Regence

Bronze Essential 8500 Deductible With 4 Copay No Deductible Office Visits

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $8,500.00 Family: $17000 Per Person: $8500
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200.00 Family: $18400 Per Person: $9200

Office Visit

Primary Doctor	CoPay: $60.00 CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Virtual Care (Telehealth) Visit Covered in Full. The first 4 PCP, Specialists, Urgent Care in-network office visits combined per calendar year are not subject to the deductible, then regular deductible and coinsurance amounts apply.
Specialist	CoPay: $60.00 CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Virtual Care (Telehealth) Visit Covered in Full. The first 4 PCP, Specialists, Urgent Care in-network office visits combined per calendar year are not subject to the deductible, then regular deductible and coinsurance amounts apply.

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: insulin limit of? $25 per 30 days? $75 for 90 day supply
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month Benefit Explanation: First fill allowed at a retail pharmacy.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility	CoPay: $60.00 CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: The first 4 PCP, Specialists, Urgent Care in-network office visits combined per calendar year are not subject to the deductible, then regular deductible and coinsurance amounts apply. Out of service area coverage is available.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: No Charge Covered: Covered Limit Quantity: 2 Limit Unit : Exam(s) per Year
Routine Dental Checkups for Adults	Covered: Not Covered