Regence Silver 3500 Legacy

Regence BlueCross BlueShield of Oregon

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Annual in-network deductible: $3,500
Metal level: Silver
Plan type: EPO
HSA-compatible plan: No (most common)

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Plan benefits

All supported filed details, including known conditions and limits. This is not the entire insurance contract. Unknown does not mean $0 or not covered.

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131 benefit rows

As an EPO, Legacy generally covers routine care only in its network, with emergency and specifically approved exceptions. Its documents use inconsistent network labels, so confirm the applicable Legacy network with Regence.

Notes & source

Regence · Legacy (Individual) · Issuer 71281. Confirm current provider participation and exact coverage in the plan documents.

Annual deductibles: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Medical and prescription drug deductible	In-network tier 1 individual: $3,500 In-network tier 1 family: $3,500 per person \| $7,000 per group In-network tier 1 coinsurance: 35.00% Out-of-network individual: Not Applicable Out-of-network family: per person not applicable \| per group not applicable Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable \| per group not applicable

Annual out-of-pocket limits: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Maximum Out of Pocket for Medical and Drug Benefits (Total)	In-network tier 1 individual: $10,150 In-network tier 1 family: $10,150 per person \| $20,300 per group Out-of-network individual: Not Applicable Out-of-network family: per person not applicable \| per group not applicable Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable \| per group not applicable

How costs are shared: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Combined medical and drug deductible Notes & source Whether covered medical and prescription costs count toward the same deductible.	Yes
Combined medical and drug spending limit Notes & source Whether covered medical and prescription costs count toward the same out-of-pocket limit.	Yes

