54
> Summary of Benefits and Coverage Asante Health Plans 1, 2, 3 and the Flexible Workforce Health Plan > Annual Required Notices > Notice of Privacy Practices > Continuation Coverage Rights under Cobra > Medicare Notice of Creditable Coverage > New Health Insurance Marketplace Coverage > Where To Get Help ASANTE 2018 BENEFIT SUMMARIES & LEGAL NOTICES

ASANTE 2018 BENEFIT SUMMARIES & LEGAL NOTICES · day retail prescription $10 copay / 90-day re tail prescription u $15 copay / retail prescription $20 copay / mail order prescription

  • Upload
    others

  • View
    0

  • Download
    0

Embed Size (px)

Citation preview

  • > Summary of Benefits and Coverage

    – Asante Health Plans 1, 2, 3 and theFlexible Workforce Health Plan

    > Annual Required Notices

    > Notice of Privacy Practices

    > Continuation Coverage Rights under Cobra

    > Medicare Notice of Creditable Coverage

    > New Health Insurance Marketplace Coverage

    > Where To Get Help

    ASANTE2018 BENEFIT SUMMARIES & LEGAL NOTICES

  • Su

    mm

    ary

    of

    Ben

    efit

    s an

    d C

    ove

    rag

    e: W

    hat t

    his

    Pla

    n C

    over

    s &

    Wha

    t You

    Pay

    For

    Cov

    ered

    Ser

    vice

    s C

    ove

    rag

    e P

    erio

    d:

    01/0

    1/20

    18 –

    12/

    31/2

    018

    AS

    AN

    TE

    HE

    AL

    TH

    PL

    AN

    1C

    ove

    rag

    e fo

    r: In

    divi

    dual

    and

    Elig

    ible

    Fam

    ily |

    Pla

    n T

    ype:

    PP

    O

    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

    18S

    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

    . For

    ge

    nera

    l def

    initi

    ons

    of c

    omm

    on te

    rms,

    suc

    h as

    allo

    wed

    am

    ount

    , bal

    ance

    bill

    ing,

    coi

    nsur

    ance

    , cop

    aym

    ent,

    dedu

    ctib

    le, p

    rovi

    der,

    or

    othe

    r un

    derli

    ned

    term

    s se

    e th

    e G

    loss

    ary.

    You

    ca

    n vi

    ew 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/

    HA

    SO

    and

    in-n

    etw

    ork

    prov

    ider

    s: $

    500

    indi

    vidu

    al /

    $1,0

    00 fa

    mily

    per

    cal

    enda

    r ye

    ar. O

    ut-o

    f-ne

    twor

    k: $

    1,00

    0 in

    divi

    dual

    / $2

    ,000

    fam

    ily p

    er c

    alen

    dar

    year

    .

    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 de

    duct

    ible

    exp

    ense

    s pa

    id b

    y al

    l fam

    ily m

    embe

    rs m

    eets

    the

    over

    all f

    amily

    ded

    uctib

    le.

    Are

    th

    ere

    serv

    ices

    co

    vere

    d

    bef

    ore

    yo

    u m

    eet

    you

    r d

    edu

    ctib

    le?

    Yes

    . Em

    erge

    ncy

    room

    car

    e an

    d th

    e fo

    llow

    ing

    serv

    ices

    re

    ceiv

    ed fr

    om A

    sant

    e/H

    AS

    O a

    nd in

    -net

    wor

    k pr

    ovid

    ers:

    pr

    even

    tive

    care

    , offi

    ce/u

    rgen

    t car

    e vi

    sits

    , pre

    scrip

    tion

    drug

    s or

    out

    patie

    nt m

    enta

    l hea

    lth a

    nd s

    ubst

    ance

    use

    di

    sord

    er o

    ffice

    /psy

    chot

    hera

    py v

    isits

    .

    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

    e/pr

    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

    on’t

    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 f

    or

    this

    pla

    n?

    Asa

    nte/

    HA

    SO

    pro

    vide

    rs: $

    2,50

    0 in

    divi

    dual

    / $5

    ,000

    fam

    ily

    per

    cale

    ndar

    yea

    r. In

    -Net

    wor

    k: $

    3,50

    0 in

    divi

    dual

    / $7

    ,000

    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/H

    AS

    O p

    rovi

    ders

    and

    in-n

    etw

    ork

    prov

    ider

    s cr

    oss

    accu

    mul

    ate.

    Out

    -of-

    netw

    ork:

    $6,

    000

    indi

    vidu

    al /

    $12,

    000

    fam

    ily p

    er c

    alen

    dar

    year

    .

