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gt Summary of Benefits and Coverage
ndash Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan amp Asante Flexible Workforce Health Plan
gt Annual Required Notices
gt Summary of Material Modification
gt Notice of Privacy Practices
gt Continuation Coverage Rights Under Cobra
gt Medicare Notice of Creditable Coverage
gt New Health Insurance Marketplace Coverage
gt Where To Get Help
ASANTE2020 BENEFIT SUMMARIES amp LEGAL NOTICES
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
PP
O H
EA
LT
H P
LA
N
Co
vera
ge
for
Indi
vidu
al a
nd E
ligib
le F
amily
| P
lan
Typ
e P
PO
1 o
f 8
Cla
ims
Adm
inis
trat
or R
egen
ce B
lueC
ross
Blu
eShi
eld
of O
rego
n
OO
0120
SC
LAX
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
500
indi
vidu
al
$10
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce li
mite
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
$40
00 fa
mily
per
cal
enda
r ye
ar O
ut-o
f-ne
twor
k $
250
0 in
divi
dual
$4
000
fam
ily p
er c
alen
dar
year
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t yet
met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly
For
exa
mpl
e th
is p
lan
cove
rs c
erta
in p
reve
ntiv
e se
rvic
es w
ithou
t cos
t sh
arin
g an
d be
fore
you
mee
t you
r de
duct
ible
See
a li
st o
f cov
ered
pr
even
tive
serv
ices
at h
ealth
care
gov
cov
erag
epr
even
tive
-car
e-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
500
indi
vidu
al
$50
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce li
mite
d ne
twor
k pr
ovid
ers
$7
500
indi
vidu
al
$15
000
fam
ily p
er c
alen
dar
year
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Out
-of-
netw
ork
$8
250
indi
vidu
al
$16
500
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f you
hav
e ot
her
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet
thei
r ow
n ou
t-of
-poc
ket l
imits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
wa
rd th
e ou
t-of
-po
cket
lim
it
2 o
f 8
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Y
es A
sant
e pr
ovid
ers
See
reg
ence
com
go
OR
Pre
ferr
ed
or c
all 1
(88
8) 3
44-8
235
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
th
e pl
ans
net
wor
k Y
ou w
ill p
ay th
e m
ost i
f you
use
an
out-
of-n
etw
ork
prov
ider
and
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
cha
rge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee a
sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at t
he
coin
sura
nce
spec
ified
afte
r de
duct
ible
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
gu
idel
ines
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e is
ava
ilabl
e at
re
genc
eco
mg
odr
uglis
t20
20O
R3
tier
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dr
ugs
the
first
fill
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill t
hrou
gh a
Reg
ence
Spe
cial
ty P
harm
acy
P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
th
at r
equi
re th
e fir
st fi
ll at
Asa
nte
Out
patie
nt
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on
fees
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vi
sit (
wai
ved
if ad
mitt
ed)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
15
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on
fees
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
If y
ou
nee
d m
enta
l hea
lth
b
ehav
iora
l hea
lth
or
sub
stan
ce a
bu
se
serv
ices
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt o
ffice
psy
chot
hera
py v
isits
on
ly A
ll ot
her
outp
atie
nt s
ervi
ces
are
cove
red
at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 15
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in p
reve
ntiv
e se
rvic
es D
epen
ding
on
the
type
of s
ervi
ces
a
coin
sura
nce
or d
educ
tible
may
app
ly M
ater
nity
ca
re m
ay in
clud
e te
sts
and
serv
ices
des
crib
ed
else
whe
re in
the
SB
C (
ie u
ltras
ound
)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
on
ly c
over
ed in
the
case
of c
ompl
icat
ions
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Li
mite
d to
100
vis
its
year
Reh
abili
tatio
n se
rvic
es
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
visi
ts
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Acu
punc
ture
(pr
ovid
ed b
y an
acu
punc
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bull
Bar
iatr
ic s
urge
ry
bull
Chi
ropr
actic
car
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bull
Cos
met
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urge
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xcep
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geni
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nom
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bull
Den
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bull
Long
-ter
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bull
Non
-em
erge
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whe
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ave
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US
bull
Priv
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nur
sing
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hom
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alth
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bull
Rou
tine
eye
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dult)
bull
Rou
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foot
car
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bull
Wei
ght l
oss
prog
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quire
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law
Oth
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Ser
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imit
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ap
ply
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th
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serv
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his
isn
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com
ple
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pla
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bull
Hab
ilita
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serv
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bull
Hea
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aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
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19 y
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of a
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p to
age
26
and
enro
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S D
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tmen
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dmin
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866)
444
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esfi
le-a
-com
plai
nta
spx
or
by E
-mai
l at
DF
RIn
sura
nceH
elp
oreg
ong
ov
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
r as
iste
ncia
en
Esp
antildeol
lla
me
al 1
(88
8) 3
44-8
235
ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
8 o
f 8
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like
S
peci
alis
t offi
ce v
isits
(pr
enat
al c
are)
C
hild
birt
hD
eliv
ery
Pro
fess
iona
l Ser
vice
s C
hild
birt
hD
eliv
ery
Fac
ility
Ser
vice
s D
iagn
ostic
test
s (u
ltras
ound
s an
d bl
ood
wor
k)
Spe
cial
ist v
isit
(ane
sthe
sia)
T
ota
l Exa
mp
le C
ost
$1
280
0 In
th
is e
xam
ple
Peg
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$0
Coi
nsur
ance
$3
000
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
560
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like
P
rimar
y ca
re p
hysi
cian
offi
ce v
isits
(in
clud
ing
dise
ase
educ
atio
n)
Dia
gnos
tic te
sts
(blo
od w
ork)
P
resc
riptio
n dr
ugs
D
urab
le m
edic
al e
quip
men
t (gl
ucos
e m
eter
) T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like
E
mer
genc
y ro
om c
are
(incl
udin
g m
edic
al
supp
lies)
D
iagn
ostic
test
(x-
ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
925
In
th
is e
xam
ple
Mia
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$1
75
Coi
nsur
ance
$2
95
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$9
70
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
RE
IMB
UR
SE
ME
NT
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
al a
nd E
ligib
le F
amily
| P
lan
Typ
e P
PO
1 o
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Cla
ims
Adm
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or R
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lueC
ross
Blu
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eld
of O
rego
n O
O01
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CLA
X
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$1
000
indi
vidu
al
$20
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce n
etw
ork
$1
500
indi
vidu
al
$30
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
lim
ited
netw
ork
prov
ider
s $
300
0 in
divi
dual
$6
000
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
000
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
over
age
prev
entiv
e-ca
re-
bene
fits
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
$40
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
ca
lend
ar y
ear
Reg
ence
lim
ited
netw
ork
prov
ider
s
$70
00 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
600
0 fa
mily
per
ca
lend
ar y
ear
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
2 o
f 8
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
10
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Cov
erag
e fo
r ac
upun
ctur
e an
d ch
iropr
actic
sp
inal
man
ipul
atio
ns is
sub
ject
to $
25
copa
ymen
t for
Reg
ence
net
wor
k pr
ovid
ers
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 50
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
guid
elin
es
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
yo
ur p
lan
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
For
all
othe
r sp
ecia
lty
drug
s th
e fir
st fi
ll m
ust b
e pr
ovid
ed a
t Asa
nte
Out
patie
nt P
harm
acie
s If
Asa
nte
Out
patie
nt
Pha
rmac
ies
are
una
ble
to fi
ll th
ey w
ill
coor
dina
te a
fill
thro
ugh
a R
egen
ce S
peci
alty
P
harm
acy
Ple
ase
refe
r to
my
HR
for
a lis
t of
med
icat
ions
that
req
uire
the
first
fill
at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vis
it (w
aive
d if
adm
itted
)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
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etw
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Reg
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lim
ited
netw
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outp
atie
nt o
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psy
chot
hera
py v
isits
on
ly A
ll ot
her
outp
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nt s
ervi
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are
cove
red
at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 10
c
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uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
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uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
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Net
wo
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rovi
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(Y
ou
will
pay
th
e le
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Reg
ence
Net
wo
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Pro
vid
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leas
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Reg
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Lim
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N
etw
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Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
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uran
ce
15
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in
prev
entiv
e se
rvic
es D
epen
ding
on
the
type
of
serv
ices
a c
oins
uran
ce o
r de
duct
ible
may
ap
ply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
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els
ewhe
re in
the
SB
C (
ie
ultr
asou
nd)
M
ater
nity
cov
erag
e fo
r de
pend
ent c
hild
ren
is
only
cov
ered
in th
e ca
se o
f com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 10
c
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uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
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uran
ce
30
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s af
ter
dedu
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le
Lim
ited
to 1
00 v
isits
ye
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Reh
abili
tatio
n se
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$10
copa
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outp
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nt v
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de
duct
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doe
s no
t ap
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10
c
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uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
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de
duct
ible
doe
s no
t ap
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30
c
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uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
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nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
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ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
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twor
kR
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etw
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Reg
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lim
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netw
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only
Inp
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cove
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at th
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insu
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fter
dedu
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Inpa
tient
lim
ited
to 3
0 da
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up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
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to 8
0 vi
sits
ye
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Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
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Hab
ilita
tion
serv
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$10
copa
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nt v
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de
duct
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t ap
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c
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uran
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inpa
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ser
vice
s
$25
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de
duct
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s no
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30
c
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uran
ce
inpa
tient
ser
vice
s
$75
copa
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outp
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nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
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in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
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twor
kR
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ce n
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Reg
ence
lim
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only
Inp
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are
cove
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at th
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insu
ranc
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fter
dedu
ctib
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Out
patie
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euro
deve
lopm
enta
l the
rapy
is
limite
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60
visi
ts
year
N
euro
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lopm
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rapy
is li
mite
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se
rvic
es fo
r in
divi
dual
s th
roug
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e 17
6 o
f 8
Co
mm
on
Med
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Eve
nt
Ser
vice
s Y
ou
May
Nee
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Wh
at Y
ou
Will
Pay
Lim
itat
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s E
xcep
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ns
amp O
ther
Imp
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Info
rmat
ion
Asa
nte
Pre
ferr
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Net
wo
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rovi
der
(Y
ou
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pay
th
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Reg
ence
Net
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Pro
vid
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leas
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Reg
ence
Lim
ited
N
etw
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Pro
vid
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(Yo
u w
ill p
ay t
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mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
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rapy
an
d sp
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ther
apy
serv
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Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
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uran
ce
20
coi
nsur
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50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
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for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 10
c
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uran
ce
30
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
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for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
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N
one
Chi
ldre
ns
dent
al c
heck
-up
N
ot c
over
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Not
cov
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N
ot c
over
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Non
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Exc
lud
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ervi
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amp O
ther
Co
vere
d S
ervi
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Ser
vice
s Y
ou
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lan
Gen
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ly D
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NO
T C
ove
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hec
k yo
ur
po
licy
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pla
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info
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bull
Non
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US
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Priv
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prov
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Rou
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Hab
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Hea
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aids
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indi
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up to
age
19
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indi
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The
pla
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EX
AM
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cov
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ser
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Peg
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Sp
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Spe
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Chi
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Del
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Chi
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Ded
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Prim
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Pre
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Dur
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ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$74
00
In t
his
exa
mp
le J
oe
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$13
82
Cop
aym
ents
$1
75
Coi
nsur
ance
$4
0
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
597
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
SA
VIN
GS
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
al a
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ligib
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amily
| P
lan
Typ
e P
PO
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Cla
ims
Adm
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lueC
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eld
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Th
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um
mar
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enef
its
and
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p y
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ch
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hea
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pla
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he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
y ca
re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chi
ropr
actic
spi
nal
man
ipul
atio
ns is
sub
ject
to 2
0 c
oins
uran
ce fo
r R
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 40
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
e dr
ugs
accr
ues
tow
ard
the
dedu
ctib
le
and
out-
of-p
ocke
t lim
it
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
y a
dditi
onal
fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill
thro
ugh
a R
egen
ce S
peci
alty
Pha
rmac
y P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
that
req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
su
rger
y ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s a
nd s
ervi
ces
desc
ribed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
-259
6
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
-a-c
ompl
aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
da
rds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
r as
iste
ncia
en
Esp
antildeol
lla
me
al 1
(88
8) 3
44-8
235
ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PL
E c
over
ed s
ervi
ces
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
ere
nt h
ealth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
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of
Ben
efit
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d C
ove
rag
e W
hat t
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Pla
n C
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s amp
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Pay
For
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n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
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t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
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mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
y ca
re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chiro
prac
tic s
pina
l m
anip
ulat
ions
is s
ubje
ct to
20
coi
nsur
ance
for
Reg
ence
net
wor
kR
egen
ce li
mite
d ne
twor
k pr
ovid
ers
and
40
coi
nsur
ance
for
out-
of-n
etw
ork
prov
ider
s
Lim
ited
to $
200
0 y
ear
for
acup
unct
ure
and
$20
00
year
for
spin
al m
anip
ulat
ions
C
oins
uran
ce a
pplie
s to
the
out-
of-p
ocke
t lim
it
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
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ugs
accr
ues
tow
ard
the
dedu
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and
out-
of-p
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it
The
firs
t fill
for
sele
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peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
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dditi
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fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
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If A
sant
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utpa
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P
harm
acie
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able
to fi
ll th
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ill c
oord
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fill
thro
ugh
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egen
ce S
peci
alty
Pha
rmac
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leas
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fer
to m
y H
R fo
r a
list o
f med
icat
ions
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req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
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uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abo
ve
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
surg
ery
cent
er)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
-259
6
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
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gon
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isio
n of
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anci
al R
egul
atio
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) 94
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84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
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94 b
y w
ritin
g to
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gon
Div
isio
n of
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anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
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aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e Y
es
If yo
u do
nt h
ave
Min
imum
Ess
entia
l Cov
erag
e fo
r a
mon
th y
oull
hav
e to
mak
e a
paym
ent w
hen
you
file
your
tax
retu
rn u
nles
s yo
u qu
alify
for
an e
xem
ptio
n fr
om th
e re
quire
men
t tha
t you
hav
e he
alth
cov
erag
e fo
r th
at m
onth
D
oes
th
is p
lan
mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
s Y
es
If yo
ur p
lan
does
nt m
eet t
he M
inim
um V
alue
Sta
ndar
ds y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
L
ang
uag
e A
cces
s S
ervi
ces
S
pani
sh (
Esp
antildeol
) P
ara
obte
ner
asis
tenc
ia e
n E
spantilde
ol l
lam
e al
1 (
888)
344
-823
5
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
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tal M
ia w
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ay is
$3
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t th
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Exa
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Th
is is
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atm
ents
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es o
f how
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n m
ight
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er m
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are
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r ac
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ts w
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e di
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epen
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ts a
nd c
oins
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Use
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rmat
ion
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re th
e po
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ased
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erag
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NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health
Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been
performed Surgery and reconstruction of the other breast as necessary to provide
a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event
For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)
Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075
Asante Health PlanAnnual Required Notices
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)
Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others
The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits
toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020
The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger
The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks
1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen
2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program
If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA
If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts
The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower
Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year
Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status
The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor
Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment
Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs
In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately
You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate
If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995
Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not
discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender
Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio
accessible electronic formats and other formats) bull Asante provides free language services to people whose primary
language is not English including o Qualified interpreters o Information written in other languages
If you need these services contact Alicia Lorenz at the phone number or email address listed below
If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)
You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at
US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)
Complaint forms are available at hhsgovocrofficefileindexhtml
20HR011
This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020
Asante Health Plan changesPlan names Asante Health Plan 1 is being
renamed Asante PPO Health Plan Asante Health Plan 2 is being
renamed Asante Savings HealthPlan or HSA
Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA
For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use
Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers
A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles The deductibles for the new
Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses
Rx expenses will be counted toward the medical out-of-pocket maximums
The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50
Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles The deductibles for the four
categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family
Out-of-pocket maximums The out-of-pocket maximums for the
four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family
Copay and coinsurance changes The office visit coinsurance for
primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)
The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)
The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50
Health Savings Account The HSA contribution limit has
increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage
Employer contributions to the HSA Asante contributes to your HSA
if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled
Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four
categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums
Whatrsquos new for 2020
The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50
Employer contributions to the HRA Asante contributes to your HRA
account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents
Other changes In the Asante Reimbursement
Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations
In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers
Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan
(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)
Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit
All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet
All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply
A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible
Dental plan changes The Willamette Dental plan will have
a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year
There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan
Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits
Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012
Critical illness and accident plans Certain insurance policies are
available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505
Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information
This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025
All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization
How We May Use and Disclose Your Protected Health Information
Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories
For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use
For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments
For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes
To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us
As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws
Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it
The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage
This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System
The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees
What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage
If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen
1 Your hours of employment are reduced or
2 Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens
1 Your spouse dies
2 Your spousersquos hours of employment are reduced
3 Your spousersquos employment ends for any reason other than his or her gross misconduct
4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or
5 You become divorced or legally separated from your spouse
Continuation Coverage Rights Under Cobra
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens
1 The parent-employee dies
2 The parent-employeersquos hours of employment are reduced
3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct
4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)
5 The parents become divorced or legally separated or
6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo
Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan
When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event
You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to
Asante Health System
How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended
Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov
If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)
Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator
Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Updated 91418 ND
PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is
eligible for coverage please contact us so that we can provide them with this notice
Important Notice from Asante About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug
coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice
There are two important things you need to know about your current coverage and Medicarersquos
prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can
get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium
2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan
When Can You Join A Medicare Drug Plan
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th
However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan
You should also know that if you drop or lose your current coverage with Asante and donrsquot join a
Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later
Page 2
If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join
For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time
If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by
Medicare in the next 12 months this notice doesnrsquot apply to you
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos
how to get more information about Medicare prescription drug plans
Visit wwwmedicaregov
Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)
Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A General Information
What is the Health Insurance Marketplace
Can I Save Money on my Health Insurance Premiums in the Marketplace
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace
How Can I Get More Information
Form Approved OMB No 1210-0149
5 31 2020
P AR T B Information About Health C overage O ffered by Y our E mployer
3 Employer name 4 Employer Identification Number (EIN)
5 Employer address 6 Employer phone number
7 City 8 State 9 ZIP code
10 Who can we contact about employee health coverage at this job
11 Phone number (if different from above) 12 Email address
Eligible Dependents include Your Legal Spouse or you or your spousersquos children under the age of 26 including biological child legally adopted child or child place with you for adoption current stepchild legally placed foster child child for whom you have legal guardianship child you are required to provide coverage for due to a court or administrative order as part of a QMCSO or NMSN or disabled child over the age of 26
Plan information including employee costs for 2020 medical plans can be found on myHR (httpshrasanteorg) or upon request to Human Resources
WHERE TO GET HELPKeep this contact information in case you have questions as you use your benefits throughout the year
Contact Phone number E-mail or website
Asante Absence Management and Workers Compensation
(541) 789-5395 ndash Medford(541) 472-7374 ndash Grants Pass(541) 789-5417 ndash Ashland
leavesasanteorg
Asante Benefits Helpline (541) 789-4551 myasantebenefitsasanteorgAsk HR
Asante Employee Health (541) 789-5008 ndash Medford(541) 472-7376 ndash Grants Pass(541) 201-4484 ndash Ashland
wwwasanteorg
Asante Human Resources (541) 789-4243 ndashMedfordAshland(541) 472-7382 ndash Grants Pass
wwwasanteorgemployee-benefits
Asante Recruitment (541) 789-4757 AsanteEmploymentasanteorg
HealthEquity mdash Flexible Spending Accounts Health Reimbursement Arrangements Health Savings Accounts
(866) 960-8055 wwwmyhealthequitycom
Hyatt Legal Plan (MetLaw) (800) 821-6400 wwwlegalplanscomAccess code MetLaw
Livongo (800) 945-4355
MercyFlights (800) 903-9000 wwwmercyflightscom
MetLife Dental (800) 942-0854 wwwmetlifecommybenefits
myStrength customerservicemystrengthcom
Regence - Advice24 (800) 267-6729 wwwregencecom
Regence - BabyWise (888) 569-2229 wwwregencecom
Regence - Case Management (866) 543-5765 wwwregencecom
Regence - Customer Service - Medical Claims Eligibility Precertification
(888) 344-8235 wwwregencecom
Regence - Employee Assistance Program
(866) 750-1327 wwwmyRBHcom
Regence - Health Coach (800) 856-8543 wwwregencecom
Regence - Pharmacy Services (844) 765-2894 wwwregencecom
The Standard (833) 760-7012 wwwstandardcom
Contact Phone number E-mail or website
The Standard Voluntary Benefits
General Questions (866) 851-2429Claims (866) 851-5505
wwwstandardcom
Asante Retirement Plan (800) 343-0860 NetBenefitscomAtWork
Vision Service Plan (VSP) (800) 877-7195 wwwvspcom
Willamette Dental (855) 433-6825 wwwwillamettedentalcom
REG-115823-1609-2017copy 201 Regence BlueCross BlueShield of Oregon
Su
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of
Ben
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ork
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Gen
eral
ly y
ou m
ust p
ay a
ll of
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cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
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fam
ily m
embe
rs o
n th
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ach
fam
ily m
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own
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vidu
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tal a
mou
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xpen
ses
paid
by
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amily
mem
bers
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ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
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bef
ore
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u m
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you
r d
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ctib
le
Yes
Cer
tain
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care
and
thos
e se
rvic
es li
sted
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low
as
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le d
oes
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pply
or
as
No
char
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Thi
s pl
an c
over
s so
me
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s an
d se
rvic
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if yo
u ha
ven
t yet
met
th
e de
duct
ible
am
ount
But
a c
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coin
sura
nce
may
app
ly
For
exa
mpl
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is p
lan
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in p
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es w
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r de
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See
a li
st o
f cov
ered
pr
even
tive
serv
ices
at h
ealth
care
gov
cov
erag
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nefit
s
Are
th
ere
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edu
ctib
les
for
spec
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ser
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No
Y
ou d
ont
have
to m
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educ
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s fo
r sp
ecifi
c se
rvic
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Wh
at is
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ut-
of-
po
cket
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it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
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vidu
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mily
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r ye
ar
Reg
ence
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k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce li
mite
d ne
twor
k pr
ovid
ers
$7
500
indi
vidu
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$15
000
fam
ily p
er c
alen
dar
year
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Out
-of-
netw
ork
$8
250
indi
vidu
al
$16
500
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f you
hav
e ot
her
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet
thei
r ow
n ou
t-of
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ket l
imits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
wa
rd th
e ou
t-of
-po
cket
lim
it
2 o
f 8
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Y
es A
sant
e pr
ovid
ers
See
reg
ence
com
go
OR
Pre
ferr
ed
or c
all 1
(88
8) 3
44-8
235
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
th
e pl
ans
net
wor
k Y
ou w
ill p
ay th
e m
ost i
f you
use
an
out-
of-n
etw
ork
prov
ider
and
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
cha
rge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee a
sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at t
he
coin
sura
nce
spec
ified
afte
r de
duct
ible
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
gu
idel
ines
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e is
ava
ilabl
e at
re
genc
eco
mg
odr
uglis
t20
20O
R3
tier
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dr
ugs
the
first
fill
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill t
hrou
gh a
Reg
ence
Spe
cial
ty P
harm
acy
P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
th
at r
equi
re th
e fir
st fi
ll at
Asa
nte
Out
patie
nt
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on
fees
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vi
sit (
wai
ved
if ad
mitt
ed)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
15
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on
fees
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
If y
ou
nee
d m
enta
l hea
lth
b
ehav
iora
l hea
lth
or
sub
stan
ce a
bu
se
serv
ices
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt o
ffice
psy
chot
hera
py v
isits
on
ly A
ll ot
her
outp
atie
nt s
ervi
ces
are
cove
red
at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 15
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in p
reve
ntiv
e se
rvic
es D
epen
ding
on
the
type
of s
ervi
ces
a
coin
sura
nce
or d
educ
tible
may
app
ly M
ater
nity
ca
re m
ay in
clud
e te
sts
and
serv
ices
des
crib
ed
else
whe
re in
the
SB
C (
ie u
ltras
ound
)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
on
ly c
over
ed in
the
case
of c
ompl
icat
ions
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Li
mite
d to
100
vis
its
year
Reh
abili
tatio
n se
rvic
es
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
visi
ts
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Acu
punc
ture
(pr
ovid
ed b
y an
acu
punc
turis
t)
bull
Bar
iatr
ic s
urge
ry
bull
Chi
ropr
actic
car
e
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
ave
ling
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
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an a
ccre
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d ed
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l ins
titut
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bull
Infe
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7 o
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Yo
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Rig
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to
Co
nti
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rag
e T
here
are
age
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s th
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an h
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if yo
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o co
ntin
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our
cove
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The
con
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info
