gt Summary of Benefits and Coverage

ndash Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan amp Asante Flexible Workforce Health Plan

gt Annual Required Notices

gt Summary of Material Modification

gt Notice of Privacy Practices

gt Continuation Coverage Rights Under Cobra

gt Medicare Notice of Creditable Coverage

gt New Health Insurance Marketplace Coverage

gt Where To Get Help

ASANTE2020 BENEFIT SUMMARIES amp LEGAL NOTICES

Su

mm

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of

Ben

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Mat

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Wh

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Reg

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net

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Reg

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accu

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Gen

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ll of

the

cost

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up

to th

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am

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bef

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this

pla

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gins

to p

ay I

f you

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fam

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fam

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own

indi

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paid

by

all f

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mem

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mee

ts th

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l fam

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Are

th

ere

serv

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bef

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yo

u m

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you

r d

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Yes

Cer

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pre

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care

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thos

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low

as

ded

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if yo

u ha

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th

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a c

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men

t or

coin

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app

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See

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Are

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No

Y

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Wh

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$7

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Reg

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Out

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The

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hav

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pla

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to m

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Wh

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in t

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ou

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Pre

miu

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bal

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ed c

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ealth

car

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is

plan

doe

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Eve

n th

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you

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thes

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don

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yo

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yo

u u

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n

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all 1

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for

a lis

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from

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twee

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wha

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Be

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Che

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Do

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Pre

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Ask

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up

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90

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plan

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this

info

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to c

ompa

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e po

rtio

n of

co

sts

you

mig

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ay u

nder

diff

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over

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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ser

vice

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No

Y

ou d

ont

have

to m

eet d

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tible

s fo

r sp

ecifi

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Wh

at is

th

e o

ut-

of-

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cket

lim

it

for

this

pla

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Asa

nte

pref

erre

d ne

twor

k pr

ovid

ers

$2

000

indi

vidu

al

$40

00 fa

mily

per

cal

enda

r ye

ar

Reg

ence

net

wor

k pr

ovid

ers

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500

indi

vidu

al

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00 fa

mily

per

ca

lend

ar y

ear

Reg

ence

lim

ited

netw

ork

prov

ider

s

$70

00 in

divi

dual

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400

0 fa

mily

per

cal

enda

r ye

ar

The

out

-of-

pock

et li

mit

amou

nts

for

Asa

nte

pref

erre

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twor

k pr

ovid

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Reg

ence

net

wor

k pr

ovid

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and

Reg

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lim

ited

netw

ork

prov

ider

s cr

oss

accu

mul

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O

ut-o

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0 in

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dual

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per

ca

lend

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ear

T

he R

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out-

of-p

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it fo

r m

edic

al a

nd p

resc

riptio

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nefit

s ar

e co

mbi

ned

The

out

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pock

et li

mit

is th

e m

ost y

ou c

ould

pay

in a

yea

r fo

r co

vere

d se

rvic

es I

f yo

u ha

ve o

ther

fam

ily m

embe

rs in

this

pla

n th

ey h

ave

to m

eet t

heir

own

out-

of-

pock

et li

mits

unt

il th

e ov

eral

l fam

ily o

ut-o

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cket

lim

it ha

s be

en m

et

2 o

f 8

Wh

at is

no

t in

clu

ded

in t

he

ou

t-o

f-p

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et li

mit

Pre

miu

ms

bal

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-bill

ed c

harg

es a

nd h

ealth

car

e th

is

plan

doe

snt

cove

r

Eve

n th

ough

you

pay

thes

e ex

pens

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hey

don

t cou

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war

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e ou

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limit

Will

yo

u p

ay le

ss if

yo

u u

se a

n

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vid

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prov

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ferr

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pay

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ou u

se a

pro

vide

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the

plan

s n

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ork

You

will

pay

the

mos

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ou u

se a

n ou

t-of

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wor

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ovid

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nd

you

mig

ht r

ecei

ve a

bill

from

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rovi

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diffe

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twee

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ovid

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ch

arge

and

wha

t you

r pl

an p

ays

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awar

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our

netw

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prov

ider

mig

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se a

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me

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ch a

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Che

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ith y

our

prov

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you

get s

ervi

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Do

yo

u n

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N

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You

can

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spec

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A

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bee

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f a d

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lies

Co

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Med

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Eve

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Ser

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May

Nee

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Wh

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Will

Pay

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Imp

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Pre

ferr

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Net

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car

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rovi

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Prim

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vis

it to

tr

eat a

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40

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Out

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ider

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afte

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ll ot

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Cov

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r al

l oth

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serv

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Pre

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ive

care

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uniz

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o ch

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N

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N

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50

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Out

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s

afte

r de

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Y

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ay h

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Ask

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n ch

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wha

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ill p

ay fo

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care

3 o

f 8

Co

mm

on

Med

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Eve

nt

Ser

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s Y

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May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

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amp O

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Imp

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Asa

nte

Pre

ferr

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Net

wo

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rovi

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ou

will

pay

th

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wo

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Pro

vid

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Pro

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ou

hav

e a

test

Dia

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you

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cov

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Gen

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Reg

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Out

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cov

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You

are

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pons

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twee

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disp

ense

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ay b

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ad

ditio

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t be

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Pha

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all

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Out

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to $

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Co

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Med

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Ser

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May

Nee

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Wh

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ou

Will

Pay

Lim

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Imp

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Pre

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Net

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Pro

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Th

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are

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this

pla

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cov

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cos

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on

the

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are

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rece

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the

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our

prov

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and

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harin

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s (d

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s c

opay

men

ts a

nd c

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ce)

and

excl

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ser

vice

s un

der

the

plan

Use

this

info

rmat

ion

to c

ompa

re th

e po

rtio

n of

co

sts

you

mig

ht p

ay u

nder

diff

eren

t hea

lth p

lans

Ple

ase

note

thes

e co

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xam

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are

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lf-on

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over

age

NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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indi

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$9

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T

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dedu

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Gen

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ou m

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ll of

the

cost

s fr

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up

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am

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to p

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fam

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ded

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Are

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reg

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pre

vent

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s

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th

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spec

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ser

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s

No

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s fo

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it

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n

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4-82

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spec

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u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

