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7/24/2019 04821_OR Group Fully Insured Bound Packet 9-12
1/28
RegenceBlueCrossBlueShieldofO
regonisanIndependent
LicenseeoftheBlueCrossandBlu
eShieldAssociation
Group Enrollment
Guide
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Regence
BlueCrossBlueShield
ofOregon
isanIndependentLicenseeoftheBlueCrossandBlue
ShieldAssociation
W H A T Y O U N E E D T O K N O W A B O U T
PREVENTIVE HEALTH CARE COVERAGE
Wondering what preventive care services are covered
by your health plan? As youre probably aware,
the federal health care reform law passed in 2010
requires insurers to include specific preventive care
services in their benefit plans. Regence supports that
initiative. In fact, Regence plans already provided benefits
for many preventive care services, as we have long
believed that preventive care and early detection
are key to the long-term health and well-being of our
members. This brochure explains preventive care
eligibility and shows which services are available to
you and the family members covered by your plan.
Whos eligible for these preventive services?
To be eligible for these preventive services, you must
first be covered by a current Regence policy.
Benefits for the federally required preventive services:
Are not required in grandfathered policies,which are essentially policies that were in effect
on March 23, 2010, as long as few or no benefit
changes have been made to them (please note
that Regence has chosen to retain grandfathered
status for a very limited number of policies)
May be covered by grandfathered plans that have
chosen to include the benefit
May apply to retiree-only plans
Apply to Association plans at the Associations
plan renewal date
What preventive services are covered?
Regence follows government guidelines to determine
which preventive services we cover1.
These guidelines are updated periodically to reflect
new scientific and medical advances. Additionally,
current services could be revised and subject to
different limitations; thus, benefits are subject tochange. New guidelines will be implemented within
one year of the recommendations publication.
You can learn more details about these services at
healthcare.gov, including recommended child and
adolescent immunization schedules.
What is the coinsurance/copay for these
preventive services?
The services listed in this brochure will be paid at 100%
(no deductibles, coinsurance or copays) when you
see preferred or participating providers (Category 1 orCategory 2) or in-network providers. Deductibles and/or
coinsurance may apply when you see other providers.
To find out if youre eligible for preventive
coverage, call the Customer Service number
on the back of your member card or go to the
Contact Us link at regence.com.
1Evidence-based preventive guidelines are developed and validated by the following government entities:
United States Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
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Men
Women
PregnantWomen
Children(0-17)
Health screenings, counseling and
services for:
Suggested guidelines
Adult abdominal aort ic aneurysm Screening is covered once per l ifet ime for men age 65and over if they have
ever smoked.
Alcohol misuse Screening and behavioral counseling intervention covered for adults
age 19and older.
Anemia (iron deficiency) Screening covered up to age 21, and pregnant women.
Bacteriur ia (ur inary tract infect ion) Screening for asymptomatic pregnant women.
Blood pressure Screening covered for adults age 18and older.
Breast cancer Screening for women age 40and older and those at increased risk.
Mammograms only.
Breast cancer chemoprevention Counseling for women at increased risk.
Breastfeeding equipment Manual and electric breastfeeding pumps are covered when purchased or rentedfrom a licensed provider. Off-the-shelf pumps from a retail outlet are not covered.
Hospital-grade pumps are not covered. See Note 1.
Breastfeeding - lactation support and
counseling
Lactation support and counseling are covered when provided by a
licensed provider.
Breastfeeding supplies Initial breastfeeding supplies provided with a breastfeeding pump. See Note 1.
Cervical cancer Screening for sexually active women.
Chlamydia infection Screening for infection.
Cholesterol Screening for men age 35and older and men ages 20-35who are at increased
risk for coronary heart disease. Screening for women age 45and older and those
20-45who are at increased risk for coronary heart disease.
Colorectal cancer Screening for those age 50and older, once every 5 years for a sigmoidoscopy and
every 10 years for a colonoscopy, fecal occult blood testing annually.
Congenital hypothyroidism Screening for newborns.
Contraceptive education and training Education and training on contraceptive methods. See Notes 1 and 2.
Contraceptive devices - implants, cervical caps,
intrauterine devices (IUDs), diaphragms
Generic contraceptive devices are covered. When no generic exists, a brand is
covered. If a generic becomes available, the brand will no longer be covered under
Preventive Care.
Insertion of a device is covered under Preventive Care. Removal is covered at
regular plan benefits if a Family Planning benefit applies. See Notes 1 and 2.
Depression screening Screening during wellness exams.
Diabetes (Type 2) Screening for adults with sustained high blood pressure.
Diabetes (Gestational) Screening for pregnant women between 24and28 weeksof gestation and the
first pre-natal visit for pregnant women at high risk for diabetes. See Note 1.
Diet behavioral counseling Counseling for adults with hyperlipidemia and other risk factors.
