04821_OR Group Fully Insured Bound Packet 9-12

7/24/2019 04821_OR Group Fully Insured Bound Packet 9-12

1/28

RegenceBlueCrossBlueShieldofO

regonisanIndependent

LicenseeoftheBlueCrossandBlu

eShieldAssociation

Group Enrollment

Guide


2/28


3/28

Regence

BlueCrossBlueShield

ofOregon

isanIndependentLicenseeoftheBlueCrossandBlue

ShieldAssociation

W H A T Y O U N E E D T O K N O W A B O U T

PREVENTIVE HEALTH CARE COVERAGE

Wondering what preventive care services are covered

by your health plan? As youre probably aware,

the federal health care reform law passed in 2010

requires insurers to include specific preventive care

services in their benefit plans. Regence supports that

initiative. In fact, Regence plans already provided benefits

for many preventive care services, as we have long

believed that preventive care and early detection

are key to the long-term health and well-being of our

members. This brochure explains preventive care

eligibility and shows which services are available to

you and the family members covered by your plan.

Whos eligible for these preventive services?

To be eligible for these preventive services, you must

first be covered by a current Regence policy.

Benefits for the federally required preventive services:

Are not required in grandfathered policies,which are essentially policies that were in effect

on March 23, 2010, as long as few or no benefit

changes have been made to them (please note

that Regence has chosen to retain grandfathered

status for a very limited number of policies)

May be covered by grandfathered plans that have

chosen to include the benefit

May apply to retiree-only plans

Apply to Association plans at the Associations

plan renewal date

What preventive services are covered?

Regence follows government guidelines to determine

which preventive services we cover1.

These guidelines are updated periodically to reflect

new scientific and medical advances. Additionally,

current services could be revised and subject to

different limitations; thus, benefits are subject tochange. New guidelines will be implemented within

one year of the recommendations publication.

You can learn more details about these services at

healthcare.gov, including recommended child and

adolescent immunization schedules.

What is the coinsurance/copay for these

preventive services?

The services listed in this brochure will be paid at 100%

(no deductibles, coinsurance or copays) when you

see preferred or participating providers (Category 1 orCategory 2) or in-network providers. Deductibles and/or

coinsurance may apply when you see other providers.

To find out if youre eligible for preventive

coverage, call the Customer Service number

on the back of your member card or go to the

Contact Us link at regence.com.

1Evidence-based preventive guidelines are developed and validated by the following government entities:

United States Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices of the

Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).


4/28

Men

Women

PregnantWomen

Children(0-17)

Health screenings, counseling and

services for:

Suggested guidelines

Adult abdominal aort ic aneurysm Screening is covered once per l ifet ime for men age 65and over if they have

ever smoked.

Alcohol misuse Screening and behavioral counseling intervention covered for adults

age 19and older.

Anemia (iron deficiency) Screening covered up to age 21, and pregnant women.

Bacteriur ia (ur inary tract infect ion) Screening for asymptomatic pregnant women.

Blood pressure Screening covered for adults age 18and older.

Breast cancer Screening for women age 40and older and those at increased risk.

Mammograms only.

Breast cancer chemoprevention Counseling for women at increased risk.

Breastfeeding equipment Manual and electric breastfeeding pumps are covered when purchased or rentedfrom a licensed provider. Off-the-shelf pumps from a retail outlet are not covered.

Hospital-grade pumps are not covered. See Note 1.

Breastfeeding - lactation support and

counseling

Lactation support and counseling are covered when provided by a

licensed provider.

Breastfeeding supplies Initial breastfeeding supplies provided with a breastfeeding pump. See Note 1.

Cervical cancer Screening for sexually active women.

Chlamydia infection Screening for infection.

Cholesterol Screening for men age 35and older and men ages 20-35who are at increased

risk for coronary heart disease. Screening for women age 45and older and those

20-45who are at increased risk for coronary heart disease.

Colorectal cancer Screening for those age 50and older, once every 5 years for a sigmoidoscopy and

every 10 years for a colonoscopy, fecal occult blood testing annually.

Congenital hypothyroidism Screening for newborns.

Contraceptive education and training Education and training on contraceptive methods. See Notes 1 and 2.

Contraceptive devices - implants, cervical caps,

intrauterine devices (IUDs), diaphragms

Generic contraceptive devices are covered. When no generic exists, a brand is

covered. If a generic becomes available, the brand will no longer be covered under

Preventive Care.

Insertion of a device is covered under Preventive Care. Removal is covered at

regular plan benefits if a Family Planning benefit applies. See Notes 1 and 2.

Depression screening Screening during wellness exams.

Diabetes (Type 2) Screening for adults with sustained high blood pressure.

Diabetes (Gestational) Screening for pregnant women between 24and28 weeksof gestation and the

first pre-natal visit for pregnant women at high risk for diabetes. See Note 1.

