Regence

IAFN Silver 6500 POS

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $6,500 Family: $13,000 Per Person: $6,500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: See policy for more information.
Specialist	CoPay: $85.00 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: $10.00 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: $85.00 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.
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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