Genetic risk assessment and BRCA (breast
cancer susceptibility) mutation counseling
For women with family risk of breast and ovarian cancer.
Gonorrhea medication Preventive medication for the eyes of newborns.
Gonorrhea screening Screening for males up to age 21and all females.
Hearing One screening in the first year of life for newborns.
Covered preventive services
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Men
Women
PregnantWomen
Children(0-17)
Hepatitis B Screening for pregnant women.
HIV Screening and counseling during wellness exams for sexually active women.Screening during wellness exams for men, women and children at increased risk.
HPV Screening for women from age 30, every 3 years. See Note 1.
Interpersonal and domestic violence Screening and counseling during wellness exams. See Note 1.
Lead screening Screening up to age 21.
Metabolic screening Screening up to age 2 months.
Obesity Screening and counseling for age 6and older.
Oral health Risk assessment for preschool children.
Osteoporosis Screening for women age 65and older and all women at increased risk.
Phenylketonuria (PKU) Newborn screening for genetic disorders.
RH(D) incompatibility Screening for pregnant women.
Sexual ly transmitted infection (STI) Counseling dur ing wellness exams.
Sickle cell Screening for children up to 12months old.
Sterilization Sterilization is covered. See Notes 1 and 2.
Syphilis Screening for those at increased risk and those up to age 21;
also includes pregnant women.
Tobacco use Counseling and interventions. Does not include programs or classes.
See also Tobacco use below.
Tuberculosis Skin test for children.
Vision Screening for children age 3up to age 5.
Immunization vaccines -
please consult your physicianfor frequency
Diphtheria, pertussis, tetanus (DPT)
Haemophilus influenzae type b (Hib)
Hepatitis A
Hepatitis B
Herpes zoster (shingles) Age 60and older.
Human papillomavirus (HPV) Up to age 27.
Inactivated poliovirus
Influenza
Measles, mumps, rubella (MMR)
Meningococcal
Pneumococcal
Rotavirus
Varicella
Covered preventive services
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Men
Women
PregnantWomen
Children(0-17)
Prescription medications
Only the types of prescription medications listed below are covered under Preventive Care.
Medications require a prescription. Over-the-counter products are not covered.
Get the most value for your health care dollar with preferred medications. Learn more at regencerx.com/learn/covered.
Aspirin use for the prevention of
cardiovascular disease
For men age 45-79and women age 55-79.
Contraceptive injectables Generic contraceptive injectables. See Notes 1 and 2.
Contraceptive pills Generic contraceptive pills. See Notes 1 and 2.
Contraceptive products-topical Diaphragms and patches. See Notes 1, 2 and 3.
Emergency contraceptive products Generic contraceptive pills. See Notes 1, 2 and 3.
Fluoride supplements For children 6months through age 6without sufficient fluoride
Folic acid supplements For all women planning or capable of pregnancy.
Iron supplements For children age 6-12months at increased risk - drops only.
Tobacco use Generic tobacco cessation medications.
Wellness exams Suggested guidelines
Well-child exams For children through 17years of age.
Annual physical exams Ages 18and over.
Notes:
1. This benefit is available upon renewal of your plan, on or after August 1, 2012.
2. This benefit may not be available to members of groups who have applied for a religious exemption from contraceptive coverage.
3. Generic contraceptives are covered. When no generic exists, a formulary brand is covered. If a generic becomes available,
the formulary brand will no longer be covered under Preventive Care.
05394rep04976-or / 09-122012. Regence BlueCross BlueShield of Oregon, all rights reserved.
Have questions? Call the Customer Service number on the back of
your member card or go to the Contact Us link at regence.com.
Covered preventive services
7/24/2019 04821_OR Group Fully Insured Bound Packet 9-12
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IndependentLicenseeoftheBlueCrossandBlueShield
Association
GIVE OUR ONLINE PROVIDER DIRECTORY A TRY
Finding a doctor online takes just seconds. Whether you want toknow if your doctor is in your network or need to find a new one,our online provider directory can help.
Browse our database
1. Go to regence.com.
2. Click on Find a Providerat the top right of the screen.
3. Enter your ZIP code.
4. Provide a clinic name or specialty (optional). Then click Search.
Find a specific doctor
1. Go toAdvanced Search.
2. Make a selection under Provider Type.
3. Key the providers last name into the Namefield under Provider Options.
4. Enter your location.
Create a list of providers
1. Make a selection under Provider Type.
2. Choose a specialty from the drop-down box that appears under your selection.
3. Under Provider Options, choose your network from the Network Affiliation
drop-down box.
4. Choose language or gender if you have a preference.
5. Enter your location.
Let us know if we can help
Customer Service can also assist you with your doctor or pharmacy search, and tell youwhether yours is in the network. Just give us a call at one of the following numbers:
Regence HSA Healthplan 2.0SM:
1 (877) 508-7357
Regence Innova,Regence EngageSM:
1 (888) 367-2116
04978-or / 12-11
2011. The Regence Group, all rights reserved.
Finding a doctorisquick and easy!