Diet behavioral counseling Counseling for adults with hyperlipidemia and other risk factors.

Genetic risk assessment and BRCA (breast

cancer susceptibility) mutation counseling

For women with family risk of breast and ovarian cancer.

Gonorrhea medication Preventive medication for the eyes of newborns.

Gonorrhea screening Screening for males up to age 21and all females.

Hearing One screening in the first year of life for newborns.

Covered preventive services


5/28

Men

Women

PregnantWomen

Children(0-17)

Hepatitis B Screening for pregnant women.

HIV Screening and counseling during wellness exams for sexually active women.Screening during wellness exams for men, women and children at increased risk.

HPV Screening for women from age 30, every 3 years. See Note 1.

Interpersonal and domestic violence Screening and counseling during wellness exams. See Note 1.

Lead screening Screening up to age 21.

Metabolic screening Screening up to age 2 months.

Obesity Screening and counseling for age 6and older.

Oral health Risk assessment for preschool children.

Osteoporosis Screening for women age 65and older and all women at increased risk.

Phenylketonuria (PKU) Newborn screening for genetic disorders.

RH(D) incompatibility Screening for pregnant women.

Sexual ly transmitted infection (STI) Counseling dur ing wellness exams.

Sickle cell Screening for children up to 12months old.

Sterilization Sterilization is covered. See Notes 1 and 2.

Syphilis Screening for those at increased risk and those up to age 21;

also includes pregnant women.

Tobacco use Counseling and interventions. Does not include programs or classes.

See also Tobacco use below.

Tuberculosis Skin test for children.

Vision Screening for children age 3up to age 5.

Immunization vaccines -

please consult your physicianfor frequency

Diphtheria, pertussis, tetanus (DPT)

Haemophilus influenzae type b (Hib)

Hepatitis A

Hepatitis B

Herpes zoster (shingles) Age 60and older.

Human papillomavirus (HPV) Up to age 27.

Inactivated poliovirus

Influenza

Measles, mumps, rubella (MMR)

Meningococcal

Pneumococcal

Rotavirus

Varicella



6/28

Men

Women

PregnantWomen

Children(0-17)

Prescription medications

Only the types of prescription medications listed below are covered under Preventive Care.

Medications require a prescription. Over-the-counter products are not covered.

Get the most value for your health care dollar with preferred medications. Learn more at regencerx.com/learn/covered.

Aspirin use for the prevention of

cardiovascular disease

For men age 45-79and women age 55-79.

Contraceptive injectables Generic contraceptive injectables. See Notes 1 and 2.

Contraceptive pills Generic contraceptive pills. See Notes 1 and 2.

Contraceptive products-topical Diaphragms and patches. See Notes 1, 2 and 3.

Emergency contraceptive products Generic contraceptive pills. See Notes 1, 2 and 3.

Fluoride supplements For children 6months through age 6without sufficient fluoride

Folic acid supplements For all women planning or capable of pregnancy.

Iron supplements For children age 6-12months at increased risk - drops only.

Tobacco use Generic tobacco cessation medications.

Wellness exams Suggested guidelines

Well-child exams For children through 17years of age.

Annual physical exams Ages 18and over.

Notes:

1. This benefit is available upon renewal of your plan, on or after August 1, 2012.

2. This benefit may not be available to members of groups who have applied for a religious exemption from contraceptive coverage.

3. Generic contraceptives are covered. When no generic exists, a formulary brand is covered. If a generic becomes available,

the formulary brand will no longer be covered under Preventive Care.

05394rep04976-or / 09-122012. Regence BlueCross BlueShield of Oregon, all rights reserved.

Have questions? Call the Customer Service number on the back of

your member card or go to the Contact Us link at regence.com.



7/28isan

IndependentLicenseeoftheBlueCrossandBlueShield

Association

GIVE OUR ONLINE PROVIDER DIRECTORY A TRY

Finding a doctor online takes just seconds. Whether you want toknow if your doctor is in your network or need to find a new one,our online provider directory can help.

Browse our database

1. Go to regence.com.

2. Click on Find a Providerat the top right of the screen.

3. Enter your ZIP code.

4. Provide a clinic name or specialty (optional). Then click Search.

Find a specific doctor

1. Go toAdvanced Search.

2. Make a selection under Provider Type.

3. Key the providers last name into the Namefield under Provider Options.

4. Enter your location.

Create a list of providers

1. Make a selection under Provider Type.

2. Choose a specialty from the drop-down box that appears under your selection.

3. Under Provider Options, choose your network from the Network Affiliation

drop-down box.

