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    Bronze HSA 5000

    Uploaded by

    Vasikaran Prabaharan
    This document summarizes the benefits and costs of the Regence Bronze HSA 5000 health insurance plan. It has a $5,000 individual or $10,000 family in-network deductible and $6,750 individual or $13,500 family in-network out-of-pocket maximum for medical services. The prescription drug deductible is shared with medical. Office visits have $40 copays in-network or 50% coinsurance out-of-network. Preventive care is covered at 0% in-network. Most other services like specialist visits, urgent care, imaging and hospital care require 50% coinsurance in-network or out-of-network after deductible.

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    Bronze HSA 5000

    Uploaded by

    Vasikaran Prabaharan
    61 views4 pages
    This document summarizes the benefits and costs of the Regence Bronze HSA 5000 health insurance plan. It has a $5,000 individual or $10,000 family in-network deductible and $6,750 individual or $13,500 family in-network out-of-pocket maximum for medical services. The prescription drug deductible is shared with medical. Office visits have $40 copays in-network or 50% coinsurance out-of-network. Preventive care is covered at 0% in-network. Most other services like specialist visits, urgent care, imaging and hospital care require 50% coinsurance in-network or out-of-network after deductible.

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    This document summarizes the benefits and costs of the Regence Bronze HSA 5000 health insurance plan. It has a $5,000 individual or $10,000 family in-network deductible and $6,750 individual or $13,500 family in-network out-of-pocket maximum for medical services. The prescription drug deductible is shared with medical. Office visits have $40 copays in-network or 50% coinsurance out-of-network. Preventive care is covered at 0% in-network. Most other services like specialist visits, urgent care, imaging and hospital care require 50% coinsurance in-network or out-of-network after deductible.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    61 views4 pages

    Bronze HSA 5000

    Uploaded by

    Vasikaran Prabaharan
    This document summarizes the benefits and costs of the Regence Bronze HSA 5000 health insurance plan. It has a $5,000 individual or $10,000 family in-network deductible and $6,750 individual or $13,500 family in-network out-of-pocket maximum for medical services. The prescription drug deductible is shared with medical. Office visits have $40 copays in-network or 50% coinsurance out-of-network. Preventive care is covered at 0% in-network. Most other services like specialist visits, urgent care, imaging and hospital care require 50% coinsurance in-network or out-of-network after deductible.

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
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    Regence Bronze HSA 5000 Regence

    Effective January 1, 2019 through December 31, 2019 Regence BlueCross BlueShield of Oregon is an
    Independent Licensee of the Blue Cross and Blue Shield Association

    Cost Share Details In-Network Out-of-Network


    Annual Deductible The total deductible you pay per calendar year $5,000 Individual $10,000 Individual
    $10,000 Family $20,000 Family
    Annual Out-of-Pocket Maximum The combined total for your deductible, coinsurance and $6,750 Individual $15,000 Individual
    copays per calendar year $13,500 Family $30,000 Family

    The In-Network Out-of-Pocket Maximum for any Member on Family Coverage is not to exceed $7,900, including the In-Network Deductible. If a Member reaches this
    maximum amount prior to satisfying the In-Network Family Out-of-Pocket Maximum, including the In-Network Deductible, benefits will be paid at 100% of the Allowed
    Amount for that Member.
    Be aware that your actual costs for covered services provided by an Out-of-Network provider may exceed the Out-of-Pocket Maximum amount. In addition, Out-of-Network
    providers can bill you for the difference between the amount charged and our allowed amount and that amount does not count toward any Out-of-Pocket Maximum.

    Medical Benefits (unless stated otherwise, a deductible applies) What You Pay
    Primary Care Visits (for Illness or Injury) Visiting a Blue Distinction Total Care (BDTC) provider will $40 copay per visit ($20 for 50%
    result in a lower out-of-pocket expense for most office visits BDTC provider visits)
    Specialist Visits $60 copay per visit ($30 for 50%
    BDTC provider visits)
    Urgent Care Visits $60 copay per visit ($30 for 50%
    BDTC provider visits)
    Other Professional Services 50% 50%

    Preventive Care/Immunizations 0%, deductible waived 50%

    Ambulance Services 50% 50%

    Ambulatory Surgical Center 40% 50%

    Complementary Care Acupuncture and chiropractic spinal manipulations $40 copay per visit $40 copay per visit
    $1,000 limit for all services combined

    Complex Imaging - Outpatient CT/PET/SPECT scans, MRIs, MRAs, etc. 50% 50%

    Emergency Room (Including Professional 50% 50%


    Charges)

    Home Health Care 50% 50%

    Hospice Care 5 consecutive days of respite care, with a maximum of 30 50% 50%
    days per lifetime

    Hospital Care - Inpatient $3,000 per day for inpatient non-emergency admissions to 50% 50%
    out-of-network facilities

    Hospital Care - Outpatient 50% 50%

    Mental Health/Substance Use Disorder - $3,000 per day for inpatient non-emergency admissions to 50% 50%
    Inpatient out-of-network facilities