vis

it a

hea

lth

car

e p

rovi

der

s o

ffic

e o

r cl

inic

Prim

ary

care

vis

it to

trea

t an

inju

ry o

r ill

ness

10

c

oins

uran

ce

15

coi

nsur

ance

Not

app

licab

le fo

r pr

imar

y ca

re v

isits

40

c

oins

uran

ce

reta

il cl

inic

vis

it

40

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Cov

erag

e in

clud

es p

rimar

y ca

re v

isits

at a

ret

ail c

linic

C

over

age

for

acup

unct

ure

and

chi

ropr

actic

spi

nal

man

ipul

atio

ns is

sub

ject

to 2

0 c

oins

uran

ce fo

r R

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

prov

ider

s an

d 40

c

oins

uran

ce fo

r ou

t-of

-net

wor

k pr

ovid

ers

Li

mite

d to

$2

000

yea

r fo

r ac

upun

ctur

e an

d $2

000

ye

ar fo

r sp

inal

man

ipul

atio

ns

Coi

nsur

ance

app

lies

to th

e ou

t-of

-poc

ket l

imit

Spe

cial

ist v

isit

10

coi

nsur

ance

15

c

oins

uran

ce

40

coi

nsur

ance

Pre

vent

ive

care

scr

eeni

ng

imm

uniz

atio

n N

o ch

arge

N

o ch

arge

N

o ch

arge

You

may

hav

e to

pay

for

serv

ices

that

are

nt

prev

entiv

e A

sk y

our

prov

ider

if th

e se

rvic

es n

eede

d ar

e pr

even

tive

The

n ch

eck

wha

t you

r pl

an w

ill p

ay fo

r

Sub

ject

to p

reve

ntiv

e ca

re g

uide

lines

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y b

lood

wor

k)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Imag

ing

(CT

PE

T

scan

s M

RIs

)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

3 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

cov

erag

e

is a

vaila

ble

at

rege

nce

com

go

drug

list2

020

OR

3tie

r

Gen

eric

dru

gs

$5 c

opay

30

-day

re

tail

pres

crip

tion

$10

copa

y 9

0-da

y re

tail

pres

crip

tion

$15

copa

y r

etai

l pr

escr

iptio

n $2

0 co

pay

mai

l or

der

pres

crip

tion

Not

cov

ered

Ded

uctib

le d

oes

not a

pply

for

drug

s sp

ecifi

cally

de

sign

ated

as

prev

entiv

e fo

r tr

eatm

ent o

f chr

onic

di

seas

es th

at a

re o

n th

e O

ptim

um V

alue

Med

icat

ion

List

C

over

age

is li

mite

d to

a 3

0-da

y su

pply

ret

ail a

nd u

p to

90

-day

sup

ply

at A

sant

e O

utpa

tient

Pha

rmac

ies

or

thro

ugh

Reg

ence

mai

l ord

er

No

char

ge fo

r F

DA

-app

rove

d w

omen

s c

ontr

acep

tives

an

d ce

rtai

n pr

even

tive

drug

s an

d im

mun

izat

ions

at a

pa

rtic

ipat

ing

phar

mac

y

Cov

erag

e in

clud

es c

ompo

und

med

icat

ions

at 3

0

coin

sura

nce

up to

$10

0 m

axim

um a

t Asa

nte

Out

patie

nt P

harm

acie

s an

d 40

c

oins

uran

ce u

p to

$2

00 m

axim

um a

t a R

egen

ce p

artic

ipat

ing

reta

il ph

arm

acy

ref

er to

you

r pl

an fo

r fu

rthe

r in

form

atio

n

Mai

l-ord

er p

resc

riptio

ns 3

5 c

oins

uran

ce u

p to

$12

0 m

axim

um O

ut-o

f-ne

twor

k pr

escr

iptio

n dr

ug c

over

age

is n

ot c

over

ed

You

are

res

pons

ible

for

the

diffe

renc

e in

cos

t bet

wee

n a

disp

ense

d br

and-

nam

e dr

ug a

nd th

e eq

uiva

lent

ge

neric

dru

g in

add

ition

to th

e co

paym

ent a

ndo

r co

insu

ranc

e T

he c

ost d

iffer

entia

l bet

wee

n ge

neric

an

d br

and-

nam

e dr

ugs

accr

ues

tow

ard

the

dedu

ctib

le

and

out-

of-p

ocke

t lim

it

The

firs

t fill

for

sele

ct s

peci

alty

dru

gs m

ay b

e pr

ovid

ed

at a

par

ticip

atin

g re

tail

phar

mac

y a

dditi

onal

fills

mus

t be

pro

vide

d at

Asa

nte

Out

patie

nt P

harm

acie

s F

or a

ll ot

her

spec

ialty

dru

gs t

he fi

rst f

ill m

ust b

e pr

ovid

ed a

t A

sant

e O

utpa

tient

Pha

rmac

ies

If A

sant

e O

utpa

tient

P

harm

acie

s ar

e un

able

to fi

ll th

ey w

ill c

oord

inat

e a

fill

thro

ugh

a R

egen

ce S

peci

alty

Pha

rmac

y P

leas

e re

fer

to m

y H

R fo

r a

list o

f med

icat

ions

that

req

uire

the

first

fil

l at A

sant

e O

utpa

tient

Pha

rmac

ies

Pre

ferr

ed b

rand

dr

ugs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

crip

tion

35

coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

escr

iptio

n 35

c

oins

uran

ce u

p to

$12

0 m

axim

um

mai

l ord

er

pres

crip

tion

Not

cov

ered

Bra

nd d

rugs

30

coi

nsur

ance

up

to $

100

max

imum

30

-day

ret

ail

pres

crip

tion

30

coi

nsur

ance

up

to $

300

max

imum

90

-day

ret

ail

pres

crip

tion

40

coi

nsur

ance

up

to $

200

max

imum

re

tail

pres

crip

tion

40

coi

nsur

ance

up

to $

600

max

imum

m

ail o

rder

pr

escr

iptio

n

Not

cov

ered

Spe

cial

ty d

rugs

R

efer

to g

ener

ic

pref

erre

d br

and

and

bran

d dr

ugs

abov

e

Ref

er to

gen

eric

pr

efer

red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

su

rger

y ce

nter

) 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

4 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

Phy

sici

ans

urge

on

fees

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

If y

ou

nee

d im

med

iate

m

edic

al a

tten

tio

n

Em

erge

ncy

room

ca

re

15

coi

nsur

ance

15

c

oins

uran

ce

15

coi

nsur

ance

15

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Em

erge

ncy

med

ical

tr

ansp

orta

tion

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

20

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Urg

ent c

are

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

If y

ou

hav

e a

ho

spit

al

stay

Fac

ility

fee

(eg

ho

spita

l roo

m)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Phy

sici

ans

urge

on

fees

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

If y

ou

nee

d m

enta

l h

ealt

h b

ehav

iora

l hea

lth

o

r su

bst

ance

ab

use

se

rvic

es

Out

patie

nt

serv

ices

10

coi

nsur

ance

of

fice

visi

t 10

c

oins

uran

ce fo

r al

l oth

er s

ervi

ces

15

coi

nsur

ance

for

prof

essi

onal

and

30

c

oins

uran

ce fo

r fa

cilit

y

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Inpa

tient

ser

vice

s 10

c

oins

uran

ce

15

coi

nsur

ance

for

prof

essi

onal

and

30

c

oins

uran

ce fo

r fa

cilit

y

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

If y

ou

are

pre

gn

ant

Offi

ce v

isits

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Cos

t sha

ring

does

not

app

ly to

cer

tain

pre

vent

ive

serv

ices

Dep

endi

ng o

n th

e ty

pe o

f ser

vice

s a

co

insu

ranc

e or

ded

uctib

le m

ay a

pply

Mat

erni

ty c

are

may

incl

ude

test

s a

nd s

ervi

ces

desc

ribed

els

ewhe

re in

th

e S

BC

(ie

ultr

asou

nd)

Mat

erni

ty c

over

age

for

depe

nden

t chi

ldre

n is

onl

y co

vere

d in

the

case

of

com

plic

atio

ns

Chi

ldbi

rth

deliv

ery

prof

essi

onal

se

rvic

es

10

coi

nsur

ance

15

c

oins

uran

ce

40

coi

nsur

ance

Chi

ldbi

rth

deliv

ery

faci

lity

serv

ices

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

5 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

nee

d h

elp

re

cove

rin

g o

r h

ave

oth

er

spec

ial h

ealt

h n

eed

s

Hom

e he

alth

car

e 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

Lim

ited

to 1

00 v

isits

ye

ar

Reh

abili

tatio

n se

rvic

es

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Inpa

tient

lim

ited

to 3

0 da

ys (

up to

60

days

for

seve

re

head

or

spin

al c

ord

inju

ry)

yea

r O

utpa

tient

lim

ited

to

80 v

isits

ye

ar

Incl

udes

phy

sica

l the

rapy

occ

upat

iona

l the

rapy

and

sp

eech

ther

apy

serv

ices

Hab

ilita

tion

serv

ices

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Out

patie

nt n

euro

deve

lopm

enta

l the

rapy

is li

mite

d to

60

vis

its

year

N

euro

deve

lopm

enta

l the

rapy

is li

mite

d to

ser

vice

s fo

r in

divi

dual

s th

roug

h ag

e 17

In

clud

es p

hysi

cal t

hera

py o

ccup

atio

nal t

hera

py a

nd

spee

ch th

erap

y se

rvic

es

Ski

lled

nurs

ing

care

N

ot a

pplic

able

20

c

oins

uran

ce

20

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Li

mite

d to

90

inpa

tient

day

s y

ear

Dur

able

med

ical

eq

uipm

ent

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Hos

pice

ser

vice

s 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Res

pite

car

e is

lim

ited

to 1

4 da

ys

lifet

ime

If y

ou

r ch

ild n

eed

s d

enta

l o

r ey

e ca

re

Chi

ldre

ns

eye

exam

N

ot c

over

ed

Not

cov

ered

N

ot c

over

ed

Non

e

Chi

ldre

ns

glas

ses

Not

cov

ered

N

ot c

over

ed

Not

cov

ered

N

one

Chi

ldre

ns

dent

al

chec

k-up

N

ot c

over

ed

Not

cov

ered

N

ot c

over

ed

Non

e

6 o

f 7

Exc

lud

ed S

ervi

ces

amp O

ther

Co

vere

d S

ervi

ces

Ser

vice

s Y

ou

r P

lan

Gen

eral

ly D

oes

NO

T C

ove

r (C

hec

k yo

ur

po

licy

or

pla

n d

ocu

men

t fo

r m

ore

info

rmat

ion

an

d a

list

of

any

oth

er e

xclu

ded

ser

vice

s)

bull

Bar

iatr

ic s

urge

ry

bull

Cos

met

ic s

urge

ry e

xcep

t con

geni

tal a

nom

alie

s

bull

Den

tal c

are

(Adu

lt)

bull

Long

-ter

m c

are

bull

Non

-em

erge

ncy

care

whe

n tr

avel

ing

outs

ide

the

US

bull

Priv

ate-

duty

nur

sing

(ex

cept

as

prov

ided

for

hom

e he

alth

)

bull

Rou

tine

eye

care

(A

dult)

bull

Rou

tine

foot

car

e

bull

Wei

ght l

oss

prog

ram

s u

nles

s re

quire

d by

law

Oth

er C

ove

red

Ser

vice

s (L

imit

atio

ns

may

ap

ply

to

th

ese

serv

ices

T

his

isn

t a

com

ple

te li

st P

leas

e se

e yo

ur

pla

n d

ocu

men

t)

bull

Acu

punc

ture

bull

Chi

ropr

actic

car

e s

pina

l man

ipul

atio

ns o

nly

bull

Hab

ilita

tion

serv

ices

bull

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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Mat

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fits

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com

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Reg

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net

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and

Reg

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prov

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accu

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Gen

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ou m

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cost

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pla

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gins

to p

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her

fam

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all f

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pay

Are

th

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bef

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u m

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you

r d

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Yes

Cer

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care

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thos

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low

as

ded

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No

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u ha

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coin

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exam

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pla

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Are

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for

spec

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No

Y

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s fo

r sp

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Wh

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th

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pla

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000

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vidu

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(sin

gle

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cal

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Reg

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mily

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he o

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it am

ount

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r A

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prov

ider

s R

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prov

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limite

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cum

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mily

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cal

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Reg

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The

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yea

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r co

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If yo

u ha

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fam

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this

pla

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e ov

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Pre

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plan

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u pa

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Will

yo

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ss if

yo

u u

se a

n

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prov

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plan

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ch a

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Che

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get s

ervi

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Do

yo

u n

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You

can

see

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spec

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A

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paym

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bee

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Co

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Med

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Ser

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Wh

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Pay

Lim

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Net

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Out

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Cov

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Reg

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mite

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Pre

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imm

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prev

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Out

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prov

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mm

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Med

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Eve

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Ser

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s Y

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May

Nee

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Wh

at Y

ou

Will

Pay

Lim

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s E

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you

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Mor

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Med

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health

Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been

performed Surgery and reconstruction of the other breast as necessary to provide

a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event

For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)

Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075

Asante Health PlanAnnual Required Notices

To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)

Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others

The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits

toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020

The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger

The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks

1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen

2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program

If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA

If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts

The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower

Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year

Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health

If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status

The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor

Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment

Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs

In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately

You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate

If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995

Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not

discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender

Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio

accessible electronic formats and other formats) bull Asante provides free language services to people whose primary

language is not English including o Qualified interpreters o Information written in other languages

If you need these services contact Alicia Lorenz at the phone number or email address listed below

If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)

You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)

Complaint forms are available at hhsgovocrofficefileindexhtml

20HR011

This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020

Asante Health Plan changesPlan names  Asante Health Plan 1 is being

renamed Asante PPO Health Plan  Asante Health Plan 2 is being

renamed Asante Savings HealthPlan or HSA

  Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA

For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use

Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers

A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles  The deductibles for the new

Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family

Out-of-pocket maximums  There will no longer be separate

out-of-pocket maximums forprescription drug expenses

Rx expenses will be counted toward the medical out-of-pocket maximums

  The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family

Copay and coinsurance changes  The office visit copay for primary

care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)

  The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)

  The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50

Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles  The deductibles for the four

categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family

Out-of-pocket maximums  The out-of-pocket maximums for the

four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family

Copay and coinsurance changes  The office visit coinsurance for

primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)

The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)

  The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50

Health Savings Account  The HSA contribution limit has

increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage

Employer contributions to the HSA Asante contributes to your HSA

if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled

Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four

categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family

Out-of-pocket maximums There will no longer be separate

out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums

Whatrsquos new for 2020

The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family

Copay and coinsurance changes The office visit copay for primary

care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)

The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)

The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50

Employer contributions to the HRA Asante contributes to your HRA

account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents

Other changes In the Asante Reimbursement

Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations

In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers

Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan

(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)

Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit

All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet

All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply

A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible

Dental plan changes The Willamette Dental plan will have

a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year

There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan

Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits

Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012

Critical illness and accident plans Certain insurance policies are

available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505

Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information

This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025

All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services

We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization

How We May Use and Disclose Your Protected Health Information

Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories

For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use

For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments

For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes

To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us

As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws

Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it

The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage

This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System

The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees

What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage

If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen

1 Your hours of employment are reduced or

2 Your employment ends for any reason other than your gross misconduct

If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens

1 Your spouse dies

2 Your spousersquos hours of employment are reduced

3 Your spousersquos employment ends for any reason other than his or her gross misconduct

4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or

5 You become divorced or legally separated from your spouse

Continuation Coverage Rights Under Cobra

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens

1 The parent-employee dies

2 The parent-employeersquos hours of employment are reduced

3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct

4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)

5 The parents become divorced or legally separated or

6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo

Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan

When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event

You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to

Asante Health System

How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended

Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov

If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)

Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator

Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Updated 91418 ND

PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is

eligible for coverage please contact us so that we can provide them with this notice

Important Notice from Asante About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug

coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice

There are two important things you need to know about your current coverage and Medicarersquos

prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium

2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan

When Can You Join A Medicare Drug Plan

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th

However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan

You should also know that if you drop or lose your current coverage with Asante and donrsquot join a

Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later

Page 2

If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join

For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time

If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by

Medicare in the next 12 months this notice doesnrsquot apply to you

For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos

how to get more information about Medicare prescription drug plans

Visit wwwmedicaregov

Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048

For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)

Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)

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if y

ou u

se a

pro

vide

r in

th

e pl

ans

net

wor

k Y

ou w

ill p

ay th

e m

ost i

f you

use

an

out-

of-n

etw

ork

prov

ider

and

you

mig

ht r

ecei

ve a

bill

from

a p

rovi

der

for

the

diffe

renc

e be

twee

n th

e pr

ovid

ers

cha

rge

and

wha

t you

r pl

an p

ays

(bal

ance

bill

ing)