4. Choose language or gender if you have a preference.

5. Enter your location.

Let us know if we can help

Customer Service can also assist you with your doctor or pharmacy search, and tell youwhether yours is in the network. Just give us a call at one of the following numbers:

Regence HSA Healthplan 2.0SM:

1 (877) 508-7357

Regence Innova,Regence EngageSM:

1 (888) 367-2116

04978-or / 12-11

2011. The Regence Group, all rights reserved.

Finding a doctorisquick and easy!


8/28


9/28

Regence has covered

A C R O S S T H E C O U N T R Y A N D

A R O U N D T H E W O R L D.

With coverage from Regence, you take your health care benefits with you

across the country and around the world. The BlueCard Program gives you

access to doctors and hospitals nearly everywhere, so youll have peace of

mind knowing that you can always find the health care provider you need.

Choices

Your Regence membership gives you a world of choices. Through the

BlueCard Worldwide Program, youre free to choose doctors and

hospitals that best suit you and your family in more than 200 countries

and territories around the world.

Designed to save money

In most cases, when you travel or live outside the Regence service

area, you can take advantage of savings the local Blue Plan has

negotiated with providers in the area where you are. For covered

services, you should not have to pay any amount above thesenegotiated rates. You should also not have to pay amounts above

any applicable out-of-pocket expenses.

Regence

BlueCrossBlueShield

ofOregon


ShieldAssociation

The BlueCardProgram

BlueCard Program Advantages

PROVIDER CHOICEYou have access to more than 85% of providers

and 96% of hospitals nationwide.

BENEFIT CONSISTENCY

BlueCard ensures that you receive in-network

benefits when choosing participating providers of any

Blue Cross and/or Blue Shield Plan.

BILLING PROTECTION

Accessing a Blue Cross and/or Blue Shield Plan

participating provider ensures that you are not

responsible for any balance billed amount.

EASE OF ACCESSIts quick and easy to locate a participating provider

at bcbs.comor by calling (1-800-810-BLUE).


10/28

03781-or / 06-11


To learn more about the BlueCard

program, call your local Blue Plan

or visit regence.com.

BlueCard and BlueCard Worldwide are registered service marks of the

Blue Cross and Blue Shield Association.

You see a provider

outside the Regence

service area

Participating provider

provides care for youLocal Blue Plan

prices the claim and

submits it to Regence

Processes the claim and

authorizes payment

Sends an explanation of

benefits to you

Local Blue Plan

pays provider

How it works


11/28

Imagine a place where you can find answers and support for all of your health needs. myRegence.com is your

complete source of health and wellness information. And its simple to understand. So whether you want to get

started on an exercise program, need tips on eating healthier, or just want to know if weve paid your claim,

visit myRegence.com today.

myRegence.comEverything youve always wanted to know about your health. In one place.

Reg

ence

BlueCrossBlueShield

ofOregon

isan

IndependentLicenseeoftheBlue

Crossand

BlueSh

ieldAssociation

RewardHealthy living has its own rewards, but Regence Rewards

points can help.

Earnpoints for browsing our health news, podcasts

and videos.

Receivepoints for healthy everyday activitiessuch as

eating fruits and veggies and walking the dog, or joining

an online wellness program.

Redeempoints for an Amazon.com gift card.

NavigateDiscover tools that help you track your your

coverage and make informed decisions about

your health care.

Reviewdetails about your coverage.

Manageyour claims online and eliminate paper

Explanation of Benefits.

Finda doctor or specialist and read patient

reviewsonline or on your mobile device.

Createa secure, confidential Personal Health Record. Discussa variety of important health and wellness topics on My Community,

a nationwide social networking site.

AdviseConsider health care decisions, explore treatment options

and plan ahead for financial needs.

Comparecost and quality of hospitals, clinics

and providers.

Researchtreatment options and out-of-pocket

cost estimates.

Learnabout medical conditions, medications and

cost-saving generics.

Exploreand enjoy health articles, videos and podcasts.


12/2801363-or / 6-08

myRegence.comWant more value for your health care dollars? Log on to myRegence.com and discover

online resources and interactive experiences focused on your health. Its easy to join and

youll earn 5,000 points with Regence Rewards just for registering.

Become an informed health care consumer.

Log on today and earn 5,000 points.

Simply use the information on your member card and follow these steps.

1. Go to myRegence.com.

2. Click New Member Registration.

3. Complete the required MyMember Account Informationfields. The name,

member and group numbers you enter must match your member card.

4. Create a user name and secure password.

5. Click Register and Login.

Take a confidential General Health Assessment. Earn up to 10,000 points.

Learn how youve been managing your health to date, and get practical tips on how to

improve your health and well-being.

Manage stress and get into shape. Earn 5,000 points at completion.

Reach for a healthy lifestyle with wellness programs on Weight Loss, Healthier Diet, Stress

Relief, Healthy Aging, going Smoke-Free and more.

Keep your health history at your fingertips. Earn up to 6,000 points.Create a secure, confidential record of your medical history with the Personal

Health Record tool. Input your own information about allergies, immunizations, emergency

contacts and more.