    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 t

    heir

    own

    out-

    of-p

    ocke

    t lim

    its u

    ntil

    the

    over

    all f

    amily

    out

    -of-

    pock

    et li

    mit

    has

    been

    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,

    pre

    scrip

    tion

    drug

    out

    -of-

    pock

    et li

    mit,

    bal

    ance

    -bi

    lled

    char

    ges,

    and

    hea

    lth c

    are

    this

    pla

    n do

    esn’

    t cov

    er.

    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

    -po

    cket

    lim

    it.

    Will

    yo

    u p

    ay le

    ss if

    yo

    u u

    se a

    n

    etw

    ork

    pro

    vid

    er?

    Yes

    . Asa

    nte/

    HA

    SO

    pro

    vide

    rs. S

    ee

    rege

    nce.

    com

    /go/

    Pre

    ferr

    ed o

    r ca

    ll 1

    (888

    ) 34

    4-82

    35 fo

    r a

    list o

    f net

    wor

    k pr

    ovid

    ers.

    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,

    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

    er’s

    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

    as 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.

  • 2 o

    f 7

    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,

    & O

    ther

    Imp

    ort

    ant

    Info

    rmat

    ion

    Asa

    nte

    /HA

    SO

    P

    rovi

    der

    (Y

    ou

    will

    pay

    th

    e le

    ast)

    In-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    Ou

    t-o

    f-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    mo

    st)

    If y

    ou

    vis

    it a

    hea

    lth

    ca

    re 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

    $15

    copa

    y / v

    isit,

    de

    duct

    ible

    doe

    s no

    t ap

    ply;

    oth

    er s

    ervi

    ces

    15%

    coi

    nsur

    ance

    $25

    copa

    y / v

    isit,

    de

    duct

    ible

    doe

    s no

    t ap

    ply;

    oth

    er

    serv

    ices

    15%

    co

    insu

    ranc

    e

    40%

    coi

    nsur

    ance

    Cop

    aym

    ent a

    pplie

    s to

    eac

    h A

    sant

    e/H

    AS

    O a

    nd

    in-n

    etw

    ork

    offic

    e vi

    sits

    onl

    y. A

    ll ot

    her

    serv

    ices

    th

    at a

    re n

    ot b

    illed

    as

    an o

    ffice

    vis

    it ar

    e co

    vere

    d at

    the

    coin

    sura

    nce

    spec

    ified

    , afte

    r de

    duct

    ible

    .

    Spe

    cial

    ist v

    isit

    $15

    copa

    y / v

    isit,

    de

    duct

    ible

    doe

    s no

    t ap

    ply;

    oth

    er s

    ervi

    ces

    15%

    coi

    nsur

    ance

    $25

    copa

    y / v

    isit,

    de

    duct

    ible

    doe

    s no

    t ap

    ply;

    oth

    er

    serv

    ices

    15%

    co

    insu

    ranc

    e

    40%

    coi

    nsur

    ance

    Pre

    vent

    ive

    care

    /scr

    eeni

    ng/

    imm

    uniz

    atio

    n N

    o ch

    arge

    N

    o ch

    arge

    40

    % c

    oins

    uran

    ce

    You

    may

    hav

    e to

    pay

    for

    serv

    ices

    that

    are

    n't

    prev

    entiv

    e. A

    sk y

    our

    prov

    ider

    if th

    e se

    rvic

    es

    need

    ed a

    re p

    reve

    ntiv

    e. T

    hen

    chec

    k w

    hat y

    our

    plan

    will

    pay

    for.

    Sub

    ject

    to p

    reve

    ntiv

    e ca

    re

    guid

    elin

    es.

    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

    Non

    e Im

    agin

    g (C

    T/P

    ET

    sca

    ns,

    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

    tr

    eat

    you

    r ill

    nes

    s o

    r co

    nd

    itio

    n

    Mor

    e in

    form

    atio

    n ab

    out

    pres

    crip

    tion

    drug

    co

    vera

    ge is

    ava

    ilabl

    e at

    re

    genc

    e.co

    m/g

    o/fo

    rmul

    ary

    /201

    8/3t

    ierS

    tand

    ard.

    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

    Out

    -of-

    pock

    et li

    mit

    $2,5

    00 p

    er in

    divi

    dual

    / $5

    ,000

    fam

    ily p

    er c

    alen

    dar

    year

    . 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

    har

    mac

    ies

    or

    thro

    ugh

    Reg

    ence

    mai

    l ord

    er.