Be

awar

e y

our

netw

ork

prov

ider

mig

ht u

se a

n ou

t-of

-net

wor

k pr

ovid

er fo

r so

me

serv

ices

(su

ch a

s la

b w

ork)

Che

ck w

ith y

our

prov

ider

bef

ore

you

get s

ervi

ces

Do

yo

u n

eed

a r

efer

ral t

o s

ee a

sp

ecia

list

N

o

You

can

see

the

spec

ialis

t you

cho

ose

with

out a

ref

erra

l

A

ll co

paym

ent a

nd c

oins

uran

ce c

osts

sho

wn

in th

is c

hart

are

afte

r yo

ur d

educ

tible

has

bee

n m

et i

f a d

educ

tible

app

lies

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

vis

it a

hea

lth

car

e p

rovi

der

s o

ffic

e o

r cl

inic

Prim

ary

care

vis

it to

tr

eat a

n in

jury

or

illne

ss

$10

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

$1

0 co

pay

ret

ail

clin

ic v

isit

ded

uctib

le

does

not

app

ly

15

coi

nsur

ance

for

all o

ther

ser

vice

s

$25

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

$2

5 co

pay

ret

ail

clin

ic v

isit

ded

uctib

le

does

not

app

ly

15

coi

nsur

ance

for

all o

ther

ser

vice

s

Not

app

licab

le fo

r pr

imar

y ca

re v

isits

$7

5 co

pay

ret

ail

clin

ic v

isit

de

duct

ible

doe

s no

t app

ly

40

coi

nsur

ance

fo

r al

l oth

er

serv

ices

40

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

offic

e vi

sits

onl

y A

ll ot

her

serv

ices

that

ar

e no

t bill

ed a

s an

offi

ce v

isit

are

cove

red

at t

he

coin

sura

nce

spec

ified

afte

r de

duct

ible

Spe

cial

ist v

isit

$10

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

15

c

oins

uran

ce fo

r al

l oth

er s

ervi

ces

$25

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

15

c

oins

uran

ce fo

r al

l oth

er s

ervi

ces

$75

copa

y o

ffice

vi

sit

dedu

ctib

le

does

not

app

ly

40

coi

nsur

ance

fo

r al

l oth

er

serv

ices

Pre

vent

ive

care

scr

eeni

ng

imm

uniz

atio

n N

o ch

arge

N

o ch

arge

N

o ch

arge

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Y

ou m

ay h

ave

to p

ay fo

r se

rvic

es th

at a

ren

t pr

even

tive

Ask

you

r pr

ovid

er if

the

serv

ices

ne

eded

are

pre

vent

ive

The

n ch

eck

wha

t you

r pl

an w

ill p

ay fo

r S

ubje

ct to

pre

vent

ive

care

gu

idel

ines

3 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y

bloo

d w

ork)

15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Im

agin

g (C

TP

ET

sc

ans

MR

Is)

15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

cov

erag

e is

ava

ilabl

e at

re

genc

eco

mg

odr

uglis

t20

20O

R3

tier

Gen

eric

dru

gs

$5 c

opay

30

-day

re

tail

pres

crip

tion

$10

copa

y 9

0-da

y re

tail

pres

crip

tion

$15

copa

y r

etai

l pr

escr

iptio

n $2

0 co

pay

mai

l or

der

pres

crip

tion

Not

cov

ered

Ded

uctib

le d

oes

not a

pply

Li

mite

d to

a 3

0-da

y su

pply

ret

ail a

nd u

p to

90-

day

supp

ly a

t Asa

nte

Out

patie

nt P

harm

acie

s or

th

roug

h R

egen

ce m

ail o

rder

N

o ch

arge

for

FD

A-a

ppro

ved

wom

ens

co

ntra

cept

ives

and

cer

tain

pre

vent

ive

drug

s an

d im

mun

izat

ions

at a

par

ticip

atin

g ph

arm

acy

C

over

age

incl

udes

com

poun

d m

edic

atio

ns a

t 30

c

oins

uran

ce u

p to

$10

0 m

axim

um a

t A

sant

e O

utpa

tient

Pha

rmac

ies

and

40

co

insu

ranc

e up

to $

200

max

imum

at a

Reg

ence

pa

rtic

ipat

ing

reta

il ph

arm

acy

ref

er to

you

r pl

an

for

furt

her

info

rmat

ion

Mai

l-ord

er p

resc

riptio

ns

35

coi

nsur

ance

up

to $

120

max

imum

Out

-of-

netw

ork

pres

crip

tion

drug

cov

erag

e is

not

co

vere

d

You

are

res

pons

ible

for

the

diffe

renc

e in

cos

t be

twee

n a

disp

ense

d br

and-

nam

e dr

ug a

nd th

e eq

uiva

lent

gen

eric

dru

g in

add

ition

to th

e co

paym

ent a

ndo

r co

insu

ranc

e

The

firs

t fill

for

sele

ct s

peci

alty

dru

gs m

ay b

e pr

ovid

ed a

t a p

artic

ipat

ing

reta

il ph

arm

acy

ad

ditio

nal f

ills

mus

t be

prov

ided

at

Asa

nte

Out

patie

nt P

harm

acie

s F

or a

ll ot

her

spec

ialty

dr

ugs

the

first

fill

mus

t be

prov

ided

at A

sant

e O

utpa

tient

Pha

rmac

ies

If A

sant

e O

utpa

tient

P

harm

acie

s ar

e un

able

to fi

ll th

ey w

ill c

oord

inat

e a

fill t

hrou

gh a

Reg

ence

Spe

cial

ty P

harm

acy

P

leas

e re

fer

to m

y H

R fo

r a

list o

f med

icat

ions

th

at r

equi

re th

e fir

st fi

ll at

Asa

nte

Out

patie

nt

Pha

rmac

ies

Pre

ferr

ed b

rand

dru

gs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

crip

tion

35

coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

escr

iptio

n 35

c

oins

uran

ce u

p to

$12

0 m

axim

um

mai

l ord

er

pres

crip

tion

Not

cov

ered

Bra

nd d

rugs

30

coi

nsur

ance

up

to $

100

max

imum

30

-day

ret

ail

pres

crip

tion

30

coi

nsur

ance

up

to $

300

max

imum

90

-day

ret

ail

pres

crip

tion

40

coi

nsur

ance

up

to $

200

max

imum

re

tail

pres

crip

tion

40

coi

nsur

ance

up

to $

600

max

imum

m

ail o

rder

pr

escr

iptio

n

Not

cov

ered

Spe

cial

ty d

rugs

R

efer

to g

ener

ic

pref

erre

d br

and

and

bran

d dr

ugs

abov

e

Ref

er to

gen

eric

pr

efer

red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

4 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

sur

gery

ce

nter

) 15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Phy

sici

ans

urge

on

fees

15

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

If y

ou

nee

d im

med

iate

m

edic

al a

tten

tio

n

Em

erge

ncy

room

car

e $1

50 c

opay

vi

sit

dedu

ctib

le d

oes

not

appl

y

$150

cop

ay

visi

t de

duct

ible

doe

s no

t ap

ply

$150

cop

ay

visi

t de

duct

ible

doe

s no

t app

ly

$150

cop

ay

visi

t de

duct

ible

doe

s no

t app

ly fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

C

opay

men

t app

lies

to th

e fa

cilit

y ch

arge

for

each

vi

sit (

wai

ved

if ad

mitt

ed)

Em

erge

ncy

med

ical

tr

ansp

orta

tion

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

20

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Urg

ent c

are

$10

copa

y v

isit

de

duct

ible

doe

s no

t ap

ply

$25

copa

y v

isit

de

duct

ible

doe

s no

t ap

ply

$75

copa

y v

isit

de

duct

ible

doe

s no

t app

ly

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

offic

eur

gent

car

e vi

sit

If y

ou

hav

e a

ho

spit

al

stay

Fac

ility

fee

(eg

ho

spita

l roo

m)

15

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

Phy

sici

ans

urge

on

fees

15

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

If y

ou

nee

d m

enta

l hea

lth

b

ehav

iora

l hea

lth

or

sub

stan

ce a

bu

se

serv

ices

Out

patie

nt s

ervi

ces

$10

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

15

c

oins

uran

ce fo

r al

l oth

er s

ervi

ces

$25

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

15

c

oins

uran

ce fo

r pr

ofes

sion

al a

nd

30

coi

nsur

ance

for

faci

lity

$75

copa

y o

ffice

vi

sit

dedu

ctib

le

does

not

app

ly

40

coi

nsur

ance

fo

r al

l oth

er

serv

ices

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

outp

atie

nt o

ffice

psy

chot

hera

py v

isits

on

ly A

ll ot

her

outp

atie

nt s

ervi

ces

are

cove

red

at

the

coin

sura

nce

spec

ified

afte

r de

duct

ible

Inpa

tient

ser

vice

s 15

c

oins

uran

ce

15

coi

nsur

ance

for

prof

essi

onal

and

30

c

oins

uran

ce fo

r fa

cilit

y

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

5 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

are

pre

gn

ant

Offi

ce v

isits

15

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

ost s

harin

g do

es n

ot a

pply

to c

erta

in p

reve

ntiv

e se

rvic

es D

epen

ding

on

the

type

of s

ervi

ces

a

coin

sura

nce

or d

educ

tible

may

app

ly M

ater

nity

ca

re m

ay in

clud

e te

sts

and

serv

ices

des

crib

ed

else

whe

re in

the

SB

C (

ie u

ltras

ound

)

Mat

erni

ty c

over

age

for

depe

nden

t chi

ldre

n is

on

ly c

over

ed in

the

case

of c

ompl

icat

ions

Chi

ldbi

rth

deliv

ery

prof

essi

onal

ser

vice

s 15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

Chi

ldbi

rth

deliv

ery

faci

lity

serv

ices

15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

If y

ou

nee

d h

elp

re

cove

rin

g o

r h

ave

oth

er

spec

ial h

ealt

h n

eed

s

Hom

e he

alth

car

e 15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Li

mite

d to

100

vis

its

year

Reh

abili

tatio

n se

rvic

es

$10

copa

y

outp

atie

nt v

isit

de

duct

ible

doe

s no

t ap

ply

15

c

oins

uran

ce

inpa

tient

ser

vice

s

$25

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

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Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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coi

nsur

ance

fo

r al

l oth

er

serv

ices

Pre

vent

ive

care

scr

eeni

ng

imm

uniz

atio

n N

o ch

arge

N

o ch

arge

N

o ch

arge

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Y

ou m

ay h

ave

to p

ay fo

r se

rvic

es th

at a

ren

t pr

even

tive

Ask

you

r pr

ovid

er if

the

serv

ices

ne

eded

are

pre

vent

ive

The

n ch

eck

wha

t you

r pl

an w

ill p

ay fo

r S

ubje

ct to

pre

vent

ive

care

3 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

guid

elin

es

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y

bloo

d w

ork)

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Im

agin

g (C

TP

ET

sc

ans

MR

Is)