Get social in My Community. Earn up to 2,400 points.

Join the conversation and earn points for posting in My Communityan online health and

wellness social networking site where members nationwide are talking, asking questions of

our experts, following bloggers and receiving support in achieving their goals.

What are you waiting for? Register now at myRegence.com!

05212 rep 03212-or / 04-12 2012. Regence BlueCross BlueShield of Oregon, all rights reserved


13/28

Find your wayaround your Rx plan

I N A F L A S H.A quick guide to your RegenceRx prescription program

Heres a quick reference sheet to help you better understand your

prescription benefits and find the Rx information you need. Its one more

tool you can use to navigate the health care system and make informed

decisions about your care. Check it out!

With more than 65,000 pharmacies in our network, its easy to find

one near you.

Using your Rx benefits

Simply present your Regence member card at the pharmacy, and the

pharmacist will submit your claim online. The system will calculate the claim

cost based on your pharmacy benefit, then the pharmacist will tell you how

much you owe.

Your member card

Take a minute to look at your member card. It verifies that you haveprescription coverage and gives our participating pharmacies everything

they need in order to submit your claim online. If you have questions, just

call us at the phone number on the back of your card.

Your deductible and copay

If you have a plan with a pharmacy deductible, then youll pay for

each covered prescription in full until youve met your deductible.

(The pharmacist will still submit your claim as usual so that your purchase

counts toward your deductible.) After you meet your deductible, then youll

simply pay your portion of the cost (copay/coinsurance).

If you have a plan with a copay only (no deductible), then youll just pay that

amount for each covered prescription medication when you pick it up.

Youll find your prescription deductible and copay amounts summarized in

your benefits booklet on myRegence.com.

Regence

BlueCrossBlueShield

ofOregon


ShieldAssociation


14/28

Generics: another way to save

Youll save money by using generic medications

whenever possible. If the medication you need is not

available in generic form, ask your doctor if another

generic can be used to treat the same condition, or if

there is a less expensive brand-name medication. Your

doctor is the best person to determine the medication

thats right for you.

Prior authorization and our Generics First policy

Some brand-name medications require prior

authorization to ensure theyre covered, such as

antidepressant, diabetes, pain, heartburn and

cholesterol medications. Go to regenceRx.com and

click on Prior Auth/Medication Quantities in the

Learn About Medications section for a list of

medications needing prior authorization.

If you take one of these medications or keep one on

hand to use as needed, then youll need to do one

of two things in order to be sure your medication will

continue to be covered:

1. Try a generic first! Switch to a generic version of

the brand-name medication you are taking. Just

ask your pharmacist to fill your prescription withthe generic rather than the brand-name.

or

2. Get prior authorization for that brand-name

medication. The brand-name medication might be

denied if it hasnt been approved ahead of time.

Ask your doctor or pharmacist to send a prior

authorization request with your medical or

medication history before your next refill. Your

pharmacist may fax your prescription profile

to 1 (888) 437-1510 or call 1 (800) 643-5918.

Filing claims and getting reimbursed

The pharmacist will file your claim for you, and well

pay the pharmacy directly, so you wont have to worry

about paperwork or getting reimbursed. In the rare

event that you do need to file a claim, we make it

painless. Just go to regenceRx.com to download the

proper claim form, or give us a call at the number on

the back of your member card.

If you misplace your member card, well replace

it. Just call us toll-free at 1 (888) 367-2116 or

visit myRegence.com.

Explore regenceRx.com: a site devoted to

your Rx benefits

Visit regenceRx.com for information specifically

related to your RegenceRx prescription benefit.

Use it to:

Find a participating pharmacy

Access our formulary

Learn about your medication choices

Preview medications to learn if they require

prior authorization, or if they have any limitations

or restrictions

Print out a prescription claim form

Go to myRegence.comto make the most

of allyour benefits

To discover all the advantages of your Regence

membership beyond prescriptions, go to

myRegence.com. There you can view and manage

details related to your medical and prescription

coverage, explore events and rewards for healthy

living, and plan ahead using our Health Cost Estimators.

Maximize your benefit: Always

show your member card to the

pharmacy where you purchase

your prescriptions.

05219rep03460-or / 04-12

2012. Regence BlueCross BlueShield of Oregon, all rights reserved.


15/28

Get more value for your dollar

WITH TIPS AND TOOLS

from regenceRx.com.

Raise your pharmacy IQ. Control your medication costs.

Your online Rx tools

Load up on cost-saving ideas and health care knowledge with the

user-friendly tools at regenceRx.com. There youll find a preferred

medication list, a glossary of insurance terms, prior authorization

information, a pharmacy locator, specialty program information, facts

about generics and much more. Here are just a few of the tools that can

help you make the most of every dollar:

RxPrice GuideBecome more informed about your medication costs

and options. After youve checked to see whether a medication is on our

preferred medication list (also known as a formulary), you can use the

RxPrice Guide to browse the costs of commonly prescribed medications.