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thos
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is t
he U
S D
epar
tmen
t of L
abor
Em
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enef
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dmin
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1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
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rm o
r th
e U
S D
epar
tmen
t of H
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and
H
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Ser
vice
s C
ente
r fo
r C
onsu
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Info
rmat
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and
Insu
ranc
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ight
at 1
(87
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gov
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stat
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sura
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may
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an a
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888)
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5 O
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cov
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ay b
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to y
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clud
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buyi
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divi
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e H
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In
sura
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Mar
ketp
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For
mor
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form
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out t
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arke
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Y
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T
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age
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if yo
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com
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gain
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our
plan
for
a de
nial
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cla
im T
his
com
plai
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cal
led
a gr
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or a
ppea
l F
or m
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info
rmat
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abou
t you
r rig
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ical
cla
im Y
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plan
doc
umen
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lso
prov
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com
plet
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form
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sub
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aim
app
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or a
grie
vanc
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y re
ason
to y
our
plan
For
mor
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form
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out
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rig
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this
not
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or
assi
stan
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cont
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he p
lan
at 1
(88
8) 3
44-8
235
or v
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com
or
the
US
Dep
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ent o
f Lab
or E
mpl
oye
e B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
do
lgov
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ahe
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rm Y
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ay a
lso
cont
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rego
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allin
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947
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sage
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Do
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Min
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Co
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Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
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t whe
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ur ta
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exe
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Do
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alu
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If
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pla
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Min
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Val
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you
may
be
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for
a pr
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you
pay
for
a pl
an th
roug
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arke
tpla
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Lan
gu
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Acc
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Ser
vice
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Spa
nish
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spantilde
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Par
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Esp
antildeol
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me
al 1
(88
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44-8
235
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To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
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med
ical
situ
atio
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e ne
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ectio
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8 o
f 8
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
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g a
Bab
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mon
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of in
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wor
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a ho
spita
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s S
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follo
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f a w
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pla
ns
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rall
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uct
ible
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00
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pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
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30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
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S
peci
alis
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C
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birt
hD
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Pro
fess
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vice
s C
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Fac
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Ser
vice
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ostic
test
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ltras
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wor
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Spe
cial
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T
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l Exa
mp
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0 In
th
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xam
ple
Peg
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$0
Coi
nsur
ance
$3
000
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
560
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
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ervi
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like
P
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hysi
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offi
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clud
ing
dise
ase
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atio
n)
Dia
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tic te
sts
(blo
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ork)
P
resc
riptio
n dr
ugs
D
urab
le m
edic
al e
quip
men
t (gl
ucos
e m
eter
) T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
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rall
ded
uct
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00
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pec
ialis
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pay
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t $2
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faci
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30
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er c
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sura
nce
30
Th
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XA
MP
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nt
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ervi
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E
mer
genc
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om c
are
(incl
udin
g m
edic
al
supp
lies)
D
iagn
ostic
test
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ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
925
In
th
is e
xam
ple
Mia
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$1
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Coi
nsur
ance
$2
95
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$9
70
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
RE
IMB
UR
SE
ME
NT
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
al a
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amily
| P
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Th
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and
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do
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p y
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ch
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se a
hea
lth
pla
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he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$1
000
indi
vidu
al
$20
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce n
etw
ork
$1
500
indi
vidu
al
$30
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
lim
ited
netw
ork
prov
ider
s $
300
0 in
divi
dual
$6
000
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
000
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
over
age
prev
entiv
e-ca
re-
bene
fits
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
$40
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
ca
lend
ar y
ear
Reg
ence
lim
ited
netw
ork
prov
ider
s
$70
00 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
600
0 fa
mily
per
ca
lend
ar y
ear
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
2 o
f 8
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
10
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Cov
erag
e fo
r ac
upun
ctur
e an
d ch
iropr
actic
sp
inal
man
ipul
atio
ns is
sub
ject
to $
25
copa
ymen
t for
Reg
ence
net
wor
k pr
ovid
ers
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 50
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
guid
elin
es
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
yo
ur p
lan
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
For
all
othe
r sp
ecia
lty
drug
s th
e fir
st fi
ll m
ust b
e pr
ovid
ed a
t Asa
nte
Out
patie
nt P
harm
acie
s If
Asa
nte
Out
patie
nt
Pha
rmac
ies
are
una
ble
to fi
ll th
ey w
ill
coor
dina
te a
fill
thro
ugh
a R
egen
ce S
peci
alty
P
harm
acy
Ple
ase
refe
r to
my
HR
for
a lis
t of
med
icat
ions
that
req
uire
the
first
fill
at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vis
it (w
aive
d if
adm
itted
)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt o
ffice
psy
chot
hera
py v
isits
on
ly A
ll ot
her
outp
atie
nt s
ervi
ces
are
cove
red
at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in
prev
entiv
e se
rvic
es D
epen
ding
on
the
type
of
serv
ices
a c
oins
uran
ce o
r de
duct
ible
may
ap
ply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
the
SB
C (
ie
ultr
asou
nd)
M
ater
nity
cov
erag
e fo
r de
pend
ent c
hild
ren
is
only
cov
ered
in th
e ca
se o
f com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s af
ter
dedu
ctib
le
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
10
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
10
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is
limite
d to
60
visi
ts
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al c
heck
-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
Th
is is
nt
a co
mp
lete
list
Ple
ase
see
you
r p
lan
do
cum
ent
)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
7 o
f 8
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cov
erag
e af
ter
it en
ds T
he c
onta
ct in
form
atio
n fo
r th
ose
agen
cies
is
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or d
olg
ove
bsa
heal
thre
form
or
the
US
Dep
artm
ent o
f Hea
lth a
nd
Hum
an S
ervi
ces
Cen
ter
for
Con
sum
er In
form
atio
n an
d In
sura
nce
Ove
rsig
ht a
t 1 (
877
) 26
7-23
23 x
6156
5 or
cci
ioc
ms
gov
or y
our
stat
e in
sura
nce
dep
artm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
avai
labl
e to
you
too
incl
udin
g bu
ying
indi
vid
ual i
nsur
ance
cov
erag
e th
roug
h th
e H
ealth
In
sura
nce
Mar
ketp
lace
For
mor
e in
form
atio
n ab
out t
he M
arke
tpla
ce v
isit
Hea
lthC
are
gov
or c
all 1
(80
0) 3
18-2
596
Y
ou
r G
riev
ance
an
d A
pp
eals
Rig
hts
T
here
are
age
ncie
s th
at c
an h
elp
if yo
u h
ave
a co
mpl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
O
R 9
7309
-040
5 th
roug
h th
e In
tern
et a
t df
ror
egon
gov
get
help
Pag
esfi
le-a
-com
plai
nta
spx
or
by E
-mai
l at
DF
RIn
sura
nceH
elp
oreg
ong
ov
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds
Y
es
If yo
ur p
lan
does
nt m
eet t
he M
inim
um V
alue
Sta
ndar
ds y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
L
ang
uag
e A
cces
s S
ervi
ces
S
pani
sh (
Esp
antildeol
) P
ara
obte
ner
asis
tenc
ia e
n E
spantilde
ol l
lam
e al
1 (
888)
344
-823
5
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
8 o
f 8
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$15
00
Cop
aym
ents
$0
Coi
nsur
ance
$2
000
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
560
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$74
00
In t
his
exa
mp
le J
oe
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$13
82
Cop
aym
ents
$1
75
Coi
nsur
ance
$4
0
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
597
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
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ered
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20 ndash
12
312
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AS
AN
TE
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AL
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Co
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Indi
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lan
Typ
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Cla
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p y
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pla
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he
SB
C s
ho
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you
ho
w y
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he
pla
n w
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ld s
har
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e co
st f
or
cove
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hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
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lan
(ca
lled
th
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rem
ium
) w
ill b
e p
rovi
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sep
arat
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T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
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r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
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com
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term
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uch
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llow
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mou
nt b
alan
ce b
illin
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oins
uran
ce c
opay
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pro
vide
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her
unde
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rms
see
the
Glo
ssar
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You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
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vera
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edu
ctib
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Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
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bene
fits
are
com
bine
d T
he d
educ
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am
ount
s fo
r A
sant
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efer
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netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
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ust b
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et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
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serv
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co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
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Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
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ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
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t hea
lthca
reg
ovc
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rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
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ont
have
to m
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educ
tible
s fo
r sp
ecifi
c se
rvic
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Wh
at is
th
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of-
po
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lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
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efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
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ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
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lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
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Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
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et li
mit
Pre
miu
ms
bal
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-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
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s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
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Net
wo
rk P
rovi
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Reg
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Pro
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Reg
ence
Lim
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N
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Pro
vid
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(Yo
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ill p
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If y
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vis
it a
hea
lth
car
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rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
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uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
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netw
ork
prov
ider
s
Cov
erag
e in
clud
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rimar
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re v
isits
at a
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ail c
linic
C
over
age
for
acup
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ure
and
chi
ropr
actic
spi
nal
man
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sub
ject
to 2
0 c
oins
uran
ce fo
r R
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 40
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
e dr
ugs
accr
ues
tow
ard
the
dedu
ctib
le
and
out-
of-p
ocke
t lim
it
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
y a
dditi
onal
fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill
thro
ugh
a R
egen
ce S
peci
alty
Pha
rmac
y P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
that
req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
su
rger
y ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s a
nd s
ervi
ces
desc
ribed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
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ry s
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ccre
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bull
Infe
rtili
ty tr
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Rig
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Co
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The
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S D
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S D
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tmen
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Info
rmat
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Insu
ranc
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ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PL
E c
over
ed s
ervi
ces
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
ere
nt h
ealth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
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TE
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OR
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Th
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har
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or
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hea
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car
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rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
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t hea
lthca
reg
ovc
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pre
vent
ive-
care
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s
Are
th
ere
oth
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edu
ctib
les
for
spec
ific
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vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
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mily
per
cal
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ar R
egen
ce
limite
d ne
twor
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ovid
ers
$6
000
indi
vidu
al (
sing
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rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
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divi
dual
$1
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mily
per
cal
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The
Reg
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net
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The
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If yo
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Pre
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You
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You
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A
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Co
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Med
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Prim
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Out
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prac
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20
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for
Reg
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mite
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ovid
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and
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coi
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for
out-
of-n
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prov
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s
Lim
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to $
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0 y
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for
acup
unct
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and
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year
for
spin
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C
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15
c
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40
coi
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Pre
vent
ive
care
scr
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imm
uniz
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o ch
arge
N
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N
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You
may
hav
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pay
for
serv
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that
are
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prev
entiv
e A
sk y
our
prov
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if th
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rvic
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The
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wha
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ill p
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Sub
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to p
reve
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If y
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hav
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test
Dia
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tic te
st (
x-ra
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10
coi
nsur
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30
c
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40
coi
nsur
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50
coi
nsur
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for
Out
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netw
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prov
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s
Imag
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(CT
PE
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scan
s M
RIs
)
10
coi
nsur
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30
c
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uran
ce
40
coi
nsur
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3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
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ion
Asa
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Pre
ferr
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Net
wo
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rovi
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wo
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Pro
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Reg
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Pro
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If y
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Mor
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rege
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drug
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Gen
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mai
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Not
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drug
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You
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cos
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Pre
ferr
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dr
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25
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up
to $
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axim
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etai
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$60
max
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90
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ret
ail
pres
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coi
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up
to $
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axim
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axim
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mai
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pres
crip
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cov
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Bra
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rugs
30
coi
nsur
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up
to $
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max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
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up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
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up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
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up
to $
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max
imum
m
ail o
rder
pr
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Not
cov
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Spe
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Ref
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gen
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pr
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bran
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and
drug
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N
ot c
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If y
ou
hav
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utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
10
c
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uran
ce
30
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
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Imp
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Info
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ion
Asa
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Pre
ferr
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Net
wo
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rovi
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(Yo
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Reg
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Reg
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Lim
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Pro
vid
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surg
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Phy
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on
fees
10
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15
coi
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40
c
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uran
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50
coi
nsur
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for
Out
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netw
ork
prov
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s
If y
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d im
med
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m
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tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
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15
c
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ce
15
coi
nsur
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15
c
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uran
ce fo
r O
ut-o
f-ne
twor
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ovid
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Em
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ncy
med
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tr
ansp
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tion
Not
app
licab
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20
coi
nsur
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20
c
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uran
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20
coi
nsur
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for
Out
-of-
netw
ork
prov
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s
Urg
ent c
are
10
coi
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30
c
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uran
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40
coi
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50
c
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uran
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r O
ut-o
f-ne
twor
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ovid
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If y
ou
hav
e a
ho
spit
al
stay
Fac
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fee
(eg
ho
spita
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10
coi
nsur
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30
c
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uran
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40
coi
nsur
ance
50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
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Phy
sici
ans
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on
fees
10
c
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uran
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15
coi
nsur
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40
c
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uran
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50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
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s
If y
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nee
d m
enta
l h
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ehav
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l hea
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ab
use
se
rvic
es
Out
patie
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serv
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10
coi
nsur
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of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
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15
coi
nsur
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for
prof
essi
onal
and
30
c
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uran
ce fo
r fa
cilit
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40
coi
nsur
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50
c
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uran
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ut-o
f-ne
twor
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ovid
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Inpa
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ser
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s 10
c
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uran
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15
coi
nsur
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for
prof
essi
onal
and
30
c
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uran
ce fo
r fa
cilit
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40
coi
nsur
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50
c
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uran
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ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
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app
ly to
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pre
vent
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serv
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Dep
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n th
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f ser
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s a
co
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ded
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Mat
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are
may
incl
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th
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Mat
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the
case
of
com
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Chi
ldbi
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deliv
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prof
essi
onal
se
rvic
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10
coi
nsur
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15
c
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uran
ce
40
coi
nsur
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Chi
ldbi
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deliv
ery
faci
lity
serv
ices
10
c
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uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
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rovi
der
(Yo
u w
ill p
ay t
he
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Reg
ence
Net
wo
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Pro
vid
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u w
ill p
ay t
he
leas
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Reg
ence
Lim
ited
N
etw
ork
Pro
vid
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ay t
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mo
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If y
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elp
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cove
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ave
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spec
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Hom
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car
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30
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40
c
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Lim
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to 1
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Reh
abili
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10
coi
nsur
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30
c
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uran
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40
coi
nsur
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50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
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s
Inpa
tient
lim
ited
to 3
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up to
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days
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seve
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head
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yea
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Incl
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occ
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rapy
and
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eech
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serv
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Hab
ilita
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serv
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10
c
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uran
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30
coi
nsur
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40
c
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uran
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50
coi
nsur
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for
Out
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prov
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Out
patie
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mite
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N
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mite
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ser
vice
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r in
divi
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In
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nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
-259
6
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
-a-c
ompl
aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e Y
es
If yo
u do
nt h
ave
Min
imum
Ess
entia
l Cov
erag
e fo
r a
mon
th y
oull
hav
e to
mak
e a
paym
ent w
hen
you
file
your
tax
retu
rn u
nles
s yo
u qu
alify
for
an e
xem
ptio
n fr
om th
e re
quire
men
t tha
t you
hav
e he
alth
cov
erag
e fo
r th
at m
onth
D
oes
th
is p
lan
mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
s Y
es
If yo
ur p
lan
does
nt m
eet t
he M
inim
um V
alue
Sta
ndar
ds y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
L
ang
uag
e A
cces
s S
ervi
ces
S
pani
sh (
Esp
antildeol
) P
ara
obte
ner
asis
tenc
ia e
n E
spantilde
ol l
lam
e al
1 (
888)
344
-823
5
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t he
alth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health
Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been
performed Surgery and reconstruction of the other breast as necessary to provide
a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event
For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)
Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075
Asante Health PlanAnnual Required Notices
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)
Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others
The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits
toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020
The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger
The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks
1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen
2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program
If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA
If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts
The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower
Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year
Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status
The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor
Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment
Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs
In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately
You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate
If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995
Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not
discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender
Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio
accessible electronic formats and other formats) bull Asante provides free language services to people whose primary
language is not English including o Qualified interpreters o Information written in other languages
If you need these services contact Alicia Lorenz at the phone number or email address listed below
If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)
You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at
US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)
Complaint forms are available at hhsgovocrofficefileindexhtml
20HR011
This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020
Asante Health Plan changesPlan names Asante Health Plan 1 is being
renamed Asante PPO Health Plan Asante Health Plan 2 is being
renamed Asante Savings HealthPlan or HSA
Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA
For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use
Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers
A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles The deductibles for the new
Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses
Rx expenses will be counted toward the medical out-of-pocket maximums
The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50
Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles The deductibles for the four
categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family
Out-of-pocket maximums The out-of-pocket maximums for the
four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family
Copay and coinsurance changes The office visit coinsurance for
primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)
The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)
The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50
Health Savings Account The HSA contribution limit has
increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage
Employer contributions to the HSA Asante contributes to your HSA
if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled
Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four
categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums
Whatrsquos new for 2020
The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50
Employer contributions to the HRA Asante contributes to your HRA
account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents
Other changes In the Asante Reimbursement
Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations
In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers
Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan
(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)
Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit
All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet
All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply
A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible
Dental plan changes The Willamette Dental plan will have
a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year
There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan
Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits
Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012
Critical illness and accident plans Certain insurance policies are
available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505
Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information
This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025
All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization
How We May Use and Disclose Your Protected Health Information
Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories
For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use
For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments
For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes
To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us
As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws
Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it
The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage
This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System
The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees
What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage
If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen
1 Your hours of employment are reduced or
2 Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens
1 Your spouse dies
2 Your spousersquos hours of employment are reduced
3 Your spousersquos employment ends for any reason other than his or her gross misconduct
4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or
5 You become divorced or legally separated from your spouse
Continuation Coverage Rights Under Cobra
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens
1 The parent-employee dies
2 The parent-employeersquos hours of employment are reduced
3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct
4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)
5 The parents become divorced or legally separated or
6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo
Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan
When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event
You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to
Asante Health System
How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended
Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov
If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)
Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator
Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Updated 91418 ND
PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is
eligible for coverage please contact us so that we can provide them with this notice
Important Notice from Asante About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug
coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice
There are two important things you need to know about your current coverage and Medicarersquos
prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can
get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium
2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan
When Can You Join A Medicare Drug Plan
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th
However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan
You should also know that if you drop or lose your current coverage with Asante and donrsquot join a
Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later
Page 2
If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join
For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time
If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by
Medicare in the next 12 months this notice doesnrsquot apply to you
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos
how to get more information about Medicare prescription drug plans
Visit wwwmedicaregov
Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)
Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A General Information
What is the Health Insurance Marketplace
Can I Save Money on my Health Insurance Premiums in the Marketplace
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace
How Can I Get More Information
Form Approved OMB No 1210-0149
5 31 2020
P AR T B Information About Health C overage O ffered by Y our E mployer
3 Employer name 4 Employer Identification Number (EIN)
5 Employer address 6 Employer phone number
7 City 8 State 9 ZIP code
10 Who can we contact about employee health coverage at this job
11 Phone number (if different from above) 12 Email address
Eligible Dependents include Your Legal Spouse or you or your spousersquos children under the age of 26 including biological child legally adopted child or child place with you for adoption current stepchild legally placed foster child child for whom you have legal guardianship child you are required to provide coverage for due to a court or administrative order as part of a QMCSO or NMSN or disabled child over the age of 26
Plan information including employee costs for 2020 medical plans can be found on myHR (httpshrasanteorg) or upon request to Human Resources
WHERE TO GET HELPKeep this contact information in case you have questions as you use your benefits throughout the year
Contact Phone number E-mail or website
Asante Absence Management and Workers Compensation
(541) 789-5395 ndash Medford(541) 472-7374 ndash Grants Pass(541) 789-5417 ndash Ashland
leavesasanteorg
Asante Benefits Helpline (541) 789-4551 myasantebenefitsasanteorgAsk HR
Asante Employee Health (541) 789-5008 ndash Medford(541) 472-7376 ndash Grants Pass(541) 201-4484 ndash Ashland
wwwasanteorg
Asante Human Resources (541) 789-4243 ndashMedfordAshland(541) 472-7382 ndash Grants Pass
wwwasanteorgemployee-benefits
Asante Recruitment (541) 789-4757 AsanteEmploymentasanteorg
HealthEquity mdash Flexible Spending Accounts Health Reimbursement Arrangements Health Savings Accounts
(866) 960-8055 wwwmyhealthequitycom
Hyatt Legal Plan (MetLaw) (800) 821-6400 wwwlegalplanscomAccess code MetLaw
Livongo (800) 945-4355
MercyFlights (800) 903-9000 wwwmercyflightscom
MetLife Dental (800) 942-0854 wwwmetlifecommybenefits
myStrength customerservicemystrengthcom
Regence - Advice24 (800) 267-6729 wwwregencecom
Regence - BabyWise (888) 569-2229 wwwregencecom
Regence - Case Management (866) 543-5765 wwwregencecom
Regence - Customer Service - Medical Claims Eligibility Precertification
(888) 344-8235 wwwregencecom
Regence - Employee Assistance Program
(866) 750-1327 wwwmyRBHcom
Regence - Health Coach (800) 856-8543 wwwregencecom
Regence - Pharmacy Services (844) 765-2894 wwwregencecom
The Standard (833) 760-7012 wwwstandardcom
Contact Phone number E-mail or website
The Standard Voluntary Benefits
General Questions (866) 851-2429Claims (866) 851-5505
wwwstandardcom
Asante Retirement Plan (800) 343-0860 NetBenefitscomAtWork
Vision Service Plan (VSP) (800) 877-7195 wwwvspcom
Willamette Dental (855) 433-6825 wwwwillamettedentalcom
REG-115823-1609-2017copy 201 Regence BlueCross BlueShield of Oregon
2 o
f 8
Will
yo
u p
ay le
ss if
yo
u u
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n
etw
ork
pro
vid
er
Y
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ovid
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See
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Pre
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all 1
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Thi
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Imp
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Pre
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rk
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etw
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Dia
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Gen
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gs
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-day
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tail
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tion
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tail
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iptio
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pay
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Not
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ered
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oes
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pply
Li
mite
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day
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nte
Out
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nt P
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arm
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C
over
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udes
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poun
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t 30
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oins
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ce u
p to
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0 m
axim
um a
t A
sant
e O
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tient
Pha
rmac
ies
and
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co
insu
ranc
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imum
at a
Reg
ence
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rtic
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ing
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il ph
arm
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er to
you
r pl
an
for
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rmat
ion
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resc
riptio
ns
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coi
nsur
ance
up
to $
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max
imum
Out
-of-
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ork
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crip
tion
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cov
erag
e is
not
co
vere
d
You
are
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pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
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and-
nam
e dr
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nd th
e eq
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lent
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dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
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The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dr
ugs
the
first
fill
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill t
hrou
gh a
Reg
ence
Spe
cial
ty P
harm
acy
P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
th
at r
equi
re th
e fir
st fi
ll at
Asa
nte
Out
patie
nt
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
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up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
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l ord
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crip
tion
Not
cov
ered
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nd d
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30
coi
nsur
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up
to $
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imum
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-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
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up
to $
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max
imum
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ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on
fees
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vi
sit (
wai
ved
if ad
mitt
ed)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
15
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on
fees
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
If y
ou
nee
d m
enta
l hea
lth
b
ehav
iora
l hea
lth
or
sub
stan
ce a
bu
se
serv
ices
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt o
ffice
psy
chot
hera
py v
isits
on
ly A
ll ot
her
outp
atie
nt s
ervi
ces
are
cove
red
at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 15
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in p
reve
ntiv
e se
rvic
es D
epen
ding
on
the
type
of s
ervi
ces
a
coin
sura
nce
or d
educ
tible
may
app
ly M
ater
nity
ca
re m
ay in
clud
e te
sts
and
serv
ices
des
crib
ed
else
whe
re in
the
SB
C (
ie u
ltras
ound
)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
on
ly c
over
ed in
the
case
of c
ompl
icat
ions
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Li
mite
d to
100
vis
its
year
Reh
abili
tatio
n se
rvic
es
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
visi
ts
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Acu
punc
ture
(pr
ovid
ed b
y an
acu
punc
turis
t)
bull
Bar
iatr
ic s
urge
ry
bull
Chi
ropr
actic
car
e
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
ave
ling
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
7 o
f 8
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
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our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
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ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
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ight
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(87
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67-2
323
x615
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or y
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onta
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e pl
an a
t 1 (
888)
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5 O
ther
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erag
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ay b
e av
aila
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clud
ing
buyi
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divi
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insu
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vera
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roug
h th
e H
ealth
In
sura
nce
Mar
ketp
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For
mor
e in
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n ab
out t
he M
arke
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Hea
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gov
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all 1
(80
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596
Y
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here
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plai
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im T
his
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plai
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ieva
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or m
ore
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rmat
ion
abou
t you
r rig
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look
at t
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natio
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efits
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cla
im Y
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umen
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plet
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For
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isit
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artm
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mpl
oye
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ecur
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atio
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ebs
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inan
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Reg
ulat
ion
Con
sum
er A
dvoc
acy
Uni
t P
O B
ox 1
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em O
R 9
7309
-040
5 th
roug
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tern
et a
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ror
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gov
get
help
Pag
esfi
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plai
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spx
or
by E
-mai
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DF
RIn
sura
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elp
oreg
ong
ov
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
r as
iste
ncia
en
Esp
antildeol
lla
me
al 1
(88
8) 3
44-8
235
ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
8 o
f 8
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like
S
peci
alis
t offi
ce v
isits
(pr
enat
al c
are)
C
hild
birt
hD
eliv
ery
Pro
fess
iona
l Ser
vice
s C
hild
birt
hD
eliv
ery
Fac
ility
Ser
vice
s D
iagn
ostic
test
s (u
ltras
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s an
d bl
ood
wor
k)
Spe
cial
ist v
isit
(ane
sthe
sia)
T
ota
l Exa
mp
le C
ost
$1
280
0 In
th
is e
xam
ple
Peg
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$0
Coi
nsur
ance
$3
000
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
560
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like
P
rimar
y ca
re p
hysi
cian
offi
ce v
isits
(in
clud
ing
dise
ase
educ
atio
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Dia
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(blo
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P
resc
riptio
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ugs
D
urab
le m
edic
al e
quip
men
t (gl
ucos
e m
eter
) T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like
E
mer
genc
y ro
om c
are
(incl
udin
g m
edic
al
supp
lies)
D
iagn
ostic
test
(x-
ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
925
In
th
is e
xam
ple
Mia
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$1
75
Coi
nsur
ance
$2
95
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$9
70
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
RE
IMB
UR
SE
ME
NT
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
al a
nd E
ligib
le F
amily
| P
lan
Typ
e P
PO
1 o
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Cla
ims
Adm
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or R
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Blu
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eld
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rego
n O
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CLA
X
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$1
000
indi
vidu
al
$20
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce n
etw
ork
$1
500
indi
vidu
al
$30
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
lim
ited
netw
ork
prov
ider
s $
300
0 in
divi
dual
$6
000
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
000
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
over
age
prev
entiv
e-ca
re-
bene
fits
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
$40
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
ca
lend
ar y
ear
Reg
ence
lim
ited
netw
ork
prov
ider
s
$70
00 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
600
0 fa
mily
per
ca
lend
ar y
ear
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
2 o
f 8
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
10
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Cov
erag
e fo
r ac
upun
ctur
e an
d ch
iropr
actic
sp
inal
man
ipul
atio
ns is
sub
ject
to $
25
copa
ymen
t for
Reg
ence
net
wor
k pr
ovid
ers
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 50
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
guid
elin
es
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
yo
ur p
lan
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
For
all
othe
r sp
ecia
lty
drug
s th
e fir
st fi
ll m
ust b
e pr
ovid
ed a
t Asa
nte
Out
patie
nt P
harm
acie
s If
Asa
nte
Out
patie
nt
Pha
rmac
ies
are
una
ble
to fi
ll th
ey w
ill
coor
dina
te a
fill
thro
ugh
a R
egen
ce S
peci
alty
P
harm
acy
Ple
ase
refe
r to
my
HR
for
a lis
t of
med
icat
ions
that
req
uire
the
first
fill
at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vis
it (w
aive
d if
adm
itted
)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
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vi
sit
dedu
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does
not
app
ly
40
coi
nsur
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fo
r al
l oth
er
serv
ices
50
coi
nsur
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for
Out
-of-
netw
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prov
ider
s
afte
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duct
ible
C
opay
men
t app
lies
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ach
Asa
nte
pref
erre
d ne
twor
kR
egen
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Reg
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lim
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netw
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psy
chot
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on
ly A
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her
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are
cove
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at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 10
c
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uran
ce
15
coi
nsur
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for
prof
essi
onal
and
30
c
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uran
ce fo
r fa
cilit
y
40
coi
nsur
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50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
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af
ter
dedu
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le
5 o
f 8
Co
mm
on
Med
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Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
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Info
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ion
Asa
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Pre
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Net
wo
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rovi
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pay
th
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Reg
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Net
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Pro
vid
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Reg
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Lim
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N
etw
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Pro
vid
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(Yo
u w
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mo
st)
If y
ou
are
pre
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ant
Offi
ce v
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10
c
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uran
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15
coi
nsur
ance
40
c
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uran
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50
coi
nsur
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for
Out
-of-
netw
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prov
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s
afte
r de
duct
ible
C
ost s
harin
g do
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pply
to c
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in
prev
entiv
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epen
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on
the
type
of
serv
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a c
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uran
ce o
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ible
may
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ply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
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es d
escr
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els
ewhe
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the
SB
C (
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ultr
asou
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M
ater
nity
cov
erag
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r de
pend
ent c
hild
ren
is
only
cov
ered
in th
e ca
se o
f com
plic
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ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 10
c
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uran
ce
15
coi
nsur
ance
40
c
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uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
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spec
ial h
ealt
h n
eed
s
Hom
e he
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car
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c
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uran
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30
coi
nsur
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40
c
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50
coi
nsur
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for
Out
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s af
ter
dedu
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Lim
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to 1
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Reh
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de
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c
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inpa
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ser
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s
$25
copa
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outp
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de
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doe
s no
t ap
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30
c
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uran
ce
inpa
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ser
vice
s
$75
copa
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outp
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de
duct
ible
doe
s no
t app
ly
40
coi
nsur
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in
patie
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ervi
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50
coi
nsur
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for
Out
-of-
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prov
ider
s
afte
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duct
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C
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men
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lies
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Asa
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lim
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only
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cove
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insu
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Inpa
tient
lim
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to 3
0 da
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up to
60
days
for
seve
re h
ead
or s
pina
l cor
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jury
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ear
O
utpa
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to 8
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Incl
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phy
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occ
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rapy
an
d sp
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apy
serv
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Hab
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de
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inpa
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vice
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$75
copa
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nt v
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de
duct
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s no
t app
ly
40
coi
nsur
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in
patie
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ervi
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50
coi
nsur
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for
Out
-of-
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prov
ider
s
afte
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duct
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C
opay
men
t app
lies
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ach
Asa
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kR
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Reg
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lim
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cove
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insu
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Out
patie
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euro
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lopm
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rapy
is
limite
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60
visi
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year
N
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is li
mite
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se
rvic
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r in
divi
dual
s th
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6 o
f 8
Co
mm
on
Med
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Eve
nt
Ser
vice
s Y
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May
Nee
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Wh
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ou
Will
Pay
Lim
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s E
xcep
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amp O
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Imp
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Info
rmat
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Asa
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Pre
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Net
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rovi
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Reg
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Net
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Pro
vid
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Reg
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Lim
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N
etw
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Pro
vid
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mo
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Incl
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phy
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rapy
an
d sp
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apy
serv
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Ski
lled
nurs
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care
N
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pplic
able
20
c
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uran
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20
coi
nsur
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50
c
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uran
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r O
ut-o
f-ne
twor
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ovid
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af
ter
dedu
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Lim
ited
to 9
0 in
patie
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ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
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20
c
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uran
ce
50
coi
nsur
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for
Out
-of-
netw
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prov
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s
afte
r de
duct
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Hos
pice
ser
vice
s 10
c
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uran
ce
30
coi
nsur
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40
c
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uran
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50
coi
nsur
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for
Out
-of-
netw
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prov
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s
afte
r de
duct
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R
espi
te c
are
is li
mite
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14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
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N
ot c
over
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Not
cov
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N
one
Chi
ldre
ns
dent
al c
heck
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N
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over
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Not
cov
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N
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over
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Non
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Exc
lud
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ervi
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amp O
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Co
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ervi
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Ser
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ou
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Gen
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ly D
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NO
T C
ove
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ur
po
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US
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Priv
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The
pla
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EX
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cov
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Prim
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care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$74
00
In t
his
exa
mp
le J
oe
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$13
82
Cop
aym
ents
$1
75
Coi
nsur
ance
$4
0
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
597
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
SA
VIN
GS
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
al a
nd E
ligib
le F
amily
| P
lan
Typ
e P
PO
1 o
f 7
Cla
ims
Adm
inis
trat
or R
egen
ce B
lueC
ross
Blu
eShi
eld
of O
rego
n O
O01
20S
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Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
y ca
re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chi
ropr
actic
spi
nal
man
ipul
atio
ns is
sub
ject
to 2
0 c
oins
uran
ce fo
r R
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 40
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
e dr
ugs
accr
ues
tow
ard
the
dedu
ctib
le
and
out-
of-p
ocke
t lim
it
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
y a
dditi
onal
fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill
thro
ugh
a R
egen
ce S
peci
alty
Pha
rmac
y P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
that
req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
su
rger
y ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s a
nd s
ervi
ces
desc
ribed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
-259
6
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
-a-c
ompl
aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
da
rds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
r as
iste
ncia
en
Esp
antildeol
lla
me
al 1
(88
8) 3
44-8
235
ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
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7 o
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The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PL
E c
over
ed s
ervi
ces
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
ere
nt h
ealth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
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of
Ben
efit
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rag
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hat t
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Pay
For
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its
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Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
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Reg
ence
Net
wo
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Pro
vid
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(Yo
u w
ill p
ay t
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Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
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st)
If y
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vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
y ca
re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chiro
prac
tic s
pina
l m
anip
ulat
ions
is s
ubje
ct to
20
coi
nsur
ance
for
Reg
ence
net
wor
kR
egen
ce li
mite
d ne
twor
k pr
ovid
ers
and
40
coi
nsur
ance
for
out-
of-n
etw
ork
prov
ider
s
Lim
ited
to $
200
0 y
ear
for
acup
unct
ure
and
$20
00
year
for
spin
al m
anip
ulat
ions
C
oins
uran
ce a
pplie
s to
the
out-
of-p
ocke
t lim
it
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
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resc
riptio
ns 3
5 c
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uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
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ugs
accr
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tow
ard
the
dedu
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and
out-
of-p
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The
firs
t fill
for
sele
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peci
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dru
gs m
ay b
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ovid
ed
at a
par
ticip
atin
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tail
phar
mac
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dditi
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mus
t be
pro
vide
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Asa
nte
Out
patie
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harm
acie
s F
or a
ll ot
her
spec
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dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
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If A
sant
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utpa
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P
harm
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able
to fi
ll th
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ill c
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fill
thro
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peci
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Pha
rmac
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leas
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fer
to m
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R fo
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list o
f med
icat
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req
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the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
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uran
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p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
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Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abo
ve
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
surg
ery
cent
er)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
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netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
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5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
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6
Yo
ur
Gri
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Ap
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ls R
igh
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The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
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o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
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gon
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isio
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anci
al R
egul
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84 o
r th
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ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
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94 b
y w
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gon
Div
isio
n of
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anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
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aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e Y
es
If yo
u do
nt h
ave
Min
imum
Ess
entia
l Cov
erag
e fo
r a
mon
th y
oull
hav
e to
mak
e a
paym
ent w
hen
you
file
your
tax
retu
rn u
nles
s yo
u qu
alify
for
an e
xem
ptio
n fr
om th
e re
quire
men
t tha
t you
hav
e he
alth
cov
erag
e fo
r th
at m
onth
D
oes
th
is p
lan
mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
s Y
es
If yo
ur p
lan
does
nt m
eet t
he M
inim
um V
alue
Sta
ndar
ds y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
L
ang
uag
e A
cces
s S
ervi
ces
S
pani
sh (
Esp
antildeol
) P
ara
obte
ner
asis
tenc
ia e
n E
spantilde
ol l
lam
e al
1 (
888)
344
-823
5
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
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les
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00
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aym
ents
$3
17
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nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
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er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
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al c
are
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ive
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es y
our
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ider
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arge
and
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y ot
her
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ors
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n th
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st s
harin
g am
ount
s (d
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tible
s c
opay
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ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
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sts
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mig
ht p
ay u
nder
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ns P
leas
e no
te th
ese
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rage
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mpl
es a
re b
ased
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erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health
Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been
performed Surgery and reconstruction of the other breast as necessary to provide
a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event
For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)
Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075
Asante Health PlanAnnual Required Notices
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)
Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others
The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits
toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020
The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger
The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks
1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen
2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program
If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA
If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts
The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower
Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year
Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status
The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor
Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment
Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs
In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately
You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate
If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995
Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not
discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender
Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio
accessible electronic formats and other formats) bull Asante provides free language services to people whose primary
language is not English including o Qualified interpreters o Information written in other languages
If you need these services contact Alicia Lorenz at the phone number or email address listed below
If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)
You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at
US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)
Complaint forms are available at hhsgovocrofficefileindexhtml
20HR011
This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020
Asante Health Plan changesPlan names Asante Health Plan 1 is being
renamed Asante PPO Health Plan Asante Health Plan 2 is being
renamed Asante Savings HealthPlan or HSA
Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA
For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use
Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers
A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles The deductibles for the new
Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses
Rx expenses will be counted toward the medical out-of-pocket maximums
The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50
Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles The deductibles for the four
categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family
Out-of-pocket maximums The out-of-pocket maximums for the
four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family
Copay and coinsurance changes The office visit coinsurance for
primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)
The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)
The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50
Health Savings Account The HSA contribution limit has
increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage
Employer contributions to the HSA Asante contributes to your HSA
if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled
Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four
categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums
Whatrsquos new for 2020
The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50
Employer contributions to the HRA Asante contributes to your HRA
account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents
Other changes In the Asante Reimbursement
Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations
In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers
Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan
(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)
Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit
All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet
All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply
A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible
Dental plan changes The Willamette Dental plan will have
a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year
There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan
Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits
Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012
Critical illness and accident plans Certain insurance policies are
available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505
Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information
This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025
All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization
How We May Use and Disclose Your Protected Health Information
Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories
For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use
For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments
For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes
To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us
As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws
Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it
The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage
This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System
The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees
What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage
If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen
1 Your hours of employment are reduced or
2 Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens
1 Your spouse dies
2 Your spousersquos hours of employment are reduced
3 Your spousersquos employment ends for any reason other than his or her gross misconduct
4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or
5 You become divorced or legally separated from your spouse
Continuation Coverage Rights Under Cobra
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens
1 The parent-employee dies
2 The parent-employeersquos hours of employment are reduced
3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct
4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)
5 The parents become divorced or legally separated or
6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo
Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan
When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event
You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to
Asante Health System
How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended
Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov
If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)
Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator
Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Updated 91418 ND
PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is
eligible for coverage please contact us so that we can provide them with this notice
Important Notice from Asante About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug
coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice
There are two important things you need to know about your current coverage and Medicarersquos
prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can
get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium
2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan
When Can You Join A Medicare Drug Plan
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th
However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan
You should also know that if you drop or lose your current coverage with Asante and donrsquot join a
Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later
Page 2
If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join
For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time
If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by
Medicare in the next 12 months this notice doesnrsquot apply to you
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos
how to get more information about Medicare prescription drug plans
Visit wwwmedicaregov
Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)
Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A General Information
What is the Health Insurance Marketplace
Can I Save Money on my Health Insurance Premiums in the Marketplace
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace
How Can I Get More Information
Form Approved OMB No 1210-0149
5 31 2020
P AR T B Information About Health C overage O ffered by Y our E mployer
3 Employer name 4 Employer Identification Number (EIN)
5 Employer address 6 Employer phone number
7 City 8 State 9 ZIP code
10 Who can we contact about employee health coverage at this job
11 Phone number (if different from above) 12 Email address
Eligible Dependents include Your Legal Spouse or you or your spousersquos children under the age of 26 including biological child legally adopted child or child place with you for adoption current stepchild legally placed foster child child for whom you have legal guardianship child you are required to provide coverage for due to a court or administrative order as part of a QMCSO or NMSN or disabled child over the age of 26
Plan information including employee costs for 2020 medical plans can be found on myHR (httpshrasanteorg) or upon request to Human Resources
WHERE TO GET HELPKeep this contact information in case you have questions as you use your benefits throughout the year
Contact Phone number E-mail or website
Asante Absence Management and Workers Compensation
(541) 789-5395 ndash Medford(541) 472-7374 ndash Grants Pass(541) 789-5417 ndash Ashland
leavesasanteorg
Asante Benefits Helpline (541) 789-4551 myasantebenefitsasanteorgAsk HR
Asante Employee Health (541) 789-5008 ndash Medford(541) 472-7376 ndash Grants Pass(541) 201-4484 ndash Ashland
wwwasanteorg
Asante Human Resources (541) 789-4243 ndashMedfordAshland(541) 472-7382 ndash Grants Pass
wwwasanteorgemployee-benefits
Asante Recruitment (541) 789-4757 AsanteEmploymentasanteorg
HealthEquity mdash Flexible Spending Accounts Health Reimbursement Arrangements Health Savings Accounts
(866) 960-8055 wwwmyhealthequitycom
Hyatt Legal Plan (MetLaw) (800) 821-6400 wwwlegalplanscomAccess code MetLaw
Livongo (800) 945-4355
MercyFlights (800) 903-9000 wwwmercyflightscom
MetLife Dental (800) 942-0854 wwwmetlifecommybenefits
myStrength customerservicemystrengthcom
Regence - Advice24 (800) 267-6729 wwwregencecom
Regence - BabyWise (888) 569-2229 wwwregencecom
Regence - Case Management (866) 543-5765 wwwregencecom
Regence - Customer Service - Medical Claims Eligibility Precertification
(888) 344-8235 wwwregencecom
Regence - Employee Assistance Program
(866) 750-1327 wwwmyRBHcom
Regence - Health Coach (800) 856-8543 wwwregencecom
Regence - Pharmacy Services (844) 765-2894 wwwregencecom
The Standard (833) 760-7012 wwwstandardcom
Contact Phone number E-mail or website
The Standard Voluntary Benefits
General Questions (866) 851-2429Claims (866) 851-5505
wwwstandardcom
Asante Retirement Plan (800) 343-0860 NetBenefitscomAtWork
Vision Service Plan (VSP) (800) 877-7195 wwwvspcom
Willamette Dental (855) 433-6825 wwwwillamettedentalcom
REG-115823-1609-2017copy 201 Regence BlueCross BlueShield of Oregon
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ail
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imum
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ail
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crip
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nsur
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to $
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ail
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40
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to $
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tail
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crip
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nsur
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to $
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ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on
fees
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vi
sit (
wai
ved
if ad
mitt
ed)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
15
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on
fees
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
If y
ou
nee
d m
enta
l hea
lth
b
ehav
iora
l hea
lth
or
sub
stan
ce a
bu
se
serv
ices
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt o
ffice
psy
chot
hera
py v
isits
on
ly A
ll ot
her
outp
atie
nt s
ervi
ces
are
cove
red
at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 15
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in p
reve
ntiv
e se
rvic
es D
epen
ding
on
the
type
of s
ervi
ces
a
coin
sura
nce
or d
educ
tible
may
app
ly M
ater
nity
ca
re m
ay in
clud
e te
sts
and
serv
ices
des
crib
ed
else
whe
re in
the
SB
C (
ie u
ltras
ound
)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
on
ly c
over
ed in
the
case
of c
ompl
icat
ions
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Li
mite
d to
100
vis
its
year
Reh
abili
tatio
n se
rvic
es
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
visi
ts
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Acu
punc
ture
(pr
ovid
ed b
y an
acu
punc
turis
t)
bull
Bar
iatr
ic s
urge
ry
bull
Chi
ropr
actic
car
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bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
ave
ling
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
7 o
f 8
Yo
ur
Rig
hts
to
Co
nti
nu
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ove
rag
e T
here
are
age
ncie
s th
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an h
elp
if yo
u w
ant t
o co
ntin
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our
cove
rage
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r it
ends
The
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tact
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rmat
ion
for
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e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
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rm o
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e U
S D
epar
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t of H
ealth
and
H
uman
Ser
vice
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ente
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onsu
mer
Info
rmat
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Insu
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323
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ay b
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clud
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vera
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roug
h th
e H
ealth
In
sura
nce
Mar
ketp
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For
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out t
he M
arke
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Hea
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all 1
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ieva
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ore
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rmat
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r rig
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look
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ion
Con
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Do
es t
his
pla
n p
rovi
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Min
imu
m E
ssen
tial
Co
vera
ge
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
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iste
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en
Esp
antildeol
lla
me
al 1
(88
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44-8
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ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
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8 o
f 8
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
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emer
genc
y ro
om v
isit
and
follo
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are)
Man
agin
g J
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s ty
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ear
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-net
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re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
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ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like
S
peci
alis
t offi
ce v
isits
(pr
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al c
are)
C
hild
birt
hD
eliv
ery
Pro
fess
iona
l Ser
vice
s C
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birt
hD
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ery
Fac
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Ser
vice
s D
iagn
ostic
test
s (u
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s an
d bl
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wor
k)
Spe
cial
ist v
isit
(ane
sthe
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T
ota
l Exa
mp
le C
ost
$1
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0 In
th
is e
xam
ple
Peg
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$0
Coi
nsur
ance
$3
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Wha
t isn
t co
vere
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Lim
its o
r ex
clus
ions
$6
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Th
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tal P
eg w
ou
ld p
ay is
$3
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◼ T
he
pla
ns
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rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
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Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
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like
P
rimar
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offi
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isits
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dise
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Dia
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P
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D
urab
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edic
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quip
men
t (gl
ucos
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) T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
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faci
lity)
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insu
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30
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oin
sura
nce
30
Th
is E
XA
MP
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nt
incl
ud
es s
ervi
ces
like
E
mer
genc
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are
(incl
udin
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edic
al
supp
lies)
D
iagn
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test
(x-
ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
925
In
th
is e
xam
ple
Mia
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$1
75
Coi
nsur
ance
$2
95
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$9
70
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
RE
IMB
UR
SE
ME
NT
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
al a
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ligib
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amily
| P
lan
Typ
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Cla
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or R
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Blu
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CLA
X
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
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C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
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ld s
har
e th
e co
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or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$1
000
indi
vidu
al
$20
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce n
etw
ork
$1
500
indi
vidu
al
$30
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
lim
ited
netw
ork
prov
ider
s $
300
0 in
divi
dual
$6
000
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
000
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
over
age
prev
entiv
e-ca
re-
bene
fits
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
$40
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
ca
lend
ar y
ear
Reg
ence
lim
ited
netw
ork
prov
ider
s
$70
00 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
600
0 fa
mily
per
ca
lend
ar y
ear
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
2 o
f 8
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
10
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Cov
erag
e fo
r ac
upun
ctur
e an
d ch
iropr
actic
sp
inal
man
ipul
atio
ns is
sub
ject
to $
25
copa
ymen
t for
Reg
ence
net
wor
k pr
ovid
ers
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 50
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
guid
elin
es
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
yo
ur p
lan
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
For
all
othe
r sp
ecia
lty
drug
s th
e fir
st fi
ll m
ust b
e pr
ovid
ed a
t Asa
nte
Out
patie
nt P
harm
acie
s If
Asa
nte
Out
patie
nt
Pha
rmac
ies
are
una
ble
to fi
ll th
ey w
ill
coor
dina
te a
fill
thro
ugh
a R
egen
ce S
peci
alty
P
harm
acy
Ple
ase
refe
r to
my
HR
for
a lis
t of
med
icat
ions
that
req
uire
the
first
fill
at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vis
it (w
aive
d if
adm
itted
)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
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nd
30
coi
nsur
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for
faci
lity
$75
copa
y o
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vi
sit
dedu
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does
not
app
ly
40
coi
nsur
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fo
r al
l oth
er
serv
ices
50
coi
nsur
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for
Out
-of-
netw
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prov
ider
s
afte
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duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
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Reg
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lim
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netw
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atie
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psy
chot
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on
ly A
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outp
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are
cove
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at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 10
c
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uran
ce
15
coi
nsur
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for
prof
essi
onal
and
30
c
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uran
ce fo
r fa
cilit
y
40
coi
nsur
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50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
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af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
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Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
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Info
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ion
Asa
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Pre
ferr
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Net
wo
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rovi
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pay
th
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Reg
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Net
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Pro
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Reg
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Lim
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N
etw
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Pro
vid
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(Yo
u w
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mo
st)
If y
ou
are
pre
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ant
Offi
ce v
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10
c
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uran
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15
coi
nsur
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40
c
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uran
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50
coi
nsur
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for
Out
-of-
netw
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prov
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s
afte
r de
duct
ible
C
ost s
harin
g do
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pply
to c
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in
prev
entiv
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epen
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on
the
type
of
serv
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a c
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uran
ce o
r de
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ible
may
ap
ply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
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es d
escr
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els
ewhe
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the
SB
C (
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ultr
asou
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M
ater
nity
cov
erag
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r de
pend
ent c
hild
ren
is
only
cov
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in th
e ca
se o
f com
plic
atio
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Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 10
c
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uran
ce
15
coi
nsur
ance
40
c
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uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
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spec
ial h
ealt
h n
eed
s
Hom
e he
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car
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c
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uran
ce
30
coi
nsur
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40
c
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uran
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50
coi
nsur
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for
Out
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prov
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s af
ter
dedu
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Lim
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to 1
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Reh
abili
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copa
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de
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t ap
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c
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uran
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inpa
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ser
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s
$25
copa
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outp
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de
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doe
s no
t ap
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30
c
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uran
ce
inpa
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ser
vice
s
$75
copa
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outp
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nt v
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de
duct
ible
doe
s no
t app
ly
40
coi
nsur
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in
patie
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ervi
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50
coi
nsur
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for
Out
-of-
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prov
ider
s
afte
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C
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men
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lies
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Asa
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lim
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only
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insu
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dedu
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Inpa
tient
lim
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to 3
0 da
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up to
60
days
for
seve
re h
ead
or s
pina
l cor
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jury
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ear
O
utpa
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lim
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to 8
0 vi
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Incl
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phy
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occ
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iona
l the
rapy
an
d sp
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apy
serv
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Hab
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c
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ce
inpa
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ser
vice
s
$75
copa
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outp
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nt v
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de
duct
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s no
t app
ly
40
coi
nsur
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in
patie
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ervi
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50
coi
nsur
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for
Out
-of-
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prov
ider
s
afte
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duct
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C
opay
men
t app
lies
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ach
Asa
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kR
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Reg
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lim
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cove
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insu
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Out
patie
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rapy
is
limite
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60
visi
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year
N
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is li
mite
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se
rvic
es fo
r in
divi
dual
s th
roug
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6 o
f 8
Co
mm
on
Med
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Eve
nt
Ser
vice
s Y
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May
Nee
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Wh
at Y
ou
Will
Pay
Lim
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s E
xcep
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amp O
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Imp
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Info
rmat
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Asa
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Pre
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Net
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rovi
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ou
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Reg
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Net
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Pro
vid
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Reg
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Lim
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N
etw
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Pro
vid
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ay t
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mo
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Incl
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phy
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rapy
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d sp
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apy
serv
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Ski
lled
nurs
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care
N
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pplic
able
20
c
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uran
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20
coi
nsur
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50
c
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uran
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r O
ut-o
f-ne
twor
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ovid
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af
ter
dedu
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Lim
ited
to 9
0 in
patie
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ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
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20
c
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uran
ce
50
coi
nsur
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for
Out
-of-
netw
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prov
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s
afte
r de
duct
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Hos
pice
ser
vice
s 10
c
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uran
ce
30
coi
nsur
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40
c
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uran
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50
coi
nsur
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for
Out
-of-
netw
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prov
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s
afte
r de
duct
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R
espi
te c
are
is li
mite
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14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
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N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
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N
ot c
over
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Not
cov
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N
one
Chi
ldre
ns
dent
al c
heck
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N
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over
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Not
cov
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N
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over
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Non
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Exc
lud
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ervi
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amp O
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Co
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ervi
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Ser
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ou
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Gen
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ly D
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NO
T C
ove
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ur
po
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US
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Priv
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The
pla
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EX
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cov
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ser
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ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$74
00
In t
his
exa
mp
le J
oe
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$13
82
Cop
aym
ents
$1
75
Coi
nsur
ance
$4
0
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
597
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
SA
VIN
GS
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
al a
nd E
ligib
le F
amily
| P
lan
Typ
e P
PO
1 o
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Cla
ims
Adm
inis
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egen
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lueC
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eld
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Th
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um
mar
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enef
its
and
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hel
p y
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ch
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hea
lth
pla
n T
he
SB
C s
ho
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ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
y ca
re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chi
ropr
actic
spi
nal
man
ipul
atio
ns is
sub
ject
to 2
0 c
oins
uran
ce fo
r R
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 40
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
e dr
ugs
accr
ues
tow
ard
the
dedu
ctib
le
and
out-
of-p
ocke
t lim
it
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
y a
dditi
onal
fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill
thro
ugh
a R
egen
ce S
peci
alty
Pha
rmac
y P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
that
req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
su
rger
y ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s a
nd s
ervi
ces
desc
ribed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
-259
6
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
-a-c
ompl
aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
da
rds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
r as
iste
ncia
en
Esp
antildeol
lla
me
al 1
(88
8) 3
44-8
235
ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
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7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PL
E c
over
ed s
ervi
ces
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
ere
nt h
ealth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
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of
Ben
efit
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f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
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Reg
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Net
wo
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Pro
vid
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(Yo
u w
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ay t
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Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
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st)
If y
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vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
y ca
re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chiro
prac
tic s
pina
l m
anip
ulat
ions
is s
ubje
ct to
20
coi
nsur
ance
for
Reg
ence
net
wor
kR
egen
ce li
mite
d ne
twor
k pr
ovid
ers
and
40
coi
nsur
ance
for
out-
of-n
etw
ork
prov
ider
s
Lim
ited
to $
200
0 y
ear
for
acup
unct
ure
and
$20
00
year
for
spin
al m
anip
ulat
ions
C
oins
uran
ce a
pplie
s to
the
out-
of-p
ocke
t lim
it
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
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resc
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ns 3
5 c
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uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
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ugs
accr
ues
tow
ard
the
dedu
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and
out-
of-p
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it
The
firs
t fill
for
sele
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peci
alty
dru
gs m
ay b
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ovid
ed
at a
par
ticip
atin
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tail
phar
mac
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mus
t be
pro
vide
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Asa
nte
Out
patie
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harm
acie
s F
or a
ll ot
her
spec
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dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
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utpa
tient
Pha
rmac
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If A
sant
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utpa
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P
harm
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able
to fi
ll th
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ill c
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fill
thro
ugh
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peci
alty
Pha
rmac
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fer
to m
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R fo
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list o
f med
icat
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req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
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Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
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uran
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p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abo
ve
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
surg
ery
cent
er)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
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netw
ork
prov
ider
s
If y
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nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
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5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
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6
Yo
ur
Gri
evan
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nd
Ap
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ls R
igh
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The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
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n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
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US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
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ntac
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gon
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isio
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egul
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84 o
r th
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ee m
essa
ge li
ne a
t 1 (
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94 b
y w
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gon
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isio
n of
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al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
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aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e Y
es
If yo
u do
nt h
ave
Min
imum
Ess
entia
l Cov
erag
e fo
r a
mon
th y
oull
hav
e to
mak
e a
paym
ent w
hen
you
file
your
tax
retu
rn u
nles
s yo
u qu
alify
for
an e
xem
ptio
n fr
om th
e re
quire
men
t tha
t you
hav
e he
alth
cov
erag
e fo
r th
at m
onth
D
oes
th
is p
lan
mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
s Y
es
If yo
ur p
lan
does
nt m
eet t
he M
inim
um V
alue
Sta
ndar
ds y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
L
ang
uag
e A
cces
s S
ervi
ces
S
pani
sh (
Esp
antildeol
) P
ara
obte
ner
asis
tenc
ia e
n E
spantilde
ol l
lam
e al
1 (
888)
344
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5
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
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ia w
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ay
Cos
t Sha
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les
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00
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aym
ents
$3
17
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ance
$1
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Wha
t isn
t co
vere
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Lim
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r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
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mpl
es o
f how
this
pla
n m
ight
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er m
edic
al c
are
You
r ac
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ts w
ill b
e di
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nt d
epen
ding
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are
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ive
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our
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ider
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st s
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ount
s (d
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s c
opay
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ts a
nd c
oins
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ce)
and
excl
uded
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vice
s un
der
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Use
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rmat
ion
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ompa
re th
e po
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n of
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ht p
ay u
nder
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leas
e no
te th
ese
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es a
re b
ased
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erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health
Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been
performed Surgery and reconstruction of the other breast as necessary to provide
a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event
For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)
Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075
Asante Health PlanAnnual Required Notices
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)
Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others
The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits
toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020
The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger
The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks
1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen
2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program
If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA
If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts
The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower
Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year
Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status
The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor
Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment
Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs
In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately
You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate
If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995
Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not
discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender
Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio
accessible electronic formats and other formats) bull Asante provides free language services to people whose primary
language is not English including o Qualified interpreters o Information written in other languages
If you need these services contact Alicia Lorenz at the phone number or email address listed below
If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)
You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at
US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)
Complaint forms are available at hhsgovocrofficefileindexhtml
20HR011
This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020
Asante Health Plan changesPlan names Asante Health Plan 1 is being
renamed Asante PPO Health Plan Asante Health Plan 2 is being
renamed Asante Savings HealthPlan or HSA
Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA
For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use
Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers
A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles The deductibles for the new
Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses
Rx expenses will be counted toward the medical out-of-pocket maximums
The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50
Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles The deductibles for the four
categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family
Out-of-pocket maximums The out-of-pocket maximums for the
four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family
Copay and coinsurance changes The office visit coinsurance for
primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)