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

cov

erag

e

is a

vaila

ble

at

rege

nce

com

go

drug

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020

OR

3tie

r

Gen

eric

dru

gs

$5 c

opay

30

-day

re

tail

pres

crip

tion

$10

copa

y 9

0-da

y re

tail

pres

crip

tion

$15

copa

y r

etai

l pr

escr

iptio

n $2

0 co

pay

mai

l or

der

pres

crip

tion

Not

cov

ered

Ded

uctib

le d

oes

not a

pply

Li

mite

d to

a 3

0-da

y su

pply

ret

ail a

nd u

p to

90-

day

supp

ly a

t Asa

nte

Out

patie

nt P

harm

acie

s or

th

roug

h R

egen

ce m

ail o

rder

N

o ch

arge

for

FD

A-a

ppro

ved

wom

ens

co

ntra

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ives

and

cer

tain

pre

vent

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drug

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d im

mun

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ions

at a

par

ticip

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g ph

arm

acy

C

over

age

incl

udes

com

poun

d m

edic

atio

ns a

t 30

c

oins

uran

ce u

p to

$10

0 m

axim

um a

t A

sant

e O

utpa

tient

Pha

rmac

ies

and

40

co

insu

ranc

e up

to $

200

max

imum

at a

Reg

ence

pa

rtic

ipat

ing

reta

il ph

arm

acy

ref

er to

yo

ur p

lan

for

furt

her

info

rmat

ion

Mai

l-ord

er p

resc

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35

coi

nsur

ance

up

to $

120

max

imum

Out

-of-

netw

ork

pres

crip

tion

drug

cov

erag

e is

not

co

vere

d

You

are

res

pons

ible

for

the

diffe

renc

e in

cos

t be

twee

n a

disp

ense

d br

and-

nam

e dr

ug a

nd th

e eq

uiva

lent

gen

eric

dru

g in

add

ition

to th

e co

paym

ent a

ndo

r co

insu

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firs

t fill

for

sele

ct s

peci

alty

dru

gs m

ay b

e pr

ovid

ed a

t a p

artic

ipat

ing

reta

il ph

arm

acy

ad

ditio

nal f

ills

mus

t be

prov

ided

at A

sant

e O

utpa

tient

Pha

rmac

ies

For

all

othe

r sp

ecia

lty

drug

s th

e fir

st fi

ll m

ust b

e pr

ovid

ed a

t Asa

nte

Out

patie

nt P

harm

acie

s If

Asa

nte

Out

patie

nt

Pha

rmac

ies

are

una

ble

to fi

ll th

ey w

ill

coor

dina

te a

fill

thro

ugh

a R

egen

ce S

peci

alty

P

harm

acy

Ple

ase

refe

r to

my

HR

for

a lis

t of

med

icat

ions

that

req

uire

the

first

fill

at A

sant

e O

utpa

tient

Pha

rmac

ies

Pre

ferr

ed b

rand

dru

gs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

crip

tion

35

coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

escr

iptio

n 35

c

oins

uran

ce u

p to

$12

0 m

axim

um

mai

l ord

er

pres

crip

tion

Not

cov

ered

Bra

nd d

rugs

30

coi

nsur

ance

up

to $

100

max

imum

30

-day

ret

ail

pres

crip

tion

30

coi

nsur

ance

up

to $

300

max

imum

90

-day

ret

ail

pres

crip

tion

40

coi

nsur

ance

up

to $

200

max

imum

re

tail

pres

crip

tion

40

coi

nsur

ance

up

to $

600

max

imum

m

ail o

rder

pr

escr

iptio

n

Not

cov

ered

Spe

cial

ty d

rugs

R

efer

to g

ener

ic

pref

erre

d br

and

and

bran

d dr

ugs

abov

e

Ref

er to

gen

eric

pr

efer

red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

4 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

sur

gery

ce

nter

) 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Phy

sici

ans

urge

on fe

es

10

coi

nsur

ance

15

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

If y

ou

nee

d im

med

iate

m

edic

al a

tten

tio

n

Em

erge

ncy

room

car

e $1

50 c

opay

vi

sit

dedu

ctib

le d

oes

not

appl

y

$150

cop

ay

visi

t de

duct

ible

doe

s no

t ap

ply

$150

cop

ay

visi

t de

duct

ible

doe

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t app

ly

$150

cop

ay

visi

t de

duct

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doe

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t app

ly fo

r O

ut-o

f-ne

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k pr

ovid

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C

opay

men

t app

lies

to th

e fa

cilit

y ch

arge

for

each

vis

it (w

aive

d if

adm

itted

)

Em

erge

ncy

med

ical

tr

ansp

orta

tion

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

20

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Urg

ent c

are

$10

copa

y v

isit

de

duct

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doe

s no

t ap

ply

$25

copa

y v

isit

de

duct

ible

doe

s no

t ap

ply

$75

copa

y v

isit

de

duct

ible

doe

s no

t app

ly

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

offic

eur

gent

car

e vi

sit

If y

ou

hav

e a

ho

spit

al

stay

Fac

ility

fee

(eg

ho

spita

l roo

m)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

Phy

sici

ans

urge

on fe

es

10

coi

nsur

ance

15

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

If y

ou

nee

d m

enta

l h

ealt

h b

ehav

iora

l hea

lth

o

r su

bst

ance

ab

use

se

rvic

es

Out

patie

nt s

ervi

ces

$10

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

10

c

oins

uran

ce fo

r al

l oth

er s

ervi

ces

$25

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

15

c

oins

uran

ce fo

r pr

ofes

sion

al a

nd

30

coi

nsur

ance

for

faci

lity

$75

copa

y o

ffice

vi

sit

dedu

ctib

le

does

not

app

ly

40

coi

nsur

ance

fo

r al

l oth

er

serv

ices

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

outp

atie

nt o

ffice

psy

chot

hera

py v

isits

on

ly A

ll ot

her

outp

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nt s

ervi

ces

are

cove

red

at

the

coin

sura

nce

spec

ified

afte

r de

duct

ible

Inpa

tient

ser

vice

s 10

c

oins

uran

ce

15

coi

nsur

ance

for

prof

essi

onal

and

30

c

oins

uran

ce fo

r fa

cilit

y

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

5 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

are

pre

gn

ant

Offi

ce v

isits

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

ost s

harin

g do

es n

ot a

pply

to c

erta

in

prev

entiv

e se

rvic

es D

epen

ding

on

the

type

of

serv

ices

a c

oins

uran

ce o

r de

duct

ible

may

ap

ply

Mat

erni

ty c

are

may

incl

ude

test

s an

d se

rvic

es d

escr

ibed

els

ewhe

re in

the

SB

C (

ie

ultr

asou

nd)

M

ater

nity

cov

erag

e fo

r de

pend

ent c

hild

ren

is

only

cov

ered

in th

e ca

se o

f com

plic

atio

ns

Chi

ldbi

rth

deliv

ery

prof

essi

onal

ser

vice

s 10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

Chi

ldbi

rth

deliv

ery

faci

lity

serv

ices

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

If y

ou

nee

d h

elp

re

cove

rin

g o

r h

ave

oth

er

spec

ial h

ealt

h n

eed

s

Hom

e he

alth

car

e 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

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ork

prov

ider

s af

ter

dedu

ctib

le

Lim

ited

to 1

00 v

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ye

ar

Reh

abili

tatio

n se

rvic

es

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copa

y

outp

atie

nt v

isit

de

duct

ible

doe

s no

t ap

ply

10

c

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uran

ce

inpa

tient

ser

vice

s

$25

copa

y

outp

atie

nt v

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de

duct

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doe

s no

t ap

ply

30

c

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ce

inpa

tient

ser

vice

s

$75

copa

y

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de

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s no

t app

ly

40

coi

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ance

in

patie

nt s

ervi

ces

50

coi

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for

Out

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prov

ider

s

afte

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opay

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t app

lies

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ach

Asa

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ork

Reg

ence

lim

ited

netw

ork

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atie

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isit

only

Inp

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nt s

ervi

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are

cove

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at th

e co

insu

ranc

e sp

ecifi

ed a

fter

dedu

ctib

le

Inpa

tient

lim

ited

to 3

0 da

ys (

up to

60

days

for

seve

re h

ead

or s

pina

l cor

d in

jury

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ear

O

utpa

tient

lim

ited

to 8

0 vi

sits

ye

ar

Incl

udes

phy

sica

l the

rapy

occ

upat

iona

l the

rapy

an

d sp

eech

ther

apy

serv

ices

Hab

ilita

tion

serv

ices

$10

copa

y

outp

atie

nt v

isit

de

duct

ible

doe

s no

t ap

ply

10

c

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uran

ce

inpa

tient

ser

vice

s

$25

copa

y

outp

atie

nt v

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de

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t ap

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30

c

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uran

ce

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tient

ser

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s

$75

copa

y

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de

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s no

t app

ly

40

coi

nsur

ance

in

patie

nt s

ervi

ces

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

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opay

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t app

lies

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ach

Asa

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ork

Reg

ence

lim

ited

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ork

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only

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nt s

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cove

red

at th

e co

insu

ranc

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ecifi

ed a

fter

dedu

ctib

le

Out

patie

nt n

euro

deve

lopm

enta

l the

rapy

is

limite

d to

60

visi

ts

year

N

euro

deve

lopm

enta

l the

rapy

is li

mite

d to

se

rvic

es fo

r in

divi

dual

s th

roug

h ag

e 17

6 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

Incl

udes

phy

sica

l the

rapy

occ

upat

iona

l the

rapy

an

d sp

eech

ther

apy

serv

ices

Ski

lled

nurs

ing

care

N

ot a

pplic

able

20

c

oins

uran

ce

20

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

Lim

ited

to 9

0 in

patie

nt d

ays

yea

r

Dur

able

med

ical

eq

uipm

ent

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

50

coi

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ompa

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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yo

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spec

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Med

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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ovid

er fo

r so

me

serv

ices

(su

ch a

s la

b w

ork)