Youll get detailed pricing on brand-name medications and their

generic alternatives.

Health CalculatorsThese online calculators can help you see

health-minded behaviors from a financial perspective. Youll learn the

cost of bad habits and the benefits of good choices. For instance,

calculate the actual out-of-pocket cost of smoking, or estimate how long

it might take to lose weight by doing your favorite activity.

ConsumerRxThese educational summaries help you understand your

medication optionswithout the medical jargon. Youll find overviews of

different conditions and the medications that are used to treat them,

along with facts and tips to help you save money.

RegenceBlueCrossBlueShield

ofOregon


ShieldAssociation

03454-or / 6-11

Visit regenceRx.comtoday, and take full advantage of all that

RegenceRx has to offer.


16/28


17/28

Prior authorization helps

protect our members

from harm and high costs.

Prior authorization is a small

step that has a huge impact on

safety and savings

We sometimes need more

information about a medication

before we can cover it. We get

that information through the

prior authorization process.

Not all medications need prior

authorization. But for those

that do, this process helps

ensure that you get the best in

safety and value.

Here are some reasons a

prescription might need

prior authorization:

It has been proven to benefit

only a limited number of people

Unusually large doses are

requested for coverage

Equally effective but more

affordable generic options

are available

Its prescribed for conditions not

covered by your health plan

It hasnt been thoroughly tested

by the scientific community or

approved by the FDA for

certain uses

If your medication is on our prior

authorization list, well need

information from your doctor

or pharmacist.

When prior authorization works

Our pharmacists and doctors

tirelessly research medications for

safety, effectiveness and overall

value. Were committed to sharing

this information with you through

the prior authorization list.

The prior authorization process

is simple:

Your doctor or pharmacist can

request prior authorization by

going to regencerx.com/pa,

calling 1 (800) 643-5918, or

faxing 1 (800) 884-4282.

Our team of clinical pharmacists

and pharmacy technicians

carefully reviews each request,

taking into consideration our

evidence-based reviews of

scientific research. Any request

that cant be approved is then

reviewed by a physician

medical director.

Well contact you, your doctor,

and your pharmacy within two

business days with our decision.

If we find that the medication is

the best value for your condition,

the medication will generally be

authorized. If not, the medication

wont be covered.

If your medication isnt covered,

well share a clear explanation of

our reasons, along with potential

covered alternatives, if available.

Your prior authorization support

Naturally, you and your doctor are

the best people to determine the

medication thats right for you. If

you have questions or concerns

about prior authorization, were

here to help. Heres how you can

reach us:

To determine if a medication

needs approval, visit

www.regencerx.comand look

under Learn About

Medications.

To review our medication

policies, visit www.regencerx.

com/learn/policy/index.html.

To speak to Pharmacy Custome

Service, call 1 (800) 643-5918.

g

g

isanIndependentLicensee

ofthe

Blue

Crossand

Blue

Shield

Association

088-or / 2-12


18/28


19/28

Prior authorization helps ensure that covered medications provide the best safety and value. Itis needed when a medication has only been proven to benet a limited number of people or ifunusually large doses are requested for coverage.

These medications require prior authorizationbecause alternatives may offer a better value Possible alternatives

Cholesterolatorvastatin, Crestor

simvastin(Zocor), pravastatin (Pravachol

), lovastatin (Mevacor

)

Lipitor, Livalo

, Vytorin

simvastin(Zocor

), pravastatin (Pravachol

), lovastatin

(Mevacor), Crestor

DepressionCymbalta

, Pristiq, Viibryd

bupropion SR (Wellbutrin SR), bupropion XL 300mg (Wellbutrin

XL), uoxetine(Prozac

), uvoxamine maleate, mirtazapine

(Remeron), paroxetine(Paxil

), sertraline(Zoloft

)

DiabetesACTOplus Met, Actos

, Avandamet

, Avandaryl,

Avandia,Bydureon, Byetta

,Duetact, Janumet

,

Janumet

XR, Januvia

, Jentadueto

, Juvisync

,KombiglyzeXR, Onglyza, Tradjenta, Victoza

metformin (Glucophage), glimepiride (Amaryl

), glipizide

(Glucotrol), glyburide (Diabeta

), insulin

High Blood PressureBenicar, Benicar HCT, Micardis, Micardis HCT

benazepril/HCT(Lotensin/HCT), captopril/HCT (Capoten/

Captozide), enalapril/HCT (Vasotec/Vaseretic

),fosinopril/

HCT(Monopril/HCT), lisinopril/HCT(Zestril/Zestoretic

,

Prinivil/Prinzide), losartan/HCT(Cozaar/Hyzaar

), moexipril/

HCT(Univasc/Uniretic), quinapril/HCT (Accupril/Accuretic

),

trandolapril(Mavik)