The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)
The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50
Health Savings Account The HSA contribution limit has
increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage
Employer contributions to the HSA Asante contributes to your HSA
if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled
Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four
categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums
Whatrsquos new for 2020
The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50
Employer contributions to the HRA Asante contributes to your HRA
account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents
Other changes In the Asante Reimbursement
Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations
In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers
Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan
(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)
Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit
All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet
All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply
A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible
Dental plan changes The Willamette Dental plan will have
a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year
There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan
Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits
Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012
Critical illness and accident plans Certain insurance policies are
available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505
Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information
This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025
All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization
How We May Use and Disclose Your Protected Health Information
Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories
For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use
For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments
For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes
To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us
As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws
Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it
The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage
This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System
The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees
What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage
If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen
1 Your hours of employment are reduced or
2 Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens
1 Your spouse dies
2 Your spousersquos hours of employment are reduced
3 Your spousersquos employment ends for any reason other than his or her gross misconduct
4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or
5 You become divorced or legally separated from your spouse
Continuation Coverage Rights Under Cobra
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens
1 The parent-employee dies
2 The parent-employeersquos hours of employment are reduced
3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct
4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)
5 The parents become divorced or legally separated or
6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo
Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan
When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event
You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to
Asante Health System
How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended
Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov
If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)
Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator
Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Updated 91418 ND
PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is
eligible for coverage please contact us so that we can provide them with this notice
Important Notice from Asante About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug
coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice
There are two important things you need to know about your current coverage and Medicarersquos
prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can
get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium
2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan
When Can You Join A Medicare Drug Plan
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th
However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan
You should also know that if you drop or lose your current coverage with Asante and donrsquot join a
Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later
Page 2
If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join
For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time
If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by
Medicare in the next 12 months this notice doesnrsquot apply to you
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos
how to get more information about Medicare prescription drug plans
Visit wwwmedicaregov
Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)
Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A General Information
What is the Health Insurance Marketplace
Can I Save Money on my Health Insurance Premiums in the Marketplace
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace
How Can I Get More Information
Form Approved OMB No 1210-0149
5 31 2020
P AR T B Information About Health C overage O ffered by Y our E mployer
3 Employer name 4 Employer Identification Number (EIN)
5 Employer address 6 Employer phone number
7 City 8 State 9 ZIP code
10 Who can we contact about employee health coverage at this job
11 Phone number (if different from above) 12 Email address
Eligible Dependents include Your Legal Spouse or you or your spousersquos children under the age of 26 including biological child legally adopted child or child place with you for adoption current stepchild legally placed foster child child for whom you have legal guardianship child you are required to provide coverage for due to a court or administrative order as part of a QMCSO or NMSN or disabled child over the age of 26
Plan information including employee costs for 2020 medical plans can be found on myHR (httpshrasanteorg) or upon request to Human Resources
WHERE TO GET HELPKeep this contact information in case you have questions as you use your benefits throughout the year
Contact Phone number E-mail or website
Asante Absence Management and Workers Compensation
(541) 789-5395 ndash Medford(541) 472-7374 ndash Grants Pass(541) 789-5417 ndash Ashland
leavesasanteorg
Asante Benefits Helpline (541) 789-4551 myasantebenefitsasanteorgAsk HR
Asante Employee Health (541) 789-5008 ndash Medford(541) 472-7376 ndash Grants Pass(541) 201-4484 ndash Ashland
wwwasanteorg
Asante Human Resources (541) 789-4243 ndashMedfordAshland(541) 472-7382 ndash Grants Pass
wwwasanteorgemployee-benefits
Asante Recruitment (541) 789-4757 AsanteEmploymentasanteorg
HealthEquity mdash Flexible Spending Accounts Health Reimbursement Arrangements Health Savings Accounts
(866) 960-8055 wwwmyhealthequitycom
Hyatt Legal Plan (MetLaw) (800) 821-6400 wwwlegalplanscomAccess code MetLaw
Livongo (800) 945-4355
MercyFlights (800) 903-9000 wwwmercyflightscom
MetLife Dental (800) 942-0854 wwwmetlifecommybenefits
myStrength customerservicemystrengthcom
Regence - Advice24 (800) 267-6729 wwwregencecom
Regence - BabyWise (888) 569-2229 wwwregencecom
Regence - Case Management (866) 543-5765 wwwregencecom
Regence - Customer Service - Medical Claims Eligibility Precertification
(888) 344-8235 wwwregencecom
Regence - Employee Assistance Program
(866) 750-1327 wwwmyRBHcom
Regence - Health Coach (800) 856-8543 wwwregencecom
Regence - Pharmacy Services (844) 765-2894 wwwregencecom
The Standard (833) 760-7012 wwwstandardcom
Contact Phone number E-mail or website
The Standard Voluntary Benefits
General Questions (866) 851-2429Claims (866) 851-5505
wwwstandardcom
Asante Retirement Plan (800) 343-0860 NetBenefitscomAtWork
Vision Service Plan (VSP) (800) 877-7195 wwwvspcom
Willamette Dental (855) 433-6825 wwwwillamettedentalcom
REG-115823-1609-2017copy 201 Regence BlueCross BlueShield of Oregon
4 o
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If y
ou
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ility
fee
(eg
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spita
l roo
m)
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nsur
ance
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oins
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ce
40
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ance
50
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oins
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ce fo
r O
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k pr
ovid
ers
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ter
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ctib
le
Phy
sici
ans
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on
fees
15
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oins
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coi
nsur
ance
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oins
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50
coi
nsur
ance
for
Out
-of-
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ork
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ider
s
afte
r de
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If y
ou
nee
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enta
l hea
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ehav
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lth
or
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stan
ce a
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se
serv
ices
Out
patie
nt s
ervi
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copa
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ffice
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sit
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ctib
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oes
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pply
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l oth
er s
ervi
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ffice
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sit
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ctib
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oes
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pply
15
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r pr
ofes
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coi
nsur
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for
faci
lity
$75
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ffice
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sit
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ctib
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ly
40
coi
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50
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-of-
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ffice
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nce
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Inpa
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ser
vice
s 15
c
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15
coi
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for
prof
essi
onal
and
30
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oins
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r fa
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af
ter
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ctib
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5 o
f 8
Co
mm
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ical
Eve
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Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
15
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in p
reve
ntiv
e se
rvic
es D
epen
ding
on
the
type
of s
ervi
ces
a
coin
sura
nce
or d
educ
tible
may
app
ly M
ater
nity
ca
re m
ay in
clud
e te
sts
and
serv
ices
des
crib
ed
else
whe
re in
the
SB
C (
ie u
ltras
ound
)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
on
ly c
over
ed in
the
case
of c
ompl
icat
ions
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Li
mite
d to
100
vis
its
year
Reh
abili
tatio
n se
rvic
es
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
15
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
visi
ts
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 15
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Acu
punc
ture
(pr
ovid
ed b
y an
acu
punc
turis
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bull
Bar
iatr
ic s
urge
ry
bull
Chi
ropr
actic
car
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bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
ave
ling
outs
ide
the
US
bull
Priv
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duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
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law
Oth
er C
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Ser
vice
s (L
imit
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may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
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men
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bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
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an a
ccre
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l ins
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bull
Infe
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7 o
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Yo
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Rig
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to
Co
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here
are
age
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if yo
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The
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info
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thos
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S D
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t of L
abor
Em
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dmin
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866)
444
-327
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dol
gov
ebs
ahe
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rm o
r th
e U
S D
epar
tmen
t of H
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and
H
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Ser
vice
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r C
onsu
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Info
rmat
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and
Insu
ranc
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at 1
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gov
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stat
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sura
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may
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888)
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5 O
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cov
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buyi
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divi
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In
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Mar
ketp
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For
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form
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plan
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his
com
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abou
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prov
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form
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our
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mor
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form
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this
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assi
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(88
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or v
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com
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the
US
Dep
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f Lab
or E
mpl
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enef
its S
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dmin
istr
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n at
1 (
866)
444
-327
2 or
do
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Do
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If
you
don
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e M
inim
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ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
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a pa
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If
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Min
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Acc
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Spa
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spantilde
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44-8
235
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To
see
exam
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of h
ow th
is p
lan
mig
ht c
over
cos
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sam
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med
ical
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The
pla
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be
resp
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for
the
othe
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sts
of th
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EX
AM
PLE
cov
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ser
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Peg
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t $2
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Ho
spit
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faci
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Th
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XA
MP
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S
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Pro
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Fac
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Spe
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ple
Peg
wo
uld
pay
Cos
t Sha
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Ded
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Cop
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nsur
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Lim
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ay is
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560
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pla
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rall
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ible
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00
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pec
ialis
t co
pay
men
t $2
5 ◼
Ho
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faci
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co
insu
ran
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30
◼
Oth
er c
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sura
nce
30
Th
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XA
MP
LE
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nt
incl
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ervi
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like
P
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clud
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Dia
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ork)
P
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D
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men
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ucos
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In
th
is e
xam
ple
Jo
e w
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ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
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$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
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tal J
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wo
uld
pay
is
$27
54
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ns
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pec
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t $2
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g m
edic
al
supp
lies)
D
iagn
ostic
test
(x-
ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
925
In
th
is e
xam
ple
Mia
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$1
75
Coi
nsur
ance
$2
95
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$9
70
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
RE
IMB
UR
SE
ME
NT
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
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amily
| P
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Cla
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Th
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and
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do
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will
hel
p y
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ch
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se a
hea
lth
pla
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he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$1
000
indi
vidu
al
$20
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce n
etw
ork
$1
500
indi
vidu
al
$30
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
lim
ited
netw
ork
prov
ider
s $
300
0 in
divi
dual
$6
000
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
000
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
over
age
prev
entiv
e-ca
re-
bene
fits
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
$40
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
ca
lend
ar y
ear
Reg
ence
lim
ited
netw
ork
prov
ider
s
$70
00 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
600
0 fa
mily
per
ca
lend
ar y
ear
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
2 o
f 8
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
10
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Cov
erag
e fo
r ac
upun
ctur
e an
d ch
iropr
actic
sp
inal
man
ipul
atio
ns is
sub
ject
to $
25
copa
ymen
t for
Reg
ence
net
wor
k pr
ovid
ers
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 50
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
guid
elin
es
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
yo
ur p
lan
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
For
all
othe
r sp
ecia
lty
drug
s th
e fir
st fi
ll m
ust b
e pr
ovid
ed a
t Asa
nte
Out
patie
nt P
harm
acie
s If
Asa
nte
Out
patie
nt
Pha
rmac
ies
are
una
ble
to fi
ll th
ey w
ill
coor
dina
te a
fill
thro
ugh
a R
egen
ce S
peci
alty
P
harm
acy
Ple
ase
refe
r to
my
HR
for
a lis
t of
med
icat
ions
that
req
uire
the
first
fill
at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vis
it (w
aive
d if
adm
itted
)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt o
ffice
psy
chot
hera
py v
isits
on
ly A
ll ot
her
outp
atie
nt s
ervi
ces
are
cove
red
at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in
prev
entiv
e se
rvic
es D
epen
ding
on
the
type
of
serv
ices
a c
oins
uran
ce o
r de
duct
ible
may
ap
ply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
the
SB
C (
ie
ultr
asou
nd)
M
ater
nity
cov
erag
e fo
r de
pend
ent c
hild
ren
is
only
cov
ered
in th
e ca
se o
f com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s af
ter
dedu
ctib
le
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
10
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
10
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is
limite
d to
60
visi
ts
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al c
heck
-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
Th
is is
nt
a co
mp
lete
list
Ple
ase
see
you
r p
lan
do
cum
ent
)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
7 o
f 8
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cov
erag
e af
ter
it en
ds T
he c
onta
ct in
form
atio
n fo
r th
ose
agen
cies
is
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or d
olg
ove
bsa
heal
thre
form
or
the
US
Dep
artm
ent o
f Hea
lth a
nd
Hum
an S
ervi
ces
Cen
ter
for
Con
sum
er In
form
atio
n an
d In
sura
nce
Ove
rsig
ht a
t 1 (
877
) 26
7-23
23 x
6156
5 or
cci
ioc
ms
gov
or y
our
stat
e in
sura
nce
dep
artm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
avai
labl
e to
you
too
incl
udin
g bu
ying
indi
vid
ual i
nsur
ance
cov
erag
e th
roug
h th
e H
ealth
In
sura
nce
Mar
ketp
lace
For
mor
e in
form
atio
n ab
out t
he M
arke
tpla
ce v
isit
Hea
lthC
are
gov
or c
all 1
(80
0) 3
18-2
596
Y
ou
r G
riev
ance
an
d A
pp
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Rig
hts
T
here
are
age
ncie
s th
at c
an h
elp
if yo
u h
ave
a co
mpl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
O
R 9
7309
-040
5 th
roug
h th
e In
tern
et a
t df
ror
egon
gov
get
help
Pag
esfi
le-a
-com
plai
nta
spx
or
by E
-mai
l at
DF
RIn
sura
nceH
elp
oreg
ong
ov
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds
Y
es
If yo
ur p
lan
does
nt m
eet t
he M
inim
um V
alue
Sta
ndar
ds y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
L
ang
uag
e A
cces
s S
ervi
ces
S
pani
sh (
Esp
antildeol
) P
ara
obte
ner
asis
tenc
ia e
n E
spantilde
ol l
lam
e al
1 (
888)
344
-823
5
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
8 o
f 8
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$15
00
Cop
aym
ents
$0
Coi
nsur
ance
$2
000
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
560
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$74
00
In t
his
exa
mp
le J
oe
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$13
82
Cop
aym
ents
$1
75
Coi
nsur
ance
$4
0
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
597
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
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hat t
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Pla
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Indi
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har
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or
cove
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hea
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car
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es N
OT
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Info
rmat
ion
ab
ou
t th
e co
st o
f th
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lan
(ca
lled
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) w
ill b
e p
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sep
arat
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T
his
is o
nly
a s
um
mar
y F
or m
ore
info
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abou
t you
r co
vera
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get
a c
opy
of th
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mpl
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term
s of
cov
erag
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o to
reg
ence
com
or
call
1 (8
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344-
8235
F
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uch
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llow
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mou
nt b
alan
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illin
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uran
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pro
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her
unde
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see
the
Glo
ssar
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You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
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cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
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s A
nsw
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Wh
y T
his
Mat
ters
Wh
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th
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vera
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edu
ctib
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Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
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bene
fits
are
com
bine
d T
he d
educ
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am
ount
s fo
r A
sant
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efer
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netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
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licy
the
over
all f
amily
ded
uctib
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ust b
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et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
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serv
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co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
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Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
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sted
be
low
as
ded
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le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
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ven
if yo
u ha
ven
t ye
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th
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ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
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ee a
list
of c
over
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prev
entiv
e se
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t hea
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reg
ovc
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pre
vent
ive-
care
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s
Are
th
ere
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edu
ctib
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for
spec
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ser
vice
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No
Y
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ont
have
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educ
tible
s fo
r sp
ecifi
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rvic
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Wh
at is
th
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of-
po
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lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
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efer
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netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
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lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
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Wh
at is
no
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clu
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in t
he
ou
t-o
f-p
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et li
mit
Pre
miu
ms
bal
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-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
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s E
xcep
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ns
amp O
ther
Imp
ort
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Info
rmat
ion
Asa
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Pre
ferr
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Net
wo
rk P
rovi
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Reg
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N
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Pro
vid
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(Yo
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If y
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vis
it a
hea
lth
car
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rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
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ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
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re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chi
ropr
actic
spi
nal
man
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atio
ns is
sub
ject
to 2
0 c
oins
uran
ce fo
r R
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 40
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
e dr
ugs
accr
ues
tow
ard
the
dedu
ctib
le
and
out-
of-p
ocke
t lim
it
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
y a
dditi
onal
fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill
thro
ugh
a R
egen
ce S
peci
alty
Pha
rmac
y P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
that
req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
su
rger
y ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s a
nd s
ervi
ces
desc
ribed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
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an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
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to
Co
nti
nu
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rag
e T
here
are
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cove
rage
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r it
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The
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tact
info
rmat
ion
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thos
e ag
enci
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is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
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enef
its S
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dmin
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1 (
866)
444
-327
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dol
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refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
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vers
ight
at 1
(87
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323
x615
65 o
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gov
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our
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You
may
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so c
onta
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5 O
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erag
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ilabl
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udin
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indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
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arke
tpla
ce F
or m
ore
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abou
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Yo
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Gri
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The
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ies
that
can
hel
p if
you
have
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ompl
aint
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r pl
an fo
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laim
Thi
s co
mpl
aint
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alle
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grie
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eal
For
mor
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form
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You
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rieva
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ore
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lan
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235
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isit
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artm
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efits
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inim
um E
ssen
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to m
ake
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alu
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If
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imum
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ue S
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ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PL
E c
over
ed s
ervi
ces
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
ere
nt h
ealth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
FL
EX
IBL
E W
OR
KF
OR
CE
HE
AL
TH
PL
AN
(A
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eld
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SH
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Th
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and
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vera
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p y
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ch
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pla
n T
he
SB
C s
ho
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you
ho
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d t
he
pla
n w
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ld s
har
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or
cove
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hea
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car
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rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
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If yo
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Pre
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Eve
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You
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You
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A
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Co
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Med
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Wh
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Pay
Lim
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Imp
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Net
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Prim
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it to
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10
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Not
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imar
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40
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Out
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Cov
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clud
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C
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acup
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and
chiro
prac
tic s
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anip
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ions
is s
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20
coi
nsur
ance
for
Reg
ence
net
wor
kR
egen
ce li
mite
d ne
twor
k pr
ovid
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and
40
coi
nsur
ance
for
out-
of-n
etw
ork
prov
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s
Lim
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to $
200
0 y
ear
for
acup
unct
ure
and
$20
00
year
for
spin
al m
anip
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ions
C
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ce a
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s to
the
out-
of-p
ocke
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it
Spe
cial
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10
coi
nsur
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15
c
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uran
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40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
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e pr
even
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The
n ch
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wha
t you
r pl
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ill p
ay fo
r
Sub
ject
to p
reve
ntiv
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re g
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lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
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10
coi
nsur
ance
30
c
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uran
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40
coi
nsur
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50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
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(Yo
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ill p
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he
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Reg
ence
Net
wo
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Pro
vid
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(Yo
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Reg
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Lim
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etw
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Pro
vid
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(Yo
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If y
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s to
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you
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s o
r co
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Mor
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form
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pres
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drug
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is a
vaila
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rege
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com
go
drug
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OR
3tie
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Gen
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dru
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tail
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copa
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0 co
pay
mai
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tion
Not
cov
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Ded
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for
drug
s sp
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de
sign
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prev
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f chr
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Cov
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clud
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at 3
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sura
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axim
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ut-o
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You
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diffe
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cos
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wee
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disp
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add
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Asa
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If A
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first
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l at A
sant
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Pha
rmac
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Pre
ferr
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rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
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c
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uran
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p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
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axim
um
reta
il pr
escr
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c
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p to
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0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
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Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
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Spe
cial
ty d
rugs
R
efer
to g
ener
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pref
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and
and
bran
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Ref
er to
gen
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pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
10
c
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uran
ce
30
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
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Net
wo
rk
Pro
vid
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(Yo
u w
ill p
ay t
he
leas
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Reg
ence
Lim
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N
etw
ork
Pro
vid
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(Yo
u w
ill p
ay t
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mo
st)
surg
ery
cent
er)
Phy
sici
ans
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on
fees
10
c
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uran
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15
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
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40
coi
nsur
ance
50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
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If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
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ehav
iora
l hea
lth
o
r su
bst
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ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
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50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
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n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
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ded
uctib
