’s medical expenses.It’s a health plan and a tax-free savings account all rolled into one.You get broad medical coverage, support and guidance from an HSA specialist plus rewards for healthy living. This plan offers optional dental packages.

Regence Evolve HSA Plan^SM 80/60/60
	Individual	Family	What you should know
Annual Deductible Deductible does not apply to certain benefits	$2,000 or $3,500	$4,000 or $7,000	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 out-of-pocket maximum	$5,000	$10,000	Once you reach this amount, Regence pays 100%
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 (Preferred)	Category 2 (Participating)	Category 3 (Non-contracted) (Member may be responsible for any provider costs above the Category 3 allowed amount)
Professional Services Deductible applies after upfront benefit limits are met. Office and inpatient services and supplies	20%	40%	40%
Hospital Services/Ambulatory Surgical Center Inpatient and outpatient services and supplies	20%	40%	40%
Complex Outpatient Imaging (CT Scan, MRI, PET, MRA, SPECT, Bone Density)	50%	50%	50%
Emergency Room Services	20%	20%	20%
Ambulance Services Air and ground ambulance to nearest facility	20%	20%	20%
Preventive Care and Immunizations Not subject to the deductible	0%	0%	40%
Genetic Testing $5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing). Deductible applies after upfront benefit limits are met	20%	40%	40%
Home Health 130 visits per calendar year	20%	40%	40%
Hospice Respite care limited to 14 days inpatient/outpatient per lifetime	20%	40%	40%
Mental Health Treatment	20%	40%	40%
Acupuncture Six visits per calendar year maximum benefit	20%	40%	40%
Spinal Manipulations 10 spinal manipulations per calendar year maximum benefit	20%	40%	40%
Durable Medical Equipment $2,500 per calendar year maximum benefit (limit does not apply to insulin pumps/supplies and lifesaving equipment such as oxygen and ventilators)	20%	40%	40%
Prostheses $2,500 per calendar year maximum benefit (this limit does not apply to surgically implanted and external breast prostheses)	20%	40%	40%
Rehabilitation Services Inpatient: $8,000 per calendar year maximum benefit Outpatient: $1,500 per calendar year maximum benefit	20%	40%	40%
Skilled Nursing Facility 30 inpatient days per calendar year	20%	40%	40%
Transplants $350,000 lifetime maximum benefit; includes donor costs	20%	40%	40%
Prescription Medications Generics only (including generic contraceptives and generic diabetic drugs and supplies); subject to medical deductible. Brand formulary diabetic drugs and supplies covered. 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.	20%	20%	20%
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 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 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
Additional Information
Preventive Care	Preventive services and immunizations are covered according to guidelines set forth by the United States Preventive Services Task Force (USPSTF), Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA). Standard plan benefits apply for any service that does not meet these guidelines.
Waiting Periods	No benefits are provided for treatment relating to a transplant until the member has been covered under this or a prior plan for 12 consecutive months. There is a nine month waiting period that must be met prior to benefits being available for pre-existing conditions. Members may receive credit from prior medical coverage. Pre-existing condition waiting periods do not apply to Members up to age 19.
Outside the Service Area	Members have the security of knowing they can access Blue Cross and/or Blue Shield (Blue Plan) providers across the country and worldwide through the BlueCard® Program. Plan benefits apply as described above, and members may receive discounts on their services.