Office and routine care: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Primary Care Visit to Treat an Injury or Illness Notes & source A visit with a primary care clinician for an illness or injury.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Virtual Care - Store and Forward & Virtual Care - Telehealth Visit $10 Copay found on the Schedule of Benefits. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Specialist Visit Notes & source A visit with a clinician who focuses on a particular condition or area of medicine.	In-network tier 1 copay: $60.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Other Practitioner Office Visit (Nurse, Physician Assistant) Notes & source An office visit with a nurse practitioner, physician assistant, or another listed clinician.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Virtual Care - Store and Forward & Virtual Care - Telehealth Visit $10 Copay found on the Schedule of Benefits. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Preventive Care/Screening/Immunization Notes & source Services intended to prevent illness or detect health problems early.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Well Baby Visits and Care Notes & source Routine visits to check a baby’s health and development.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Benefit details: Human donor milk must be covered as it is covered by the state base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Tests and imaging: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Imaging (CT/PET Scans, MRIs) Notes & source Advanced scans used to examine the inside of the body.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Laboratory Outpatient and Professional Services Notes & source Laboratory testing without inpatient admission.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
X-rays and Diagnostic Imaging Notes & source X-rays and other listed images used to help diagnose a health problem.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Allergy Testing Notes & source Tests used to identify substances that trigger allergic reactions.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Not an essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Urgent and emergency care: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Urgent Care Centers or Facilities Notes & source Care at an urgent care center for problems that need prompt attention.	In-network tier 1 copay: $60.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Out of service area coverage is available. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Emergency Room Services Notes & source Evaluation and treatment of a medical emergency in an emergency department.	In-network tier 1 copay: $400.00 In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Benefit details: Out of service area coverage is available. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): After $400 Copayment and In-Network Deductible, 35% Coinsurance. Copayment does not accrue toward the deductible. Out-of-network copay: $400.00 Out-of-network coinsurance: 35.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Emergency Transportation/Ambulance Notes & source Ambulance or other listed transportation for an emergency.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Benefit details: Out of service area coverage is available. Out-of-network copay: Not Applicable Out-of-network coinsurance: 35.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Hospital and surgery: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Notes & source The charge for using an outpatient facility, separate from a clinician’s professional fee.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Benefit details: Care provided at an in-network Ambulatory Surgery Center may be covered at a lower cost share, see Schedule of Benefits for cost share information. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Outpatient Surgery Physician/Surgical Services Notes & source The surgeon’s or other clinician’s services for surgery without inpatient admission.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Inpatient Hospital Services (e.g., Hospital Stay) Notes & source Hospital facility services after admission as an inpatient.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Inpatient Physician and Surgical Services Notes & source Clinicians’ professional services during an inpatient hospital stay.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Cosmetic Surgery Notes & source Surgery mainly intended to change appearance.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Benefit details: Covers cosmetic surgery when medically necessary. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Transplant Notes & source Medical care involving transplantation of an organ or tissue.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Reconstructive Surgery Notes & source Surgery to restore function or repair a body part affected by injury, illness, or a birth condition.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Benefit details: Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Mental health and substance use: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Mental/Behavioral Health Outpatient Services Notes & source Mental or behavioral health care without inpatient admission.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Virtual Care - Store and Forward & Virtual Care - Telehealth Visit $10 Copay found on the Schedule of Benefits. Outpatient office/psychotherapy visits - Copayment, Deductible waived. Other outpatient services - Coinsurance after Deductible. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Mental/Behavioral Health Inpatient Services Notes & source Mental or behavioral health treatment during an inpatient stay.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Substance Abuse Disorder Outpatient Services Notes & source Treatment for substance use disorders without inpatient admission.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Virtual Care - Store and Forward & Virtual Care - Telehealth Visit $10 Copay found on the Schedule of Benefits. Outpatient office/psychotherapy visits - Copayment, Deductible waived. Other outpatient services - Coinsurance after Deductible. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Substance Abuse Disorder Inpatient Services Notes & source Treatment for substance use disorders during an inpatient stay.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Prescription drugs: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Generic Drugs Notes & source Medicines classified by the plan as generic drugs.	In-network tier 1 copay: $20.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 90 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): $20 Copayment, Deductible waived for each Preferred Generic Medication. Copayment does not accrue toward the deductible. $35 Copayment, Deductible waived, for each Generic Medication. Copayment does not accrue toward the deductible. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Preferred Brand Drugs Notes & source Brand-name medicines placed in the plan’s preferred drug category.	In-network tier 1 copay: $60.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 90 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): $60 Copayment, Deductible waived, for each Preferred Brand-Name Medication. Copayment does not accrue toward the deductible. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Non-Preferred Brand Drugs Notes & source Brand-name medicines outside the plan’s preferred drug category.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coverage: Covered Service limit: Yes Limit amount: 90 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): 50% Coinsurance, Deductible waived, for each Brand-Name Medication. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Specialty Drugs Notes & source Medicines placed in the plan’s specialty category, often requiring special handling or monitoring.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-10-12): 20% Coinsurance for each Preferred Specialty Medication; 50% Coinsurance for each Specialty Medication. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Supply limits and coverage conditions Notes & source Retail, mail-order and specialty prescription terms, with the source drug tiers and exceptions retained.	Generic Drugs; Preferred Brand Drugs · Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Non-Preferred Brand Drugs · Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. Insulin limit: $35 for a 30 day supply and $105 for a 90 day. Specialty Drugs · Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill.
Formulary tier 1 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply.	Drug category: Preferred Generic Three-month in-network mail order: Yes
Formulary tier 2 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply.	Drug category: Generic Three-month in-network mail order: Yes
Formulary tier 3 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply.	Drug category: Preferred Brand Three-month in-network mail order: Yes
Formulary tier 4 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply.	Drug category: Brand Three-month in-network mail order: Yes
Formulary tier 5 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply.	Drug category: Preferred Generic, Preferred Brand, Specialty Drugs Three-month in-network mail order: No
Formulary tier 6 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply.	Drug category: Generic, Brand, Specialty Drugs Three-month in-network mail order: No
Formulary tier 7 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply.	Drug category: Medical Service Drugs Three-month in-network mail order: No