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ay a
pply
Mat
erni
ty c
are
may
incl
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test
s an
d se
rvic
es d
escr
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ewhe
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th
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BC
(ie
ultr
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Mat
erni
ty c
over
age
for
depe
nden
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ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
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(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
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(Yo
u w
ill p
ay t
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mo
st)
If y
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nee
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elp
re
cove
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g o
r h
ave
oth
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spec
ial h
ealt
h n
eed
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Hom
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alth
car
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c
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uran
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30
coi
nsur
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40
c
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uran
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Lim
ited
to 1
00 v
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ye
ar
Reh
abili
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n se
rvic
es
10
coi
nsur
ance
30
c
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uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
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ry)
yea
r O
utpa
tient
lim
ited
to
80 v
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ar
Incl
udes
phy
sica
l the
rapy
occ
upat
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rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
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uran
ce
30
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
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s
Out
patie
nt n
euro
deve
lopm
enta
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rapy
is li
mite
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60
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its
year
N
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rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
-259
6
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
-a-c
ompl
aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e Y
es
If yo
u do
nt h
ave
Min
imum
Ess
entia
l Cov
erag
e fo
r a
mon
th y
oull
hav
e to
mak
e a
paym
ent w
hen
you
file
your
tax
retu
rn u
nles
s yo
u qu
alify
for
an e
xem
ptio
n fr
om th
e re
quire
men
t tha
t you
hav
e he
alth
cov
erag
e fo
r th
at m
onth
D
oes
th
is p
lan
mee
t th
e M
inim
um
Val
ue
Sta
nd
ard
s Y
es
If yo
ur p
lan
does
nt m
eet t
he M
inim
um V
alue
Sta
ndar
ds y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
L
ang
uag
e A
cces
s S
ervi
ces
S
pani
sh (
Esp
antildeol
) P
ara
obte
ner
asis
tenc
ia e
n E
spantilde
ol l
lam
e al
1 (
888)
344
-823
5
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t he
alth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health
Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been
performed Surgery and reconstruction of the other breast as necessary to provide
a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event
For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)
Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075
Asante Health PlanAnnual Required Notices
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)
Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others
The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits
toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020
The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger
The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks
1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen
2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program
If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA
If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts
The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower
Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year
Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status
The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor
Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment
Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs
In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately
You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate
If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995
Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not
discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender
Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio
accessible electronic formats and other formats) bull Asante provides free language services to people whose primary
language is not English including o Qualified interpreters o Information written in other languages
If you need these services contact Alicia Lorenz at the phone number or email address listed below
If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)
You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at
US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)
Complaint forms are available at hhsgovocrofficefileindexhtml
20HR011
This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020
Asante Health Plan changesPlan names Asante Health Plan 1 is being
renamed Asante PPO Health Plan Asante Health Plan 2 is being
renamed Asante Savings HealthPlan or HSA
Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA
For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use
Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers
A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles The deductibles for the new
Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses
Rx expenses will be counted toward the medical out-of-pocket maximums
The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50
Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles The deductibles for the four
categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family
Out-of-pocket maximums The out-of-pocket maximums for the
four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family
Copay and coinsurance changes The office visit coinsurance for
primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)
The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)
The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50
Health Savings Account The HSA contribution limit has
increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage
Employer contributions to the HSA Asante contributes to your HSA
if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled
Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four
categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums
Whatrsquos new for 2020
The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50
Employer contributions to the HRA Asante contributes to your HRA
account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents
Other changes In the Asante Reimbursement
Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations
In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers
Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan
(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)
Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit
All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet
All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply
A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible
Dental plan changes The Willamette Dental plan will have
a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year
There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan
Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits
Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012
Critical illness and accident plans Certain insurance policies are
available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505
Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information
This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025
All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization
How We May Use and Disclose Your Protected Health Information
Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories
For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use
For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments
For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes
To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us
As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws
Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it
The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage
This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System
The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees
What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage
If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen
1 Your hours of employment are reduced or
2 Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens
1 Your spouse dies
2 Your spousersquos hours of employment are reduced
3 Your spousersquos employment ends for any reason other than his or her gross misconduct
4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or
5 You become divorced or legally separated from your spouse
Continuation Coverage Rights Under Cobra
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens
1 The parent-employee dies
2 The parent-employeersquos hours of employment are reduced
3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct
4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)
5 The parents become divorced or legally separated or
6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo
Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan
When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event
You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to
Asante Health System
How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended
Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov
If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)
Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator
Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Updated 91418 ND
PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is
eligible for coverage please contact us so that we can provide them with this notice
Important Notice from Asante About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug
coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice
There are two important things you need to know about your current coverage and Medicarersquos
prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can
get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium
2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan
When Can You Join A Medicare Drug Plan
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th
However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan
You should also know that if you drop or lose your current coverage with Asante and donrsquot join a
Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later
Page 2
If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join
For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time
If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by
Medicare in the next 12 months this notice doesnrsquot apply to you
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos
how to get more information about Medicare prescription drug plans
Visit wwwmedicaregov
Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)
Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A General Information
What is the Health Insurance Marketplace
Can I Save Money on my Health Insurance Premiums in the Marketplace
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace
How Can I Get More Information
Form Approved OMB No 1210-0149
5 31 2020
P AR T B Information About Health C overage O ffered by Y our E mployer
3 Employer name 4 Employer Identification Number (EIN)
5 Employer address 6 Employer phone number
7 City 8 State 9 ZIP code
10 Who can we contact about employee health coverage at this job
11 Phone number (if different from above) 12 Email address
Eligible Dependents include Your Legal Spouse or you or your spousersquos children under the age of 26 including biological child legally adopted child or child place with you for adoption current stepchild legally placed foster child child for whom you have legal guardianship child you are required to provide coverage for due to a court or administrative order as part of a QMCSO or NMSN or disabled child over the age of 26
Plan information including employee costs for 2020 medical plans can be found on myHR (httpshrasanteorg) or upon request to Human Resources
WHERE TO GET HELPKeep this contact information in case you have questions as you use your benefits throughout the year
Contact Phone number E-mail or website
Asante Absence Management and Workers Compensation
(541) 789-5395 ndash Medford(541) 472-7374 ndash Grants Pass(541) 789-5417 ndash Ashland
leavesasanteorg
Asante Benefits Helpline (541) 789-4551 myasantebenefitsasanteorgAsk HR
Asante Employee Health (541) 789-5008 ndash Medford(541) 472-7376 ndash Grants Pass(541) 201-4484 ndash Ashland
wwwasanteorg
Asante Human Resources (541) 789-4243 ndashMedfordAshland(541) 472-7382 ndash Grants Pass
wwwasanteorgemployee-benefits
Asante Recruitment (541) 789-4757 AsanteEmploymentasanteorg
HealthEquity mdash Flexible Spending Accounts Health Reimbursement Arrangements Health Savings Accounts
(866) 960-8055 wwwmyhealthequitycom
Hyatt Legal Plan (MetLaw) (800) 821-6400 wwwlegalplanscomAccess code MetLaw
Livongo (800) 945-4355
MercyFlights (800) 903-9000 wwwmercyflightscom
MetLife Dental (800) 942-0854 wwwmetlifecommybenefits
myStrength customerservicemystrengthcom
Regence - Advice24 (800) 267-6729 wwwregencecom
Regence - BabyWise (888) 569-2229 wwwregencecom
Regence - Case Management (866) 543-5765 wwwregencecom
Regence - Customer Service - Medical Claims Eligibility Precertification
(888) 344-8235 wwwregencecom
Regence - Employee Assistance Program
(866) 750-1327 wwwmyRBHcom
Regence - Health Coach (800) 856-8543 wwwregencecom
Regence - Pharmacy Services (844) 765-2894 wwwregencecom
The Standard (833) 760-7012 wwwstandardcom
Contact Phone number E-mail or website
The Standard Voluntary Benefits
General Questions (866) 851-2429Claims (866) 851-5505
wwwstandardcom
Asante Retirement Plan (800) 343-0860 NetBenefitscomAtWork
Vision Service Plan (VSP) (800) 877-7195 wwwvspcom
Willamette Dental (855) 433-6825 wwwwillamettedentalcom
REG-115823-1609-2017copy 201 Regence BlueCross BlueShield of Oregon
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
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Nee
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Wh
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ort
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rmat
ion
Asa
nte
Pre
ferr
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rk P
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etw
ork
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vid
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(Yo
u w
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ay t
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If y
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ce v
isits
15
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-of-
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ly M
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ices
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SB
C (
ie u
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Mat
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n is
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ly c
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the
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ompl
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Chi
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essi
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30
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nsur
ance
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Chi
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rth
deliv
ery
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lity
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15
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Hom
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nsur
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-of-
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-of-
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ence
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Inp
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are
cove
red
at th
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e sp
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ctib
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Inpa
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60
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15
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s no
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30
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copa
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nt v
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40
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Out
-of-
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ence
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Out
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nt n
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mite
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ts
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N
euro
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lopm
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l the
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is li
mite
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se
rvic
es fo
r in
divi
dual
s th
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h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
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Will
Pay
Lim
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Imp
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ion
Asa
nte
Pre
ferr
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ence
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vid
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ence
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Dur
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Out
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nsur
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nsur
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Out
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te c
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days
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If y
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r ch
ild n
eed
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r ey
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Chi
ldre
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N
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n d
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men
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r m
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info
rmat
ion
an
d a
list
of
any
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er e
xclu
ded
ser
vice
s)
bull
Acu
punc
ture
(pr
ovid
ed b
y an
acu
punc
turis
t)
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ic s
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ropr
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-ter
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Non
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care
whe
n tr
ave
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outs
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the
US
bull
Priv
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nur
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cept
as
prov
ided
for
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)
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Rou
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(A
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Rou
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car
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Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
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red
Ser
vice
s (L
imit
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ns
may
ap
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th
ese
serv
ices
T
his
isn
t a
com
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st P
leas
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ur
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n d
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Hab
ilita
tion
serv
ices
bull
Hea
ring
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for
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vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
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ry s
choo
l or
an a
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titut
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rtili
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7 o
f 8
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Co
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here
are
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s th
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an h
elp
if yo
u w
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ntin
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rage
afte
r it
ends
The
con
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info
rmat
ion
for
thos
e ag
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he U
S D
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tmen
t of L
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Em
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enef
its S
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dmin
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n at
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866)
444
-327
2 or
dol
gov
ebs
ahe
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refo
rm o
r th
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S D
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tmen
t of H
ealth
and
H
uman
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s C
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r C
onsu
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Info
rmat
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and
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ranc
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vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
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gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
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a de
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im Y
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form
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plan
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mor
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form
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your
rig
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this
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assi
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lan
at 1
(88
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or v
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com
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the
US
Dep
artm
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f Lab
or E
mpl
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enef
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dmin
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inan
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by c
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03)
947
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4 or
the
toll
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mes
sage
line
at 1
(88
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77-
4894
by
writ
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to th
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rego
n D
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Do
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pla
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ssen
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Co
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Yes
If
you
don
t hav
e M
inim
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over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
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t whe
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turn
unl
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you
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exe
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the
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pla
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alu
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tan
dar
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Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
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Acc
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s
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al 1
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44-8
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ndashndash
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ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
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over
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sam
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med
ical
situ
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ee th
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nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
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8 o
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The
pla
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be
resp
onsi
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for
the
othe
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sts
of th
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EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
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y (9
mon
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◼ T
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pla
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$5
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ialis
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pay
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t $2
5 ◼
Ho
spit
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faci
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co
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30
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sura
nce
30
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eve
nt
incl
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ces
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t $2
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P
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phys
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ost
$1
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In
th
is e
xam
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Mia
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
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ents
$1
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nsur
ance
$2
95
Wha
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$0
Th
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ia w
ou
ld p
ay is
$9
70
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
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of
Ben
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For
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ab
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um
mar
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or m
ore
info
rmat
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abou
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vera
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get
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opy
of th
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mpl
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term
s of
cov
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o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
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al d
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s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
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oins
uran
ce c
opay
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pro
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r ot
her
unde
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see
the
Glo
ssar
y
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can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
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req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
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Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$1
000
indi
vidu
al
$20
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce n
etw
ork
$1
500
indi
vidu
al
$30
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
lim
ited
netw
ork
prov
ider
s $
300
0 in
divi
dual
$6
000
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
000
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
over
age
prev
entiv
e-ca
re-
bene
fits
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
$40
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
ca
lend
ar y
ear
Reg
ence
lim
ited
netw
ork
prov
ider
s
$70
00 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
600
0 fa
mily
per
ca
lend
ar y
ear
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
2 o
f 8
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
10
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Cov
erag
e fo
r ac
upun
ctur
e an
d ch
iropr
actic
sp
inal
man
ipul
atio
ns is
sub
ject
to $
25
copa
ymen
t for
Reg
ence
net
wor
k pr
ovid
ers
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 50
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
guid
elin
es
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
yo
ur p
lan
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
For
all
othe
r sp
ecia
lty
drug
s th
e fir
st fi
ll m
ust b
e pr
ovid
ed a
t Asa
nte
Out
patie
nt P
harm
acie
s If
Asa
nte
Out
patie
nt
Pha
rmac
ies
are
una
ble
to fi
ll th
ey w
ill
coor
dina
te a
fill
thro
ugh
a R
egen
ce S
peci
alty
P
harm
acy
Ple
ase
refe
r to
my
HR
for
a lis
t of
med
icat
ions
that
req
uire
the
first
fill
at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vis
it (w
aive
d if
adm
itted
)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
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uran
ce
20
coi
nsur
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for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
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$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
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ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
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30
c
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40
coi
nsur
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50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
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af
ter
dedu
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Phy
sici
ans
urge
on fe
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10
coi
nsur
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15
c
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uran
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40
coi
nsur
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50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
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af
ter
dedu
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If y
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nee
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ehav
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r su
bst
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ab
use
se
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Out
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ces
$10
copa
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vi
sit
dedu
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10
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r al
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er s
ervi
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$25
copa
y o
ffice
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sit
dedu
ctib
le d
oes
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15
c
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uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
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for
faci
lity
$75
copa
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vi
sit
dedu
ctib
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does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
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outp
atie
nt o
ffice
psy
chot
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py v
isits
on
ly A
ll ot
her
outp
atie
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ervi
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are
cove
red
at
the
coin
sura
nce
spec
ified
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r de
duct
ible
Inpa
tient
ser
vice
s 10
c
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uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
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uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
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Net
wo
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rovi
der
(Y
ou
will
pay
th
e le
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Reg
ence
Net
wo
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Pro
vid
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leas
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Reg
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Lim
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N
etw
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Pro
vid
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(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
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10
c
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uran
ce
15
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in
prev
entiv
e se
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epen
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on
the
type
of
serv
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a c
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uran
ce o
r de
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ible
may
ap
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Mat
erni
ty c
are
may
incl
ude
test
s an
d se
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es d
escr
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els
ewhe
re in
the
SB
C (
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ultr
asou
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M
ater
nity
cov
erag
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r de
pend
ent c
hild
ren
is
only
cov
ered
in th
e ca
se o
f com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 10
c
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uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
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uran
ce
50
coi
nsur
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for
Out
-of-
netw
ork
prov
ider
s af
ter
dedu
ctib
le
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
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$10
copa
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outp
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isit
de
duct
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doe
s no
t ap
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c
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uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
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30
c
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uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
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etw
ork
Reg
ence
lim
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netw
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atie
nt v
isit
only
Inp
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ervi
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are
cove
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at th
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insu
ranc
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fter
dedu
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Inpa
tient
lim
ited
to 3
0 da
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up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
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$10
copa
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outp
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nt v
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de
duct
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t ap
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10
c
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uran
ce
inpa
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ser
vice
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$25
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outp
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de
duct
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t ap
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30
c
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uran
ce
inpa
tient
ser
vice
s
$75
copa
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outp
atie
nt v
isit
de
duct
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doe
s no
t app
ly
40
coi
nsur
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in
patie
nt s
ervi
ces
50
coi
nsur
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for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
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lim
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netw
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atie
nt v
isit
only
Inp
atie
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ervi
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are
cove
red
at th
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insu
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fter
dedu
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Out
patie
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euro
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enta
l the
rapy
is
limite
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60
visi
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year
N
euro
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lopm
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rapy
is li
mite
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se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
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Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
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ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
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Pre
ferr
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Net
wo
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rovi
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(Y
ou
will
pay
th
e le
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Reg
ence
Net
wo
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Pro
vid
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leas
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Reg
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Lim
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N
etw
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Pro
vid
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ill p
ay t
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mo
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Incl
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phy
sica
l the
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occ
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iona
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rapy
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d sp
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apy
serv
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Ski
lled
nurs
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care
N
ot a
pplic
able
20
c
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uran
ce
20
coi
nsur
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50
c
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uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
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af
ter
dedu
ctib
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Lim
ited
to 9
0 in
patie
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ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
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20
c
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uran
ce
50
coi
nsur
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for
Out
-of-
netw
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prov
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s
afte
r de
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Hos
pice
ser
vice
s 10
c
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uran
ce
30
coi
nsur
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40
c
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uran
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50
coi
nsur
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for
Out
-of-
netw
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prov
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s
afte
r de
duct
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R
espi
te c
are
is li
mite
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14
days
lif
etim
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If y
ou
r ch
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eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
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N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
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N
ot c
over
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Not
cov
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N
one
Chi
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ns
dent
al c
heck
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N
ot c
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Not
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Non
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Exc
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ervi
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Co
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ervi
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Ser
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Gen
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NO
T C
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vice
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Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
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om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$15
00
Cop
aym
ents
$0
Coi
nsur
ance
$2
000
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
560
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$74
00
In t
his
exa
mp
le J
oe
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$13
82
Cop
aym
ents
$1
75
Coi
nsur
ance
$4
0
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
597
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
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s C
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rag
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010
120
20 ndash
12
312
020
AS
AN
TE
SA
VIN
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HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
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ligib
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Typ
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Cla
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Th
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p y
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pla
n w
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ld s
har
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or
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hea
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car
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es N
OT
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Info
rmat
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ab
ou
t th
e co
st o
f th
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lan
(ca
lled
th
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rem
ium
) w
ill b
e p
rovi
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sep
arat
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T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
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serv
ices
co
vere
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bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
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vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
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k ou
t-of
-poc
ket l
imit
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The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
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t in
