Regence HSA Healthplan > Own Your Health Care Dollars

Regence HSA Healthplan

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Unique Features

Own your health care dollars with a tax-advantaged account that covers medical expenses beyond your health plan. Or choose to save.
Unlimited, up-front preventive care plus personalized tools and support you need to make the plan your own.
Comprehensive wellness programs like Care Enhance^® Nurseline & Regence Health Coach^SM.

Coverage at a Glance

Deductible:	$1,500 - $3,500 single $3,000 - $7,000 family	Prescriptions Dental Vision No Referrals Maternity Preventive Care Alternative Care Mental Health
Annual OOP Max:	$5,000 single, $10,000 family
Coinsurance Max:	not applicable
Lifetime Max:	$2,000,000 per member
Copay:	none
Coinsurance:	80% In-Network, 60% Out-of-Network
Providers:	Traditional (Regence BlueCross BlueShield of Utah) and ValueCare Networks

Basic Features

Cost Sharing
Deductible	$1,500/$2,500/$3,500 single $3,000/$5,000/$7,000 family
Annual OOP Max	$5,000 single/$10,000 family Amount includes your deductible Maximum applies to in-network services only. No maximum for out-of-network services.
Coinsurance Max	not applicable
Lifetime Max	$2,000,000 per member
Copay	none
Coinsurance	You pay 20% for most in-network services. You pay 40% for most out-of-network services.
Everyday Needs
Prescriptions	You pay 50% at participating and non-participating pharmacies. Subject to deductible
Preventive Care	You pay 20% for in-network providers. You pay 40% for out-of-network providers. Deductible waived No annual limit
Vision	Not covered
Office Visits	Deductible and coinsurance
X-Ray Services	Deductible and coinsurance
Lab Services	Deductible and coinsurance
Special Needs
Alternative Care	Not covered
Maternity	Not covered
Mental Health Care	You pay 50% for in-network and out-of-network providers. Limited to $1,500 per person per calendar year.
Other Considerations
Networks	Traditional (Regence BlueCross BlueShield of Utah) and ValueCare Networks

Benefit Summaries

Benefit Summary: $1,500 Single/$3,000 Family Deductible

Benefit Summary: $2,500 Single/$5,000 Family Deductible

Benefit Summary: $3,500 Single/$7,000 Family Deductible

Rates

Rates: HSA Healthpan - Effective July 1, 2009

Rates: Individual and Family Plans - Effective July 1, 2009

Rates: Individual and Family Plans Calculation Worksheet - Effective July 1, 2009

Exclusions & Limitations

Exclusions

This is only a partial summary of exclusions. The Agreement contains a complete list of exclusions.

Artificial heart, pancreas, or liver implants; bone marrow transplants except in the treatment of certain conditions (see Agreement for details)
Certain treatments of mental disorders (e.g., biofeedback, sensitivity training, hypnosis, family or marital problems, behavior disorders, psychosexual dysfunction, learning disabilities, mental retardation)
Cosmetic surgery; weight-loss treatment, including but not limited to surgical procedures and their reversals or revisions
Counseling services, training or educational services, or services received to apply toward earning a degree
Custodial care; Over-the-counter drugs and medicines
Experimental or investigational treatments or procedures
Genetic studies; non-prescription contraceptives; reversal of sterilization; resterilization; artificial insemination; and in vitro fertilization
Massage therapy; music, art, dance, or recreation therapy
Maternity Care
Physical fitness exercise equipment and spa or club memberships
Services covered by Workers Compensation, government-sponsored programs and other insurance (such as no-fault automobile insurance)
Services determined by Us to be not Medically Necessary
Services for TMJ dysfunction; dental care; jaw surgery for augmentation or reduction; services to increase vertical dimension/restore occlusion
Services for which the Claimant has no legal obligation to pay
Services provided before the coverage begins or after coverage ends
Services provided for or in connection with a non-Covered Service, including complications resulting directly from non-Covered Services
Services rendered by a member of the patient’s immediate family
Services not licensed in Utah; Treatments or procedures outside generally accepted health care practice including holistic, homeopathic, ecological or environmental medicine; acupuncture
Services not specifically listed in the Agreement as covered
Services rendered by halfway houses, public or private schools
Surgical correction of refractive errors of vision; eyeglasses, hearing aids or similar devices; routine foot care; corrective shoes and shoe accessories; personal convenience or hygiene items; special formulas, food supplements, or special diets
Taxes, surcharges, tariffs, duties, assessments, or similar charges
Services provided for or in connection with erectile dysfunction
Telephone consultations, “missed” appointments, travel expenses, shipping, handling, postage, interest or finance charges
Treatment caused by participation in illegal acts of violence; services provided as a result of a court order or other legal proceedings

Limitations

During the 12 months immediately following the date We received Your application, NO BENEFITS will be provided for Sterilization and a Preexisting Condition ("PEC"). Your limitation will be reduced by the aggregate periods of Creditable Coverage applicable to You as of the date We received Your application.
A "Preexisting Condition" is a physical or mental condition for which medical advice, diagnosis, care or treatment was recommended or received within 6 months prior to the date We received Your application. See the Agreement for details regarding crediting of coverage.
Limited coverage is available for certain solid organ transplants and bone marrow and stem cell transplants (see the Agreement for details).

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