Pregnancy and childbirth: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Prenatal and Postnatal Care Notes & source Care during pregnancy and after childbirth.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Delivery and All Inpatient Services for Maternity Care Notes & source Care for childbirth and related inpatient services.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Abortion for Which Public Funding is Prohibited Notes & source The filing’s category for abortion services that cannot receive public funding.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Benefit details: Coverage includes termination of pregnancy for all members. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Therapy and recovery: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Hospice Services Notes & source Care focused on comfort and support near the end of life.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 14 Limit unit: Days per Lifetime Benefit details: Limit applies to respite care only Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Home Health Care Services Notes & source Medical care delivered at home under a care plan.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 130 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Skilled Nursing Facility Notes & source Care in a facility providing skilled nursing or rehabilitation.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 60 Limit unit: Days per Year Benefit details: Coverage is limited to 60-inpatient days/year. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Outpatient Rehabilitation Services Notes & source Therapy to help restore abilities after illness or injury without inpatient admission.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 25 Limit unit: Visit(s) per Year Benefit details: Limit combined with Occupational, Physical, and Speech therapy. Visit limit does not apply to Mental Health/Substance Abuse. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Habilitation Services Notes & source Therapy to help develop or maintain skills needed for daily activities.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Rehabilitative Speech Therapy Notes & source Therapy to restore speech, communication, or swallowing abilities.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage is limited to 30-inpatient days/year and 25-outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Rehabilitative Occupational and Rehabilitative Physical Therapy Notes & source Therapy to restore movement or the ability to carry out everyday tasks.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage is limited to 30-inpatient days/year and 25-outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services and 25 visits for Habilitative Services. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Infusion Therapy Notes & source Treatment that delivers medicine or fluids through a needle or catheter.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Benefit details: Covered under applicable benefit (such as office visit). Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Durable Medical Equipment Notes & source Medical equipment for repeated use, such as a wheelchair or home oxygen equipment.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Other services: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Infertility Treatment Notes & source Medical services to evaluate or treat difficulty becoming pregnant.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Exclusions: Only evaluations to determine if and why a covered member is infertile and artificial insemination are covered. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Chiropractic Care Notes & source Care provided by a chiropractor, including listed spinal or joint treatments.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 10 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Hearing Aids Notes & source Devices that help improve hearing.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per 3 Years Exclusions: An annual hearing exam and one hearing aid per ear every 3 years is covered. Cochlear Implants for children are also covered. Benefit details: Coverage is limited to one hearing aid per ear every 3 years. Cochlear Implants are also covered. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Routine Foot Care Notes & source Regular foot care, such as listed nail or callus services.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Acupuncture Notes & source Treatment using thin needles placed at specific points on the body.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Dialysis Notes & source Treatment that filters the blood when the kidneys cannot do so adequately.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Chemotherapy Notes & source Drug treatment used for cancer and certain other conditions.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Exclusions: Coverage of oral anti-cancer drugs is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy; other chemotherapy is covered under the applicable service (such as office visit). Benefit details: Covered under the base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Radiation Notes & source Treatment using targeted radiation, commonly for cancer.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Benefit details: Covered under the base benchmark plan; covered under applicable benefit (such as office visit). Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Diabetes Education Notes & source Instruction to help a person manage diabetes.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Prosthetic Devices Notes & source Devices that replace a missing body part.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Temporomandibular joint (TMJ) treatment Notes & source Treatment for problems affecting the jaw joint and nearby muscles.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Nutritional Counseling Notes & source Professional guidance on food choices and nutrition.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Diabetes Care Management Notes & source Coordinated support for managing diabetes and its treatment.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Inherited Metabolic Disorder - PKU Notes & source Care for phenylketonuria, an inherited condition affecting how the body processes part of dietary protein.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Gender Affirming Care Notes & source Health services that support a person’s gender identity.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Benefit details: Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Hearing exams Notes & source Assessments of hearing; consult the filed benefit for limits and member costs.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: No Charge Coverage: Covered Benefit details: Coverage is limited to an initial assessment and one annual hearing exam. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Bariatric Surgery Notes & source Listed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms.	Source statement: Bariatric Surgery is listed in the source exclusions; review the qualifications. Source exclusion context: The 2027 sample SBC generally excludes bariatric surgery; cosmetic surgery except congenital anomalies; adult dental care; infertility treatment; long-term care; private-duty nursing; routine adult eye care; and weight-loss programs. The sample booklet preserves specified artificial-insemination services and infertility diagnostic procedures under Other Professional Services. This is a partial list with exceptions; consult the issued contract for full terms.

