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> 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