Regence

IAFN Bronze Essential 8500 With 4 Copay No Deductible Office Visits POS

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $8,500 Family: $17000 Per Person: $8500
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,200 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 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. Virtual Care (Telehealth) Visit Covered in Full. See policy for more information.
Specialist	CoPay: $60.00 CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Virtual Care (Telehealth) Visit Covered in Full. The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. Virtual Care (Telehealth) Visit Covered in Full. See policy for more information.

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Insulin limit of $100 for a 30 day supply and $300 for 90 day supply. See policy for more information.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: See policy for more information.
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: See policy for more information.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Limit Quantity: 30 Limit Unit : Item(s) per Month Benefit Explanation: See policy for more information.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: See policy for more information.
Inpatient Services	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: See policy for more information.

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: See policy for more information.
Urgent Care Facility	CoPay: $60.00 CoInsurance: 10.00% Coinsurance after deductible Covered: Covered Benefit Explanation: The first 4 In-Network PCP, In-Network Specialists, Urgent Care office visits combined per calendar year are not subject to the deductible. See policy for more information.

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
Benefit Explanation: See policy for more information.

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 Benefit Explanation: See policy for more information.
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered Limit Quantity: 2 Limit Unit : Exam(s) per Year Benefit Explanation: See policy for more information.
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Quantitative limits apply. See policy for more information.