Regence BlueShield     Evolve Plus     Evolve Core   HSA Plans     Evolve HSA 50     Evolve HSA 80     Evolve HSA 100   Plan Rates   Apply Now!   Provider Directory   Waiting Period     & Exclusions   FAQ's   LifeWise of WA   Group Health   HSA Plans     HSA Overview     Qualified Expenses     Regence HSA Plans     LifeWise HSA Plan     Group Health HSA   Individual Dental   Group Medical   Group Dental   Grp Life & Disability   About the Plan   Premiums   Application   US Citizens   Foreign Nationals   Long Term		(Available to Washington State Residents Only) SUMMARY OF BENEFITS REGENCE EVOLVE HSA 100 PLAN FOR INDIVIDUALS & FAMILIES Deductible, coinsurance and copay represent WHAT YOU PAY. Lifetime Maximum Benefit $2,000,000 Calendar Year Deductible Applies to all covered expenses except where noted Deductible per calendar year $5,000 for single coverage $10,000 for family coverage Family coverage: no one family member is eligible for benefits until the entire family deductible is met. 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 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 0% 0% 0% Hospital Services/Ambulatory Surgical Center Inpatient and outpatient services and supplies 0% 0% 0% Complex Outpatient Imaging (CT Scan, MRI, PET, MRA, SPECT, Bone Density) 0% 0% 0% Emergency Room Services 0% 0% 0% Ambulance Services Air and ground ambulance to the nearest facility 0% 0% 0% Preventive Care (excludes complex imaging) No benefit limit 0% 0% 0% Immunizations - Adult and Childhood No benefit limit 0% 0% 0% Genetic Testing $5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing) 0% 0% 0% Home Health 130 visits per calendar year 0% 0% 0% Hospice Respite care limited to 14 days inpatient/outpatient per lifetime 0% 0% 0% Mental Health Treatment 0% 0% 0% Acupuncture Six visits per calendar year maximum benefit 0% 0% 0% Spinal Manipulations 10 spinal manipulations per calendar year maximum benefit 0% 0% 0% 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) 0% 0% 0% Prostheses $2,500 per calendar year maximum benefit (this limit does not apply to surgically implanted and external breast prostheses) 0% 0% 0% Rehabilitation Services Inpatient: $8,000 per calendar year maximum benefit Outpatient: $1,500 per calendar year maximum benefit 0% 0% 0% Skilled Nursing Facility 30 inpatient days per calendar year 0% 0% 0% Transplants $350,000 lifetime maximum benefit, includes donor costs 0% 0% 0% Prescription Medications: Generics only (including generic contraceptives and generic diabetic drugs and supplies); $2,000 per calendar year maximum benefit; subject to deductible. Brand formulary diabetic drugs and supplies covered. No benefit limit for generic or brand formulary diabetic drugs and supplies. 0% 0% 0% Optional Benefits Available (Optional benefits that are not elected are excluded from coverage) 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 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 Additional Information Waiting Periods 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. Outside the Service Area 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. 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. 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. Copyright© 1998-2010, Maddock & Associates  |  Privacy Statement Problems viewing this page? Contact the webmaster.