Che

ck w

ith y

our

prov

ider

bef

ore

you

get s

ervi

ces

Do

yo

u n

eed

a r

efer

ral t

o s

ee

a sp

ecia

list

N

o

You

can

see

the

spec

ialis

t you

cho

ose

with

out a

ref

erra

l

A

ll co

paym

ent a

nd c

oins

uran

ce c

osts

sho

wn

in th

is c

hart

are

afte

r yo

ur d

educ

tible

has

bee

n m

et i

f a d

educ

tible

app

lies

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

vis

it a

hea

lth

car

e p

rovi

der

s o

ffic

e o

r cl

inic

Prim

ary

care

vis

it to

trea

t an

inju

ry o

r ill

ness

10

c

oins

uran

ce

15

coi

nsur

ance

Not

app

licab

le fo

r pr

imar

y ca

re v

isits

40

c

oins

uran

ce

reta

il cl

inic

vis

it

40

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Cov

erag

e in

clud

es p

rimar

y ca

re v

isits

at a

ret

ail c

linic

C

over

age

for

acup

unct

ure

and

chiro

prac

tic s

pina

l m

anip

ulat

ions

is s

ubje

ct to

20

coi

nsur

ance

for

Reg

ence

net

wor

kR

egen

ce li

mite

d ne

twor

k pr

ovid

ers

and

40

coi

nsur

ance

for

out-

of-n

etw

ork

prov

ider

s

Lim

ited

to $

200

0 y

ear

for

acup

unct

ure

and

$20

00

year

for

spin

al m

anip

ulat

ions

C

oins

uran

ce a

pplie

s to

the

out-

of-p

ocke

t lim

it

Spe

cial

ist v

isit

10

coi

nsur

ance

15

c

oins

uran

ce

40

coi

nsur

ance

Pre

vent

ive

care

scr

eeni

ng

imm

uniz

atio

n N

o ch

arge

N

o ch

arge

N

o ch

arge

You

may

hav

e to

pay

for

serv

ices

that

are

nt

prev

entiv

e A

sk y

our

prov

ider

if th

e se

rvic

es n

eede

d ar

e pr

even

tive

The

n ch

eck

wha

t you

r pl

an w

ill p

ay fo

r

Sub

ject

to p

reve

ntiv

e ca

re g

uide

lines

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y b

lood

wor

k)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Imag

ing

(CT

PE

T

scan

s M

RIs

)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

3 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

cov

erag

e

is a

vaila

ble

at

rege

nce

com

go

drug

list2

020

OR

3tie

r

Gen

eric

dru

gs

$5 c

opay

30

-day

re

tail

pres

crip

tion

$10

copa

y 9

0-da

y re

tail

pres

crip

tion

$15

copa

y r

etai

l pr

escr

iptio

n $2

0 co

pay

mai

l or

der

pres

crip

tion

Not

cov

ered

Ded

uctib

le d

oes

not a

pply

for

drug

s sp

ecifi

cally

de

sign

ated

as

prev

entiv

e fo

r tr

eatm

ent o

f chr

onic

di

seas

es th

at a

re o

n th

e O

ptim

um V

alue

Med

icat

ion

List

C

over

age

is li

mite

d to

a 3

0-da

y su

pply

ret

ail a

nd u

p to

90

-day

sup

ply

at A

sant

e O

utpa

tient

Pha

rmac

ies

or

thro

ugh

Reg

ence

mai

l ord

er

No

char

ge fo

r F

DA

-app

rove

d w

omen

s c

ontr

acep

tives

an

d ce

rtai

n pr

even

tive

drug

s an

d im

mun

izat

ions

at a

pa

rtic

ipat

ing

phar

mac

y

Cov

erag

e in

clud

es c

ompo

und

med

icat

ions

at 3

0

coin

sura

nce

up to

$10

0 m

axim

um a

t Asa

nte

Out

patie

nt P

harm

acie

s an

d 40

c

oins

uran

ce u

p to

$2

00 m

axim

um a

t a R

egen

ce p

artic

ipat

ing

reta

il ph

arm

acy

ref

er to

you

r pl

an fo

r fu

rthe

r in

form

atio

n

Mai

l-ord

er p

resc

riptio

ns 3

5 c

oins

uran

ce u

p to

$12

0 m

axim

um O

ut-o

f-ne

twor

k pr

escr

iptio

n dr

ug c

over

age

is n

ot c

over

ed

You

are

res

pons

ible

for

the

diffe

renc

e in

cos

t bet

wee

n a

disp

ense

d br

and-

nam

e dr

ug a

nd th

e eq

uiva

lent

ge

neric

dru

g in

add

ition

to th

e co

paym

ent a

ndo

r co

insu

ranc

e T

he c

ost d

iffer

entia

l bet

wee

n ge

neric

an

d br

and-

nam

e dr

ugs

accr

ues

tow

ard

the

dedu

ctib

le

and

out-

of-p

ocke

t lim

it

The

firs

t fill

for

sele

ct s

peci

alty

dru

gs m

ay b

e pr

ovid

ed

at a

par

ticip

atin

g re

tail

phar

mac

y a

dditi

onal

fills

mus

t be

pro

vide

d at

Asa

nte

Out

patie

nt P

harm

acie

s F

or a

ll ot

her

spec

ialty

dru

gs t

he fi

rst f

ill m

ust b

e pr

ovid

ed a

t A

sant

e O

utpa

tient

Pha

rmac

ies

If A

sant

e O

utpa

tient

P

harm

acie

s ar

e un

able

to fi

ll th

ey w

ill c

oord

inat

e a

fill

thro

ugh

a R

egen

ce S

peci

alty

Pha

rmac

y P

leas

e re

fer

to m

y H

R fo

r a

list o

f med

icat

ions

that

req

uire

the

first

fil

l at A

sant

e O

utpa

tient

Pha

rmac

ies

Pre

ferr

ed b

rand

dr

ugs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

crip

tion

35

coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

escr

iptio

n 35

c

oins

uran

ce u

p to

$12

0 m

axim

um

mai

l ord

er

pres

crip

tion

Not

cov

ered

Bra

nd d

rugs

30

coi

nsur

ance

up

to $

100

max

imum

30

-day

ret

ail

pres

crip

tion

30

coi

nsur

ance

up

to $

300

max

imum

90

-day

ret

ail

pres

crip

tion

40

coi

nsur

ance

up

to $

200

max

imum

re

tail

pres

crip

tion

40

coi

nsur

ance

up

to $

600

max

imum

m

ail o

rder

pr

escr

iptio

n

Not

cov

ered

Spe

cial

ty d

rugs

R

efer

to g

ener

ic

pref

erre

d br

and

and

bran

d dr

ugs

abo

ve

Ref

er to

gen

eric

pr

efer

red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

4 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

surg

ery

cent

er)

Phy

sici

ans

urge

on

fees

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

If y

ou

nee

d im

med

iate

m

edic

al a

tten

tio

n

Em

erge

ncy

room

ca

re

15

coi

nsur

ance

15

c

oins

uran

ce

15

coi

nsur

ance

15

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Em

erge

ncy

med

ical

tr

ansp

orta

tion

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

20

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Urg

ent c

are

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

If y

ou

hav

e a

ho

spit

al

stay

Fac

ility

fee

(eg

ho

spita

l roo

m)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Phy

sici

ans

urge

on

fees

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

If y

ou

nee

d m

enta

l h

ealt

h b

ehav

iora

l hea

lth

o

r su

bst

ance

ab

use

se

rvic

es

Out

patie

nt

serv

ices

10

coi

nsur

ance

of

fice

visi

t 10

c

oins

uran

ce fo

r al

l oth

er s

ervi

ces

15

coi

nsur

ance

for

prof

essi

onal

and

30

c

oins

uran

ce fo

r fa

cilit

y

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Inpa

tient

ser

vice

s 10

c

oins

uran

ce

15

coi

nsur

ance

for

prof

essi

onal

and

30

c

oins

uran

ce fo

r fa

cilit

y

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

If y

ou

are

pre

gn

ant

Offi

ce v

isits

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Cos

t sha

ring

does

not

app

ly to

cer

tain

pre

vent

ive

serv

ices

Dep

endi

ng o

n th

e ty

pe o

f ser

vice

s a

co

insu

ranc

e or

ded

uctib

le m

ay a

pply

Mat

erni

ty c

are

may

incl

ude

test

s an

d se

rvic

es d

escr

ibed

els

ewhe

re in

th

e S

BC

(ie

ultr

asou

nd)

Mat

erni

ty c

over

age

for

depe

nden

t chi

ldre

n is

onl

y co

vere

d in

the

case

of

com

plic

atio

ns

Chi

ldbi

rth

deliv

ery

prof

essi

onal

se

rvic

es

10

coi

nsur

ance

15

c

oins

uran

ce

40

coi

nsur

ance

Chi

ldbi

rth

deliv

ery

faci

lity

serv

ices

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

5 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

nee

d h

elp

re

cove

rin

g o

r h

ave

oth

er

spec

ial h

ealt

h n

eed

s

Hom

e he

alth

car

e 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

Lim

ited

to 1

00 v

isits

ye

ar

Reh

abili

tatio

n se

rvic

es

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Inpa

tient

lim

ited

to 3

0 da

ys (

up to

60

days

for

seve

re

head

or

spin

al c

ord

inju

ry)

yea

r O

utpa

tient

lim

ited

to

80 v

isits

ye

ar

Incl

udes

phy

sica

l the

rapy

occ

upat

iona

l the

rapy

and

sp

eech

ther

apy

serv

ices

Hab

ilita

tion

serv

ices

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Out

patie

nt n

euro

deve

lopm

enta

l the

rapy

is li

mite

d to

60

vis

its

year

N

euro

deve

lopm

enta

l the

rapy

is li

mite

d to

ser

vice

s fo

r in

divi

dual

s th

roug

h ag

e 17

In

clud

es p

hysi

cal t

hera

py o

ccup

atio

nal t

hera

py a

nd

spee

ch th

erap

y se

rvic

es

Ski

lled

nurs

ing

care

N

ot a

pplic

able

20

c

oins

uran

ce

20

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Li

mite

d to

90

inpa

tient

day

s y

ear

Dur

able

med

ical

eq

uipm

ent

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Hos

pice

ser

vice

s 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Res

pite

car

e is

lim

ited

to 1

4 da

ys

lifet

ime

If y

ou

r ch

ild n

eed

s d

enta

l o

r ey

e ca

re

Chi

ldre

ns

eye

exam

N

ot c

over

ed

Not

cov

ered

N

ot c

over

ed

Non

e

Chi

ldre

ns

glas

ses

Not

cov

ered

N

ot c

over

ed

Not

cov

ered

N

one

Chi

ldre

ns

dent

al

chec

k-up

N

ot c

over

ed

Not

cov

ered

N

ot c

over

ed

Non

e

6 o

f 7

Exc

lud

ed S

ervi

ces

amp O

ther

Co

vere

d S

ervi

ces

Ser

vice

s Y

ou

r P

lan

Gen

eral

ly D

oes

NO

T C

ove

r (C

hec

k yo

ur

po

licy

or

pla

n d

ocu

men

t fo

r m

ore

info

rmat

ion

an

d a

list

of

any

oth

er e

xclu

ded

ser

vice

s)

bull

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health

Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been

performed Surgery and reconstruction of the other breast as necessary to provide

a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event

For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)

Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075

Asante Health PlanAnnual Required Notices

To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)

Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others

The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits

toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020

The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger

The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks

1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen

2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program

If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA

If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts

The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower

Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year

Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health

If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status

The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor

Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment

Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs

In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately

You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate

If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995

Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not

discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender

Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio

accessible electronic formats and other formats) bull Asante provides free language services to people whose primary

language is not English including o Qualified interpreters o Information written in other languages

If you need these services contact Alicia Lorenz at the phone number or email address listed below

If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)

You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)

Complaint forms are available at hhsgovocrofficefileindexhtml

20HR011

This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020

Asante Health Plan changesPlan names  Asante Health Plan 1 is being

renamed Asante PPO Health Plan  Asante Health Plan 2 is being

renamed Asante Savings HealthPlan or HSA

  Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA

For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use

Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers

A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles  The deductibles for the new

Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family

Out-of-pocket maximums  There will no longer be separate

out-of-pocket maximums forprescription drug expenses

Rx expenses will be counted toward the medical out-of-pocket maximums

  The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family

Copay and coinsurance changes  The office visit copay for primary

care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)

  The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)

  The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50

Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles  The deductibles for the four

categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family

Out-of-pocket maximums  The out-of-pocket maximums for the

four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family

Copay and coinsurance changes  The office visit coinsurance for

primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)

The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)

  The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50

Health Savings Account  The HSA contribution limit has

increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage

Employer contributions to the HSA Asante contributes to your HSA

if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled

Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four

categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family

Out-of-pocket maximums There will no longer be separate

out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums

Whatrsquos new for 2020

The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family

Copay and coinsurance changes The office visit copay for primary

care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)

The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)

The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50

Employer contributions to the HRA Asante contributes to your HRA

account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents

Other changes In the Asante Reimbursement

Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations

In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers

Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan

(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)

Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit

All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet

All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply

A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible

Dental plan changes The Willamette Dental plan will have

a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year

There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan

Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits

Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012

Critical illness and accident plans Certain insurance policies are

available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505

Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information

This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025

All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services

We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization

How We May Use and Disclose Your Protected Health Information

Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories

For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use

For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments

For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes

To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us

As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws

Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it

The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage

This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System

The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees

What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage

If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen

1 Your hours of employment are reduced or

2 Your employment ends for any reason other than your gross misconduct

If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens

1 Your spouse dies

2 Your spousersquos hours of employment are reduced

3 Your spousersquos employment ends for any reason other than his or her gross misconduct

4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or

5 You become divorced or legally separated from your spouse

Continuation Coverage Rights Under Cobra

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens

1 The parent-employee dies

2 The parent-employeersquos hours of employment are reduced

3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct

4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)