    No

    char

    ge fo

    r F

    DA

    -app

    rove

    d w

    omen

    's

    cont

    race

    ptiv

    es a

    nd c

    erta

    in p

    reve

    ntiv

    e dr

    ugs

    and

    imm

    uniz

    atio

    ns a

    t a p

    artic

    ipat

    ing

    phar

    mac

    y.

    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

    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

    /

    35%

    coi

    nsur

    ance

    up

    to $

    60 m

    axim

    um

    / ret

    ail p

    resc

    riptio

    n 35

    % c

    oins

    uran

    ce

    up to

    $12

    0 m

    axim

    um /

    mai

    l

    Not

    cov

    ered

  • 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,

    & O

    ther

    Imp

    ort

    ant

    Info

    rmat

    ion

    Asa

    nte

    /HA

    SO

    P

    rovi

    der

    (Y

    ou

    will

    pay

    th

    e le

    ast)

    In-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    Ou

    t-o

    f-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    mo

    st)

    90-d

    ay r

    etai

    l pr

    escr

    iptio

    n or

    der

    pres

    crip

    tion

    copa

    ymen

    t and

    /or

    coin

    sura

    nce.

    T

    he fi

    rst f

    ill fo

    r sp

    ecia

    lty d

    rugs

    may

    be

    prov

    ided

    at

    a r

    etai

    l pha

    rmac

    y, a

    dditi

    onal

    fills

    mus

    t be

    prov

    ided

    at A

    sant

    e O

    utpa

    tient

    Pha

    rmac

    ies.

    Non

    -pre

    ferr

    ed b

    rand

    dr

    ugs

    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

    orde

    r pr

    escr

    iptio

    n

    Not

    cov

    ered

    Spe

    cial

    ty d

    rugs

    Ref

    er to

    gen

    eric

    , pr

    efer

    red

    bran

    d an

    d no

    n–pr

    efer

    red

    bran

    d dr

    ugs

    abov

    e.

    Ref

    er to

    gen

    eric

    , pr

    efer

    red

    bran

    d an

    d no

    n–pr

    efer

    red

    bran

    d dr

    ugs

    abov

    e.

    Not

    cov

    ered

    If y

    ou

    hav

    e o

    utp

    atie

    nt

    surg

    ery

    Fac

    ility

    fee

    (e.g

    ., am

    bula

    tory

    sur

    gery

    ce

    nter

    ) 15

    % c

    oins

    uran

    ce

    30%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    Non

    e

    Phy

    sici

    an/s

    urge

    on fe

    es

    15%

    coi

    nsur

    ance

    15

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    N

    one

    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 ap

    ply

    Cop

    aym

    ent a

    pplie

    s to

    the

    faci

    lity

    char

    ge fo

    r ea

    ch v

    isit

    (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

    Non

    e

    Urg

    ent c

    are

    $15

    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

    $25

    copa

    y / v

    isit,

    de

    duct

    ible

    doe

    s no

    t ap

    ply

    Cop

    aym

    ent a

    pplie

    s to

    eac

    h of

    fice/

    urge

    nt c

    are

    visi

    t.

    If y

    ou

    hav

    e a

    ho

    spit

    al

    stay

    Fac

    ility

    fee

    (e.g

    ., ho

    spita

    l ro

    om)

    15%

    coi

    nsur

    ance

    30

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    N

    one

    Phy

    sici

    an/s

    urge

    on fe

    es

    15%

    coi

    nsur

    ance

    15

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    N

    one

  • 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,

    & O

    ther

    Imp

    ort

    ant

    Info

    rmat

    ion

    Asa

    nte

    /HA

    SO

    P

    rovi

    der

    (Y

    ou

    will

    pay

    th

    e le

    ast)

    In-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    Ou

    t-o

    f-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    mo

    st)

    If y

    ou

    nee

    d m

    enta

    l h

    ealt

    h, b

    ehav

    iora

    l h

    ealt

    h, o

    r su

    bst

    ance

    ab

    use

    ser

    vice

    s

    Out

    patie

    nt s

    ervi

    ces

    $15

    copa

    y /

    offic

    e/ps

    ycho

    ther

    apy

    visi

    t, de

    duct

    ible

    doe

    s no

    t app

    ly; o

    ther

    se

    rvic

    es 1

    5%

    coin

    sura

    nce

    $25

    copa

    y /

    offic

    e/ps

    ycho

    ther

    apy

    visi

    t, de

    duct

    ible

    do

    es n

    ot a

    pply

    ; 15

    % c

    oins

    uran

    ce

    for

    prof

    essi

    onal

    and

    30

    % c

    oins

    uran

    ce

    for

    faci

    lity

    40%

    coi

    nsur

    ance

    Cop

    aym

    ent a

    pplie

    s to

    eac

    h A

    sant

    e/H

    AS

    O a

    nd

    in-n

    etw

    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 th

    e co

    insu

    ranc

    e sp

    ecifi

    ed, a

    fter

    dedu

    ctib

    le.

