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| Deductible: |
|
|---|---|
| Annual OOP Max: | $5,000 single |
| Lifetime Max: | $2 million per member |
| Copay: | Not applicable on this plan |
| Coinsurance: | 20% Participating, 40% Non-Participating |
| Coinsurance Max: | Not applicable on this plan |
| Network(s): | Participating Network Find a Doctor |
| Prescription benefits | |
| Dental | |
| Vision | |
| No Referrals | |
| Maternity | |
| Preventive Care | |
| Alternative Care | |
| Mental Health |
| Deductibles: | $3,500 individual |
|---|---|
| Annual OOP Max: |
|
| Coinsurance Max: | Not applicable on this plan |
| Lifetime Max: | $2 million paid by Regence per member |
| Copay: | Not applicable on this plan |
| Coinsurance: |
|
| Prescriptions: |
|
|---|---|
| Preventive Care: |
|
| Vision: | Not covered |
| Office Visits: | Deductible and coinsurance apply |
| Diagnostic x-ray services: | Deductible and coinsurance apply |
| Outpatient Laboratory services: | Deductible and coinsurance apply |
| Alternative care: | Deductible and coinsurance apply |
|---|---|
| Maternity: | |
| Mental Health: |
|
| Network(s): | Participating Network |
|---|
Dental PlanAdd our Individual Dentacare dental plan to round out your coverage. It offers:
|
| Acupuncture | 12 office visits per calendar year |
|---|---|
| Alcoholism | Not covered |
| Ambulance | $5,000 annual limit |
| Cosmetic/Reconstructive Surgery | Not covered |
| Custodial Care and Rest Cures | Not covered |
| Drug Abuse/Addiction Treatment | Not covered |
| Durable Medical Equipment | $2,500 annual limit |
| Family Planning | Not covered |
| Growth Hormone Benefit | $20,000 annual limit |
| Hearing Aids | Not covered |
| Home Health Care | 130 days per calendar year |
| Maternity | |
| Mental Health Treatment | Not covered |
| Obesity or Weight Control | Not covered |
| Orthognathic Surgery | Not covered |
| Rehabilitative Care (inpatient) | $15,000 annual limit |
| Rehabilitative Care (outpatient) | $1,500 annual limit |
| Skilled Nursing Facility | 14 days per stay |
| Spinal Manipulation | 10 office visits per calendar year |
| Temporomandibular Joint Disorder | Not covered |
| Transplants |
|
| Tobacco Addiction Treatment | Not covered |
| Vision | Not covered |
| Allergies | 9-month waiting period |
|---|---|
| Ear Infections (otitis media) | 9-month waiting period |
| Pre-existing conditions | 9-month waiting period |
| Removal of Tonsils and Adenoids | 9-month waiting period |
| Sterilization | 9-month waiting period |
| This does not contain all limitations and exclusions. Please refer to your policy for a complete list of benefits and the limitations and exclusions that apply. |
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