Regence

Regence Cascade Bronze Legacy LHP Network

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $6,000 Family: $12,000 Per Person: $6,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,550 Family: $17,100 Per Person: $8,550

Office Visit

Primary Doctor	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $100.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible 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: Not Applicable CoInsurance: 40.00% Coinsurance after deductible 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: $32.00 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. 71281WA1360005 both WAF017, WAF022 apply; 71281WA1360006 both WAF020, WAF023 apply; 71281WA1360007 both WAF021, WAF024 apply; 71281WA1360001 both WAF004, WAF014 apply; 71281WA1360004 both WAF008, WAF013 apply. Alliance Silver 3200 Exchange Legacy LHP & Alliance Bronze Care on Demand 8500 Exchange Legacy LHP plans Generic Drug cost share represents Preferred Generic Drugs in Tier 1. Non-preferred Generic Drugs that fall into Tier 2 are covered at a higher cost share.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible 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. Alliance Silver 3200 Exchange Legacy LHP & Alliance Bronze Care on Demand 8500 Exchange Legacy LHP plans - Specialty medications that fall into Tier 6 Specialty are non-preferred medications and covered at 50% coinsurance after deductible.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% 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	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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