clu
ded
in t
he
ou
t-o
f-p
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et li
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Eve
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yo
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efer
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out a
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Net
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Reg
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Net
wo
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Pro
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Reg
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Lim
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N
etw
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vid
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If y
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Cov
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ret
ail c
linic
C
over
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for
acup
unct
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and
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ropr
actic
spi
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man
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sub
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to 2
0 c
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egen
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etw
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ork
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oins
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Li
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yea
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ar fo
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ipul
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t-of
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ket l
imit
Spe
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isit
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nsur
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15
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oins
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ce
40
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ance
Pre
vent
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eeni
ng
imm
uniz
atio
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o ch
arge
N
o ch
arge
N
o ch
arge
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ices
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sk y
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even
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eck
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ill p
ay fo
r
Sub
ject
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ntiv
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uide
lines
If y
ou
hav
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Dia
gnos
tic te
st (
x-ra
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lood
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10
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oins
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ce
40
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50
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Out
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Imag
ing
(CT
PE
T
scan
s M
RIs
)
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30
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oins
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ce
40
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3 o
f 7
Co
mm
on
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Eve
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ou
Will
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xcep
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ort
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rmat
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nte
Pre
ferr
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Net
wo
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rovi
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u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
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Pro
vid
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u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
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N
etw
ork
Pro
vid
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(Yo
u w
ill p
ay t
he
mo
st)
If y
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d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
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n
Mor
e in
form
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out
pres
crip
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drug
cov
erag
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is a
vaila
ble
at
rege
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com
go
drug
list2
020
OR
3tie
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Gen
eric
dru
gs
$5 c
opay
30
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re
tail
pres
crip
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$10
copa
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0-da
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tail
pres
crip
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$15
copa
y r
etai
l pr
escr
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n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
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r tr
eatm
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f chr
onic
di
seas
es th
at a
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n th
e O
ptim
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alue
Med
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List
C
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is li
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0-da
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p to
90
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sup
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at A
sant
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utpa
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Pha
rmac
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or
thro
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Reg
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mai
l ord
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No
char
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r F
DA
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rove
d w
omen
s c
ontr
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an
d ce
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even
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drug
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d im
mun
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ions
at a
pa
rtic
ipat
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phar
mac
y
Cov
erag
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clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
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uran
ce u
p to
$2
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axim
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t a R
egen
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artic
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ing
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arm
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ref
er to
you
r pl
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r fu
rthe
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form
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Mai
l-ord
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resc
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ns 3
5 c
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uran
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p to
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0 m
axim
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ut-o
f-ne
twor
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escr
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over
age
is n
ot c
over
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You
are
res
pons
ible
for
the
diffe
renc
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cos
t bet
wee
n a
disp
ense
d br
and-
nam
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nd th
e eq
uiva
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dru
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add
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to th
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paym
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he c
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accr
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The
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dru
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phar
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mus
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pro
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Asa
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Out
patie
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harm
acie
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or a
ll ot
her
spec
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dru
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he fi
rst f
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ust b
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ovid
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t A
sant
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tient
Pha
rmac
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If A
sant
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P
harm
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able
to fi
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ill c
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fill
thro
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a R
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peci
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Pha
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to m
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R fo
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list o
f med
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that
req
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the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
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Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
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uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
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uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
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crip
tion
Not
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Bra
nd d
rugs
30
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nsur
ance
up
to $
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max
imum
30
-day
ret
ail
pres
crip
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nsur
ance
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300
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imum
90
-day
ret
ail
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crip
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nsur
ance
up
to $
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re
tail
pres
crip
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40
coi
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ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
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Spe
cial
ty d
rugs
R
efer
to g
ener
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pref
erre
d br
and
and
bran
d dr
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abov
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Ref
er to
gen
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pr
efer
red
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d an
d br
and
drug
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ove
N
ot c
over
ed
If y
ou
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e o
utp
atie
nt
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ery
Fac
ility
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(eg
am
bula
tory
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rger
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nter
) 10
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oins
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ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
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nt
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vice
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ou
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Nee
d
Wh
at Y
ou
Will
Pay
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itat
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s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
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oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s a
nd s
ervi
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desc
ribed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
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60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
-259
6
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
-a-c
ompl
aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
da
rds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
r as
iste
ncia
en
Esp
antildeol
lla
me
al 1
(88
8) 3
44-8
235
ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PL
E c
over
ed s
ervi
ces
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
ere
nt h
ealth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
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12
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or
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hea
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car
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Info
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ab
ou
t th
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lan
(ca
lled
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ill b
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nly
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um
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or m
ore
info
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abou
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vera
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get
a c
opy
of th
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mpl
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term
s of
cov
erag
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o to
reg
ence
com
or
call
1 (8
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344-
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F
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uch
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llow
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mou
nt b
alan
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illin
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uran
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opay
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pro
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her
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see
the
Glo
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You
can
vie
w th
e G
loss
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at h
ealth
care
gov
sbc
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cal
l 1 (
888)
344
-823
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req
uest
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Imp
ort
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Qu
esti
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nsw
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Wh
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his
Mat
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Wh
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th
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vera
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edu
ctib
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Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
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n th
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licy
the
over
all f
amily
ded
uctib
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ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
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ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
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ee a
list
of c
over
ed
prev
entiv
e se
rvic
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t hea
lthca
reg
ovc
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rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
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et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
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nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
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Net
wo
rk P
rovi
der
(Yo
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ill p
ay t
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Reg
ence
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wo
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Pro
vid
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he
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Reg
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Lim
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N
etw
ork
Pro
vid
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(Yo
u w
ill p
ay t
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mo
st)
If y
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vis
it a
hea
lth
car
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rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
y ca
re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chiro
prac
tic s
pina
l m
anip
ulat
ions
is s
ubje
ct to
20
coi
nsur
ance
for
Reg
ence
net
wor
kR
egen
ce li
mite
d ne
twor
k pr
ovid
ers
and
40
coi
nsur
ance
for
out-
of-n
etw
ork
prov
ider
s
Lim
ited
to $
200
0 y
ear
for
acup
unct
ure
and
$20
00
year
for
spin
al m
anip
ulat
ions
C
oins
uran
ce a
pplie
s to
the
out-
of-p
ocke
t lim
it
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
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a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
e dr
ugs
accr
ues
tow
ard
the
dedu
ctib
le
and
out-
of-p
ocke
t lim
it
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
y a
dditi
onal
fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill
thro
ugh
a R
egen
ce S
peci
alty
Pha
rmac
y P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
that
req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abo
ve
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
surg
ery
cent
er)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
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bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
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Yo
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Rig
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to
Co
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are
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r it
ends
The
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tact
info
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thos
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he U
S D
epar
tmen
t of L
abor
Em
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its S
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dmin
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866)
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ahe
alth
refo
rm o
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e U
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epar
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ealth
and
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uman
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vice
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ente
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onsu
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Info
rmat
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Insu
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ight
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323
x615
65 o
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ms
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or y
our
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e in
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nce
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rtm
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You
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onta
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erag
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udin
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indi
vidu
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nce
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rage
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Hea
lth
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arke
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or m
ore
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Yo
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Gri
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Ap
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The
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can
hel
p if
you
have
a c
ompl
aint
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inst
you
r pl
an fo
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deni
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f a c
laim
Thi
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mpl
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grie
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app
eal
For
mor
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form
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You
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(86
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alem
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thro
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file
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D
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pro
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inim
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If yo
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entia
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lan
mee
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inim
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Val
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Sta
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inim
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alue
Sta
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spantilde
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1 (
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ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
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o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
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ituat
ion
see
the
next
sec
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ndashndashndashndash
ndashndashndashndash
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7 o
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The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
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EX
AM
PLE
cov
ered
ser
vice
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Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
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wor
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e-na
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a ho
spita
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are)
Man
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re o
f a w
ell-
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rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
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Spe
cial
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ffice
vis
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pren
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Chi
ldbi
rth
Del
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rofe
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nal S
ervi
ces
Chi
ldbi
rth
Del
iver
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acili
ty S
ervi
ces
Dia
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(ultr
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nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t he
alth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health
Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been
performed Surgery and reconstruction of the other breast as necessary to provide
a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event
For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)
Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075
Asante Health PlanAnnual Required Notices
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)
Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others
The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits
toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020
The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger
The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks
1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen
2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program
If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA
If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts
The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower
Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year
Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status
The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor
Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment
Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs
In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately
You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate
If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995
Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not
discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender
Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio
accessible electronic formats and other formats) bull Asante provides free language services to people whose primary
language is not English including o Qualified interpreters o Information written in other languages
If you need these services contact Alicia Lorenz at the phone number or email address listed below
If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)
You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at
US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)
Complaint forms are available at hhsgovocrofficefileindexhtml
20HR011
This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020
Asante Health Plan changesPlan names Asante Health Plan 1 is being
renamed Asante PPO Health Plan Asante Health Plan 2 is being
renamed Asante Savings HealthPlan or HSA
Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA
For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use
Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers
A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles The deductibles for the new
Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses
Rx expenses will be counted toward the medical out-of-pocket maximums
The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50
Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles The deductibles for the four
categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family
Out-of-pocket maximums The out-of-pocket maximums for the
four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family
Copay and coinsurance changes The office visit coinsurance for
primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)
The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)
The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50
Health Savings Account The HSA contribution limit has
increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage
Employer contributions to the HSA Asante contributes to your HSA
if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled
Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four
categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums
Whatrsquos new for 2020
The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50
Employer contributions to the HRA Asante contributes to your HRA
account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents
Other changes In the Asante Reimbursement
Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations
In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers
Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan
(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)
Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit
All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet
All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply
A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible
Dental plan changes The Willamette Dental plan will have
a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year
There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan
Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits
Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012
Critical illness and accident plans Certain insurance policies are
available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505
Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information
This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025
All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization
How We May Use and Disclose Your Protected Health Information
Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories
For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use
For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments
For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes
To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us
As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws
Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it
The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage
This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System
The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees
What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage
If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen
1 Your hours of employment are reduced or
2 Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens
1 Your spouse dies
2 Your spousersquos hours of employment are reduced
3 Your spousersquos employment ends for any reason other than his or her gross misconduct
4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or
5 You become divorced or legally separated from your spouse
Continuation Coverage Rights Under Cobra
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens
1 The parent-employee dies
2 The parent-employeersquos hours of employment are reduced
3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct
4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)
5 The parents become divorced or legally separated or
6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo
Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan
When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event
You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to
Asante Health System
How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended
Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov
If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)
Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator
Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Updated 91418 ND
PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is
eligible for coverage please contact us so that we can provide them with this notice
Important Notice from Asante About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug
coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice
There are two important things you need to know about your current coverage and Medicarersquos
prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can
get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium
2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan
When Can You Join A Medicare Drug Plan
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th
However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan
You should also know that if you drop or lose your current coverage with Asante and donrsquot join a
Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later
Page 2
If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join
For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time
If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by
Medicare in the next 12 months this notice doesnrsquot apply to you
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos
how to get more information about Medicare prescription drug plans
Visit wwwmedicaregov
Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)
Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A General Information
What is the Health Insurance Marketplace
Can I Save Money on my Health Insurance Premiums in the Marketplace
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace
How Can I Get More Information
Form Approved OMB No 1210-0149
5 31 2020
P AR T B Information About Health C overage O ffered by Y our E mployer
3 Employer name 4 Employer Identification Number (EIN)
5 Employer address 6 Employer phone number
7 City 8 State 9 ZIP code
10 Who can we contact about employee health coverage at this job
11 Phone number (if different from above) 12 Email address
Eligible Dependents include Your Legal Spouse or you or your spousersquos children under the age of 26 including biological child legally adopted child or child place with you for adoption current stepchild legally placed foster child child for whom you have legal guardianship child you are required to provide coverage for due to a court or administrative order as part of a QMCSO or NMSN or disabled child over the age of 26
Plan information including employee costs for 2020 medical plans can be found on myHR (httpshrasanteorg) or upon request to Human Resources
WHERE TO GET HELPKeep this contact information in case you have questions as you use your benefits throughout the year
Contact Phone number E-mail or website
Asante Absence Management and Workers Compensation
(541) 789-5395 ndash Medford(541) 472-7374 ndash Grants Pass(541) 789-5417 ndash Ashland
leavesasanteorg
Asante Benefits Helpline (541) 789-4551 myasantebenefitsasanteorgAsk HR
Asante Employee Health (541) 789-5008 ndash Medford(541) 472-7376 ndash Grants Pass(541) 201-4484 ndash Ashland
wwwasanteorg
Asante Human Resources (541) 789-4243 ndashMedfordAshland(541) 472-7382 ndash Grants Pass
wwwasanteorgemployee-benefits
Asante Recruitment (541) 789-4757 AsanteEmploymentasanteorg
HealthEquity mdash Flexible Spending Accounts Health Reimbursement Arrangements Health Savings Accounts
(866) 960-8055 wwwmyhealthequitycom
Hyatt Legal Plan (MetLaw) (800) 821-6400 wwwlegalplanscomAccess code MetLaw
Livongo (800) 945-4355
MercyFlights (800) 903-9000 wwwmercyflightscom
MetLife Dental (800) 942-0854 wwwmetlifecommybenefits
myStrength customerservicemystrengthcom
Regence - Advice24 (800) 267-6729 wwwregencecom
Regence - BabyWise (888) 569-2229 wwwregencecom
Regence - Case Management (866) 543-5765 wwwregencecom
Regence - Customer Service - Medical Claims Eligibility Precertification
(888) 344-8235 wwwregencecom
Regence - Employee Assistance Program
(866) 750-1327 wwwmyRBHcom
Regence - Health Coach (800) 856-8543 wwwregencecom
Regence - Pharmacy Services (844) 765-2894 wwwregencecom
The Standard (833) 760-7012 wwwstandardcom
Contact Phone number E-mail or website
The Standard Voluntary Benefits
General Questions (866) 851-2429Claims (866) 851-5505
wwwstandardcom
Asante Retirement Plan (800) 343-0860 NetBenefitscomAtWork
Vision Service Plan (VSP) (800) 877-7195 wwwvspcom
Willamette Dental (855) 433-6825 wwwwillamettedentalcom
REG-115823-1609-2017copy 201 Regence BlueCross BlueShield of Oregon
6 o
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hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
7 o
f 8
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tion
s m
ay b
e av
aila
ble
to y
ou to
o in
clud
ing
buyi
ng in
divi
dual
insu
ranc
e co
vera
ge th
roug
h th
e H
ealth
In
sura
nce
Mar
ketp
lace
For
mor
e in
form
atio
n ab
out t
he M
arke
tpla
ce v
isit
Hea
lthC
are
gov
or c
all 1
(80
0) 3
18-2
596
Y
ou
r G
riev
ance
an
d A
pp
eals
Rig
hts
T
here
are
age
ncie
s th
at c
an h
elp
if yo
u ha
ve a
com
plai
nt a
gain
st y
our
plan
for
a de
nial
of a
cla
im T
his
com
plai
nt is
cal
led
a gr
ieva
nce
or a
ppea
l F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
look
at t
he e
xpla
natio
n of
ben
efits
you
will
rec
eive
for
that
med
ical
cla
im Y
our
plan
doc
umen
ts a
lso
prov
ide
com
plet
e in
form
atio
n to
sub
mit
a cl
aim
app
eal
or a
grie
vanc
e fo
r an
y re
ason
to y
our
plan
For
mor
e in
form
atio
n ab
out
your
rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oye
e B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
do
lgov
ebs
ahe
alth
refo
rm Y
ou m
ay a
lso
cont
act t
he O
rego
n D
ivis
ion
of F
inan
cial
Reg
ulat
ion
by c
allin
g (5
03)
947
-798
4 or
the
toll
free
mes
sage
line
at 1
(88
8) 8
77-
4894
by
writ
ing
to th
e O
rego
n D
ivis
ion
of F
inan
cial
Reg
ulat
ion
Con
sum
er A
dvoc
acy
Uni
t P
O B
ox 1
4480
Sal
em O
R 9
7309
-040
5 th
roug
h th
e In
tern
et a
t df
ror
egon
gov
get
help
Pag
esfi
le-a
-com
plai
nta
spx
or
by E
-mai
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DF
RIn
sura
nceH
elp
oreg
ong
ov
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
r as
iste
ncia
en
Esp
antildeol
lla
me
al 1
(88
8) 3
44-8
235
ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
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ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
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8 o
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The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
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wor
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are
and
a ho
spita
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s S
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Man
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ear
of r
outin
e in
-net
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re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like
S
peci
alis
t offi
ce v
isits
(pr
enat
al c
are)
C
hild
birt
hD
eliv
ery
Pro
fess
iona
l Ser
vice
s C
hild
birt
hD
eliv
ery
Fac
ility
Ser
vice
s D
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ostic
test
s (u
ltras
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s an
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ood
wor
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cial
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isit
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sthe
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l Exa
mp
le C
ost
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th
is e
xam
ple
Peg
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$0
Coi
nsur
ance
$3
000
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
560
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
◼
Oth
er c
oin
sura
nce
30
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
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like
P
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hysi
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offi
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(in
clud
ing
dise
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Dia
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(blo
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edic
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quip
men
t (gl
ucos
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) T
ota
l Exa
mp
le C
ost
$7
400
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th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30
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er c
oin
sura
nce
30
Th
is E
XA
MP
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nt
incl
ud
es s
ervi
ces
like
E
mer
genc
y ro
om c
are
(incl
udin
g m
edic
al
supp
lies)
D
iagn
ostic
test
(x-
ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
925
In
th
is e
xam
ple
Mia
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$1
75
Coi
nsur
ance
$2
95
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$9
70
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d
010
120
20 ndash
12
312
020
AS
AN
TE
RE
IMB
UR
SE
ME
NT
HE
AL
TH
PL
AN
Co
vera
ge
for
Indi
vidu
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ligib
le F
amily
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lan
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e P
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Cla
ims
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egen
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Blu
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CLA
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Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es N
OT
E
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely
T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$1
000
indi
vidu
al
$20
00 fa
mily
per
cal
enda
r ye
ar R
egen
ce n
etw
ork
$1
500
indi
vidu
al
$30
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
lim
ited
netw
ork
prov
ider
s $
300
0 in
divi
dual
$6
000
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
000
indi
vidu
al
$70
00 fa
mily
per
cal
enda
r ye
ar
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
over
age
prev
entiv
e-ca
re-
bene
fits
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
$40
00 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
500
indi
vidu
al
$70
00 fa
mily
per
ca
lend
ar y
ear
Reg
ence
lim
ited
netw
ork
prov
ider
s
$70
00 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
600
0 fa
mily
per
ca
lend
ar y
ear
T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es I
f yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et
2 o
f 8
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
you
pay
thes
e ex
pens
es t
hey
don
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$1
0 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
10
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
$2
5 co
pay
ret
ail
clin
ic v
isit
ded
uctib
le
does
not
app
ly
15
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
$7
5 co
pay
ret
ail
clin
ic v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Cov
erag
e fo
r ac
upun
ctur
e an
d ch
iropr
actic
sp
inal
man
ipul
atio
ns is
sub
ject
to $
25
copa
ymen
t for
Reg
ence
net
wor
k pr
ovid
ers
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 50
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren
t pr
even
tive
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r S
ubje
ct to
pre
vent
ive
care
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
guid
elin
es
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y
bloo
d w
ork)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Im
agin
g (C
TP
ET
sc
ans
MR
Is)
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
Li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90-
day
supp
ly a
t Asa
nte
Out
patie
nt P
harm
acie
s or
th
roug
h R
egen
ce m
ail o
rder
N
o ch
arge
for
FD
A-a
ppro
ved
wom
ens
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy
C
over
age
incl
udes
com
poun
d m
edic
atio
ns a
t 30
c
oins
uran
ce u
p to
$10
0 m
axim
um a
t A
sant
e O
utpa
tient
Pha
rmac
ies
and
40
co
insu
ranc
e up
to $
200
max
imum
at a
Reg
ence
pa
rtic
ipat
ing
reta
il ph
arm
acy
ref
er to
yo
ur p
lan
for
furt
her
info
rmat
ion
Mai
l-ord
er p
resc
riptio
ns
35
coi
nsur
ance
up
to $
120
max
imum
Out
-of-
netw
ork
pres
crip
tion
drug
cov
erag
e is
not
co
vere
d
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t be
twee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
gen
eric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed a
t a p
artic
ipat
ing
reta
il ph
arm
acy
ad
ditio
nal f
ills
mus
t be
prov
ided
at A
sant
e O
utpa
tient
Pha
rmac
ies
For
all
othe
r sp
ecia
lty
drug
s th
e fir
st fi
ll m
ust b
e pr
ovid
ed a
t Asa
nte
Out
patie
nt P
harm
acie
s If
Asa
nte
Out
patie
nt
Pha
rmac
ies
are
una
ble
to fi
ll th
ey w
ill
coor
dina
te a
fill
thro
ugh
a R
egen
ce S
peci
alty
P
harm
acy
Ple
ase
refe
r to
my
HR
for
a lis
t of
med
icat
ions
that
req
uire
the
first
fill
at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dru
gs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
4 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
sur
gery
ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
car
e $1
50 c
opay
vi
sit
dedu
ctib
le d
oes
not
appl
y
$150
cop
ay
visi
t de
duct
ible
doe
s no
t ap
ply
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly
$150
cop
ay
visi
t de
duct
ible
doe
s no
t app
ly fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
C
opay
men
t app
lies
to th
e fa
cilit
y ch
arge
for
each
vis
it (w
aive
d if
adm
itted
)
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Urg
ent c
are
$10
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$25
copa
y v
isit
de
duct
ible
doe
s no
t ap
ply
$75
copa
y v
isit
de
duct
ible
doe
s no
t app
ly
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
offic
eur
gent
car
e vi
sit
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Phy
sici
ans
urge
on fe
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt s
ervi
ces
$10
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y o
ffice
vi
sit
dedu
ctib
le d
oes
not a
pply
15
c
oins
uran
ce fo
r pr
ofes
sion
al a
nd
30
coi
nsur
ance
for
faci
lity
$75
copa
y o
ffice
vi
sit
dedu
ctib
le
does
not
app
ly
40
coi
nsur
ance
fo
r al
l oth
er
serv
ices
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt o
ffice
psy
chot
hera
py v
isits
on
ly A
ll ot
her
outp
atie
nt s
ervi
ces
are
cove
red
at
the
coin
sura
nce
spec
ified
afte
r de
duct
ible
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
5 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
ost s
harin
g do