    Inpa

    tient

    ser

    vice

    s 15

    % c

    oins

    uran

    ce

    15%

    coi

    nsur

    ance

    fo

    r pr

    ofes

    sion

    al a

    nd

    30%

    coi

    nsur

    ance

    fo

    r fa

    cilit

    y

    40%

    coi

    nsur

    ance

    N

    one

    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

    Cos

    t sha

    ring

    does

    not

    app

    ly to

    cer

    tain

    pr

    even

    tive

    serv

    ices

    . Dep

    endi

    ng o

    n th

    e ty

    pe o

    f se

    rvic

    es, a

    coi

    nsur

    ance

    or

    dedu

    ctib

    le m

    ay

    appl

    y. M

    ater

    nity

    car

    e m

    ay in

    clud

    e te

    sts

    and

    serv

    ices

    des

    crib

    ed e

    lsew

    here

    in th

    e S

    BC

    (i.e

    . ul

    tras

    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 s

    pec

    ial h

    ealt

    h

    nee

    ds

    Hom

    e he

    alth

    car

    e 15

    % 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

    15%

    coi

    nsur

    ance

    30

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    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

    15

    % c

    oins

    uran

    ce

    30%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    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

    . In

    clud

    es p

    hysi

    cal t

    hera

    py, o

    ccup

    atio

    nal t

    hera

    py

    and

    spee

    ch th

    erap

    y se

    rvic

    es.

    Ski

    lled

    nurs

    ing

    care

    N

    ot a

    pplic

    able

    20

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    Li

    mite

    d to

    90

    inpa

    tient

    day

    s / y

    ear.

  • 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,

    & O

    ther

    Imp

    ort

    ant

    Info

    rmat

    ion

    Asa

    nte

    /HA

    SO

    P

    rovi

    der

    (Y

    ou

    will

    pay

    th

    e le

    ast)

    In-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    Ou

    t-o

    f-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    mo

    st)

    Dur

    able

    med

    ical

    eq

    uipm

    ent

    15%

    coi

    nsur

    ance

    20

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    N

    one

    Hos

    pice

    ser

    vice

    s 15

    % c

    oins

    uran

    ce

    30%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    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 or

    eye

    care

    Chi

    ldre

    n’s

    eye

    exam

    N

    ot c

    over

    ed

    Not

    cov

    ered

    N

    ot c

    over

    ed

    Non

    e

    Chi

    ldre

    n’s

    glas

    ses

    Not

    cov

    ered

    N

    ot c

    over

    ed

    Not

    cov

    ered

    N

    one

    Chi

    ldre

    n’s

    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

    & 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.)

    Acu

    punc

    ture

    Bar

    iatr

    ic s

    urge

    ry

    Chi

    ropr

    actic

    car

    e

    Cos

    met

    ic s

    urge

    ry, e

    xcep

    t con

    geni

    tal a

    nom

    alie

    s

    Den

    tal c

    are

    (Adu

    lt)

    Hea

    ring

    aids

    Long

    -ter

    m c

    are

    Non

    -em

    erge

    ncy

    care

    whe

    n tr

    avel

    ing

    outs

    ide

    the

    U.S

    .

    Priv

    ate-

    duty

    nur

    sing

    (ex

    cept

    as

    prov

    ided

    for

    hom

    e he

    alth

    )

    Rou

    tine

    eye

    care

    (A

    dult)

    Rou

    tine

    foot

    car

    e

    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

    co

    mp

    lete

    list

    . Ple

    ase

    see

    you

    r p

    lan

    do

    cum

    ent.

    )

    Hab

    ilita

    tion

    serv

    ices

    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

    a/he

    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

    iio.c

    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

    avai

    labl

    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

    e.go

    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

    hav

    e 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 y

    our

    right

    s, th

    is n

    otic

    e, o

    r as

    sist

    ance

    , co

    ntac

    t the

    pla

    n at

    1 (

    888)

    344

    -823

    5 or

    vis

    it re

    genc

    e.co

    m o

    r th

    e 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

    do

    l.gov

    /ebs

    a/he

    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-

    7984

    or

    the

    toll

    free

    mes

    sage

    line

    at 1

    (88

    8) 8

    77-

  • 6 o

    f 7

    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

    r.or

    egon

    .gov

    /get

    help

    /Pag

    es/fi

    le-a

    -com

    plai

    nt.a

    spx;

    or

    by E

    -mai

    l at:

    cp.in

    s@or

    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

    dar

    ds?