Amturnide, Atacand, Atacand-HCT, Avalide,

Avapro, Azor, Diovan, Diovan HCT, Edarbi,Exforge, Exforge HCT, Tekamlo, Tekturna

, TekturnaHCT, Teveten, Teveten HCT, Tribenzor, Twynsta,Valturna

benazepril/HCT (Lotensin/HCT), captopril/HCT(Capoten/

Captozide), enalapril/HCT (Vasotec/Vaseretic

), fosinopril/

HCT(Monopril/HCT), lisinopril/HCT(Zestril/Zestoretic

, Prinivil/

Prinzide), losartan/HCT(Cozaar/Hyzaar

), moexipril/HCT (Univasc/

Uniretic), quinapril/HCT(Accupril/Accuretic

), trandolapril

(Mavik), Benicar

, Benicar HCT

, Micardis

, Micardis HCT

Mental HealthAbilify

, Fanapt

, Geodon

, Invega

, Latuda

, Saphris

,

ziprasidone

clozapine (Clozaril), olanzapine (Zyprexa

), risperidone

(Risperdal), Seroquel

, Seroquel XR

MigrainesMaxalt

, Maxalt-MLT

, Relpax

sumatriptan (Imitrex)

Alsuma, Amerge, Axert

, Frova

, naratriptan HCL,

SumavelDosePro, Treximet, Zomig, Zomig-ZMT

sumatriptan (Imitrex), Maxalt

, Maxalt-MLT

, Relpax

Multiple SclerosisExtavia

Avonex, Copaxone

, Rebif

Betaseron

Avonex, Copaxone

, Rebif

, Extavia

Nasal SteroidsBeconase AQ

, Nasonex

, Omnaris

, Qnasl, Rhinocort

Aqua, Veramyst

unisolide (Nasalide), uticasone(Flonase

), triamcinolone

acetonide(Nasacort

AQ)

Pain and InammationCelebrex

Generic non-steroidal anti-infammatory medications (NSAIDs)such as: diclofenac(Voltaren

), etodolac (Lodine

), urbiprofen

(Ansaid), ibuprofen(Motrin

), indomethacin(Indocin

),

ketoprofen (Orudis), nabumetone (Relafen

), naproxen

(Naprosyn), oxaprozin (Daypro

), piroxicam (Feldene

), salsalate

(Disalcid), sulindac(Clinoril

),tolmetin(Tolectin

)

Stomach Acidlansoprazole, pantoprazole, Dexilant, Kapidex omeprazole(Prilosec

)

Aciphex, Nexium

, Prevacid

, Protonix

, Vimovo omeprazole(Prilosec

), Dexilant, Kapidex

Effective 04/12NOTE: Our medication Prior Authorization List is subject to change. If the requested medication is

authorized, there maybe limits to the amount of medication that is eligible for coverage. Please call ourCustomer Service Department if you have any questions.

Prescription Prior Authorization


20/28

The Bottom Line Safety is our top priority and our prior authorization program helps you and your doctorschoose quality medications that provide the most value. Some alternatives might also help you save money.

04-12

These medications require prior authorization to determine if they can be coveredfor your medical condition

Abstral

Actiq

Actonel

Actonelwith Calcium

Adcirca

Anitor

Amphetamine-

Dextroamphetamine ER

cap (Mfgs: Global, Barr/

Teva)

Ampyra

Arcalyst

Atelvia

Blood Glucose test stripsand meters (Mfgs: Abbott,Lifescan/JJ, Roche)

ciclopirox (solution)

Cimzia

CNL 8

Doryx

Egrifta

Embeda

Enbrel

Erivedge

Fentora

Firazyr

Forteo

Gilenya

Gleevec

Growth Hormone

Humira

Incivek

Increlex

Inlyta

itraconazole

Jaka

Kalydeco

Kineret

Lamisil

Lazanda

Letairis

Lyrica

Modanil

Nexavar

Nuvigil

Onsolis

Orencia SQ injection

Pegasys

PEG-Intron

PenLac

Promacta

Provigil

Qualaquin

Relistor

Revatio

Revlimid

Savella

Simponi

Solodyn

SporanoxSprycel

Subsys

Sutent

Sylatron

Tarceva

Tasigna

terbinane

Tracleer

Tykerb

Tyvaso

Vandetanib

Ventavis

Victrelis

Votrient

Xalkori

Xenazine

Xyrem

Zavesca

Zelboraf

Zolinza

ZolpiMistZytiga

These medications require prior authorizationif prescribed above the maximum quantity

