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Regence SummitSM $5,000

Idaho Health Plans | Summit Plan - $5,000 Deductible

    • Alternative care covers acupuncture, naturopathy, chiropractic, and massage therapy.
    • No limits for office visits, preventive care, and generic medications.
    • Vision care: 100% coverage for annual exam, plus up to $100 for glasses and/or contacts.
     

Coverage at a Glance


Deductible:
Annual OOP Max: Not applicable on this plan
Lifetime Max: $2 million per member
Copay: $20
Coinsurance: 20% preferred providers, 40% non-preferred
Coinsurance Max: $2,000 per member
Network(s): Regence PPO Network

Find a Doctor
 
Yes Prescription benefits
No Dental
Yes Vision
Yes No Referrals
Yes Maternity
Yes Preventive Care
Yes Alternative Care
Yes Mental Health

Basic Features

Cost Sharing
Deductibles:
  • $5,000 per member
  • Family maximum of two individual deductibles
Annual OOP Max: Not applicable on this plan
Coinsurance Max:
  • You pay $0 after reaching $2,000 coinsurance maximum per member, per calendar year
  • Family coinsurance maximum of three individual maximums
Lifetime Max: $2 million paid by Regence per member
Copay: You pay $20 when using preferred or non-preferred providers
Coinsurance:
  • You pay 20% when using preferred providers
  • You pay 40% when using non-preferred providers
Everyday Needs
Prescriptions:
  • $10 copay (no limits) for generic medications purchased at the pharmacy
  • You pay 50% for all brand medications
  • Mail order available
  • No deductible
  • Brand medications limited to $2,000 per calendar year
Preventive Care:
  • You pay $20 copay for office visit (any provider)
  • No deductible
  • You pay coinsurance for routine lab and x-ray, no deductible
  • No limits per calendar year
Vision:
  • You pay $0 for one routine eye exam per calendar year
  • You pay $0 for glasses and/or contacts up to $100 per year
Office Visits:

You pay $20 copay using preferred or non-preferred providers
Diagnostic x-ray services: Deductible and coinsurance
Outpatient Laboratory services: Deductible and coinsurance
Special Needs
Alternative care:
  • Covers chiropractic, naturopathic, acupuncture, and massage therapy
  • Deductible and coinsurance
  • $500 limit for all services combined per calendar year
Maternity:
  • Separate $5,000 deductible
  • Coinsurance
Mental Health:
  • Deductible and 50% coinsurance
  • Includes chemical dependency treatment
  • $1,500 limit per calendar year
Other considerations
Network(s):

Preferred Providers

  • Regence PPO Network

Non-Preferred Providers

  • Providers outside of the Regence PPO Network

Benefit Summary

Rates

Fourth quarter rates are effective 10/1/2009 through 12/31/2009.

Medical Exclusions and Limitations

Alcoholism and Chemical Dependency $1,500 calendar year maximum for inpatient and outpatient combined
Alternative Care $500 calendar year maximum for all combined
Cosmetic OR Reconstructive Surgery Excluded, except as specified by law
Custodial Care and Rest Cures Excluded
Diabetic Education $400 calendar year maximum
Durable Medical Equipment Not limited
Eye Exams and Hardware One exam and $100 for hardware each calendar year
Experimental/Investigational Excluded
Family Planning Excluded except oral contraceptives and contraceptive devices
Foot Care Excluded
Hearing Aids Excluded
Home Health Care $5,000 calendar year maximum
Hospice $5,000 lifetime maximum
Human Growth Hormone Therapy $25,000 calendar year maximum
Labs and X-rays Not limited
Maternity Care Separate $5,000 deductible
Mental Health Treatment $1,500 calendar year maximum for inpatient and outpatient combined
Medically Unnecessary Services Excluded
Obesity or Weight Control Excluded
Physician Office Visits Not limited
Prescription medications Generic: Unlimited
Brand Medications: $2,000 calendar year maximum
Rehabilitative Care (inpatient) Not limited
Rehabilitative Care (outpatient) $800 per calendar year maximum per therapy
  • Occupational Therapy
  • Physical Therapy
  • Respiratory Therapy
  • Speech Therapy
Skilled Nursing Facility 30 days calendar year maximum
TMJ Disorder and Orthognathic Surgery $2,000 lifetime maximum
Transplants $250,000 lifetime maximum
Occupational Therapy
Physical Therapy Limited to $800 per calendar year
Respiratory Therapy Limited to $800 per calendar year
Preventative Care
Lab and x-ray Not limited
Routine Baby and Child Care Not limited
Routine Immunizations Not limited
Routine Physical Exams Not limited
This does not include all benefits, limitations, exclusions and other terms of coverage (such as eligibility and cancellation provisions) applicable to this plan. Please refer to your contract of a complete list and more in-depth explanation of benefits and the limitations and exclusions that apply.

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