5 The parents become divorced or legally separated or

6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo

Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan

When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event

You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to

Asante Health System

How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended

Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov

If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)

Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator

Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Updated 91418 ND

PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is

eligible for coverage please contact us so that we can provide them with this notice

Important Notice from Asante About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug

coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice

There are two important things you need to know about your current coverage and Medicarersquos

prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium

2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan

When Can You Join A Medicare Drug Plan

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th

However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan

You should also know that if you drop or lose your current coverage with Asante and donrsquot join a

Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later

Page 2

If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join

For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time

If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by

Medicare in the next 12 months this notice doesnrsquot apply to you

For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos

how to get more information about Medicare prescription drug plans

Visit wwwmedicaregov

Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048

For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)

Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)

2 o

f 8

Will

yo

u p

ay le

ss if

yo

u u

se a

n

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ork

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vid

er

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ence

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go

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Pre

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all 1

(88

8) 3

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t of n

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ork

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Ask

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3 o

f 8

Co

mm

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Med

ical

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May

Nee

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Wh

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ou

Will

Pay

Lim

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xcep

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Imp

ort

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Asa

nte

Pre

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rk P

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pay

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Net

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Dia

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ork)

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netw

ork

prov

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r de

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g (C

TP

ET

sc

ans

MR

Is)

15

c

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coi

nsur

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c

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uran

ce

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

cov

erag

e is

ava

ilabl

e at

re

genc

eco

mg

odr

uglis

t20

20O

R3

tier

Gen

eric

dru

gs

$5 c

opay

30

-day

re

tail

pres

crip

tion

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copa

y 9

0-da

y re

tail

pres

crip

tion

$15

copa

y r

etai

l pr

escr

iptio

n $2

0 co

pay

mai

l or

der

pres

crip

tion

Not

cov

ered

Ded

uctib

le d

oes

not a

pply

Li

mite

d to

a 3

0-da

y su

pply

ret

ail a

nd u

p to

90-

day

supp

ly a

t Asa

nte

Out

patie

nt P

harm

acie

s or

th

roug

h R

egen

ce m

ail o

rder

N

o ch

arge

for

FD

A-a

ppro

ved

wom

ens

co

ntra

cept

ives

and

cer

tain

pre

vent

ive

drug

s an

d im

mun

izat

ions

at a

par

ticip

atin

g ph

arm

acy

C

over

age

incl

udes

com

poun

d m

edic

atio

ns a

t 30

c

oins

uran

ce u

p to

$10

0 m

axim

um a

t A

sant

e O

utpa

tient

Pha

rmac

ies

and

40

co

insu

ranc

e up

to $

200

max

imum

at a

Reg

ence

pa

rtic

ipat

ing

reta

il ph

arm

acy

ref

er to

you

r pl

an

for

furt

her

info

rmat

ion

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l-ord

er p

resc

riptio

ns

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coi

nsur

ance

up

to $

120

max

imum

Out

-of-

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ork

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crip

tion

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erag

e is

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vere

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You

are

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pons

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for

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cos

t be

twee

n a

disp

ense

d br

and-

nam

e dr

ug a

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e eq

uiva

lent

gen

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dru

g in

add

ition

to th

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paym

ent a

ndo

r co

insu

ranc

e

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firs

t fill

for

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ct s

peci

alty

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gs m

ay b

e pr

ovid

ed a

t a p

artic

ipat

ing

reta

il ph

arm

acy

ad

ditio

nal f

ills

mus

t be

prov

ided

at

Asa

nte

Out

patie

nt P

harm

acie

s F

or a

ll ot

her

spec

ialty

dr

ugs

the

first

fill

mus

t be

prov

ided

at A

sant

e O

utpa

tient

Pha

rmac

ies

If A

sant

e O

utpa

tient

P

harm

acie

s ar

e un

able

to fi

ll th

ey w

ill c

oord

inat

e a

fill t

hrou

gh a

Reg

ence

Spe

cial

ty P

harm

acy

P

leas

e re

fer

to m

y H

R fo

r a

list o

f med

icat

ions

th

at r

equi

re th

e fir

st fi

ll at

Asa

nte

Out

patie

nt

Pha

rmac

ies

Pre

ferr

ed b

rand

dru

gs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

crip

tion

35

coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

escr

iptio

n 35

c

oins

uran

ce u

p to

$12

0 m

axim

um

mai

l ord

er

pres

crip

tion

Not

cov

ered

Bra

nd d

rugs

30

coi

nsur

ance

up

to $

100

max

imum

30

-day

ret

ail

pres

crip

tion

30

coi

nsur

ance

up

to $

300

max

imum

90

-day

ret

ail

pres

crip

tion

40

coi

nsur

ance

up

to $

200

max

imum

re

tail

pres

crip

tion

40

coi

nsur

ance

up

to $

600

max

imum

m

ail o

rder

pr

escr

iptio

n

Not

cov

ered

Spe

cial

ty d

rugs

R

efer

to g

ener

ic

pref

erre

d br

and

and

bran

d dr

ugs

abov

e

Ref

er to

gen

eric

pr

efer

red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

4 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

sur

gery

ce

nter

) 15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Phy

sici

ans

urge

on

fees

15

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

If y

ou

nee

d im

med

iate

m

edic

al a

tten

tio

n

Em

erge

ncy

room

car

e $1

50 c

opay

vi

sit

dedu

ctib

le d

oes

not

appl

y

$150

cop

ay

visi

t de

duct

ible

doe

s no

t ap

ply

$150

cop

ay

visi

t de

duct

ible

doe

s no

t app

ly

$150

cop

ay

visi

t de

duct

ible

doe

s no

t app

ly fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

C

opay

men

t app

lies

to th

e fa

cilit

y ch

arge

for

each

vi

sit (

wai

ved

if ad

mitt

ed)

Em

erge

ncy

med

ical

tr

ansp

orta

tion

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

20

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Urg

ent c

are

$10

copa

y v

isit

de

duct

ible

doe

s no

t ap

ply

$25

copa

y v

isit

de

duct

ible

doe

s no

t ap

ply

$75

copa

y v

isit

de

duct

ible

doe

s no

t app

ly

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

offic

eur

gent

car

e vi

sit

If y

ou

hav

e a

ho

spit

al

stay

Fac

ility

fee

(eg

ho

spita

l roo

m)

15

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

Phy

sici

ans

urge

on

fees

15

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

If y

ou

nee

d m

enta

l hea

lth

b

ehav

iora

l hea

lth

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ce)

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excl

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ser

vice

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plan

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this

info

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to c

ompa

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e po

rtio

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co

sts

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mig

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ay u

nder

diff

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over

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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bee

n m

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f a d

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lies

Co

mm

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Med

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Eve

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Ser

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s Y

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May

Nee

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Wh

at Y

ou

Will

Pay

Lim

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Pre

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Prim

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it to

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eat a

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ss

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sit

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oes

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pay

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ail

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ly

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for

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vice

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ffice

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sit

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ded

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does

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ly

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nsur

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for

all o

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ser

vice

s

Not

app

licab

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r pr

imar

y ca

re v

isits

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pay

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ail

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s no

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40

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nsur

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r al

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Out

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ider

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afte

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C

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fter

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Cov

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ovid

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d 50

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r ou

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mite

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r fo

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d $2

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ar fo

r sp

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app

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to th

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sit

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ly

40

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fo

r al

l oth

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serv

ices

Pre

vent

ive

care

scr

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ng

imm

uniz

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o ch

arge

N

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N

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arge

50

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nsur

ance

for

Out

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ork

prov

ider

s

afte

r de

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Y

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ay h

ave

to p

ay fo

r se

rvic

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at a

ren

t pr

even

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Ask

you

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n ch

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wha

t you

r pl

an w

ill p

ay fo

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vent

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care

3 o

f 8

Co

mm

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Med

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Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

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rmat

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nte

Pre

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Net

wo

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rovi

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wo

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Pro

vid

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es

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ou

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e a

test

Dia

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st (

x-ra

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ork)

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40

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for

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s

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Im

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g (C

TP

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ans

MR

Is)

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If y

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nee

d d

rug

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tre

at

you

r ill

nes

s o

r co

nd

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n

Mor

e in

form

atio

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out

pres

crip

tion

drug

cov

erag

e

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vaila

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at

rege

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Gen

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tail

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tail

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copa

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etai

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escr

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0 co

pay

mai

l or

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pres

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Not

cov

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Ded

uctib

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oes

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pply

Li

mite

d to

a 3

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y su

pply

ret

ail a

nd u

p to

90-

day

supp

ly a

t Asa

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Out

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ail o

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C

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edic

atio

ns a

t 30

c

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p to

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0 m

axim

um a

t A

sant

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tient

Pha

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and

40

co

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at a

Reg

ence

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rtic

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il ph

arm

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yo

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lan

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furt

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to $

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max

imum

Out

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ork

pres

crip

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drug

cov

erag

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not

co

vere

d

You

are

res

pons

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for

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diffe

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cos

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twee

n a

disp

ense

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and-

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e dr

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ay b

e pr

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t a p

artic

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arm

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ad

ditio

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ills

mus

t be

prov

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at A

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e O

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tient

Pha

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For

all

othe

r sp

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lty

drug

s th

e fir

st fi

ll m

ust b

e pr

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t Asa

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Asa

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ey w

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fill

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peci

alty

P

harm

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Ple

ase

refe

r to

my

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for

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t of

med

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first

fill

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sant

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tient

Pha

rmac

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Pre

ferr

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rand

dru

gs

25

coi

nsur

ance

up

to $

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um

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ay r

etai

l pr

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n 25

c

oins

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ce u

p to

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max

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ail

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ance

up

to $

60 m

axim

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il pr

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l ord

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rugs

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to $

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imum

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ail

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coi

nsur

ance

up

to $

300

max

imum

90

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up

to $

200

max

imum

re

tail

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coi

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to $

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imum

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ail o

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pr

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Spe

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d br

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drug

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ed

4 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

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ion

Asa

nte

Pre

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Net

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rovi

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will

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ast)

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ence

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Pro

vid

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sici

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ter

dedu

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If y

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med

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tten

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n

Em

erge

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car

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opay

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sit

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20

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Urg

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copa

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Reg

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lim

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sit

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hav

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ho

spit

al

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30

c

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ce

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50

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af

ter

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sici

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urge

on fe

es

10

coi

nsur

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15

c

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40

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50

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af

ter

dedu

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If y

ou

nee

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l h

ealt

h b

ehav

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r su

bst

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use

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patie

nt s

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y o

ffice

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Inpa

tient

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for

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r fa

cilit

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40

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50

c

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ce fo

r O

ut-o

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af

ter

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5 o

f 8

Co

mm

on

Med

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Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

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s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

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rmat

ion

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nte

Pre

ferr

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Net

wo

rk P

rovi

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(Y

ou

will

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ast)

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ence

Net

wo

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Pro

vid

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u w

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ence

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u w

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Offi

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type

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ap

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erni

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d se

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e ca

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15

coi

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40

c

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Chi

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deliv

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faci

lity

serv

ices

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nsur

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40

c

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ou

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elp

re

cove

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g o

r h

ave

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h n

eed

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e he

alth

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

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You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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Med

