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(Available to Washington State Residents Only)
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SUMMARY OF BENEFITS
REGENCE EVOLVE HSA PLAN (50/50/50)
FOR INDIVIDUALS & FAMILIES
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Deductible, coinsurance and copay represent WHAT YOU PAY.
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Lifetime Maximum Benefit |
$2,000,000
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Calendar Year Deductible
Applies to all covered expenses except where noted
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Deductible per calendar year
$2,000 or $3,500 for single coverage
$4,000 or $7,000 for family coverage
Family coverage: no one family member is eligible for benefits until the entire family deductible is met.
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Calendar Year Out-of-Pocket Maximum
Out-of-pocket maximum amount per calendar year, including deducible, applies to all covered expenses.
When the out-of-pocket maximum is reached, this plan provides benefits at 100% of the allowed amount for the remainder fo the calendar year. |
Out-of-pocket maximum per calendar year
$5,000 for single coverage
$10,000 for family coverage
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Covered Services |
Category 1 Preferred |
Category 2 Participating |
Category 3 Non-contracted |
Member Responsibility
Coinsurance applies after deductible is met and until coinsurance maximum is reached. |
Professional Services
Office and inpatient services and supplies
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50%
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50%
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50%
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Hospital Services/Ambulatory Surgical Center
Inpatient and outpatient services and supplies
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50% |
50% |
50% |
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Complex Outpatient Imaging (CT Scan, MRI, PET, MRA, SPECT, Bone Density)
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50% |
50% |
50% |
Emergency Room Services
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50% |
50% |
50% |
Ambulance Services
Air and ground ambulance to the nearest facility
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50% |
50% |
50% |
Preventive Care (excludes complex imaging)
Not subject to the deductible, no benefit limit
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50% |
50% |
50% |
Immunizations - Adult and Childhood
Not subject to the deductible, no benefit limit
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50% |
50% |
50% |
Genetic Testing
$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing)
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50% |
50% |
50% |
Home Health
130 visits per calendar year
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50% |
50% |
50% |
Hospice
Respite care limited to 14 days inpatient/outpatient per lifetime
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50% |
50% |
50% |
Mental Health Treatment
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50% |
50% |
50% |
Acupuncture
Six visits per calendar year maximum benefit
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50% |
50% |
50% |
Spinal Manipulations
10 spinal manipulations per calendar year maximum benefit
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50% |
50% |
50% |
Durable Medical Equipment
$2,500 per calendar year maximum benefit (this limit does not apply to insulin pumps/supplies and lifesaving equipment such as oxygen and ventilators)
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50% |
50% |
50% |
Prostheses
$2,500 per calendar year maximum benefit (this limit does not apply to surgically implanted and external breast prostheses)
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50% |
50% |
50% |
Rehabilitation Services
Inpatient: $8,000 per calendar year maximum benefit
Outpatient: $1,500 per calendar year maximum benefit
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50% |
50% |
50% |
Skilled Nursing Facility
30 inpatient days per calendar year
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50% |
50% |
50% |
Transplants
$350,000 lifetime maximum benefit, includes donor costs
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50% |
50% |
50% |
Prescription Medication Coverage:
Generics only (including generic contraceptives and generic diabetic drugs and supplies); subject to medical deductible. Brand formulary diabetic drugs and supplies covered.
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50% |
50% |
50% |
Optional Benefits Available
(Optional benefits that are not elected are excluded from coverage) |
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Covered Services |
Evolve HSA
Member Responsibility |
Dental Option I
$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.
Waiting Periods: 6 months for Basic Services and 12 months for Major Services. |
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
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Dental Option II
Waiting Periods: 6 months for all covered services
$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
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| Additional Information |
Waiting Periods
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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.
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Outside the Service Area
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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.
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This is a brief summary of benefits; it is not a certificate of coverage. For full coverage provisions, including a description of waiting periods, limitations, and exclusions, refer to the plan contract.
Click here to review the General Medical Exclusions for this plan.
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E-mail us for more information and a free quote or CALL TOLL FREE
1-800-875-4490 (in the U.S.)
or 1-253-854-0199 (outside the U.S.)
Fax: 1-253-896-9411
Mailing address: Maddock & Associates, 1407 Willow Road E, Suite C, Tacoma, WA 98424
Serving all of Washington at 800-875-4490, Seattle at 206-682-1628,
Bellevue at 425-454-6834, Kent at 253-854-0199 and Tacoma at 253-572-3291.
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