Regence

IAFN Gold 2500 With Dental and Vision Exam POS

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $2,500 Family: $5,000 Per Person: $2,500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: See policy for more information.
Specialist	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: See policy for more information.

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% 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: $5.00 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: $70.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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.
Routine Dental Checkups for Adults	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 1 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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