Regence Evolve HSA PlanSM 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 |
$2,000,000 per individual member |
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 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
(You pay 20%) |
Category 2 & 3
(You pay 40%)
|
Professional Services
Office and inpatient services and supplies |
20% |
40% |
Coinsurance applies after deductible is met and until out-of-pocket maximum is reached. |
Hospital Services/Ambulatory Surgical Center
Inpatient and outpatient services and supplies |
20% |
40% |
| Prescription Medication |
Generics only (including generic contraceptives and generic diabetic drugs and supplies); 20% after deductible is met. Self administered chemotherapy
(includes generic/ brand/non-formulary) |
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 |
20%; No deductible or age or annual limits |
40%; No deductible or age or annual limits |
Routine office visits including well-baby care and routine physical exams
Routine laboratory, radiology and diagnostic procedures including mammography and prostate screenings
Routine procedures including routine colonoscopies
Immunizations for adults and children |
Immunizations
|
20%; not subject to deductible |
40%; not subject to deductible |
(adult and child) No benefit limit |
Complex Outpatient Imaging
|
50% |
50% |
(CT Scan, MRI, PET, MRA, SPECT, Bone Density) |
| Vision Care |
Not covered |
Not covered |
|
| Emergency Room Services |
20% |
20% |
|
| Ambulance Services |
20% |
20% |
Air and ground ambulance to nearest facility |
| Maternity Care |
Not covered |
Not covered |
|
| Genetic Testing |
20% |
40% |
$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing) |
| Home Health |
20% |
40% |
130 visits per calendar year |
| Hospice |
20% |
40% |
Respite care limited to 14 days inpatient/outpatient per lifetime |
| Mental Health Treatment |
20% |
40% |
|
| Acupuncture |
20% |
40% |
Six visits per calendar year maximum benefit |
| Spinal Manipulations |
20% |
40% |
10 spinal manipulations per calendar year maximum benefit |
| Durable Medical Equipment |
20% |
40% |
$2,500 per calendar year maximum benefit (limit does not apply to insulin pumps/supplies and lifesaving equipment such as oxygen and ventilators) |
| Orthotics |
20% |
40% |
$500 per calendar year maximum benefit (limit does not apply to diabetic orthotics) |
| Rehabilitation Services |
20% |
40% |
Inpatient: $8,000 per calendar year maximum benefit
Outpatient: $1,500 per calendar year maximum benefit |
| Skilled Nursing Facility |
20% |
40% |
30 inpatient days per calendar year |
| Transplant |
20% |
40% |
$350,000 life time maximum including donor cost |
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 |
Asuris NW Health 