Dental and vision: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Routine Eye Exam for Children Notes & source Regular vision exams for children.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Exam(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Eye Glasses for Children Notes & source Prescription eyeglasses for children.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per Year Benefit details: Coverage is limited to one frame and one pair (two lenses)/ calendar year or contacts (in lieu of glasses). Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Dental Check-Up for Children Notes & source Routine dental exams for children.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: No Charge Coverage: Covered Service limit: Yes Limit amount: 2 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Basic Dental Care - Child Notes & source Dental services classified as basic care for children, such as listed fillings.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 20.00% Coverage: Covered Service limit: Yes Limit amount: 2 Limit unit: Exam(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Orthodontia - Child Notes & source Treatment to align children’s teeth or jaws, such as braces.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coverage: Covered Benefit details: Medically necessary orthodontia must be covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Major Dental Care - Child Notes & source Dental services classified as major care for children.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 50.00% Coverage: Covered Benefit details: Quantitative limits apply; see essential health benefits base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Dental Anesthesia Notes & source Anesthesia used during dental treatment.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 35.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Network and access: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Provider network Notes & source The insurer’s name for the network linked to this plan. Check the current provider directory to confirm a doctor or hospital participates.	Legacy (Individual)
Specialist referral Notes & source Whether the plan generally requires a referral before seeing a specialist. Check the listed exceptions.	No
Referral details Notes & source The insurer’s explanation of when specialist referrals are needed.	The 2027 sample booklet says referrals are not required before using covered benefits. Some covered services require preauthorization by contracted providers. Medical-necessity and network rules still apply; consult the issued booklet for service-specific requirements.
Provider tiers Notes & source Whether in-network providers are grouped into tiers with different member costs.	No
National network Notes & source Whether the filing lists a national provider network; this does not confirm any particular provider participates.	No
Care outside the country Notes & source Whether the filing lists coverage outside the country; restrictions may apply.	No
International care details Notes & source The insurer’s explanation of coverage and restrictions outside the country.	Possible source conflict: the 2027 sample SBC lists non-emergency care when traveling outside the U.S., while the sample booklet limits out-of-area Inter-Plan benefits to emergencies and certain prior-approved services. Blue Cross Blue Shield Global Core may help access covered services, but does not expand those benefits. Upfront payment, itemized claims and balance billing may apply. Confirm non-emergency overseas coverage with Regence.
Care outside the service area Notes & source Whether the filing lists coverage away from the plan’s normal service area.	No
Outside-area care details Notes & source The insurer’s explanation of care covered away from the normal service area.	Legacy EPO: the 2027 sample booklet limits services processed through out-of-area Inter-Plan Arrangements to emergency care (including ambulance) outside Regence’s or its affiliates’ geographic area, plus out-of-network services Regence has approved in advance when reasonable in-network access is unavailable. Other services under those arrangements are not covered. Confirm network and travel benefits with Regence.

Health accounts: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
HSA-compatible plan Notes & source Whether the filing identifies the plan as HSA-compatible; your personal ability to contribute also depends on other rules.	No
Filed employer account contribution Notes & source Whether the plan filing includes an employer HSA or HRA contribution; it does not describe your employer’s actual contribution.	No
HSA in source plan name Notes & source Source name evidence only; this does not establish personal HSA eligibility.	No

Plan features and exclusions: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Wellness program Notes & source Whether the filing lists a program intended to support healthy habits.	No
Condition support programs Notes & source Programs listed to help members manage ongoing health conditions.	Case management for serious illness or injury with potential continuing major or complex care needs. Licensed health-care professionals provide information, support and guidance, coordinate with treating professionals, and may propose alternative benefits. See the 2027 sample booklet and contact Regence for applicable services.
Unique plan design Notes & source Whether the insurer marked the benefit design as distinct in its filing.	Yes
Plan exclusions Notes & source Services or situations the insurer lists as excluded from coverage.	The 2027 sample SBC generally excludes bariatric surgery; cosmetic surgery except congenital anomalies; adult dental care; infertility treatment; long-term care; private-duty nursing; routine adult eye care; and weight-loss programs. The sample booklet preserves specified artificial-insemination services and infertility diagnostic procedures under Other Professional Services. This is a partial list with exceptions; consult the issued contract for full terms.
Pregnancy notice Notes & source Whether the filing indicates a pregnancy-related notice requirement.	No
Child-only coverage Notes & source How the filing describes coverage offered for children without an enrolled adult.	Allows Adult and Child-Only

Standardized coverage examples: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Having a baby example	Example deductible: $3,500 Example copays: $10 Example coinsurance: $3,100 Example uncovered costs: $60
Managing diabetes example	Example deductible: $900 Example copays: $800 Example coinsurance: $0 Example uncovered costs: $200
Simple fracture example	Example deductible: $1,700 Example copays: $700 Example coinsurance: $0 Example uncovered costs: $0

Filing assumptions: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Calculated actuarial value Notes & source An estimate of the share of covered costs the plan pays for a standard population, not your expected spending.	0.72731760877038
Insurer actuarial value Notes & source The insurer’s estimate of the plan’s share of covered costs for a standard population.	70.91%
Tier 1 filing assumption Notes & source The use of tier 1 providers assumed in the filing, not a prediction of your care.	100%
Composite premium available Notes & source Whether the filing offers a shared premium rate instead of separate age-based rates.	No

