Regence

Regence Cascade Gold Individual and Family Network

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	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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