    Y

    es

    If yo

    ur p

    lan

    does

    n’t 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

    añol

    ): P

    ara

    obte

    ner

    asis

    tenc

    ia e

    n E

    spañ

    ol, l

    lam

    e al

    1 (

    888)

    344

    -823

    5.

    ––––

    ––––

    ––––

    ––––

    ––––

    ––T

    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

    tion.

    ––––

    ––––

    ––––

    ––––

    ––––

    ––

  • 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

    n’s

    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

    h/D

    eliv

    ery

    Pro

    fess

    iona

    l Ser

    vice

    s C

    hild

    birt

    h/D

    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

    2,80

    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

    n’s

    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

    $2,7

    54

    T

    he

    pla

    n’s

    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 o

    f 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

    01012017.04PF12LNoticeNDMARegence

    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 [email protected] Customer Service for all other plans Civil Rights Coordinator MS CS B32B, P.O. Box 1271 Portland, OR 97207-1271 1-888-344-6347, (TTY: 711) [email protected]

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. 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 http://www.hhs.gov/ocr/office/file/index.html.

  • Language assistance

    01012017.04PF12LNoticeNDMARegence

    ATENCIÓN: si habla español, tiene a su disposición

    servicios gratuitos de asistencia lingüística. 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)。

    CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ

    trợ ngôn ngữ miễn phí dành 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 français, des services

    d'aide linguistique vous sont proposés 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

    (TTY:711)まで、お電話にてご連絡ください。

    ti’go Diné

    Bizaad, saad

    1-888-344-6347 (TTY: 711.)

    FAKATOKANGA’I: Kapau ‘oku ke Lea-

    Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai

    atu ha tokoni ta’etotongi, pea te ke lava ‘o ma’u ia.

    ha’o 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)

    ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 1-888-344-6347 (TTY: 711)។

    ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡ ੇਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-888-344-6347 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।

    ACHTUNG: Wenn Sie Deutsch sprechen, stehen

    Ihnen kostenlose Sprachdienstleistungen zur

    Verfügung. 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)

    ध्यान दिनहुोस्: तपार्इलं ेनेपाली बोल्नहुुन्छ भने तपार्इकंो दनदतत भाषा सहायता सेवाहरू

    दनिःशलु्क रूपमा उपलब्ध छ । फोन गनुुहोस ्1-888-344-6347 (दिदिवार्इ:

    711

    ATENȚIE: Dacă vorbiți limba română, 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: ถา้คุณพดูภาษาไทย คุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-888-344-6347 (TTY: 711)

    ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີ ພ້ອມໃຫ້ທ່ານ.

    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 التیتسه د،یکنی 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 &

    Wha

    t You

    Pay

    For

    Cov

    ered

    Ser

    vice

    s C

    ove

    rag

    e P

    erio

    d:

    01/0

    1/20

    18 –

    12/

    31/2

    018

    AS

    AN

    TE

    HE

    AL

    TH

    PL

    AN

    2

    C

    ove

    rag

    e fo

    r: In

    divi

    dual

    and

    Elig

    ible

    Fam

    ily |

    Pla

    n T

    ype:

    PP

    O

    1 o

    f 6

    Cla

    ims

    Adm

    inis

    trat

    or: R

    egen

    ce B

    lueC

    ross

    Blu

    eShi

    eld

    of O

    rego

    n O

    O01

    18S

    HH

    3X

    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

    . For

    ge

    nera

    l def

    initi

    ons

    of c

    omm

    on te

    rms,

    suc

    h as

    allo

    wed

    am

    ount

    , bal

    ance

    bill

    ing,

    coi

    nsur

    ance

    , cop

    aym

    ent,

    dedu

    ctib

    le, p

    rovi

    der,

    or

    othe

    r un

    derli

    ned

    term

    s se

    e th

    e G

    loss

    ary.

    You

    ca

    n vi

    ew 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?

    $1

    ,350

    indi

    vidu

    al (

    sing

    le c

    over

    age)

    / $

    2,70

    0 fa

    mily

    per

    ca

    lend

    ar y

    ear.

    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?