Plan identifiers and filing context: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Plan ID Notes & source The identifier used to distinguish this plan in the filing.	71281WA1390004
Plan variation ID Notes & source Identifies this plan’s specific version of benefits and cost sharing.	71281WA1390004-00
Plan variation name Notes & source The insurer’s name for this version of the plan.	Regence Silver 3500 Legacy
Cost-sharing variation Notes & source The filed category for this version of the plan’s member costs.	Standard Silver Off Exchange Plan
Product ID Notes & source The identifier for the product family this plan belongs to.	71281WA139
Network ID Notes & source Identifies this plan’s provider network within this insurer’s filing.	WAN002
Service area ID Notes & source Identifies the area where the insurer offers this plan.	WAS002
Drug list ID Notes & source Identifies the prescription drug list referenced by this plan.	WAF010
Marketplace status Notes & source Whether the filing describes the plan as offered through the health insurance marketplace.	Off the Exchange
New or existing plan Notes & source Whether the insurer filed this as a new or continuing plan.	Existing
Effective date Notes & source The start date listed for this plan in the filing.	1/1/2027
Plan name	Regence Silver 3500 Legacy
Legal issuer	Regence BlueCross BlueShield of Oregon
Plan type	EPO

Carrier virtual care: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Virtual care options	2027 sample booklet: telehealth (live remote visits) and store-and-forward services (asynchronous care) have an in-network cost share of $10 Copay, Deductible waived. This Legacy EPO has in-network benefits only, subject to the booklet’s exceptions. Some providers may offer lower cost sharing; confirm the provider and service with Regence. Separate facility fees use the Other Professional Services benefit.

Unknown or not provided (15)

Unknown or not provided: Regence Silver 3500 Legacy
Benefit	Regence Silver 3500 Legacy
Specialty drug coinsurance cap How costs are shared	Not supplied in selected filing
Hospital copay day limit How costs are shared	Unknown
Primary care visits before cost sharing How costs are shared	Not supplied in selected filing
Primary care copays before other charges How costs are shared	Unknown
Filed contribution amount Health accounts	Not supplied in selected filing
Plan design Plan features and exclusions	Unknown
Adult dental waiting period Plan features and exclusions	Not supplied in selected filing
Waiting period length Plan features and exclusions	Not supplied in selected filing
Tier 2 filing assumption Filing assumptions	Unknown
Essential benefit premium share Filing assumptions	Not supplied in selected filing
Children’s dental allocation Filing assumptions	Not supplied in selected filing
Rate description Filing assumptions	Not supplied in selected filing
Child-only plan ID Plan identifiers and filing context	Not supplied in selected filing
Tribal cost-sharing variation Plan identifiers and filing context	Not supplied in selected filing
Expiration date Plan identifiers and filing context	Unknown

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Plan documents

2027 · Public plan ID 71281WA1390004 · Benefit variant 71281WA1390004-00

Summary of Benefits and Coverage (SBC)

Document notes

Original identity review: 2027 carrier sample SBC. The enrolled coverage period and group name are placeholders; this is not an executed group contract. Network label discrepancy: the selected filing maps this small-group plan to WAN002, labelled Legacy (Individual), while the carrier’s 2027 small-group catalog and sample documents call it Legacy. Exact plan title, issuer, EPO type and Clark County scope agree; confirm network applicability with Regence. Possible source conflict: the 2027 sample SBC lists non-emergency care when traveling outside the U.S., while the sample booklet limits out-of-area Inter-Plan benefits to emergencies and certain prior-approved services. Blue Cross Blue Shield Global Core may help access covered services, but does not expand those benefits. Upfront payment, itemized claims and balance billing may apply. Confirm non-emergency overseas coverage with Regence. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Carrier document index

Document notes

Carrier source index; formats and available documents vary. 2027 carrier sample SBC. The enrolled coverage period and group name are placeholders; this is not an executed group contract. Network label discrepancy: the selected filing maps this small-group plan to WAN002, labelled Legacy (Individual), while the carrier’s 2027 small-group catalog and sample documents call it Legacy. Exact plan title, issuer, EPO type and Clark County scope agree; confirm network applicability with Regence. Possible source conflict: the 2027 sample SBC lists non-emergency care when traveling outside the U.S., while the sample booklet limits out-of-area Inter-Plan benefits to emergencies and certain prior-approved services. Blue Cross Blue Shield Global Core may help access covered services, but does not expand those benefits. Upfront payment, itemized claims and balance billing may apply. Confirm non-emergency overseas coverage with Regence.

