Regence

IAFN Bronze Essential 8000 With 4 Copay No Deductible Office Visits POS

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $8,000
  • Family: $16,000
  • Per Person: $8,000
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $60.00 Copay with deductible
  • CoInsurance: 10.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent care office visits combined per calendar year; are not subject to the deductible for in-network providers. See policy for more information.
Specialist
  • CoPay: $60.00 Copay with deductible
  • CoInsurance: 10.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent care office visits combined per calendar year; are not subject to the deductible for in-network providers. See policy for more information.

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: See policy for more information.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: See policy for more information.
Generic Drugs
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: See policy for more information.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 40.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: See policy for more information.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 10.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: See policy for more information.
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 10.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: See policy for more information.

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 10.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: See policy for more information.
Urgent Care Facility
  • CoPay: $60.00 Copay with deductible
  • CoInsurance: 10.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent care office visits combined per calendar year; are not subject to the deductible for in-network providers. See policy for more information.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 10.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: See policy for more information.
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 10.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: See policy for more information.

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Exam(s) per Year
  • Benefit Explanation: See policy for more information.

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 2
  • Limit Unit : Exam(s) per Year
  • Benefit Explanation: See policy for more information.
Basic Dental Care - Child
  • CoPay: Not Applicable
  • CoInsurance: 20.00%
  • Covered: Covered
  • Limit Quantity: 2
  • Limit Unit : Exam(s) per Year
  • Benefit Explanation: See policy for more information.
Major Dental Care - Child
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered
  • Benefit Explanation: Quantitative limits apply. See policy for more information.
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