Regence BlueCross BlueShield of Oregon Health Insurance Plans for Oregon Evolve Plus Plan Benefits

Oregon Health Insurance Plans

Health Quote Request

LifeWise Health Plans of Oregon

Regence BC BS of OR

Moda Health

PacificSource

Providence Health Plans

HealthNet of Oregon

Kaiser Permanente

Oregon Medical Insurance Pool

Medicare Supplement Plans

Medicare Advantage Plans

Other Insurance

Regence BlueCross BlueShield of Oregon

Regence Evolve Plus Benefits

Individual

Family

What you should know

Annual Deductible
(choose one; based on calendar year)

$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

$5,500 coinsurance maximum

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 2With 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

(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.

(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%

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%

$4,500 every two calendar years maximum(inpatient and outpatient combined)

Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery

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%

$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