Benefit

A-100 PLAN

Choice of Provider

Your choice of doctor/hospital

Your choice of doctor/hospital

Must use Kaiser provider & facility

Annual Deductible
(per calendar year)

$100 Person
$300 Family

$500 Person
$1,500 Family

No deductible

Major Medical Benefits
(per calendar year)

After deductible, all eligible services paid at 80% of 1st $5,000, then 100%

After deductible, all eligible services paid at 80% of 1st $5,000, then 100%

Paid in full after applicable co-payment

Lifetime Maximum

$2,000,000

$2,000,000

No limit

Hospital Services:
Inpatient Semi-private room
(Visit website or see booklet for Outpatient Benefits)

After deductible, paid at 80%

80% after deductible

Paid in full

Physicians Services
Office Visits
Lab & X-Ray
Surgery

After deductible, paid at 80%
After deductible, paid at 80%
After deductible, paid at 80%

80% after deductible

80% after deductible

80% after deductible

Paid in Full after $5 Co-payment per visit

Prescription Drugs

Generic medications:
$10 Copay
(retail)/$30 Copay (mail order)
Preferred Brand Medications:
80% (retail and mail order
Non-preferred Brand medications:
50% (retail and mail order)
Individual prescription medication out-of-pocket limit per calendar year $1,000 (separate from medical). After your maximum out-of-pocket is met each calendar year, we pay 100%.
(See CHOICES list on website http://www.regence.com)

Generic medications:
$10 Copay
(retail)/$30 Copay (mail order)
Preferred Brand Medications:
80% (retail and mail order
Non-preferred Brand medications:
50% (retail and mail order)
Individual prescription medication out-of-pocket limit per calendar year $1,000 (separate from medical). After your maximum out-of-pocket is met each calendar year, we pay 100%.
(See CHOICES list on website http://www.regence.com)

Users drug formulary; $5 co-pay, 30 day supply; $5 co-pay, 90 day supply via mail order

Ambulance

80% after deductible

80% after deductible

$50 + $5 co-pay per trip

Emergency Room Care

$100 co-pay (waived if admitted) then 80%

$100 co-pay (waived if admitted) then 80%

$50 + $5 co-pay

Additional Accident

80% after deductible

80% after deductible

Paid as regular benefit

Maternity Care

80% after deductible

80% after deductible

Prenatal & postnatal paid in full

Preventive Care

Paid at 100%

Paid at 100%

Paid in full - all members

Annual Breast/Pelvic Exam
(Females)

Paid at 100%

Paid at 100%

Paid in full after $5 co-pay

Periodic Health Plan

Paid per schedule up to $500 per covered member

Paid per schedule up to $500 per covered member

Paid in full after $5 co-pay per visit

Chiropractic Services

80% after deductible

80% after deductible

Not covered