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Regence has covered
A C R O S S T H E C O U N T R Y A N D
A R O U N D T H E W O R L D.
With coverage from Regence, you take your health care benefits with you
across the country and around the world. The BlueCard Program gives you
access to doctors and hospitals nearly everywhere, so youll have peace of
mind knowing that you can always find the health care provider you need.
Choices
Your Regence membership gives you a world of choices. Through the
BlueCard Worldwide Program, youre free to choose doctors and
hospitals that best suit you and your family in more than 200 countries
and territories around the world.
Designed to save money
In most cases, when you travel or live outside the Regence service
area, you can take advantage of savings the local Blue Plan has
negotiated with providers in the area where you are. For covered
services, you should not have to pay any amount above thesenegotiated rates. You should also not have to pay amounts above
any applicable out-of-pocket expenses.
Regence
BlueCrossBlueShield
ofOregon
isanIndependentLicenseeoftheBlueCrossandBlue
ShieldAssociation
The BlueCardProgram
BlueCard Program Advantages
PROVIDER CHOICEYou have access to more than 85% of providers
and 96% of hospitals nationwide.
BENEFIT CONSISTENCY
BlueCard ensures that you receive in-network
benefits when choosing participating providers of any
Blue Cross and/or Blue Shield Plan.
BILLING PROTECTION
Accessing a Blue Cross and/or Blue Shield Plan
participating provider ensures that you are not
responsible for any balance billed amount.
EASE OF ACCESSIts quick and easy to locate a participating provider
at bcbs.comor by calling (1-800-810-BLUE).
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03781-or / 06-11
2010. The Regence Group, all rights reserved.
To learn more about the BlueCard
program, call your local Blue Plan
or visit regence.com.
BlueCard and BlueCard Worldwide are registered service marks of the
Blue Cross and Blue Shield Association.
You see a provider
outside the Regence
service area
Participating provider
provides care for youLocal Blue Plan
prices the claim and
submits it to Regence
Processes the claim and
authorizes payment
Sends an explanation of
benefits to you
Local Blue Plan
pays provider
How it works
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Imagine a place where you can find answers and support for all of your health needs. myRegence.com is your
complete source of health and wellness information. And its simple to understand. So whether you want to get
started on an exercise program, need tips on eating healthier, or just want to know if weve paid your claim,
visit myRegence.com today.
myRegence.comEverything youve always wanted to know about your health. In one place.
Reg
ence
BlueCrossBlueShield
ofOregon
isan
IndependentLicenseeoftheBlue
Crossand
BlueSh
ieldAssociation
RewardHealthy living has its own rewards, but Regence Rewards
points can help.
Earnpoints for browsing our health news, podcasts
and videos.
Receivepoints for healthy everyday activitiessuch as
eating fruits and veggies and walking the dog, or joining
an online wellness program.
Redeempoints for an Amazon.com gift card.
NavigateDiscover tools that help you track your your
coverage and make informed decisions about
your health care.
Reviewdetails about your coverage.
Manageyour claims online and eliminate paper
Explanation of Benefits.
Finda doctor or specialist and read patient
reviewsonline or on your mobile device.
Createa secure, confidential Personal Health Record. Discussa variety of important health and wellness topics on My Community,
a nationwide social networking site.
AdviseConsider health care decisions, explore treatment options
and plan ahead for financial needs.
Comparecost and quality of hospitals, clinics
and providers.
Researchtreatment options and out-of-pocket
cost estimates.
Learnabout medical conditions, medications and
cost-saving generics.
Exploreand enjoy health articles, videos and podcasts.
7/24/2019 04821_OR Group Fully Insured Bound Packet 9-12
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myRegence.comWant more value for your health care dollars? Log on to myRegence.com and discover
online resources and interactive experiences focused on your health. Its easy to join and
youll earn 5,000 points with Regence Rewards just for registering.
Become an informed health care consumer.
Log on today and earn 5,000 points.
Simply use the information on your member card and follow these steps.
1. Go to myRegence.com.
2. Click New Member Registration.
3. Complete the required MyMember Account Informationfields. The name,
member and group numbers you enter must match your member card.
4. Create a user name and secure password.
5. Click Register and Login.
Take a confidential General Health Assessment. Earn up to 10,000 points.
Learn how youve been managing your health to date, and get practical tips on how to
improve your health and well-being.
Manage stress and get into shape. Earn 5,000 points at completion.
Reach for a healthy lifestyle with wellness programs on Weight Loss, Healthier Diet, Stress
Relief, Healthy Aging, going Smoke-Free and more.
