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Regence

Regence Cascade Gold MultiCare Connected Care Network

Plan Overview

Medical Deductable
  • Individual: $500
  • Family: $1,000
  • Per Person: $500
Prescription Drug Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $5,250
  • Family: $10,500
  • Per Person: $5,250

Office Visit

Primary Doctor
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: $40.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Non Preferred Brand Drugs
  • CoPay: $100.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Generic Drugs
  • CoPay: $10.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. 87718WA2170013 both WAF018 and WAF020, 87718WA2170014 both WAF025 and WAF023, 87718WA2170015 both WAF027 and WAF024, 87718WA2170016 both WAF018 and WAF020, 87718WA2170017 both WAF025 and WAF023, 87718WA2170018 both WAF027 and WAF024, 87718WA2170019 both WAF018 and WAF020, 87718WA2170020 both WAF025 and WAF023, 87718WA2170021 both WAF027 and WAF024, 87718WA2170022 both WAF018 and WAF020, 87718WA2170023 both WAF025 and WAF023, 87718WA2170024 both WAF027 and WAF024
Specialty Drugs
  • CoPay: $100.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill.

Inpatient Coverage

Hospital Services
  • CoPay: $525.00 Copay per Day
  • CoInsurance: Not Applicable
  • Covered: Covered
Inpatient Services
  • CoPay: $525.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: $450.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility
  • CoPay: $35.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: $525.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: $525.00
  • CoInsurance: Not Applicable
  • 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
  • Covered: Not Covered
Basic Dental Care - Child
  • Covered: Not Covered
Major Dental Care - Child
  • Covered: Not Covered
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