Regence Evolve HSA 100 PlanSM |
| |
Individual |
Family |
What you should know |
Annual Deductible
Deductible does not apply to certain benefits |
$5,000 |
$10,000 |
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 |
Annual out-of-pocket maximum includes all deductibles. After annual out-of pocket maximum is met, you pay 0% for all covered services; some limits apply. |
| Annual Benefit Maximum |
$2,000,000 |
This is the highest dollar amount we will pay toward essential benefits in a calendar year - per person. |
| 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 0% |
Category 2 & 3
You pay 0%
|
Professional Services
Office and inpatient services and supplies |
0% |
0% |
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 |
0% |
0% |
| Prescription Medication |
Generics only (including generic contraceptives and generic diabetic drugs and supplies); 0% after deductible is met. Self administered chemotherapy
(includes generic/ brand/non-formulary) |
$2,000 annual limit |
| Preventive Care |
0%; No deductible or age or annual limits |
0% |
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
|
0%; not subject to deductible |
0% |
(adult and child) No benefit limit |
Complex Outpatient Imaging
|
0% |
0% |
(CT Scan, MRI, PET, MRA, SPECT, Bone Density) |
| Vision Care |
Not covered |
Not covered |
|
| Emergency Room Services |
0% |
0% |
|
| Ambulance Services |
0% |
0% |
Air and ground ambulance to nearest facility |
| Maternity Care |
Not covered |
Not covered |
|
| Genetic Testing |
0% |
0% |
$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing) |
| Home Health |
0% |
0% |
130 visits per calendar year |
| Hospice |
0% |
0% |
Respite care limited to 14 days inpatient/outpatient per lifetime |
| Mental Health Treatment |
0% |
0% |
|
| Acupuncture |
0% |
0% |
Six visits per calendar year maximum benefit |
| Spinal Manipulations |
0% |
0% |
10 spinal manipulations per calendar year maximum benefit |
| Durable Medical Equipment |
0% |
0% |
$2,500 per calendar year maximum benefit (limit does not apply to insulin pumps/supplies and lifesaving equipment such as oxygen and ventilators) |
| Orthotics |
0% |
0% |
$500 per calendar year maximum benefit (limit does not apply to diabetic orthotics) |
| Rehabilitation Services |
0% |
0% |
Inpatient: 10 days per calendar year
Outpatient: 25 visits per calendar year |
| Skilled Nursing Facility |
0% |
0% |
30 inpatient days per calendar year |
| Transplant |
0% |
0% |
$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 