Keep your health history at your fingertips. Earn up to 6,000 points.Create a secure, confidential record of your medical history with the Personal
Health Record tool. Input your own information about allergies, immunizations, emergency
contacts and more.
Get social in My Community. Earn up to 2,400 points.
Join the conversation and earn points for posting in My Communityan online health and
wellness social networking site where members nationwide are talking, asking questions of
our experts, following bloggers and receiving support in achieving their goals.
What are you waiting for? Register now at myRegence.com!
05212 rep 03212-or / 04-12 2012. Regence BlueCross BlueShield of Oregon, all rights reserved
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Find your wayaround your Rx plan
I N A F L A S H.A quick guide to your RegenceRx prescription program
Heres a quick reference sheet to help you better understand your
prescription benefits and find the Rx information you need. Its one more
tool you can use to navigate the health care system and make informed
decisions about your care. Check it out!
With more than 65,000 pharmacies in our network, its easy to find
one near you.
Using your Rx benefits
Simply present your Regence member card at the pharmacy, and the
pharmacist will submit your claim online. The system will calculate the claim
cost based on your pharmacy benefit, then the pharmacist will tell you how
much you owe.
Your member card
Take a minute to look at your member card. It verifies that you haveprescription coverage and gives our participating pharmacies everything
they need in order to submit your claim online. If you have questions, just
call us at the phone number on the back of your card.
Your deductible and copay
If you have a plan with a pharmacy deductible, then youll pay for
each covered prescription in full until youve met your deductible.
(The pharmacist will still submit your claim as usual so that your purchase
counts toward your deductible.) After you meet your deductible, then youll
simply pay your portion of the cost (copay/coinsurance).
If you have a plan with a copay only (no deductible), then youll just pay that
amount for each covered prescription medication when you pick it up.
Youll find your prescription deductible and copay amounts summarized in
your benefits booklet on myRegence.com.
Regence
BlueCrossBlueShield
ofOregon
isanIndependentLicenseeoftheBlueCrossandBlue
ShieldAssociation
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Generics: another way to save
Youll save money by using generic medications
whenever possible. If the medication you need is not
available in generic form, ask your doctor if another
generic can be used to treat the same condition, or if
there is a less expensive brand-name medication. Your
doctor is the best person to determine the medication
thats right for you.
Prior authorization and our Generics First policy
Some brand-name medications require prior
authorization to ensure theyre covered, such as
antidepressant, diabetes, pain, heartburn and
cholesterol medications. Go to regenceRx.com and
click on Prior Auth/Medication Quantities in the
Learn About Medications section for a list of
medications needing prior authorization.
If you take one of these medications or keep one on
hand to use as needed, then youll need to do one
of two things in order to be sure your medication will
continue to be covered:
1. Try a generic first! Switch to a generic version of
the brand-name medication you are taking. Just
ask your pharmacist to fill your prescription withthe generic rather than the brand-name.
or
2. Get prior authorization for that brand-name
medication. The brand-name medication might be
denied if it hasnt been approved ahead of time.
Ask your doctor or pharmacist to send a prior
authorization request with your medical or
medication history before your next refill. Your
pharmacist may fax your prescription profile
to 1 (888) 437-1510 or call 1 (800) 643-5918.
Filing claims and getting reimbursed
The pharmacist will file your claim for you, and well
pay the pharmacy directly, so you wont have to worry
about paperwork or getting reimbursed. In the rare
event that you do need to file a claim, we make it
painless. Just go to regenceRx.com to download the
proper claim form, or give us a call at the number on
the back of your member card.
If you misplace your member card, well replace
it. Just call us toll-free at 1 (888) 367-2116 or
visit myRegence.com.
Explore regenceRx.com: a site devoted to
your Rx benefits
Visit regenceRx.com for information specifically
related to your RegenceRx prescription benefit.
Use it to:
Find a participating pharmacy
Access our formulary
Learn about your medication choices
Preview medications to learn if they require
prior authorization, or if they have any limitations
or restrictions
Print out a prescription claim form
Go to myRegence.comto make the most
of allyour benefits
To discover all the advantages of your Regence
membership beyond prescriptions, go to
myRegence.com. There you can view and manage
details related to your medical and prescription
coverage, explore events and rewards for healthy
living, and plan ahead using our Health Cost Estimators.
Maximize your benefit: Always
show your member card to the
pharmacy where you purchase
your prescriptions.
05219rep03460-or / 04-12
2012. Regence BlueCross BlueShield of Oregon, all rights reserved.
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Get more value for your dollar
WITH TIPS AND TOOLS
from regenceRx.com.
Raise your pharmacy IQ. Control your medication costs.