Maximum quantity per monthunless otherwise specifed

Ambien CR(zolpidem tartrate er) 14 tablets

Edluar 14 tablets

Exalgo 120 tablets

Imitrex(sumatriptan succinate) tablet 12 tablets

Imitrex(sumatriptan succinate) injection 6 injections

Imitrexnasal spray 6 canisters

Infergeninjection 12 injections

Intermezzo 14 tablets

Lunesta 14 tablets

OpanaER 80 mg per day

Relenza 10 discs (2 treatment courses) per 6 months

Rozerem

14 tabletsTamiu

30mg 40 capsules (2 treatment courses) per 6 months

Tamiu45mg & 75mg 20 capsules (2 treatment courses) per 6 months

Tamiu12mg/ml 150ml (2 treatment courses) per 6 months

NOTE: In addition to the above medications, there are limits to the amount of medication eligible for coverage for all prescriptions. Theselimits are based on your prescription benet along with information from the FDA and scientic literature about maximum, safe, effectivedosages.

Prescription Prior Authorization


21/28

RegenceBlueCrossBlueShieldofO

regon

isanIndependentLicenseeoftheBlueCross

andBlueShieldAssociation

Integrated Care ManagementWhen youre dealing with a health challenge, a helping hand can make

all the difference. A Personal Care Team is ready to assist you with an

ongoing medical condition, or serious illness or injury. The program

provides easy access to one-on-one support at no extra cost to you.

This program is not insurance, but is offered in addition to your medical

plan to help you get information and support when you need it.

Specialized support in times of need

Imagine having a team of clinical health experts helping you manage a

complex or chronic medical condition. Thats what youll experience with

a Regence Personal Care Team.

Our specialists utilize a holistic approach. Well partner with you to develop

a customized care plan that supports your health goals and specific

challenges. Youll communicate directly with a designated nurse, social

worker or care advocate. Behind the scenes youll be supported by a team

of experts. Together, well work with you and your doctors to manage yourcare. Teams can include certified case managers, pediatric and maternity

nurses, behavioral health clinicians, transplant specialists, and others who

understand you and what youre facing.

The goal is to get you the right care at the right time and help you

achieve the best possible health.

Who uses Integrated Care Management services?

We provide support for a variety of medical concerns. Here are some real-life

examples of members whove been helped by a Personal Care Team:

A pregnant mother whos just found out shes carrying triplets and feels

overwhelmed by the challenges facing her family

An 84-year-old man whose leg wounds were infected with

antibiotic-resistant bacteria

A 48-year-old man suffering from a lung disease who now receives

intravenous treatment in the comfort of his own home

A 17-year-old student whose kidney transplant saved her life

T E A M C A N H E L P.

Facing a health chal lenge?

YOUR PERSONAL CARE


22/28

What you can expect

A big-picture viewpoint of your

health can lead to targeted

interventions, extra support for

managing medications, custom

treatment plans and even

suggestions for lifestyle changes.

All of these can significantly

impact your overall health.

Expect your Personal Care Team to:

Answer questions and provide

information about your condition,

illness or injury

Be your advocate and help you

navigate the health care system

Work with your doctors and

support your care plan

Help you make informed

decisions based on all yourtreatment options

Make sure youre getting the most

from your health care benefits

Help you understand what

actions you can take to improve

your health

We know that addressing potential

health issues early on can mean

better health outcomes in the long

run. Thats why a care advocate

may reach out directly to you or

a family member if it appears you

could use some help.

Need help or want to learn more?

Call toll-free: 1 (866) 543-5765.

04615-or / 09-11



23/28

Feeling good .

Regence Advantages

As a Regence member, you can enjoy savings on the followinghealth-related products and services. This discount program is offeredto all Regence members at no additional cost (although somediscounted programs offered by vendors may carry separate fees).

Regence Advantages is not insurance but is offered in addition to your

medical and/or dental plan(s) to help you stay healthy and live better.

TruVision: Significant discounts are offered on laser visioncorrection procedures such as LASIK and PRK. Also, save 10% to 15%on mail-order contact lenses.

TruHearing: TruHearing offers deep discounts on state-of-the-artdigital hearing aids, and contracts with a national network of audiologistsand hearing instrument specialists to provide lower costs on expertadvice and service. It offers two programs to choose fromTruHearingValueAdd and TruHearing MemberPlus. Both include special healthplan-contracted pricing on hearing aids, one-time loss or damage

replacement for three years, a 45-day money back guarantee and48 batteries per hearing aid purchased. Similar to warehousememberships, TruHearing MemberPlus saves you an additional $300 to$1,100 on hearing aids for an annual membership fee of $108.

QualSight:QualSight makes LASIK easy for members. You can save40-50% off the national average price of Traditional LASIK or receivesignificant savings on procedures such as Custom Bladeless (all laser)LASIK. Find out if you are a potential candidate for this life-changingprocedure today. Call 1 (866) 750-7561 to learn more or visit QualSight.com.