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Offi

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Out

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Chi

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Co

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Med

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Eve

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Ser

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Wh

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Pre

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Hom

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pla

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actu

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you

rece

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our

prov

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ount

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educ

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s c

opay

men

ts a

nd c

oins

uran

ce)

and

excl

uded

ser

vice

s un

der

the

plan

Use

this

info

rmat

ion

to c

ompa

re th

e po

rtio

n of

co

sts

you

mig

ht p

ay u

nder

diff

ere

nt h

ealth

pla

ns P

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te th

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cove

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mpl

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re b

ased

on

self-

only

cov

erag

e

NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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pla

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cer

tain

pre

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out c

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shar

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befo

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list

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th

ere

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er d

edu

ctib

les

for

spec

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ser

vice

s

No

Y

ou d

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have

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eet d

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s fo

r sp

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Wh

at is

th

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ut-

of-

po

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lim

it

for

this

pla

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Asa

nte

pref

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d ne

twor

k pr

ovid

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$2

000

indi

vidu

al

(sin

gle

cove

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) $

300

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mily

per

cal

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ar

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k pr

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sing

le

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mily

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cal

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r ye

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limite

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k pr

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000

indi

vidu

al (

sing

le

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) $

120

00 fa

mily

per

cal

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he o

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it am

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r A

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ider

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limite

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cros

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cum

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pay

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yea

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nd h

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plan

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yo

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expe

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Will

yo

u p

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yo

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n

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ch a

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Che

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prov

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bef

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you

get s

ervi

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Do

yo

u n

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N

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You

can

see

the

spec

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with

out a

ref

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l

A

ll co

paym

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nd c

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are

afte

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tible

has

bee

n m

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f a d

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app

lies

Co

mm

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Med

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Eve

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Ser

vice

s Y

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May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

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xcep

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amp O

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Imp

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Pre

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Net

wo

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rovi

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u w

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Reg

ence

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wo

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Pro

vid

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u w

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Reg

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Lim

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N

etw

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vid

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(Yo

u w

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mo

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If y

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vis

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hea

lth

car

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rovi

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Prim

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care

vis

it to

trea

t an

inju

ry o

r ill

ness

10

c

oins

uran

ce

15

coi

nsur

ance

Not

app

licab

le fo

r pr

imar

y ca

re v

isits

40

c

oins

uran

ce

reta

il cl

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vis

it

40

coi

nsur

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for

Out

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netw

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prov

ider

s

Cov

erag

e in

clud

es p

rimar

y ca

re v

isits

at a

ret

ail c

linic

C

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age

for

acup

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and

chiro

prac

tic s

pina

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ulat

ions

is s

ubje

ct to

20

coi

nsur

ance

for

Reg

ence

net

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kR

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ce li

mite

d ne

twor

k pr

ovid

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and

40

coi

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for

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of-n

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prov

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s

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to $

200

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ear

for

acup

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and

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for

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of-p

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it

Spe

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c

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40

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Pre

vent

ive

care

scr

eeni

ng

imm

uniz

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n N

o ch

arge

N

o ch

arge

N

o ch

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You

may

hav

e to

pay

for

serv

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that

are

nt

prev

entiv

e A

sk y

our

prov

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if th

e se

rvic

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eede

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n ch

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wha

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ou

hav

e a

test

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gnos

tic te

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x-ra

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coi

nsur

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30

c

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40

coi

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coi

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for

Out

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prov

ider

s

Imag

ing

(CT

PE

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scan

s M

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)

10

coi

nsur

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30

c

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ce

40

coi

nsur

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3 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

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rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

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n

Mor

e in

form

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n ab

out

pres

crip

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drug

cov

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vaila

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at

rege

nce

com

go

drug

list2

020

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Gen

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cov

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Ded

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for

drug

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sign

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n th

e O

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mac

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Cov

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med

icat

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at 3

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coin

sura

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up to

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um a

t Asa

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Out

patie

nt P

harm

acie

s an

d 40

c

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p to

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p to

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k pr

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over

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is n

ot c

over

ed

You

are

res

pons

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for

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diffe

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cos

t bet

wee

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disp

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and-

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to th

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Out

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ll ot

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spec

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he fi

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ust b

e pr

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t A

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tient

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If A

sant

e O

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P

harm

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e un

able

to fi

ll th

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fill

thro

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peci

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rmac

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leas

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fer

to m

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r a

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f med

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req

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first

fil

l at A

sant

e O

utpa

tient

Pha

rmac

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Pre

ferr

ed b

rand

dr

ugs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

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tion

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up

to $

60 m

axim

um

reta

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c

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p to

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axim

um

mai

l ord

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pres

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Not

cov

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Bra

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rugs

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coi

nsur

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up

to $

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max

imum

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up

to $

300

max

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90

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coi

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up

to $

200

max

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re

tail

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gen

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pr

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red

bran

d an

d br

and

drug

s ab

ove

N

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over

ed

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

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netw

ork

prov

ider

s

4 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

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itat

ion

s E

xcep

tio

ns

amp O

ther

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rmat

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Asa

nte

Pre

ferr

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Net

wo

rk P

rovi

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u w

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ay t

he

leas

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Reg

ence

Net

wo

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Pro

vid

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(Yo

u w

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leas

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Reg

ence

Lim

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N

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ork

Pro

vid

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u w

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mo

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surg

ery

cent

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sici

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10

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15

coi

nsur

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40

c

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prov

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If y

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med

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m

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ncy

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15

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15

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20

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Out

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Urg

ent c

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10

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30

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40

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ho

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ce

40

coi

nsur

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50

c

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uran

ce fo

r O

ut-o

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sici

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on

fees

10

c

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15

coi

nsur

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40

c

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50

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nsur

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for

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prov

ider

s

If y

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nee

d m

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l h

ealt

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ehav

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of

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Inpa

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for

prof

essi

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and

30

c

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r fa

cilit

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40

coi

nsur

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50

c

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uran

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twor

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ovid

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ou

are

pre

gn

ant

Offi

ce v

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10

c

oins

uran

ce

15

coi

nsur

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40

c

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Out

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co

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Mat

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Chi

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nsur

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40

c

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f 7

Co

mm

on

Med

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nt

Ser

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s Y

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May

Nee

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Wh

at Y

ou

Will

Pay

Lim

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health

Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been

performed Surgery and reconstruction of the other breast as necessary to provide

a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event

For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)

Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075

Asante Health PlanAnnual Required Notices

To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)

Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others

The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits

toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020

The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger

The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks

1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen

2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program

If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA

If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts

The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower

Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year

Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health

If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status

The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor

Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment

Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs

In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately

You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate

If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995

Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not

discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender

Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio

accessible electronic formats and other formats) bull Asante provides free language services to people whose primary

language is not English including o Qualified interpreters o Information written in other languages

If you need these services contact Alicia Lorenz at the phone number or email address listed below

If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)

You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)

Complaint forms are available at hhsgovocrofficefileindexhtml

20HR011

This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020

Asante Health Plan changesPlan names  Asante Health Plan 1 is being

renamed Asante PPO Health Plan  Asante Health Plan 2 is being

renamed Asante Savings HealthPlan or HSA

  Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA

For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use

Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers

A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles  The deductibles for the new

Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family

Out-of-pocket maximums  There will no longer be separate

out-of-pocket maximums forprescription drug expenses

Rx expenses will be counted toward the medical out-of-pocket maximums

  The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family

Copay and coinsurance changes  The office visit copay for primary

care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)

  The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)

  The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50

Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles  The deductibles for the four

categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family

Out-of-pocket maximums  The out-of-pocket maximums for the

four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family

Copay and coinsurance changes  The office visit coinsurance for

primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)

The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)

  The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50

Health Savings Account  The HSA contribution limit has

increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage

Employer contributions to the HSA Asante contributes to your HSA

if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled

Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four

categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family

Out-of-pocket maximums There will no longer be separate

out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums

Whatrsquos new for 2020

The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family

Copay and coinsurance changes The office visit copay for primary

care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)

The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)

The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50

Employer contributions to the HRA Asante contributes to your HRA

account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents

Other changes In the Asante Reimbursement

Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations

In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers

Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan

(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)

Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit

All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet

All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply

A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible

Dental plan changes The Willamette Dental plan will have

a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year

There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan

Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits

Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012

Critical illness and accident plans Certain insurance policies are

available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505

Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information

This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025

All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services

We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization

How We May Use and Disclose Your Protected Health Information

Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories

For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use

For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments

For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes

To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us

As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws

Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it

The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage

This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System

The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees

What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage

If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen

1 Your hours of employment are reduced or

2 Your employment ends for any reason other than your gross misconduct

If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens

1 Your spouse dies

2 Your spousersquos hours of employment are reduced

3 Your spousersquos employment ends for any reason other than his or her gross misconduct

4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or

5 You become divorced or legally separated from your spouse

Continuation Coverage Rights Under Cobra

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens

1 The parent-employee dies

2 The parent-employeersquos hours of employment are reduced

3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct

4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)

5 The parents become divorced or legally separated or

6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo

Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan

When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event

You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to

Asante Health System

How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended

Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov

If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)

Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator

Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Updated 91418 ND

PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is

eligible for coverage please contact us so that we can provide them with this notice

Important Notice from Asante About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug

coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice

There are two important things you need to know about your current coverage and Medicarersquos

prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium

2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan

When Can You Join A Medicare Drug Plan

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th

However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan

You should also know that if you drop or lose your current coverage with Asante and donrsquot join a

Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later

Page 2

If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join

For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time

If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by

Medicare in the next 12 months this notice doesnrsquot apply to you

For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos

how to get more information about Medicare prescription drug plans

Visit wwwmedicaregov

Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048

For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)

Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)

3 o

f 8

Co

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Med

ical

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Ser

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Wh

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Dia

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x-ra

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15

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Out

-of-

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ider

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crip

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cov

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ilabl

e at

re

genc

eco

mg

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uglis

t20

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R3

tier

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gs

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opay

30

-day

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copa

y 9

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p to

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to $

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ork

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add

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r co

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for

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artic

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prov

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harm

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tient

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icat

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imum

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4 o

f 8

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-of-

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15

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ce

15

coi

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r de

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If y

ou

nee

d im

med

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m

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tten

tio

n

Em

erge

ncy

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e $1

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opay

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sit

dedu

ctib

le d

oes

not

appl

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$150

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t de

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s no

t ap

ply

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ly

$150

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r O

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e fa

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ved

if ad

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orta

tion

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20

coi

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ce

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copa

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copa

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40

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r O

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ter

dedu

ctib

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sici

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on

fees

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uran

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coi

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coi

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for

Out

-of-

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ork

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afte

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lth

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patie

nt s

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copa

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ffice

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sit

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ctib

le d

oes

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pply

15

c

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uran

ce fo

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l oth

er s

ervi

ces

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copa

y o

ffice

vi

sit

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ctib

le d

oes

not a

pply

15

c

oins

uran

ce fo

r pr

ofes

sion

al a

nd

30

coi

nsur

ance

for

faci

lity

$75

copa

y o

ffice

vi

sit

dedu

ctib

le

does

not

app

ly

40

coi

nsur

ance

fo

r al

l oth

er

serv

ices

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

outp

atie

nt o

ffice

psy

chot

hera

py v

isits

on

ly A

ll ot

her

outp

atie

nt s

ervi

ces

are

cove

red

at

the

coin

sura

nce

spec

ified

afte

r de

duct

ible

Inpa

tient

ser

vice

s 15

c

oins

uran

ce

15

coi

nsur

ance

for

prof

essi

onal

and

30

c

oins

uran

ce fo

r fa

cilit

y

40

coi

nsur

ance

50

c

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Reh

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th

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rece

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our

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and

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s c

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men

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nd c

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ce)

and

excl

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ser

vice

s un

der

the

plan

Use

this

info

rmat

ion

to c

ompa

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e po

rtio

n of

co

sts

you

mig

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ay u

nder

diff

eren

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over

age

NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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dedu