Your online Rx tools
Load up on cost-saving ideas and health care knowledge with the
user-friendly tools at regenceRx.com. There youll find a preferred
medication list, a glossary of insurance terms, prior authorization
information, a pharmacy locator, specialty program information, facts
about generics and much more. Here are just a few of the tools that can
help you make the most of every dollar:
RxPrice GuideBecome more informed about your medication costs
and options. After youve checked to see whether a medication is on our
preferred medication list (also known as a formulary), you can use the
RxPrice Guide to browse the costs of commonly prescribed medications.
Youll get detailed pricing on brand-name medications and their
generic alternatives.
Health CalculatorsThese online calculators can help you see
health-minded behaviors from a financial perspective. Youll learn the
cost of bad habits and the benefits of good choices. For instance,
calculate the actual out-of-pocket cost of smoking, or estimate how long
it might take to lose weight by doing your favorite activity.
ConsumerRxThese educational summaries help you understand your
medication optionswithout the medical jargon. Youll find overviews of
different conditions and the medications that are used to treat them,
along with facts and tips to help you save money.
RegenceBlueCrossBlueShield
ofOregon
isanIndependentLicenseeoftheBlueCrossandBlue
ShieldAssociation
03454-or / 6-11
Visit regenceRx.comtoday, and take full advantage of all that
RegenceRx has to offer.
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Prior authorization helps
protect our members
from harm and high costs.
Prior authorization is a small
step that has a huge impact on
safety and savings
We sometimes need more
information about a medication
before we can cover it. We get
that information through the
prior authorization process.
Not all medications need prior
authorization. But for those
that do, this process helps
ensure that you get the best in
safety and value.
Here are some reasons a
prescription might need
prior authorization:
It has been proven to benefit
only a limited number of people
Unusually large doses are
requested for coverage
Equally effective but more
affordable generic options
are available
Its prescribed for conditions not
covered by your health plan
It hasnt been thoroughly tested
by the scientific community or
approved by the FDA for
certain uses
If your medication is on our prior
authorization list, well need
information from your doctor
or pharmacist.
When prior authorization works
Our pharmacists and doctors
tirelessly research medications for
safety, effectiveness and overall
value. Were committed to sharing
this information with you through
the prior authorization list.
The prior authorization process
is simple:
Your doctor or pharmacist can
request prior authorization by
going to regencerx.com/pa,
calling 1 (800) 643-5918, or
faxing 1 (800) 884-4282.
Our team of clinical pharmacists
and pharmacy technicians
carefully reviews each request,
taking into consideration our
evidence-based reviews of
scientific research. Any request
that cant be approved is then
reviewed by a physician
medical director.
Well contact you, your doctor,
and your pharmacy within two
business days with our decision.
If we find that the medication is
the best value for your condition,
the medication will generally be
authorized. If not, the medication
wont be covered.
If your medication isnt covered,
well share a clear explanation of
our reasons, along with potential
covered alternatives, if available.
Your prior authorization support
Naturally, you and your doctor are
the best people to determine the
medication thats right for you. If
you have questions or concerns
about prior authorization, were
here to help. Heres how you can
reach us:
To determine if a medication
needs approval, visit
www.regencerx.comand look
under Learn About
Medications.
To review our medication
policies, visit www.regencerx.
com/learn/policy/index.html.
To speak to Pharmacy Custome
Service, call 1 (800) 643-5918.
g
g
isanIndependentLicensee
ofthe
Blue
Crossand
Blue
Shield
Association
088-or / 2-12
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Prior authorization helps ensure that covered medications provide the best safety and value. Itis needed when a medication has only been proven to benet a limited number of people or ifunusually large doses are requested for coverage.
