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Oregon Medical Insurance > Regence BlueCross BlueShield of Oregon > Evolve Plus Benefits


Regence Evolve Plus SM
 
Individual
Family
 What you should know
Annual Deductible
(choose one; based on calendar year)
$1,000, $2,500, $5,000, or $7,500
Family deductible is three times the individual deductible
 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
$4,000 (for $1,000 deductible only) / $5,500 (for all other deductibles) coinsurance maximum
$12,000 (for $1,000 deductible only) Family coinsurance maximum is three times the individual maximum for all other deductibles
 On Regence Evlove Core and Plus, this is the total amount you pay for coinsurance, in addition to the deductible, in a calendar year before the plan covers the full cost (100%) of eligible expenses.
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
Category 2 & 3
Upfront Office Visits
(Injury and Illness)
$25 per visit for first four visits per person.
After four, then subject to deductible and coinsurance.
Copay applies only to the office exam. All other services provided during the visit are subject to the applicable deductible and coinsurance
Other Professional Service
20%
50%
 Deductible applies after upfront benefit limits are met. Office and inpatient services and supplies
Hospital Services/Ambulatory Surgical Center
20%
50%
 Inpatient and outpatient services and supplies
Prescription Medication*
$10 copay for generics
$500 deductible, 50% coinsurance for brand formulary only
$4,500 per year maximum for all drugs (including contraceptives).
 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
50%; 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
0%; not subject to deductible
 (adult and child) No benefit limit
Upfront Outpatient Radiology and Laboratory
0% for first $400 per year; then subject to deductible and coinsurance
 (limit does not apply to preventive care or complex outpatient imaging).
Complex Outpatient Imaging
50%; $1,500 per year maximum.
50%; $1,500 per year maximum.
 (CT Scan, MRI, PET, MRA, SPECT, Bone Density)
Vision Care
20%; Routine eye exam and hardware covered to a combined $150 per calendar year maximum; not subject to deductible or coinsurance maximum
  
Complementary Care
20% limited to 8 visits per calendar year maximum;
not subject to deductible or coinsurance
 Complementary care includes naturopathic, chiropractic, and acupuncture services and supplies.
Ambulance Services
20%
20%
 Air and ground ambulance to nearest facility
Emergency Room Services
$100 copay per ER visit
(waived if admitted), then 20%
  
Maternity Care
20%
50%
  
Genetic Testing
20%
50%
 $5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing)
Home Health
20%
50%
 130 visits per calendar year
Hospice
20%
50%
 Respite care limited to 14 days inpatient/outpatient per lifetime
Mental Health Treatment
20%
50%
 Inpatient: 6 days per calendar yearOutpatient: 12 visits per calendar year
Neurodevelopmental Therapy
20%
50%
 For children age 17 and underInpatient and outpatient combined:$1,500 per calendar year maximum benefit
Durable Medical Equipment
20%
50%
 $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%
50%
  
Rehabilitation Services
20%
50%
 Inpatient: $8,000 per calendar year maximum benefit
Outpatient: $1,500 per calendar year maximum benefit
Skilled Nursing Facility
20%
50%
 30 inpatient days per calendar year
Transplant
20%
50%
 $250,000 life time maximum including donor cost
Alcoholism Treatment
20%
20%
 $4,500 every two calendar years maximum(inpatient and outpatient combined)
Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery
50%
50%
 $2,500 per lifetime maximum benefit
Hearing Aids and Evaluations
20%
50%
 (for dependents who meet criteria)$4,000 every four calendar years maximum
Tobacco Use Cessation Programs
20%
20%
 $500 lifetime maximum
*Prescription Medication Coverage

$10 copay for generics
$500 deductible, 50% coinsurance for brand formulary only.
$4,500 per calendar year maximum for all drugs (including contraceptives)

(On $1,000 deductible medical plan: $500 prescription medications deductible is waived and 50% coinsurance applies to brand formulary and non-formulary.)

Self administered chemotherapy drugs: self administered chemotherapy drugs will not accumulate to the Rx benefit maximum.
$10 generics, $50 brand formulary, $100 non-formulary.

Tobacco Cessation prescription drugs: (Including generic/brand/non-formulary)
$500 lifetime maximum. Tobacco cessation drugs will not accumulate to RX benefit maximum. $10 copay for generics; 50% coinsurance for brand formulary and non-formulary.
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 Plus 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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