    Y

    es. C

    erta

    in p

    resc

    riptio

    n dr

    ugs

    and

    prev

    entiv

    e ca

    re.

    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

    re.g

    ov/c

    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

    on’t

    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/

    HA

    SO

    pro

    vide

    rs: $

    2,00

    0 in

    divi

    dual

    (si

    ngle

    co

    vera

    ge)

    / $4,

    000

    fam

    ily p

    er c

    alen

    dar

    year

    . In-

    netw

    ork:

    $3

    ,000

    indi

    vidu

    al (

    sing

    le c

    over

    age)

    / $6

    ,000

    fam

    ily p

    er

    cale

    ndar

    yea

    r. T

    he o

    ut-o

    f-po

    cket

    lim

    it am

    ount

    s fo

    r A

    sant

    e/H

    AS

    O p

    rovi

    ders

    and

    in-n

    etw

    ork

    prov

    ider

    s cr

    oss

    accu

    mul

    ate.

    Out

    -of-

    netw

    ork:

    $5,

    000

    indi

    vidu

    al /

    $10,

    000

    fam

    ily p

    er c

    alen

    dar

    year

    .

    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.

    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

    sn’t

    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/

    HA

    SO

    pro

    vide

    rs. S

    ee

    rege

    nce.

    com

    /go/

    Pre

    ferr

    ed o

    r ca

    ll 1

    (888

    ) 34

    4-82

    35 fo

    r a

    list o

    f net

    wor

    k pr

    ovid

    ers.

    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

    er’s

    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.

  • 2 o

    f 6

    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,

    & O

    ther

    Imp

    ort

    ant

    Info

    rmat

    ion

    Asa

    nte

    /HA

    SO

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    In-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    Ou

    t-o

    f-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    mo

    st)

    If y

    ou

    vis

    it a

    hea

    lth

    ca

    re p

    rovi

    der

    ’s o

    ffic

    e o

    r cl

    inic

    Prim

    ary

    care

    vis

    it to

    trea

    t an

    inju

    ry

    or il

    lnes

    s 10

    % c

    oins

    uran

    ce

    15%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    Cov

    erag

    e fo

    r co

    mpl

    emen

    tary

    car

    e (a

    cupu

    nctu

    re

    and

    chiro

    prac

    tic s

    pina

    l man

    ipul

    atio

    ns)

    is s

    ubje

    ct to

    20

    % c

    oins

    uran

    ce fo

    r in

    -net

    wor

    k pr

    ovid

    ers

    and

    40%

    co

    insu

    ranc

    e 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

    40

    % c

    oins

    uran

    ce

    You

    may

    hav

    e to

    pay

    for

    serv

    ices

    that

    are

    n't

    prev

    entiv

    e. A

    sk y

    our

    prov

    ider

    if th

    e se

    rvic

    es

    need

    ed a

    re p

    reve

    ntiv

    e. T

    hen

    chec

    k w

    hat y

    our

    plan

    w

    ill p

    ay fo

    r. S

    ubje

    ct to

    pre

    vent

    ive

    care

    gui

    delin

    es.

    If y

    ou

    hav

    e a

    test

    Dia

    gnos

    tic te

    st (

    x-ra

    y, b

    lood

    wor

    k)

    15%

    coi

    nsur

    ance

    30

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    Non

    e Im

    agin

    g (C

    T/P

    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

    tr

    eat

    you

    r ill

    nes

    s o

    r co

    nd

    itio

    n

    Mor

    e in

    form

    atio

    n ab

    out

    pres

    crip

    tion

    drug

    co

    vera

    ge is

    ava

    ilabl

    e at

    re

    genc

    e.co

    m/g

    o/fo

    rmul

    ary

    /201

    8/3t

    ierS

    tand

    ard.

    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

    Cov

    erag

    e is

    lim

    ited

    to a

    30

    -day

    sup

    ply

    reta

    il an

    d up

    to

    90-

    day

    supp

    ly a

    t Asa

    nte

    Out

    patie

    nt P

    harm

    acie

    s or

    thro

    ugh

    Reg

    ence

    mai

    l ord

    er.

    No

    char

    ge fo

    r F

    DA

    -app

    rove

    d w

    omen

    's

    cont

    race

    ptiv

    es a

    nd c

    erta

    in p

    reve

    ntiv

    e dr

    ugs

    and

    imm

    uniz

    atio

    ns a

    t a p

    artic

    ipat

    ing

    phar

    mac

    y.