These medications require prior authorizationbecause alternatives may offer a better value Possible alternatives
Cholesterolatorvastatin, Crestor
simvastin(Zocor), pravastatin (Pravachol
), lovastatin (Mevacor
)
Lipitor, Livalo
, Vytorin
simvastin(Zocor
), pravastatin (Pravachol
), lovastatin
(Mevacor), Crestor
DepressionCymbalta
, Pristiq, Viibryd
bupropion SR (Wellbutrin SR), bupropion XL 300mg (Wellbutrin
XL), uoxetine(Prozac
), uvoxamine maleate, mirtazapine
(Remeron), paroxetine(Paxil
), sertraline(Zoloft
)
DiabetesACTOplus Met, Actos
, Avandamet
, Avandaryl,
Avandia,Bydureon, Byetta
,Duetact, Janumet
,
Janumet
XR, Januvia
, Jentadueto
, Juvisync
,KombiglyzeXR, Onglyza, Tradjenta, Victoza
metformin (Glucophage), glimepiride (Amaryl
), glipizide
(Glucotrol), glyburide (Diabeta
), insulin
High Blood PressureBenicar, Benicar HCT, Micardis, Micardis HCT
benazepril/HCT(Lotensin/HCT), captopril/HCT (Capoten/
Captozide), enalapril/HCT (Vasotec/Vaseretic
),fosinopril/
HCT(Monopril/HCT), lisinopril/HCT(Zestril/Zestoretic
,
Prinivil/Prinzide), losartan/HCT(Cozaar/Hyzaar
), moexipril/
HCT(Univasc/Uniretic), quinapril/HCT (Accupril/Accuretic
),
trandolapril(Mavik)
Amturnide, Atacand, Atacand-HCT, Avalide,
Avapro, Azor, Diovan, Diovan HCT, Edarbi,Exforge, Exforge HCT, Tekamlo, Tekturna
, TekturnaHCT, Teveten, Teveten HCT, Tribenzor, Twynsta,Valturna
benazepril/HCT (Lotensin/HCT), captopril/HCT(Capoten/
Captozide), enalapril/HCT (Vasotec/Vaseretic
), fosinopril/
HCT(Monopril/HCT), lisinopril/HCT(Zestril/Zestoretic
, Prinivil/
Prinzide), losartan/HCT(Cozaar/Hyzaar
), moexipril/HCT (Univasc/
Uniretic), quinapril/HCT(Accupril/Accuretic
), trandolapril
(Mavik), Benicar
, Benicar HCT
, Micardis
, Micardis HCT
Mental HealthAbilify
, Fanapt
, Geodon
, Invega
, Latuda
, Saphris
,
ziprasidone
clozapine (Clozaril), olanzapine (Zyprexa
), risperidone
(Risperdal), Seroquel
, Seroquel XR
MigrainesMaxalt
, Maxalt-MLT
, Relpax
sumatriptan (Imitrex)
Alsuma, Amerge, Axert
, Frova
, naratriptan HCL,
SumavelDosePro, Treximet, Zomig, Zomig-ZMT
sumatriptan (Imitrex), Maxalt
, Maxalt-MLT
, Relpax
Multiple SclerosisExtavia
Avonex, Copaxone
, Rebif
Betaseron
Avonex, Copaxone
, Rebif
, Extavia
Nasal SteroidsBeconase AQ
, Nasonex
, Omnaris
, Qnasl, Rhinocort
Aqua, Veramyst
unisolide (Nasalide), uticasone(Flonase
), triamcinolone
acetonide(Nasacort
AQ)
Pain and InammationCelebrex
Generic non-steroidal anti-infammatory medications (NSAIDs)such as: diclofenac(Voltaren
), etodolac (Lodine
), urbiprofen
(Ansaid), ibuprofen(Motrin
), indomethacin(Indocin
),
ketoprofen (Orudis), nabumetone (Relafen
), naproxen
(Naprosyn), oxaprozin (Daypro
), piroxicam (Feldene
), salsalate
(Disalcid), sulindac(Clinoril
),tolmetin(Tolectin
)
Stomach Acidlansoprazole, pantoprazole, Dexilant, Kapidex omeprazole(Prilosec
)
Aciphex, Nexium
, Prevacid
, Protonix
, Vimovo omeprazole(Prilosec
), Dexilant, Kapidex
Effective 04/12NOTE: Our medication Prior Authorization List is subject to change. If the requested medication is
authorized, there maybe limits to the amount of medication that is eligible for coverage. Please call ourCustomer Service Department if you have any questions.
Prescription Prior Authorization
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The Bottom Line Safety is our top priority and our prior authorization program helps you and your doctorschoose quality medications that provide the most value. Some alternatives might also help you save money.
04-12
These medications require prior authorization to determine if they can be coveredfor your medical condition
Abstral
Actiq
Actonel
Actonelwith Calcium
Adcirca
Anitor
Amphetamine-
Dextroamphetamine ER
cap (Mfgs: Global, Barr/
Teva)
Ampyra
Arcalyst
Atelvia
Blood Glucose test stripsand meters (Mfgs: Abbott,Lifescan/JJ, Roche)
ciclopirox (solution)
Cimzia
CNL 8
Doryx
Egrifta
Embeda
Enbrel
Erivedge
Fentora
Firazyr
Forteo
Gilenya
Gleevec
Growth Hormone
Humira
Incivek
Increlex
Inlyta
itraconazole
Jaka
Kalydeco
Kineret
Lamisil
Lazanda
Letairis
Lyrica
Modanil
Nexavar
Nuvigil
Onsolis
Orencia SQ injection
Pegasys
PEG-Intron
PenLac
Promacta
Provigil
Qualaquin
Relistor
Revatio
Revlimid
Savella
Simponi
Solodyn
SporanoxSprycel
Subsys
Sutent
Sylatron
Tarceva
Tasigna
terbinane
Tracleer
Tykerb
Tyvaso
Vandetanib
Ventavis
Victrelis
Votrient
Xalkori
Xenazine
Xyrem
Zavesca
Zelboraf
Zolinza
ZolpiMistZytiga
These medications require prior authorizationif prescribed above the maximum quantity
Maximum quantity per monthunless otherwise specifed
Ambien CR(zolpidem tartrate er) 14 tablets
Edluar 14 tablets
Exalgo 120 tablets
Imitrex(sumatriptan succinate) tablet 12 tablets
Imitrex(sumatriptan succinate) injection 6 injections
Imitrexnasal spray 6 canisters
Infergeninjection 12 injections
Intermezzo 14 tablets
Lunesta 14 tablets
OpanaER 80 mg per day
Relenza 10 discs (2 treatment courses) per 6 months
Rozerem
14 tabletsTamiu
30mg 40 capsules (2 treatment courses) per 6 months
Tamiu45mg & 75mg 20 capsules (2 treatment courses) per 6 months
Tamiu12mg/ml 150ml (2 treatment courses) per 6 months
NOTE: In addition to the above medications, there are limits to the amount of medication eligible for coverage for all prescriptions. Theselimits are based on your prescription benet along with information from the FDA and scientic literature about maximum, safe, effectivedosages.