2027 Medical Benefit Summary — Regence Silver 3500 Legacy

Document notes

Original identity review: 2027 carrier medical benefit summary, January 1–December 31, 2027. Read with the sample SBC and booklet; this summary is not the issued group contract. Network label discrepancy: the selected filing maps this small-group plan to WAN002, labelled Legacy (Individual), while the carrier’s 2027 small-group catalog and sample documents call it Legacy. Exact plan title, issuer, EPO type and Clark County scope agree; confirm network applicability with Regence. Possible source conflict: the 2027 sample SBC lists non-emergency care when traveling outside the U.S., while the sample booklet limits out-of-area Inter-Plan benefits to emergencies and certain prior-approved services. Blue Cross Blue Shield Global Core may help access covered services, but does not expand those benefits. Upfront payment, itemized claims and balance billing may apply. Confirm non-emergency overseas coverage with Regence. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

2027 Sample Benefit Booklet — Regence Silver 3500 Legacy

Document notes

Original identity review: 2027 carrier sample benefit booklet with plan-specific benefit inserts. Group name, plan name, group number and enrolled effective date contain placeholders; confirm the issued contract and current provider participation. Network label discrepancy: the selected filing maps this small-group plan to WAN002, labelled Legacy (Individual), while the carrier’s 2027 small-group catalog and sample documents call it Legacy. Exact plan title, issuer, EPO type and Clark County scope agree; confirm network applicability with Regence. Possible source conflict: the 2027 sample SBC lists non-emergency care when traveling outside the U.S., while the sample booklet limits out-of-area Inter-Plan benefits to emergencies and certain prior-approved services. Blue Cross Blue Shield Global Core may help access covered services, but does not expand those benefits. Upfront payment, itemized claims and balance billing may apply. Confirm non-emergency overseas coverage with Regence. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

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Regence Silver 3500 Legacy

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Plan benefits

▾Network overview

▾Annual deductibles (1)

Medical and prescription drug deductible

▾Annual out-of-pocket limits (1)

Maximum Out of Pocket for Medical and Drug Benefits (Total)

▾How costs are shared (2)

Combined medical and drug deductible

Combined medical and drug spending limit

▾Office and routine care (5)

Primary Care Visit to Treat an Injury or Illness

Specialist Visit

Other Practitioner Office Visit (Nurse, Physician Assistant)

Preventive Care/Screening/Immunization

Well Baby Visits and Care

▾Tests and imaging (4)

Imaging (CT/PET Scans, MRIs)

Laboratory Outpatient and Professional Services

X-rays and Diagnostic Imaging

Allergy Testing

▾Urgent and emergency care (3)

Urgent Care Centers or Facilities

Emergency Room Services

Emergency Transportation/Ambulance

▾Hospital and surgery (7)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Outpatient Surgery Physician/Surgical Services

Inpatient Hospital Services (e.g., Hospital Stay)

Inpatient Physician and Surgical Services

Cosmetic Surgery

Transplant

Reconstructive Surgery

▾Mental health and substance use (4)

Mental/Behavioral Health Outpatient Services

Mental/Behavioral Health Inpatient Services

Substance Abuse Disorder Outpatient Services

Substance Abuse Disorder Inpatient Services

▾Prescription drugs (12)

Generic Drugs

Preferred Brand Drugs

Non-Preferred Brand Drugs

Specialty Drugs

Supply limits and coverage conditions

Formulary tier 1

Formulary tier 2

Formulary tier 3

Formulary tier 4

Formulary tier 5

Formulary tier 6

Formulary tier 7

▾Pregnancy and childbirth (3)

Prenatal and Postnatal Care

Delivery and All Inpatient Services for Maternity Care

Abortion for Which Public Funding is Prohibited

▾Therapy and recovery (9)

Hospice Services

Home Health Care Services

Skilled Nursing Facility

Outpatient Rehabilitation Services

Habilitation Services

Rehabilitative Speech Therapy

Rehabilitative Occupational and Rehabilitative Physical Therapy

Infusion Therapy

Durable Medical Equipment

▾Other services (17)

Infertility Treatment

Chiropractic Care

Hearing Aids

Routine Foot Care

Acupuncture

Dialysis

Chemotherapy

Radiation

Diabetes Education

Prosthetic Devices

Temporomandibular joint (TMJ) treatment

Nutritional Counseling

Diabetes Care Management