    Ded

    uctib

    le w

    aive

    d fo

    r ge

    neric

    or

    bran

    d-na

    me

    drug

    s sp

    ecifi

    cally

    des

    igna

    ted

    as p

    reve

    ntiv

    e fo

    r tr

    eatm

    ent

    of c

    hron

    ic d

    isea

    ses

    that

    are

    on

    the

    Opt

    imum

    Val

    ue

    Med

    icat

    ion

    List

    . N

    o ch

    arge

    for

    FD

    A-a

    ppro

    ved

    wom

    en's

    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.

    Y

    ou a

    re r

    espo

    nsib

    le fo

    r th

    e di

    ffere

    nce

    in c

    ost

    betw

    een

    a di

    spen

    sed

    bran

    d-na

    me

    drug

    and

    the

    equi

    vale

    nt g

    ener

    ic d

    rug,

    in a

    dditi

    on to

    the

    copa

    ymen

    t and

    /or

    coin

    sura

    nce.

    T

    he fi

    rst f

    ill fo

    r sp

    ecia

    lty d

    rugs

    may

    be

    prov

    ided

    at a

    Pre

    ferr

    ed b

    rand

    dr

    ugs

    25%

    coi

    nsur

    ance

    up

    to $

    30 m

    axim

    um /

    30-

    day

    reta

    il pr

    escr

    iptio

    n 25

    % c

    oins

    uran

    ce u

    p to

    $60

    max

    imum

    / 90

    -da

    y re

    tail

    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

    Non

    -pre

    ferr

    ed

    bran

    d dr

    ugs

    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

    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

  • 3 o

    f 6

    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,

    & O

    ther

    Imp

    ort

    ant

    Info

    rmat

    ion

    Asa

    nte

    /HA

    SO

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    In-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    Ou

    t-o

    f-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    mo

    st)

    pres

    crip

    tion

    reta

    il ph

    arm

    acy,

    add

    ition

    al fi

    lls m

    ust b

    e pr

    ovid

    ed a

    t A

    sant

    e O

    utpa

    tient

    Pha

    rmac

    ies.

    Spe

    cial

    ty d

    rugs

    Ref

    er to

    gen

    eric

    , pr

    efer

    red

    bran

    d an

    d no

    n–pr

    efer

    red

    bran

    d dr

    ugs

    abov

    e.

    Ref

    er to

    gen

    eric

    , pr

    efer

    red

    bran

    d an

    d no

    n–pr

    efer

    red

    bran

    d dr

    ugs

    abov

    e.

    Not

    cov

    ered

    If y

    ou

    hav

    e o

    utp

    atie

    nt

    surg

    ery

    Fac

    ility

    fee

    (e.g

    ., am

    bula

    tory

    su

    rger

    y ce

    nter

    ) 15

    % c

    oins

    uran

    ce

    30%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    Non

    e

    Phy

    sici

    an/s

    urge

    on

    fees

    15

    % c

    oins

    uran

    ce

    15%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    Non

    e

    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

    N

    one

    Em

    erge

    ncy

    med

    ical

    tr

    ansp

    orta

    tion

    Not

    app

    licab

    le

    20%

    coi

    nsur

    ance

    20

    % c

    oins

    uran

    ce

    Non

    e

    Urg

    ent c

    are

    10%

    coi

    nsur

    ance

    30

    % c

    oins

    uran

    ce

    30%

    coi

    nsur

    ance

    N

    one

    If y

    ou

    hav

    e a

    ho

    spit

    al

    stay

    Fac

    ility

    fee

    (e.g

    ., ho

    spita

    l roo

    m)

    15%

    coi

    nsur

    ance

    30

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    N

    one

    Phy

    sici

    an/s

    urge

    on

    fees

    15

    % c

    oins

    uran

    ce

    15%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    Non

    e

    If y

    ou

    nee

    d m

    enta

    l h

    ealt

    h, b

    ehav

    iora

    l h

    ealt

    h, o

    r su

    bst

    ance

    ab

    use

    ser

    vice

    s

    Out

    patie

    nt

    serv

    ices

    10%

    coi

    nsur

    ance

    / of

    fice/

    psyc

    hoth

    erap

    y vi

    sit;

    othe

    r se

    rvic

    es

    15%

    coi

    nsur

    ance

    15%

    coi

    nsur

    ance

    for

    prof

    essi

    onal

    and

    30

    % c

    oins

    uran

    ce fo

    r fa

    cilit

    y

    40%

    coi

    nsur

    ance

    N

    one

    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

    N

    one

    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

    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

    care

    may

    incl

    ude

    test

    s an

    d se

    rvic

    es d

    escr

    ibed

    el

    sew

    here

    in th

    e S

    BC

    (i.e

    . ultr

    asou

    nd).