Prescription Prior Authorization
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RegenceBlueCrossBlueShieldofO
regon
isanIndependentLicenseeoftheBlueCross
andBlueShieldAssociation
Integrated Care ManagementWhen youre dealing with a health challenge, a helping hand can make
all the difference. A Personal Care Team is ready to assist you with an
ongoing medical condition, or serious illness or injury. The program
provides easy access to one-on-one support at no extra cost to you.
This program is not insurance, but is offered in addition to your medical
plan to help you get information and support when you need it.
Specialized support in times of need
Imagine having a team of clinical health experts helping you manage a
complex or chronic medical condition. Thats what youll experience with
a Regence Personal Care Team.
Our specialists utilize a holistic approach. Well partner with you to develop
a customized care plan that supports your health goals and specific
challenges. Youll communicate directly with a designated nurse, social
worker or care advocate. Behind the scenes youll be supported by a team
of experts. Together, well work with you and your doctors to manage yourcare. Teams can include certified case managers, pediatric and maternity
nurses, behavioral health clinicians, transplant specialists, and others who
understand you and what youre facing.
The goal is to get you the right care at the right time and help you
achieve the best possible health.
Who uses Integrated Care Management services?
We provide support for a variety of medical concerns. Here are some real-life
examples of members whove been helped by a Personal Care Team:
A pregnant mother whos just found out shes carrying triplets and feels
overwhelmed by the challenges facing her family
An 84-year-old man whose leg wounds were infected with
antibiotic-resistant bacteria
A 48-year-old man suffering from a lung disease who now receives
intravenous treatment in the comfort of his own home
A 17-year-old student whose kidney transplant saved her life
T E A M C A N H E L P.
Facing a health chal lenge?
YOUR PERSONAL CARE
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What you can expect
A big-picture viewpoint of your
health can lead to targeted
interventions, extra support for
managing medications, custom
treatment plans and even
suggestions for lifestyle changes.
All of these can significantly
impact your overall health.
Expect your Personal Care Team to:
Answer questions and provide
information about your condition,
illness or injury
Be your advocate and help you
navigate the health care system
Work with your doctors and
support your care plan
Help you make informed
decisions based on all yourtreatment options
Make sure youre getting the most
from your health care benefits
Help you understand what
actions you can take to improve
your health
We know that addressing potential
health issues early on can mean
better health outcomes in the long
run. Thats why a care advocate
may reach out directly to you or
a family member if it appears you
could use some help.
Need help or want to learn more?
Call toll-free: 1 (866) 543-5765.
04615-or / 09-11
2011. The Regence Group, all rights reserved.
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Feeling good .
Regence Advantages
As a Regence member, you can enjoy savings on the followinghealth-related products and services. This discount program is offeredto all Regence members at no additional cost (although somediscounted programs offered by vendors may carry separate fees).
Regence Advantages is not insurance but is offered in addition to your
medical and/or dental plan(s) to help you stay healthy and live better.
TruVision: Significant discounts are offered on laser visioncorrection procedures such as LASIK and PRK. Also, save 10% to 15%on mail-order contact lenses.
TruHearing: TruHearing offers deep discounts on state-of-the-artdigital hearing aids, and contracts with a national network of audiologistsand hearing instrument specialists to provide lower costs on expertadvice and service. It offers two programs to choose fromTruHearingValueAdd and TruHearing MemberPlus. Both include special healthplan-contracted pricing on hearing aids, one-time loss or damage
replacement for three years, a 45-day money back guarantee and48 batteries per hearing aid purchased. Similar to warehousememberships, TruHearing MemberPlus saves you an additional $300 to$1,100 on hearing aids for an annual membership fee of $108.