EpicDental: Purchase smile-protecting supplies at 25% off,including mouthwash, gums, mints and toothpaste. All items contain

xylitol, a natural ingredient that fights cavities.

CHP CAMaffinity Program:As a Regence member, youre eligiblefor the CHP CAMaffinity Program, which provides a 20% discounton complementary and alternative medicine (CAM) services offeredthrough The CHP Groups growing network of chiropractors,acupuncturists, naturopathic physicians and massage therapists.

Re

genceBlueCrossBlueShield

ofOregon

isa

nIndependentLicenseeoftheBlueCrossandBlueShieldAssociation

Regence is completely independent from the companies that provide these products and services.Regence does not endorse or guarantee the products and services offered or their effectiveness.Regence reserves the right to change the program at any time without prior notice.


24/28

05704rep05270-or / 09-12

2012. Regence BlueCross BlueShield of Oregon, all rights reserved.

CHP Active and Healthy: CHPActive and Healthy is the discountprogram that gets you up,moving, and saving money! Withdiscounts offered by thousandsof participating vendors (e.g.health clubs, ski resorts, sporting

events, museums, etc.) for a smallannual fee, its your source forgreat deals on healthy andfun activities.

Banfield Pet Hospital:As aRegence member, you receivea waived enrollment fee forBanfield Pet Hospitals OptimumWellness Plans, packages ofpreventive care that includeannual blood work, vaccinations,de-worming, unlimited officevisits, plus much more. Banfield isthe largest veterinary hospital inthe world with 800 hospitalsin 43 states; most located insidePetSmartTM. Learn moreat banfield.com/regence.

Take Shape for Life:Save$25 or more on your firstmonths order! This safe weightmanagement and health programuses clinically proven Medifast

products and a personal healthcoach to provide one-on-oneguidance and encouragement.The program helps you loseweight and manage diseaseand health through nutritionalintervention, free access tohealth care professionals,educational materials, andthe Habits of Health system.There are no hidden costs orstart-up fees. Learn more at

stayhealthy4ever.com.

CorCell Saving Babys Cord

Blood: Cord blood stem cellsare now being used to treat morethan 70 diseases, and researchis ongoing to find treatmentsfor even more. Regence haspartnered with CorCell to offer

a $350 discount when you bankyour babys umbilical cord blood.Protect your child or give the giftof cord blood preservation toyour grandchild, niece, nephew,friend or other loved one. Visitcorcell.com for more information.

HearPO: Receive a 40%discount on diagnostic services,including hearing exams, andsignificant savings on hearingaids. Youll enjoy a 60-day no-risktrial period; one-year follow-up care; a three-year warranty,including coverage for loss anddamage; and free batteries(160 cells per hearing aid)allwith a lowest-price guarantee.

Everest, The First Nationwide

Funeral Planning and Concierge

Service: Save $50 off theenrollment fee for Everests suiteof funeral-planning services. With

advisors available 24 hours aday, youll get the information youneed to make informed decisionsabout all funeral-related issues,within your budget, and with afuneral home of your choice.

National Allergy Supply: Save 15on products for non-drug allergyrelief, including pillow and mattreencasings, air filtration products,asthma management tools, greencleaning products and personalcare products. National Allergy

Supply provides discount prices,outstanding service and a 60-dayunconditional return policy with nrestocking fees.

EyeMed Vision Care:Save 35%on a complete pair of glasses(frames and lenses). Save 15%on non-disposable contactsand $10 on contact lens fittings.These discounts are available atleading retailers and many privatepractice locations.

Jenny:Jenny Craig plans arepersonalized and offer one-on-onsupport from trained weight-lossconsultants. With every Jenny CraProgram youll receive weeklyscheduled consultations, plannedor personalized menus, and freeonline support at jennycraig.com.Choose from two special offers:

A Free 30-day Program*

25% off a Premium Program* Beltone**:Receive a free

screening, a 25% discounton Beltone hearing aids, aone-year supply of hearing-aidbatteries and free follow-upvisits and testing.

Safe Beginnings:Save 15% onSafe Beginnings products, includsafety gates, cabinet locks, outletcovers, window guards, and many

other baby-proofing productsWant to learn more?

Go tomyRegence.com/advantage

or regence.com/advantages

* Plus the cost of food. Plus the cost of shipping, if applicable. Offer applies to initial membership

fee only and is valid at participating centres in the United States, Canada and Puerto Rico andthrough Jenny Craig At Home. Each offer is a separate offer and can be used only once perperson. Restrictions apply.

** Discounts through HearPO (also includes extended family), TruHearing and Beltone areavailable to members and their parents and grandparents.


25/28


26/28


27/28


28/28

Documents

04821_OR Group Fully Insured Bound Packet 9-12