    Mat

    erni

    ty

    cove

    rage

    for

    depe

    nden

    t chi

    ldre

    n is

    onl

    y co

    vere

    d in

    Chi

    ldbi

    rth/

    deliv

    ery

    prof

    essi

    onal

    se

    rvic

    es

    15%

    coi

    nsur

    ance

    30

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    Chi

    ldbi

    rth/

    deliv

    ery

    faci

    lity

    serv

    ices

    15

    % c

    oins

    uran

    ce

    30%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

  • 4 o

    f 6

    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,

    & O

    ther

    Imp

    ort

    ant

    Info

    rmat

    ion

    Asa

    nte

    /HA

    SO

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    In-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    leas

    t)

    Ou

    t-o

    f-n

    etw

    ork

    P

    rovi

    der

    (Yo

    u w

    ill p

    ay t

    he

    mo

    st)

    the

    case

    of c

    ompl

    icat

    ions

    .

    If y

    ou

    nee

    d h

    elp

    re

    cove

    rin

    g o

    r h

    ave

    oth

    er s

    pec

    ial h

    ealt

    h

    nee

    ds

    Hom

    e he

    alth

    car

    e 15

    % 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

    15%

    coi

    nsur

    ance

    30

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    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.

    Out

    patie

    nt

    limite

    d to

    80

    visi

    ts /

    year

    . In

    clud

    es p

    hysi

    cal t

    hera

    py, o

    ccup

    atio

    nal t

    hera

    py

    and

    spee

    ch th

    erap

    y se

    rvic

    es.

    Hab

    ilita

    tion

    serv

    ices

    15

    % c

    oins

    uran

    ce

    30%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    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

    and

    spee

    ch th

    erap

    y se

    rvic

    es.

    Ski

    lled

    nurs

    ing

    care

    N

    ot a

    pplic

    able

    20

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    Li

    mite

    d to

    90

    inpa

    tient

    day

    s / y

    ear.

    Dur

    able

    med

    ical

    eq

    uipm

    ent

    15%

    coi

    nsur

    ance

    20

    % c

    oins

    uran

    ce

    40%

    coi

    nsur

    ance

    N

    one

    Hos

    pice

    ser

    vice

    s 15

    % c

    oins

    uran

    ce

    30%

    coi

    nsur

    ance

    40

    % c

    oins

    uran

    ce

    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 or

    eye

    care

    Chi

    ldre

    n’s

    eye

    exam

    N

    ot c

    over

    ed

    Not

    cov

    ered

    N

    ot c

    over

    ed

    Non

    e

    Chi

    ldre

    n’s

    glas

    ses

    Not

    cov

    ered

    N

    ot c

    over

    ed

    Not

    cov

    ered

    N

    one

    Chi

    ldre

    n’s

    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

    & 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.)

    Bar

    iatr

    ic s

    urge

    ry

    Cos

    met

    ic s

    urge

    ry, e

    xcep

    t con

    geni

    tal a

    nom

    alie

    s

    Den

    tal c

    are

    (Adu

    lt)

    Hea

    ring

    aids

    Long

    -ter

    m c

    are

    Non

    -em

    erge

    ncy

    care

    whe

    n tr

    avel

    ing

    outs

    ide

    the

    U.S

    .

    Priv

    ate-

    duty

    nur

    sing

    (ex

    cept

    as

    prov

    ided

    for

    hom

    e he

    alth

    )

    Rou

    tine

    eye

    care

    (A

    dult)

    Rou

    tine

    foot

    car

    e

    Wei

    ght l

    oss

    prog

    ram

    s, u

    nles

    s re

    quire

    d by

    law

  • 5 o

    f 6

    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

    co

    mp

    lete

    list

    . Ple

    ase

    see

    you

    r p

    lan

    do

    cum

    ent.

    )

    Acu

    punc

    ture

    Chi

    ropr

    actic

    car

    e, s

    pina

    l man

    ipul

    atio

    ns o

    nly

    Hab

    ilita

    tion

    serv

    ices

    Infe

    rtili

    ty tr

    eate

    men

    t

    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

    a/he

    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

    iio.c

    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

    avai

    labl

    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

    e.go

    v or

    cal

    l 1 (

    800

    ) 31

    8-25

    96.

    Yo

    ur

    Gri

    evan

    ce a

    nd

    Ap

    pea

    ls R