    Mental Health/Substance Use Disorder - $40 copay per outpatient 50%


    Outpatient office/psychotherapy visit
    ($20 for BDTC provider visits)
    Palliative Care 30 visits per calendar year 50% 50%

    Radiology and Laboratory - Outpatient 50% 50%

    Rehabilitation Services - Inpatient 30 days per year (up to 60 days for head or spinal cord 50% 50%
    injury)
    $3,000 per day for inpatient non-emergency admissions to
    out-of-network facilities

    Regence BlueCross BlueShield of Oregon, Small Group, 09/11/2018


    2019 Regence Bronze HSA5000 Page 1
    Medical Benefits (unless stated otherwise, a deductible applies) What You Pay
    Rehabilitation Services - Outpatient 30 visits per calendar year $40 copay per visit ($20 for 50%
    BDTC provider visits)
    Skilled Nursing Facility (SNF) Care 60 days per calendar year 50% 50%

    Spinal Manipulations - Osteopathic 50% 50%

    Telehealth $10 copay per session Not covered

    Prescription Medication Benefits (unless stated otherwise, a deductible applies) What You Pay
    Annual Deductible The total deductible you pay per calendar year Shared with medical

    Annual Out-of-Pocket Maximum The combined total for your deductible, coinsurance and Shared with medical
    copays per calendar year

    Preferred Generic Deductible waived on retail prescriptions for medications on 50%*+ retail prescription / 45%+ mail order prescription
    the Optimum Value Medication List (OVML) located on our
    website
    90-day supply for retail or mail order
    Generic Deductible waived on retail prescriptions for OVML 50%*+ retail prescription / 45%+ mail order prescription
    medications
    90-day supply for retail or mail order
    Preferred Brand Deductible waived on retail prescriptions for OVML 50%*+ retail prescription / 45%+ mail order prescription
    medications
    90-day supply for retail or mail order
    Brand Deductible waived on retail prescriptions for OVML 50%*+ retail prescription / 45%+ mail order prescription
    medications
    90-day supply for retail or mail order
    Preferred Specialty 30-day supply for retail 20%+ participating pharmacy retail prescription

    Specialty 30-day supply for retail 50%+ participating pharmacy retail prescription

    *$5 copay or 5% coinsurance discount for non-specialty medications when filled at a preferred pharmacy. Your amount will not be lower than $0.
    +
    50% for each self-administered Cancer Chemotherapy medication

    This benefit summary provides a brief description of your plan benefits, limitations and/or exclusions under your plan and is not a guarantee of payment. Once enrolled, you
    can view your benefits booklet online at regence.com. PLEASE REFER TO YOUR BENEFITS BOOKLET OR SUMMARY PLAN DESCRIPTION FOR A COMPLETE LIST
    OF BENEFITS, THE LIMITATIONS AND/OR EXCLUSIONS THAT APPLY, AND A DEFINITION OF MEDICAL NECESSITY. Regence is providing this benefit summary for
    illustrative purposes only. Regence makes no warranties or representations regarding compliance with applicable federal, state, or local laws, or the accuracy of the benefit
    summary. This document is not the legally required Summary of Benefits and Coverage that an employer is required to provide to employees and members under Federal
    law, and the group must provide a legally compliant Summary of Benefits and Coverage to its employees and members.

    1 (877) 508-7357 - TTY: 711 | 100 SW Market Street, Portland, OR 97201 | regence.com

    Regence BlueCross BlueShield of Oregon, Small Group, 09/11/2018


    2019 Regence Bronze HSA 5000 Page 2
    NONDISCRIMINATION NOTICE
    Regence complies with applicable Federal civil rights laws and does not discriminate on the
    basis of race, color, national origin, age, disability, or sex. Regence does not exclude people
    or treat them differently because of race, color, national origin, age, disability, or sex.

    Regence:
    Provides free aids and services to people with disabilities to communicate effectively
    with us, such as:
     Qualified sign language interpreters
     Written information in other formats (large print, audio, and accessible electronic
    formats, other formats)

    Provides free language services to people whose primary language is not English,
    such as:
     Qualified interpreters
     Information written in other languages

    If you need these services listed above, You can also file a civil rights complaint with the
    please contact: U.S. Department of Health and Human Services,
    Office for Civil Rights electronically through the
    Medicare Customer Service Office for Civil Rights Complaint Portal at
    1-800-541-8981 (TTY: 711) https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or
    by mail or phone at:
    Customer Service for all other plans
    1-888-344-6347 (TTY: 711) U.S. Department of Health and Human Services
    200 Independence Avenue SW,
    If you believe that Regence has failed to Room 509F HHH Building
    provide these services or discriminated in Washington, DC 20201
    another way on the basis of race, color,
    national origin, age, disability, or sex, you can 1-800-368-1019, 800-537-7697 (TDD).
    file a grievance with our civil rights coordinator
    below: Complaint forms are available at
    http://www.hhs.gov/ocr/office/file/index.html.
    Medicare Customer Service
    Civil Rights Coordinator
    MS: B32AG, PO Box 1827
    Medford, OR 97501
    1-866-749-0355, (TTY: 711)
    Fax: 1-888-309-8784
    medicareappeals@regence.com

