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Oregon Medical Insurance > Regence BlueCross BlueShield of Oregon > Evolve HSA 80/60/60 Benefits


Regence Evolve HSA PlanSM 80/60/60
 
Individual
Family
 What you should know
Annual Deductible
(choose one; based on calendar year)
$1,500 or $3,500
$3,000 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 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
(80% coverage)
Category 2 & 3
(60% coverage)
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); Tobacco Cessation prescription drugs (includes generic/brand/nonformulary) $500 lifetime maximum.
 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
(excludes complex imaging) No benefit limit
0%; not subject to deductible
40%; not subject to deductible
 Includes routine physical exams, lab and X-ray (includes PAP and PSA screening), and well-baby care.
Immunizations
0%; not subject to deductible
40%; not subject to deductible
 (adult and child) No benefit limit
Upfront Outpatient Radiology and Laboratory
20%
40%
 (limit does not apply to preventive care or complex outpatient imaging).
Complex Outpatient Imaging
50%
50%
 (CT Scan, MRI, PET, MRA, SPECT, Bone Density)
Vision Care
Excluded
Excluded
  
Complementary Care
Excluded
Excluded
 Complementary care includes naturopathic, chiropractic, and acupuncture services and supplies.
Ambulance Services
20%
40%
 Air and ground ambulance to nearest facility
Emergency Room Services
20%
40%
  
Maternity Care
20%
40%
  
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%
 Inpatient: 6 days per calendar yearOutpatient: 12 visits per calendar year
Neurodevelopmental Therapy
20%
40%
 For children age 17 and underInpatient and outpatient combined:$1,500 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 and Prostheses
20%
40%
  
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%
 $250,000 life time maximum including donor cost
Alcoholism Treatment
20%
20%
 $4,500 every two calendar years maximum(inpatient and outpatient combined)
Hearing Aids and Evaluations
20%
40%
 (for dependents who meet criteria)$4,000 every four calendar years maximum
Tobacco Use Cessation Programs
20%
40%
 $500 lifetime maximum
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

 
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