es n
ot a
pply
to c
erta
in
prev
entiv
e se
rvic
es D
epen
ding
on
the
type
of
serv
ices
a c
oins
uran
ce o
r de
duct
ible
may
ap
ply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
the
SB
C (
ie
ultr
asou
nd)
M
ater
nity
cov
erag
e fo
r de
pend
ent c
hild
ren
is
only
cov
ered
in th
e ca
se o
f com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s af
ter
dedu
ctib
le
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
10
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re h
ead
or s
pina
l cor
d in
jury
) y
ear
O
utpa
tient
lim
ited
to 8
0 vi
sits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
$10
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
10
c
oins
uran
ce
inpa
tient
ser
vice
s
$25
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t ap
ply
30
c
oins
uran
ce
inpa
tient
ser
vice
s
$75
copa
y
outp
atie
nt v
isit
de
duct
ible
doe
s no
t app
ly
40
coi
nsur
ance
in
patie
nt s
ervi
ces
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
kR
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
outp
atie
nt v
isit
only
Inp
atie
nt s
ervi
ces
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed a
fter
dedu
ctib
le
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is
limite
d to
60
visi
ts
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
se
rvic
es fo
r in
divi
dual
s th
roug
h ag
e 17
6 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
an
d sp
eech
ther
apy
serv
ices
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
af
ter
dedu
ctib
le
Lim
ited
to 9
0 in
patie
nt d
ays
yea
r
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
afte
r de
duct
ible
R
espi
te c
are
is li
mite
d to
14
days
lif
etim
e
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al c
heck
-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
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xclu
ded
ser
vice
s)
bull
Bar
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urge
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bull
Cos
met
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urge
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xcep
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geni
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nom
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bull
Den
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are
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bull
Long
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bull
Non
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avel
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US
bull
Priv
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age
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form
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plai
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-mai
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elp
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ong
ov
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds
Y
es
If yo
ur p
lan
does
nt m
eet t
he M
inim
um V
alue
Sta
ndar
ds y
ou m
ay b
e el
igib
le fo
r a
prem
ium
tax
cred
it to
hel
p yo
u pa
y fo
r a
plan
thro
ugh
the
Mar
ketp
lace
L
ang
uag
e A
cces
s S
ervi
ces
S
pani
sh (
Esp
antildeol
) P
ara
obte
ner
asis
tenc
ia e
n E
spantilde
ol l
lam
e al
1 (
888)
344
-823
5
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
8 o
f 8
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$15
00
Cop
aym
ents
$0
Coi
nsur
ance
$2
000
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
560
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
To
tal E
xam
ple
Co
st
$74
00
In t
his
exa
mp
le J
oe
wo
uld
pay
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
858
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$27
54
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
500
◼
Sp
ecia
list
cop
aym
ent
$25
◼ H
osp
ital
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cilit
y) c
oin
sura
nce
30
◼ O
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co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
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clud
ing
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su
pplie
s)
Dia
gnos
tic te
st (
x-ra
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Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$13
82
Cop
aym
ents
$1
75
Coi
nsur
ance
$4
0
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$1
597
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
n C
over
s amp
Wha
t You
Pay
For
Cov
ered
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s C
ove
rag
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erio
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010
120
20 ndash
12
312
020
AS
AN
TE
SA
VIN
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HE
AL
TH
PL
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Indi
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Th
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p y
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pla
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ho
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he
pla
n w
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ld s
har
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hea
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OT
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Info
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ab
ou
t th
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st o
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lan
(ca
lled
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rem
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) w
ill b
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rovi
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arat
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T
his
is o
nly
a s
um
mar
y F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e g
o to
reg
ence
com
or
call
1 (8
88)
344-
8235
F
or g
ener
al d
efin
ition
s of
com
mon
term
s s
uch
as a
llow
ed a
mou
nt b
alan
ce b
illin
g c
oins
uran
ce c
opay
men
t de
duct
ible
pro
vide
r o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y
You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
Wh
at is
th
e o
vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
tible
am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
le m
ust b
e m
et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
ere
serv
ices
co
vere
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bef
ore
yo
u m
eet
you
r d
edu
ctib
le
Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven
t ye
t met
th
e de
duct
ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
reg
ovc
ove
rage
pre
vent
ive-
care
-be
nefit
s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
ou d
ont
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
e pr
efer
red
netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
-poc
ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
d
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
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nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
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wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
es p
rimar
y ca
re v
isits
at a
ret
ail c
linic
C
over
age
for
acup
unct
ure
and
chi
ropr
actic
spi
nal
man
ipul
atio
ns is
sub
ject
to 2
0 c
oins
uran
ce fo
r R
egen
ce n
etw
ork
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 40
c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers
Li
mite
d to
$2
000
yea
r fo
r ac
upun
ctur
e an
d $2
000
ye
ar fo
r sp
inal
man
ipul
atio
ns
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
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a 3
0-da
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pply
ret
ail a
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p to
90
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sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
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ugs
accr
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tow
ard
the
dedu
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and
out-
of-p
ocke
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it
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
y a
dditi
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fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
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ill c
oord
inat
e a
fill
thro
ugh
a R
egen
ce S
peci
alty
Pha
rmac
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leas
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fer
to m
y H
R fo
r a
list o
f med
icat
ions
that
req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abov
e
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
su
rger
y ce
nter
) 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s a
nd s
ervi
ces
desc
ribed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is t
he U
S D
epar
tmen
t of L
abor
Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
gov
ebs
ahe
alth
refo
rm o
r th
e U
S D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iioc
ms
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5 O
ther
cov
erag
e op
tions
may
be
ava
ilabl
e to
you
too
incl
udin
g bu
ying
indi
vidu
al in
sura
nce
cove
rage
thro
ugh
the
Hea
lth
Insu
ranc
e M
arke
tpla
ce F
or m
ore
info
rmat
ion
abou
t the
Mar
ketp
lace
vis
it H
ealth
Car
ego
v or
cal
l 1 (
800)
318
-259
6
Yo
ur
Gri
evan
ce a
nd
Ap
pea
ls R
igh
ts
The
re a
re a
genc
ies
that
can
hel
p if
you
have
a c
ompl
aint
aga
inst
you
r pl
an fo
r a
deni
al o
f a c
laim
Thi
s co
mpl
aint
is c
alle
d a
grie
vanc
e or
app
eal
For
mor
e in
form
atio
n ab
out y
our
right
s lo
ok a
t the
exp
lana
tion
of b
enef
its y
ou w
ill r
ecei
ve fo
r th
at m
edic
al c
laim
You
r pl
an d
ocum
ents
als
o pr
ovid
e co
mpl
ete
info
rmat
ion
to s
ubm
it a
clai
m a
ppea
l or
a g
rieva
nce
for
any
reas
on to
you
r pl
an F
or m
ore
info
rmat
ion
abou
t you
r rig
hts
this
not
ice
or
assi
stan
ce
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce
com
or
the
US
Dep
artm
ent o
f Lab
or E
mpl
oyee
Ben
efits
Sec
urity
Adm
inis
trat
ion
at 1
(86
6) 4
44-3
272
or
dolg
ove
bsa
heal
thre
form
You
may
als
o co
ntac
t the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n by
cal
ling
(503
) 94
7-79
84 o
r th
e to
ll fr
ee m
essa
ge li
ne a
t 1 (
888)
877
-48
94 b
y w
ritin
g to
the
Ore
gon
Div
isio
n of
Fin
anci
al R
egul
atio
n C
onsu
mer
Adv
ocac
y U
nit
PO
Box
144
80 S
alem
OR
973
09-0
405
thro
ugh
the
Inte
rnet
at
dfr
oreg
ong
ovg
ethe
lpP
ages
file
-a-c
ompl
aint
asp
x o
r by
E-m
ail a
t D
FR
Insu
ranc
eHel
por
egon
gov
D
oes
th
is p
lan
pro
vid
e M
inim
um
Ess
enti
al C
ove
rag
e
Yes
If
you
don
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
you
ll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
da
rds
Yes
If
your
pla
n do
esn
t mee
t the
Min
imum
Val
ue S
tand
ards
you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce
Lan
gu
age
Acc
ess
Ser
vice
s
Spa
nish
(E
spantilde
ol)
Par
a ob
tene
r as
iste
ncia
en
Esp
antildeol
lla
me
al 1
(88
8) 3
44-8
235
ndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n s
ee th
e ne
xt s
ectio
nndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PL
E c
over
ed s
ervi
ces
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
ere
nt h
ealth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e W
hat t
his
Pla
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Wha
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Pay
For
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010
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12
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p y
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pla
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ho
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you
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he
pla
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ld s
har
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e co
st f
or
cove
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hea
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car
e se
rvic
es N
OT
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Info
rmat
ion
ab
ou
t th
e co
st o
f th
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lan
(ca
lled
th
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rem
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) w
ill b
e p
rovi
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sep
arat
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T
his
is o
nly
a s
um
mar
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or m
ore
info
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abou
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vera
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get
a c
opy
of th
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mpl
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term
s of
cov
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o to
reg
ence
com
or
call
1 (8
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344-
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F
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com
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term
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uch
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llow
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mou
nt b
alan
ce b
illin
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uran
ce c
opay
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t de
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pro
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her
unde
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see
the
Glo
ssar
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You
can
vie
w th
e G
loss
ary
at h
ealth
care
gov
sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy
Imp
ort
ant
Qu
esti
on
s A
nsw
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Wh
y T
his
Mat
ters
Wh
at is
th
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vera
ll d
edu
ctib
le
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s $
140
0 in
divi
dual
(si
ngle
cov
erag
e)
$28
00
fam
ily p
er c
alen
dar
year
Reg
ence
lim
ited
netw
ork
prov
ider
s $
350
0 in
divi
dual
(si
ngle
cov
erag
e)
$70
00
fam
ily p
er c
alen
dar
year
Out
-of-
netw
ork
$4
500
indi
vidu
al (
sing
le c
over
age)
$9
000
fam
ily p
er c
alen
dar
year
T
he R
egen
ce n
etw
ork
dedu
ctib
le fo
r m
edic
al a
nd
pres
crip
tion
bene
fits
are
com
bine
d T
he d
educ
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am
ount
s fo
r A
sant
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efer
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netw
ork
prov
ider
s
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate
Gen
eral
ly y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e po
licy
the
over
all f
amily
ded
uctib
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ust b
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et b
efor
e th
e pl
an b
egin
s to
pay
Are
th
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serv
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co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
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Yes
Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
ded
uctib
le d
oes
not a
pply
or
as
No
char
ge
Thi
s pl
an c
over
s so
me
item
s an
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ven
if yo
u ha
ven
t ye
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th
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ible
am
ount
But
a c
opay
men
t or
coin
sura
nce
may
app
ly F
or
exam
ple
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le S
ee a
list
of c
over
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prev
entiv
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t hea
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reg
ovc
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pre
vent
ive-
care
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s
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s
No
Y
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ont
have
to m
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educ
tible
s fo
r sp
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rvic
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Wh
at is
th
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ut-
of-
po
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lim
it
for
this
pla
n
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers
$2
000
indi
vidu
al
(sin
gle
cove
rage
) $
300
0 fa
mily
per
cal
enda
r ye
ar
Reg
ence
net
wor
k pr
ovid
ers
$3
000
indi
vidu
al (
sing
le
cove
rage
) $
600
0 fa
mily
per
cal
enda
r ye
ar R
egen
ce
limite
d ne
twor
k pr
ovid
ers
$6
000
indi
vidu
al (
sing
le
cove
rage
) $
120
00 fa
mily
per
cal
enda
r ye
ar T
he o
ut-o
f-po
cket
lim
it am
ount
s fo
r A
sant
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efer
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netw
ork
prov
ider
s R
egen
ce n
etw
ork
prov
ider
s an
d R
egen
ce
limite
d ne
twor
k pr
ovid
ers
cros
s ac
cum
ulat
e O
ut-o
f-ne
twor
k $
800
0 in
divi
dual
$1
400
0 fa
mily
per
cal
enda
r ye
ar
The
Reg
ence
net
wor
k ou
t-of
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ket l
imit
for
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es
If yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it m
ust b
e m
et
2 o
f 7
med
ical
and
pre
scrip
tion
bene
fits
are
com
bine
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Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
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et li
mit
Pre
miu
ms
bal
ance
-bill
ed c
harg
es a
nd h
ealth
car
e th
is
plan
doe
snt
cove
r
Eve
n th
ough
yo
u pa
y th
ese
expe
nses
th
ey d
ont
coun
t tow
ard
the
out-
of-p
ocke
t lim
it
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er
Yes
Asa
nte
prov
ider
s S
ee
rege
nce
com
go
OR
Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
s n
etw
ork
You
will
pay
the
mos
t if y
ou u
se a
n o
ut-o
f-ne
twor
k pr
ovid
er a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
ers
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
Be
awar
e y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list
N
o
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et i
f a d
educ
tible
app
lies
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
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s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
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Net
wo
rk P
rovi
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Reg
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Reg
ence
Lim
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N
etw
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Pro
vid
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(Yo
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If y
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vis
it a
hea
lth
car
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rovi
der
s o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
trea
t an
inju
ry o
r ill
ness
10
c
oins
uran
ce
15
coi
nsur
ance
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
40
c
oins
uran
ce
reta
il cl
inic
vis
it
40
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cov
erag
e in
clud
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rimar
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re v
isits
at a
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ail c
linic
C
over
age
for
acup
unct
ure
and
chiro
prac
tic s
pina
l m
anip
ulat
ions
is s
ubje
ct to
20
coi
nsur
ance
for
Reg
ence
net
wor
kR
egen
ce li
mite
d ne
twor
k pr
ovid
ers
and
40
coi
nsur
ance
for
out-
of-n
etw
ork
prov
ider
s
Lim
ited
to $
200
0 y
ear
for
acup
unct
ure
and
$20
00
year
for
spin
al m
anip
ulat
ions
C
oins
uran
ce a
pplie
s to
the
out-
of-p
ocke
t lim
it
Spe
cial
ist v
isit
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Pre
vent
ive
care
scr
eeni
ng
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
You
may
hav
e to
pay
for
serv
ices
that
are
nt
prev
entiv
e A
sk y
our
prov
ider
if th
e se
rvic
es n
eede
d ar
e pr
even
tive
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r
Sub
ject
to p
reve
ntiv
e ca
re g
uide
lines
If y
ou
hav
e a
test
Dia
gnos
tic te
st (
x-ra
y b
lood
wor
k)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Imag
ing
(CT
PE
T
scan
s M
RIs
)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
3 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d d
rug
s to
tre
at
you
r ill
nes
s o
r co
nd
itio
n
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
cov
erag
e
is a
vaila
ble
at
rege
nce
com
go
drug
list2
020
OR
3tie
r
Gen
eric
dru
gs
$5 c
opay
30
-day
re
tail
pres
crip
tion
$10
copa
y 9
0-da
y re
tail
pres
crip
tion
$15
copa
y r
etai
l pr
escr
iptio
n $2
0 co
pay
mai
l or
der
pres
crip
tion
Not
cov
ered
Ded
uctib
le d
oes
not a
pply
for
drug
s sp
ecifi
cally
de
sign
ated
as
prev
entiv
e fo
r tr
eatm
ent o
f chr
onic
di
seas
es th
at a
re o
n th
e O
ptim
um V
alue
Med
icat
ion
List
C
over
age
is li
mite
d to
a 3
0-da
y su
pply
ret
ail a
nd u
p to
90
-day
sup
ply
at A
sant
e O
utpa
tient
Pha
rmac
ies
or
thro
ugh
Reg
ence
mai
l ord
er
No
char
ge fo
r F
DA
-app
rove
d w
omen
s c
ontr
acep
tives
an
d ce
rtai
n pr
even
tive
drug
s an
d im
mun
izat
ions
at a
pa
rtic
ipat
ing
phar
mac
y
Cov
erag
e in
clud
es c
ompo
und
med
icat
ions
at 3
0
coin
sura
nce
up to
$10
0 m
axim
um a
t Asa
nte
Out
patie
nt P
harm
acie
s an
d 40
c
oins
uran
ce u
p to
$2
00 m
axim
um a
t a R
egen
ce p
artic
ipat
ing
reta
il ph
arm
acy
ref
er to
you
r pl
an fo
r fu
rthe
r in
form
atio
n
Mai
l-ord
er p
resc
riptio
ns 3
5 c
oins
uran
ce u
p to
$12
0 m
axim
um O
ut-o
f-ne
twor
k pr
escr
iptio
n dr
ug c
over
age
is n
ot c
over
ed
You
are
res
pons
ible
for
the
diffe
renc
e in
cos
t bet
wee
n a
disp
ense
d br
and-
nam
e dr
ug a
nd th
e eq
uiva
lent
ge
neric
dru
g in
add
ition
to th
e co
paym
ent a
ndo
r co
insu
ranc
e T
he c
ost d
iffer
entia
l bet
wee
n ge
neric
an
d br
and-
nam
e dr
ugs
accr
ues
tow
ard
the
dedu
ctib
le
and
out-
of-p
ocke
t lim
it
The
firs
t fill
for
sele
ct s
peci
alty
dru
gs m
ay b
e pr
ovid
ed
at a
par
ticip
atin
g re
tail
phar
mac
y a
dditi
onal
fills
mus
t be
pro
vide
d at
Asa
nte
Out
patie
nt P
harm
acie
s F
or a
ll ot
her
spec
ialty
dru
gs t
he fi
rst f
ill m
ust b
e pr
ovid
ed a
t A
sant
e O
utpa
tient
Pha
rmac
ies
If A
sant
e O
utpa
tient
P
harm
acie
s ar
e un
able
to fi
ll th
ey w
ill c
oord
inat
e a
fill
thro
ugh
a R
egen
ce S
peci
alty
Pha
rmac
y P
leas
e re
fer
to m
y H
R fo
r a
list o
f med
icat
ions
that
req
uire
the
first
fil
l at A
sant
e O
utpa
tient
Pha
rmac
ies
Pre
ferr
ed b
rand
dr
ugs
25
coi
nsur
ance
up
to $
30 m
axim
um
30-d
ay r
etai
l pr
escr
iptio
n 25
c
oins
uran
ce u
p to
$60
max
imum
90
-day
ret
ail
pres
crip
tion
35
coi
nsur
ance
up
to $
60 m
axim
um
reta
il pr
escr
iptio
n 35
c
oins
uran
ce u
p to
$12
0 m
axim
um
mai
l ord
er
pres
crip
tion
Not
cov
ered
Bra
nd d
rugs
30
coi
nsur
ance
up
to $
100
max
imum
30
-day
ret
ail
pres
crip
tion
30
coi
nsur
ance
up
to $
300
max
imum
90
-day
ret
ail
pres
crip
tion
40
coi
nsur
ance
up
to $
200
max
imum
re
tail
pres
crip
tion
40
coi
nsur
ance
up
to $
600
max
imum
m
ail o
rder
pr
escr
iptio
n
Not
cov
ered
Spe
cial
ty d
rugs
R
efer
to g
ener
ic
pref
erre
d br
and
and
bran
d dr
ugs
abo
ve
Ref
er to
gen
eric
pr
efer
red
bran
d an
d br
and
drug
s ab
ove
N
ot c
over
ed
If y
ou
hav
e o
utp
atie
nt
surg
ery
Fac
ility
fee
(eg
am
bula
tory
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
4 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
surg
ery
cent
er)
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d im
med
iate
m
edic
al a
tten
tio
n
Em
erge
ncy
room
ca
re
15
coi
nsur
ance
15
c
oins
uran
ce
15
coi
nsur
ance
15
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Em
erge
ncy
med
ical
tr
ansp
orta
tion
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
20
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Urg
ent c
are
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(eg
ho
spita
l roo
m)
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Phy
sici
ans
urge
on
fees
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
If y
ou
nee
d m
enta
l h
ealt
h b
ehav
iora
l hea
lth
o
r su
bst
ance
ab
use
se
rvic
es
Out
patie
nt
serv
ices
10
coi
nsur
ance
of
fice
visi
t 10
c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Inpa
tient
ser
vice
s 10
c
oins
uran
ce
15
coi
nsur
ance
for
prof
essi
onal
and
30
c
oins
uran
ce fo
r fa
cilit
y
40
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
If y
ou
are
pre
gn
ant
Offi
ce v
isits
10
c
oins
uran
ce
15
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Cos
t sha
ring
does
not
app
ly to
cer
tain
pre
vent
ive
serv
ices
Dep
endi
ng o
n th
e ty
pe o
f ser
vice
s a
co
insu
ranc
e or
ded
uctib
le m
ay a
pply
Mat
erni
ty c
are
may
incl
ude
test
s an
d se
rvic
es d
escr
ibed
els
ewhe
re in
th
e S
BC
(ie
ultr
asou
nd)
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
onl
y co
vere
d in
the
case
of
com
plic
atio
ns
Chi
ldbi
rth
deliv
ery
prof
essi
onal
se
rvic
es
10
coi
nsur
ance
15
c
oins
uran
ce
40
coi
nsur
ance
Chi
ldbi
rth
deliv
ery
faci
lity
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
5 o
f 7
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s E
xcep
tio
ns
amp O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
Lim
ited
to 1
00 v
isits
ye
ar
Reh
abili
tatio
n se
rvic
es
10
coi
nsur
ance
30
c
oins
uran
ce
40
coi
nsur
ance
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Inpa
tient
lim
ited
to 3
0 da
ys (
up to
60
days
for
seve
re
head
or
spin
al c
ord
inju
ry)
yea
r O
utpa
tient
lim
ited
to
80 v
isits
ye
ar
Incl
udes
phy
sica
l the
rapy
occ
upat
iona
l the
rapy
and
sp
eech
ther
apy
serv
ices
Hab
ilita
tion
serv
ices
10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Out
patie
nt n
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
60
vis
its
year
N
euro
deve
lopm
enta
l the
rapy
is li
mite
d to
ser
vice
s fo
r in
divi
dual
s th
roug
h ag
e 17
In
clud
es p
hysi
cal t
hera
py o
ccup
atio
nal t
hera
py a
nd
spee
ch th
erap
y se
rvic
es
Ski
lled
nurs
ing
care
N
ot a
pplic
able
20
c
oins
uran
ce
20
coi
nsur
ance
50
c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers
Li
mite
d to
90
inpa
tient
day
s y
ear
Dur
able
med
ical
eq
uipm
ent
Not
app
licab
le
20
coi
nsur
ance
20
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Hos
pice
ser
vice
s 10
c
oins
uran
ce
30
coi
nsur
ance
40
c
oins
uran
ce
50
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s
Res
pite
car
e is
lim
ited
to 1
4 da
ys
lifet
ime
If y
ou
r ch
ild n
eed
s d
enta
l o
r ey
e ca
re
Chi
ldre
ns
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
ns
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
ns
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
6 o
f 7
Exc
lud
ed S
ervi
ces
amp O
ther
Co
vere
d S
ervi
ces
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s)
bull
Bar
iatr
ic s
urge
ry
bull
Cos
met
ic s
urge
ry e
xcep
t con
geni
tal a
nom
alie
s
bull
Den
tal c
are
(Adu
lt)
bull
Long
-ter
m c
are
bull
Non
-em
erge
ncy
care
whe
n tr
avel
ing
outs
ide
the
US
bull
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
bull
Rou
tine
eye
care
(A
dult)
bull
Rou
tine
foot
car
e
bull
Wei
ght l
oss
prog
ram
s u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
T
his
isn
t a
com
ple
te li
st P
leas
e se
e yo
ur
pla
n d
ocu
men
t)
bull
Acu
punc
ture
bull
Chi
ropr
actic
car
e s
pina
l man
ipul
atio
ns o
nly
bull
Hab
ilita
tion
serv
ices
bull
Hea
ring
aids
for
indi
vidu
als
up to
age
19
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
bull
Infe
rtili
ty tr
eatm
ent
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e T
here
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ncie
s th
at c
an h
elp
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u w
ant t
o co
ntin
ue y
our
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rage
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r it
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The
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tact
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rmat
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abor
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ploy
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enef
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ecur
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ebs
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ealth
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uman
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ompl
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Thi
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alle
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ecei
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ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashT
o se
e ex
ampl
es o
f how
this
pla
n m
ight
cov
er c
osts
for
a sa
mpl
e m
edic
al s
ituat
ion
see
the
next
sec
tionndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
ndashndashndashndash
7 o
f 7
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
s S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Spe
cial
ist o
ffice
vis
its (
pren
atal
car
e)
Chi
ldbi
rth
Del
iver
y P
rofe
ssio
nal S
ervi
ces
Chi
ldbi
rth
Del
iver
y F
acili
ty S
ervi
ces
Dia
gnos
tic te
sts
(ultr
asou
nds
and
bloo
d w
ork)
S
peci
alis
t vis
it (a
nest
hesi
a)
To
tal E
xam
ple
Co
st
$12
800
In t
his
exa
mp
le P
eg w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
47
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal P
eg w
ou
ld p
ay is
$1
547
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Prim
ary
care
phy
sici
an o
ffice
vis
its (
incl
udin
g di
seas
e ed
ucat
ion)
D
iagn
ostic
test
s (b
lood
wor
k)
Pre
scrip
tion
drug
s
Dur
able
med
ical
equ
ipm
ent (
gluc
ose
met
er)
T
ota
l Exa
mp
le C
ost
$7
400
In
th
is e
xam
ple
Jo
e w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$0
Coi
nsur
ance
$1
600
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal J
oe
wo
uld
pay
is
$30
60
◼ T
he
pla
ns
ove
rall
ded
uct
ible
$1
400
◼
Sp
ecia
list
coin
sura
nce
15
◼ H
osp
ital
(fa
cilit
y) c
oin
sura
nce
30
◼ O
ther
co
insu
ran
ce
30
T
his
EX
AM
PL
E e
ven
t in
clu
des
ser
vice
s lik
e
Em
erge
ncy
room
car
e (in
clud
ing
med
ical
su
pplie
s)
Dia
gnos
tic te
st (
x-ra
y)
Dur
able
med
ical
equ
ipm
ent (
crut
ches
) R
ehab
ilita
tion
serv
ices
(ph
ysic
al th
erap
y)
To
tal E
xam
ple
Co
st
$19
25
In t
his
exa
mp
le M
ia w
ou
ld p
ay
Cos
t Sha
ring
Ded
uctib
les
$14
00
Cop
aym
ents
$3
17
Coi
nsur
ance
$1
283
Wha
t isn
t co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal M
ia w
ou
ld p
ay is
$3
255
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les
Th
is is
no
t a
cost
est
imat
or
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive
the
pric
es y
our
prov
ider
s ch
arge
and
man
y ot
her
fact
ors
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t he
alth
pla
ns P
leas
e no
te th
ese
cove
rage
exa
mpl
es a
re b
ased
on
self-
only
cov
erag
e
NONDISCRIMINATION NOTICE
0101201704PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as
Qualified sign language interpreters
Written information in other formats (large print audio and accessible electronic formats other formats)
Provides free language services to people whose primary language is not English such as
Qualified interpreters
Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom
You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml
Language assistance
0101201704PF12LNoticeNDMARegence
ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten
servicios gratuitos de asistencia linguumliacutestica Llame al
1-888-344-6347 (TTY 711)
注意如果您使用繁體中文您可以免費獲得語言
援助服務請致電 1-888-344-6347 (TTY 711)
CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ
trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-
344-6347 (TTY 711)
주의 한국어를 사용하시는 경우 언어 지원
서비스를 무료로 이용하실 수 있습니다 1-888-
344-6347 (TTY 711) 번으로 전화해 주십시오
PAUNAWA Kung nagsasalita ka ng Tagalog maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad Tumawag sa 1-888-344-6347 (TTY
711)
ВНИМАНИЕ Если вы говорите на русском языке
то вам доступны бесплатные услуги перевода
Звоните 1-888-344-6347 (телетайп 711)
ATTENTION Si vous parlez franccedilais des services
daide linguistique vous sont proposeacutes gratuitement
Appelez le 1-888-344-6347 (ATS 711)
注意事項日本語を話される場合無料の言語支
援をご利用いただけます1-888-344-6347
(TTY711)までお電話にてご連絡ください
tirsquogo Dineacute
Bizaad saad
1-888-344-6347 (TTY 711)
FAKATOKANGArsquoI Kapau lsquooku ke Lea-
Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai
atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia
harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY
711)
OBAVJEŠTENJE Ako govorite srpsko-hrvatski
usluge jezičke pomoći dostupne su vam besplatno
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom 711)
បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-
6347 (TTY 711)
ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ
ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-
6347 (TTY 711) ਤ ਕਾਲ ਕਰ
ACHTUNG Wenn Sie Deutsch sprechen stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)
ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)
УВАГА Якщо ви розмовляєте українською
мовою ви можете звернутися до безкоштовної
служби мовної підтримки Телефонуйте за
номером 1-888-344-6347 (телетайп 711)
धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर
दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ
711
ATENȚIE Dacă vorbiți limba romacircnă vă stau la
dispoziție servicii de asistență lingvistică gratuit
Sunați la 1-888-344-6347 (TTY 711)
MAANDO To a waawi [Adamawa] e woodi ballooji-
ma to ekkitaaki wolde caahu Noddu 1-888-344-6347
(TTY 711)
โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)
ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ
ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ
ໂທຣ 1-888-344-6347 (TTY 711)
Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa
afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin
bilbilaa
شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه
دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم
6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم
TTY 711)هاتف الصم والبكم )رقم
This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health
Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been
performed Surgery and reconstruction of the other breast as necessary to provide
a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event
For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)
Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075
Asante Health PlanAnnual Required Notices
To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)
Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others
The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits
toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020
The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger
The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks
1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen
2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program
If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA
If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts
The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower
Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year
Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health
If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status
The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor
Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment
Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs
In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately
You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate
If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995
Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not
discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender
Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio
accessible electronic formats and other formats) bull Asante provides free language services to people whose primary
language is not English including o Qualified interpreters o Information written in other languages
If you need these services contact Alicia Lorenz at the phone number or email address listed below
If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)
You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at
US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)
Complaint forms are available at hhsgovocrofficefileindexhtml
20HR011
This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020
Asante Health Plan changesPlan names Asante Health Plan 1 is being
renamed Asante PPO Health Plan Asante Health Plan 2 is being
renamed Asante Savings HealthPlan or HSA
Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA
For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use
Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers
A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles The deductibles for the new
Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses
Rx expenses will be counted toward the medical out-of-pocket maximums
The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50
Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles The deductibles for the four
categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family
Out-of-pocket maximums The out-of-pocket maximums for the
four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family
Copay and coinsurance changes The office visit coinsurance for
primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)
The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)
The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50
Health Savings Account The HSA contribution limit has
increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage
Employer contributions to the HSA Asante contributes to your HSA
if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled
Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four
categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family
Out-of-pocket maximums There will no longer be separate
out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums
Whatrsquos new for 2020
The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family
Copay and coinsurance changes The office visit copay for primary
care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)
The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)
The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50
Employer contributions to the HRA Asante contributes to your HRA
account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents
Other changes In the Asante Reimbursement
Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations
In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers
Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan
(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)
Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit
All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet
All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply
A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible
Dental plan changes The Willamette Dental plan will have
a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year
There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan
Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits
Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012
Critical illness and accident plans Certain insurance policies are
available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505
Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information
This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025
All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services
We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization
How We May Use and Disclose Your Protected Health Information
Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories
For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use
For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments
For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes
To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us
As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws
Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it
The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage
This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System
The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees
What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage
If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen
1 Your hours of employment are reduced or
2 Your employment ends for any reason other than your gross misconduct
If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens
1 Your spouse dies
2 Your spousersquos hours of employment are reduced
3 Your spousersquos employment ends for any reason other than his or her gross misconduct
4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or
5 You become divorced or legally separated from your spouse
Continuation Coverage Rights Under Cobra
Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens
1 The parent-employee dies
2 The parent-employeersquos hours of employment are reduced
3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct
4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)
5 The parents become divorced or legally separated or
6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo
Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan
When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event
You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to
Asante Health System
How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended
Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to
Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov
If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)
Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator
Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806
Updated 91418 ND
PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is
eligible for coverage please contact us so that we can provide them with this notice
Important Notice from Asante About Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug
coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice
There are two important things you need to know about your current coverage and Medicarersquos
prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can
get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium
2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan
When Can You Join A Medicare Drug Plan
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th
However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan
If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan
When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan
You should also know that if you drop or lose your current coverage with Asante and donrsquot join a
Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later
Page 2
If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join
For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time
If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by
Medicare in the next 12 months this notice doesnrsquot apply to you
For More Information About Your Options Under Medicare Prescription Drug Coverage
More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos
how to get more information about Medicare prescription drug plans
Visit wwwmedicaregov
Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help
Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048
For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)
Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)
New Health Insurance Marketplace Coverage Options and Your Health Coverage
PART A General Information
What is the Health Insurance Marketplace
Can I Save Money on my Health Insurance Premiums in the Marketplace
Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace
How Can I Get More Information
Form Approved OMB No 1210-0149
5 31 2020
P AR T B Information About Health C overage O ffered by Y our E mployer
3 Employer name 4 Employer Identification Number (EIN)
5 Employer address 6 Employer phone number
7 City 8 State 9 ZIP code
10 Who can we contact about employee health coverage at this job
11 Phone number (if different from above) 12 Email address
Eligible Dependents include Your Legal Spouse or you or your spousersquos children under the age of 26 including biological child legally adopted child or child place with you for adoption current stepchild legally placed foster child child for whom you have legal guardianship child you are required to provide coverage for due to a court or administrative order as part of a QMCSO or NMSN or disabled child over the age of 26
Plan information including employee costs for 2020 medical plans can be found on myHR (httpshrasanteorg) or upon request to Human Resources
WHERE TO GET HELPKeep this contact information in case you have questions as you use your benefits throughout the year
Contact Phone number E-mail or website
Asante Absence Management and Workers Compensation
(541) 789-5395 ndash Medford(541) 472-7374 ndash Grants Pass(541) 789-5417 ndash Ashland
leavesasanteorg
Asante Benefits Helpline (541) 789-4551 myasantebenefitsasanteorgAsk HR
Asante Employee Health (541) 789-5008 ndash Medford(541) 472-7376 ndash Grants Pass(541) 201-4484 ndash Ashland
wwwasanteorg
Asante Human Resources (541) 789-4243 ndashMedfordAshland(541) 472-7382 ndash Grants Pass
wwwasanteorgemployee-benefits
Asante Recruitment (541) 789-4757 AsanteEmploymentasanteorg
HealthEquity mdash Flexible Spending Accounts Health Reimbursement Arrangements Health Savings Accounts
(866) 960-8055 wwwmyhealthequitycom
Hyatt Legal Plan (MetLaw) (800) 821-6400 wwwlegalplanscomAccess code MetLaw
Livongo (800) 945-4355
MercyFlights (800) 903-9000 wwwmercyflightscom
MetLife Dental (800) 942-0854 wwwmetlifecommybenefits
myStrength customerservicemystrengthcom
Regence - Advice24 (800) 267-6729 wwwregencecom
Regence - BabyWise (888) 569-2229 wwwregencecom
Regence - Case Management (866) 543-5765 wwwregencecom
Regence - Customer Service - Medical Claims Eligibility Precertification
(888) 344-8235 wwwregencecom
Regence - Employee Assistance Program
(866) 750-1327 wwwmyRBHcom
Regence - Health Coach (800) 856-8543 wwwregencecom
Regence - Pharmacy Services (844) 765-2894 wwwregencecom
The Standard (833) 760-7012 wwwstandardcom
Contact Phone number E-mail or website
The Standard Voluntary Benefits
General Questions (866) 851-2429Claims (866) 851-5505
wwwstandardcom
Asante Retirement Plan (800) 343-0860 NetBenefitscomAtWork
Vision Service Plan (VSP) (800) 877-7195 wwwvspcom
Willamette Dental (855) 433-6825 wwwwillamettedentalcom
REG-115823-1609-2017copy 201 Regence BlueCross BlueShield of Oregon
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