    Customer Service for all other plans


    Civil Rights Coordinator
    MS CS B32B, P.O. Box 1271
    Portland, OR 97207-1271
    1-888-344-6347, (TTY: 711)
    CS@regence.com

    01012017.04PF12LNoticeNDMARegence
    Language assistance
    ATENCIÓN: si habla español, tiene a su disposición ប្រយ័ត្ន៖ បរើសិនជាអ្ន កនិយាយ ភាសាខ្មែ រ,
    servicios gratuitos de asistencia lingüística. Llame al បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន ួល
    1-888-344-6347 (TTY: 711). គឺអាចមានសំរារ់រំប រ ើអ្ន ក។ ចូ រ ទូ រស័ព្ទ 1-888-344-
    6347 (TTY: 711)។
    注意：如果您使用繁體中文，您可以免費獲得語言
    援助服務。請致電 1-888-344-6347 (TTY: 711)。 ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰ ਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱ ਚ

    CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-888-344-
    trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888- 6347 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।
    344-6347 (TTY: 711).

    주의: 한국어를 사용하시는 경우, 언어 지원 ACHTUNG: Wenn Sie Deutsch sprechen, stehen
    Ihnen kostenlose Sprachdienstleistungen zur
    서비스를 무료로 이용하실 수 있습니다. 1-888-
    Verfügung. Rufnummer: 1-888-344-6347 (TTY: 711)
    344-6347 (TTY: 711) 번으로 전화해 주십시오.
    ማስታወሻ:- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ
    PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፤ በሚከተለው ቁጥር
    kang gumamit ng mga serbisyo ng tulong sa wika nang ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው:- 711)፡፡
    walang bayad. Tumawag sa 1-888-344-6347 (TTY:
    711). УВАГА! Якщо ви розмовляєте українською
    мовою, ви можете звернутися до безкоштовної
    ВНИМАНИЕ: Если вы говорите на русском языке, служби мовної підтримки. Телефонуйте за
    то вам доступны бесплатные услуги перевода. номером 1-888-344-6347 (телетайп: 711)
    Звоните 1-888-344-6347 (телетайп: 711).
    ध्यान दिनहु ोस्: तपार्इंले नेपाली बोल्नहु ुन्छ भने तपार्इंको दनदतत भाषा सहायता सेवाहरू
    ATTENTION : Si vous parlez français, des services
    दनिःशल्ु क रूपमा उपलब्ध छ । फोन गनुहोस् 1-888-344-6347 (दिदिवार्इ:
    d'aide linguistique vous sont proposés gratuitement.
    Appelez le 1-888-344-6347 (ATS : 711) 711

    注意事項：日本語を話される場合、無料の言語支 ATENȚIE: Dacă vorbiți limba română, vă stau la


    dispoziție servicii de asistență lingvistică, gratuit.
    援をご利用いただけます。1-888-344-6347
    Sunați la 1-888-344-6347 (TTY: 711)
    （TTY:711）まで、お電話にてご連絡ください。
    MAANDO: To a waawi [Adamawa], e woodi ballooji-
    ti’go Diné ma to ekkitaaki wolde caahu. Noddu 1-888-344-6347
    Bizaad, saad (TTY: 711)
    1-888-344-6347 (TTY: 711.)
    โปรดทราบ: ถ้าคุณพูดภาษาไทย คุณสามารถใช้บริ การช่วยเหลือทางภาษาได้ฟรี
    FAKATOKANGA’I: Kapau ‘oku ke Lea- โทร 1-888-344-6347 (TTY: 711)
    Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai
    atu ha tokoni ta’etotongi, pea te ke lava ‘o ma’u ia. ້ າພາສາ ລາວ,
    ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ
    ha’o telefonimai mai ki he fika 1-888-344-6347 (TTY: ການບ
    ໍ ິ ລການຊ
    ່ ວຍເຫ
    ຼື ອດ ່ໍ ເສ
    ້ ານພາສາ, ໂດຍບ ັ ຽຄ
    ່ າ, ແມ
    ່ ນມ
    ີ ພ
    ້ ອມໃຫ
    ້ ທ
    ່ ານ.
    711) ໂທຣ 1-888-344-6347 (TTY: 711)
    OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa
    usluge jezičke pomoći dostupne su vam besplatno. afaanii tola ni jira. 1-888-344-6347 (TTY: 711) tiin
    Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa bilbilaa.
    oštećenim govorom ili sluhom: 711)

    ‫ تسهیالت زبانی بصورت رایگان برای شما‬،‫ اگر به زبان فارسی صحبت می کنید‬:‫توجه‬
    .‫ تماس بگیرید‬1-888-344-6347 (TTY: 711) ‫ با‬.‫فراهم می باشد‬

    1-888-344-6347 ‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغویة تتوافر لك بالمجان‬،‫ إذا كنت تتحدث فاذكر اللغة‬:‫ملحوظة‬
    (TTY: 711 ‫(رقم هاتف الصم والبكم‬
    01012017.04PF12LNoticeNDMARegence

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