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Contact us
8am - 6pm(Pacific)
Monday - Friday
Catastrophic Plan
Back to overview| Plan Benefit | In-Network | Out-of-Network |
|---|---|---|
| Lifetime Maximum per Insured Calendar Year Maximum per Insured |
$5 million $1 million |
|
| Individual Calendar-Year Deductible | Individual: $10,000 Family: $30,000 |
Individual: $30,000 Family: $90,000 |
| Coinsurance | 80% | 50% |
| Individual Calendar-Year Out-of-Pocket Maximum |
Medical Services and Supplies: $3,000 Inpatient Confinement and Surgery $6,000 Family: 3x Individual |
Individual: 3x In-network Family: 3x Individual |
|
Physician Charge at Office Visit (Other covered services performed are subject to deductible and coinsurance) |
$40 Co-pay or Deductible and 80% Coinsurance |
Deductible and 50% Coinsurance |
| Routine Mammography | 100% of Covered Charges | 100% of Covered Charges |
|
Emergency Room (ER co-pay waived if immediately admitted) |
$100 Co-pay, then deductible and 80% coinsurance |
$100 Co-pay, then deductible and 50% coinsurance |
| Ambulance | Deductible and 80% coinsurance | |
|
OUTPATIENT Diagnostic Lab, X-ray and Tests |
Deductible and 80% coinsurance |
Deductible and 50% coinsurance |
|
Diagnostic Imaging including MRI, CT, and Nuclear Imaging |
Deductible and 80% coinsurance |
Deductible and 50% coinsurance |
| Surgery |
Deductible and 80% coinsurance |
Deductible and 50% coinsurance |
|
General outpatient medical services and supplies; non-surgical back treatment |
Deductible and 80% coinsurance |
Deductible and 50% coinsurance |
|
Mental, nervous and chemical dependency care |
Deductible and 80% coinsurance |
Deductible and 50% coinsurance |
|
INPATIENT Surgical services and confinement |
Deductible and 80% coinsurance |
Deductible and 50% coinsurance |
| Mental and nervous care |
Deductible and 80% coinsurance |
Deductible and 50% coinsurance |
Prescription Card
| Carrier | ACE |
|---|---|
| Plan Processor | Regence Rx |
| AM Best Rating | A+ |
| Pharmacy Plan | Generic Coverage 96% of top name-brand drugs included |
| Maximum Monthly Benefit | $200 Individual $400 Family |
| Annual Deductible | $0 |
| COPAYMENT Generic (the lesser of) |
$10 or the pharmacy's usual and customary |
| Preferred Brand | Network discounted drug prices or the pharmacy's usual and customary, whichever is less |
| Non-Preferred Brand | Network discounted drug prices or the pharmacy's usual and customary, whichever is less |
| Brand-Name Drugs in excess of $100 | Could be obtained for free in some instances through Patients Pharmacy Assistance Program |
| Non-Covered Drugs | Network discounted drug prices or the pharmacy's usual and customary, whichever is less |
| Network | More than 52,000 locations nationwide - 100% of chain-store pharmacies and 91% of independent stores participating |
| Mandatory Generic | Yes |
| Mail Order | 90-day supply |
| Online Information available at http://www.RegenceRx.com |
Pharmacy locator Preferred Medication list Rx Price Guide Generic Medications Link to mail-order service |