QualSight:QualSight makes LASIK easy for members. You can save40-50% off the national average price of Traditional LASIK or receivesignificant savings on procedures such as Custom Bladeless (all laser)LASIK. Find out if you are a potential candidate for this life-changingprocedure today. Call 1 (866) 750-7561 to learn more or visit QualSight.com.
EpicDental: Purchase smile-protecting supplies at 25% off,including mouthwash, gums, mints and toothpaste. All items contain
xylitol, a natural ingredient that fights cavities.
CHP CAMaffinity Program:As a Regence member, youre eligiblefor the CHP CAMaffinity Program, which provides a 20% discounton complementary and alternative medicine (CAM) services offeredthrough The CHP Groups growing network of chiropractors,acupuncturists, naturopathic physicians and massage therapists.
Re
genceBlueCrossBlueShield
ofOregon
isa
nIndependentLicenseeoftheBlueCrossandBlueShieldAssociation
Regence is completely independent from the companies that provide these products and services.Regence does not endorse or guarantee the products and services offered or their effectiveness.Regence reserves the right to change the program at any time without prior notice.
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05704rep05270-or / 09-12
2012. Regence BlueCross BlueShield of Oregon, all rights reserved.
CHP Active and Healthy: CHPActive and Healthy is the discountprogram that gets you up,moving, and saving money! Withdiscounts offered by thousandsof participating vendors (e.g.health clubs, ski resorts, sporting
events, museums, etc.) for a smallannual fee, its your source forgreat deals on healthy andfun activities.
Banfield Pet Hospital:As aRegence member, you receivea waived enrollment fee forBanfield Pet Hospitals OptimumWellness Plans, packages ofpreventive care that includeannual blood work, vaccinations,de-worming, unlimited officevisits, plus much more. Banfield isthe largest veterinary hospital inthe world with 800 hospitalsin 43 states; most located insidePetSmartTM. Learn moreat banfield.com/regence.
Take Shape for Life:Save$25 or more on your firstmonths order! This safe weightmanagement and health programuses clinically proven Medifast
products and a personal healthcoach to provide one-on-oneguidance and encouragement.The program helps you loseweight and manage diseaseand health through nutritionalintervention, free access tohealth care professionals,educational materials, andthe Habits of Health system.There are no hidden costs orstart-up fees. Learn more at
stayhealthy4ever.com.
CorCell Saving Babys Cord
Blood: Cord blood stem cellsare now being used to treat morethan 70 diseases, and researchis ongoing to find treatmentsfor even more. Regence haspartnered with CorCell to offer
a $350 discount when you bankyour babys umbilical cord blood.Protect your child or give the giftof cord blood preservation toyour grandchild, niece, nephew,friend or other loved one. Visitcorcell.com for more information.
HearPO: Receive a 40%discount on diagnostic services,including hearing exams, andsignificant savings on hearingaids. Youll enjoy a 60-day no-risktrial period; one-year follow-up care; a three-year warranty,including coverage for loss anddamage; and free batteries(160 cells per hearing aid)allwith a lowest-price guarantee.
Everest, The First Nationwide
Funeral Planning and Concierge
Service: Save $50 off theenrollment fee for Everests suiteof funeral-planning services. With
advisors available 24 hours aday, youll get the information youneed to make informed decisionsabout all funeral-related issues,within your budget, and with afuneral home of your choice.
National Allergy Supply: Save 15on products for non-drug allergyrelief, including pillow and mattreencasings, air filtration products,asthma management tools, greencleaning products and personalcare products. National Allergy
Supply provides discount prices,outstanding service and a 60-dayunconditional return policy with nrestocking fees.
EyeMed Vision Care:Save 35%on a complete pair of glasses(frames and lenses). Save 15%on non-disposable contactsand $10 on contact lens fittings.These discounts are available atleading retailers and many privatepractice locations.
Jenny:Jenny Craig plans arepersonalized and offer one-on-onsupport from trained weight-lossconsultants. With every Jenny CraProgram youll receive weeklyscheduled consultations, plannedor personalized menus, and freeonline support at jennycraig.com.Choose from two special offers:
A Free 30-day Program*
25% off a Premium Program* Beltone**:Receive a free
screening, a 25% discounton Beltone hearing aids, aone-year supply of hearing-aidbatteries and free follow-upvisits and testing.
Safe Beginnings:Save 15% onSafe Beginnings products, includsafety gates, cabinet locks, outletcovers, window guards, and many
other baby-proofing productsWant to learn more?
Go tomyRegence.com/advantage
or regence.com/advantages
* Plus the cost of food. Plus the cost of shipping, if applicable. Offer applies to initial membership
fee only and is valid at participating centres in the United States, Canada and Puerto Rico andthrough Jenny Craig At Home. Each offer is a separate offer and can be used only once perperson. Restrictions apply.
** Discounts through HearPO (also includes extended family), TruHearing and Beltone areavailable to members and their parents and grandparents.
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