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le d

oes

not a

pply

$2

5 co

pay

ret

ail

clin

ic v

isit

ded

uctib

le

does

not

app

ly

15

coi

nsur

ance

for

all o

ther

ser

vice

s

Not

app

licab

le fo

r pr

imar

y ca

re v

isits

$7

5 co

pay

ret

ail

clin

ic v

isit

de

duct

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doe

s no

t app

ly

40

coi

nsur

ance

fo

r al

l oth

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serv

ices

40

coi

nsur

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for

Out

-of-

netw

ork

prov

ider

s

afte

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C

opay

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ach

Asa

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Reg

ence

lim

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offic

e vi

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ll ot

her

serv

ices

that

ar

e no

t bill

ed a

s an

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ce v

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are

cove

red

at th

e co

insu

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e sp

ecifi

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fter

dedu

ctib

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Cov

erag

e fo

r ac

upun

ctur

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d ch

iropr

actic

sp

inal

man

ipul

atio

ns is

sub

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to $

25

copa

ymen

t for

Reg

ence

net

wor

k pr

ovid

ers

Reg

ence

lim

ited

netw

ork

prov

ider

s an

d 50

c

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uran

ce fo

r ou

t-of

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wor

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ovid

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Li

mite

d to

$2

000

yea

r fo

r ac

upun

ctur

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d $2

000

ye

ar fo

r sp

inal

man

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Coi

nsur

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app

lies

to th

e ou

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ket l

imit

Spe

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ist v

isit

$10

copa

y o

ffice

vi

sit

dedu

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not a

pply

10

c

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ce fo

r al

l oth

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ervi

ces

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copa

y o

ffice

vi

sit

dedu

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oes

not a

pply

15

c

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ce fo

r al

l oth

er s

ervi

ces

$75

copa

y o

ffice

vi

sit

dedu

ctib

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does

not

app

ly

40

coi

nsur

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fo

r al

l oth

er

serv

ices

Pre

vent

ive

care

scr

eeni

ng

imm

uniz

atio

n N

o ch

arge

N

o ch

arge

N

o ch

arge

50

coi

nsur

ance

for

Out

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netw

ork

prov

ider

s

afte

r de

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Y

ou m

ay h

ave

to p

ay fo

r se

rvic

es th

at a

ren

t pr

even

tive

Ask

you

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ovid

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the

serv

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ne

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pre

vent

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The

n ch

eck

wha

t you

r pl

an w

ill p

ay fo

r S

ubje

ct to

pre

vent

ive

care

3 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

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rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

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Pro

vid

er

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u w

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he

leas

t)

Reg

ence

Lim

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N

etw

ork

Pro

vid

er

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he

mo

st)

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elin

es

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y

bloo

d w

ork)

10

c

oins

uran

ce

30

coi

nsur

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40

c

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uran

ce

50

coi

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for

Out

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netw

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prov

ider

s

afte

r de

duct

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Im

agin

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TP

ET

sc

ans

MR

Is)

10

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30

coi

nsur

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40

c

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ce

If y

ou

nee

d d

rug

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tre

at

you

r ill

nes

s o

r co

nd

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n

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

cov

erag

e

is a

vaila

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at

rege

nce

com

go

drug

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020

OR

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r

Gen

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dru

gs

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opay

30

-day

re

tail

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tion

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copa

y 9

0-da

y re

tail

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crip

tion

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copa

y r

etai

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escr

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0 co

pay

mai

l or

der

pres

crip

tion

Not

cov

ered

Ded

uctib

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oes

not a

pply

Li

mite

d to

a 3

0-da

y su

pply

ret

ail a

nd u

p to

90-

day

supp

ly a

t Asa

nte

Out

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nt P

harm

acie

s or

th

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ail o

rder

N

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FD

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mun

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arm

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C

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poun

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edic

atio

ns a

t 30

c

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uran

ce u

p to

$10

0 m

axim

um a

t A

sant

e O

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tient

Pha

rmac

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and

40

co

insu

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to $

200

max

imum

at a

Reg

ence

pa

rtic

ipat

ing

reta

il ph

arm

acy

ref

er to

yo

ur p

lan

for

furt

her

info

rmat

ion

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l-ord

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nsur

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up

to $

120

max

imum

Out

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netw

ork

pres

crip

tion

drug

cov

erag

e is

not

co

vere

d

You

are

res

pons

ible

for

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diffe

renc

e in

cos

t be

twee

n a

disp

ense

d br

and-

nam

e dr

ug a

nd th

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dru

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add

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to th

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firs

t fill

for

sele

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peci

alty

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gs m

ay b

e pr

ovid

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t a p

artic

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ing

reta

il ph

arm

acy

ad

ditio

nal f

ills

mus

t be

prov

ided

at A

sant

e O

utpa

tient

Pha

rmac

ies

For

all

othe

r sp

ecia

lty

drug

s th

e fir

st fi

ll m

ust b

e pr

ovid

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t Asa

nte

Out

patie

nt P

harm

acie

s If

Asa

nte

Out

patie

nt

Pha

rmac

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are

una

ble

to fi

ll th

ey w

ill

coor

dina

te a

fill

thro

ugh

a R

egen

ce S

peci

alty

P

harm

acy

Ple

ase

refe

r to

my

HR

for

a lis

t of

med

icat

ions

that

req

uire

the

first

fill

at A

sant

e O

utpa

tient

Pha

rmac

ies

Pre

ferr

ed b

rand

dru

gs

25

coi

nsur

ance

up

to $

30 m

axim

um

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ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

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tion

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coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

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iptio

n 35

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ce u

p to

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0 m

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mai

l ord

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tion

Not

cov

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Bra

nd d

rugs

30

coi

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up

to $

100

max

imum

30

-day

ret

ail

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30

coi

nsur

ance

up

to $

300

max

imum

90

-day

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ail

pres

crip

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40

coi

nsur

ance

up

to $

200

max

imum

re

tail

pres

crip

tion

40

coi

nsur

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up

to $

600

max

imum

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ail o

rder

pr

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n

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cov

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Spe

cial

ty d

rugs

R

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to g

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and

and

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Ref

er to

gen

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pr

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red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

4 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

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Asa

nte

Pre

ferr

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Net

wo

rk P

rovi

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(Y

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will

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ast)

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ence

Net

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vid

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med

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Em

erge

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car

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opay

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itted

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20

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Out

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are

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copa

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de

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for

Out

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prov

ider

s

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lies

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Reg

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lim

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sit

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ou

hav

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al

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30

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ce

40

coi

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50

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af

ter

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sici

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urge

on fe

es

10

coi

nsur

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15

c

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ce

40

coi

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50

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ut-o

f-ne

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ter

dedu

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nee

d m

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ealt

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ehav

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r su

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use

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Out

patie

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ffice

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sit

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sit

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r pr

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sit

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Out

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coin

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Inpa

tient

ser

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c

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coi

nsur

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for

prof

essi

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and

30

c

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ce fo

r fa

cilit

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40

coi

nsur

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50

c

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uran

ce fo

r O

ut-o

f-ne

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k pr

ovid

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af

ter

dedu

ctib

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5 o

f 8

Co

mm

on

Med

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Eve

nt

Ser

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s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

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rmat

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Asa

nte

Pre

ferr

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Net

wo

rk P

rovi

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(Y

ou

will

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th

e le

ast)

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ence

Net

wo

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Pro

vid

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u w

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ence

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Offi

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15

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40

c

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Chi

ldbi

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deliv

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faci

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40

c

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elp

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g o

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ave

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alth

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rapy

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rapy

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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to $

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up

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Med

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Pre

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prov

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10

c

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15

coi

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40

c

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Out

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prov

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s

If y

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of

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30

c

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40

coi

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50

c

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r O

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Inpa

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ser

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15

coi

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50

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ou

are

pre

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Offi

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10

c

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coi

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40

c

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Out

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Cos

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Chi

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10

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30

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40

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5 o

f 7

Co

mm

on

Med

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Eve

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Ser

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s Y

ou

May

Nee

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Wh

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Will

Pay

Lim

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Imp

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Pre

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Hom

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c

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coi

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up to

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to c

ompa

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co

sts

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mig

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ay u

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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yea

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pla

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nd h

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ese

expe

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ont

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Will

yo

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yo

u u

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n

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plan

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You

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awar

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our

netw

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prov

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mig

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se a

n ou

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ovid

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me

serv

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ch a

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b w

ork)

Che

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ith y

our

prov

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bef

ore

you

get s

ervi

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Do

yo

u n

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a r

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ral t

o s

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a sp

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list

N

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You

can

see

the

spec

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with

out a

ref

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l

A

ll co

paym

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nd c

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are

afte

r yo

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tible

has

bee

n m

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f a d

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app

lies

Co

mm

on

Med

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Eve

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Ser

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s Y

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May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

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amp O

ther

Imp

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Asa

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Pre

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Net

wo

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rovi

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u w

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wo

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vid

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N

etw

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vid

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mo

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If y

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vis

it a

hea

lth

car

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rovi

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r cl

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Prim

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care

vis

it to

trea

t an

inju

ry o

r ill

ness

10

c

oins

uran

ce

15

coi

nsur

ance

Not

app

licab

le fo

r pr

imar

y ca

re v

isits

40

c

oins

uran

ce

reta

il cl

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vis

it

40

coi

nsur

ance

for

Out

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netw

ork

prov

ider

s

Cov

erag

e in

clud

es p

rimar

y ca

re v

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at a

ret

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linic

C

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age

for

acup

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and

chiro

prac

tic s

pina

l m

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ulat

ions

is s

ubje

ct to

20

coi

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ance

for

Reg

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net

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ce li

mite

d ne

twor

k pr

ovid

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and

40

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for

out-

of-n

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prov

ider

s

Lim

ited

to $

200

0 y

ear

for

acup

unct

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and

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00

year

for

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al m

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pplie

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the

out-

of-p

ocke

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it

Spe

cial

ist v

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10

coi

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15

c

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40

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Pre

vent

ive

care

scr

eeni

ng

imm

uniz

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n N

o ch

arge

N

o ch

arge

N

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arge

You

may

hav

e to

pay

for

serv

ices

that

are

nt

prev

entiv

e A

sk y

our

prov

ider

if th

e se

rvic

es n

eede

d ar

e pr

even

tive

The

n ch

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wha

t you

r pl

an w

ill p

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r

Sub

ject

to p

reve

ntiv

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re g

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lines

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y b

lood

wor

k)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

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50

coi

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for

Out

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ork

prov

ider

s

Imag

ing

(CT

PE

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scan

s M

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)

10

coi

nsur

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30

c

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ce

40

coi

nsur

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3 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

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(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

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n

Mor

e in

form

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n ab

out

pres

crip

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drug

cov

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vaila

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at

rege

nce

com

go

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list2

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Gen

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pres

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Not

cov

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Ded

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pply

for

drug

s sp

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cally

de

sign

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as

prev

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r tr

eatm

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f chr

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seas

es th

at a

re o

n th

e O

ptim

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over

age

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mite

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p to

90

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sup

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at A

sant

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Pha

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thro

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Reg

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d ce

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drug

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mun

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pa

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phar

mac

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Cov

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clud

es c

ompo

und

med

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ions

at 3

0

coin

sura

nce

up to

$10

0 m

axim

um a

t Asa

nte

Out

patie

nt P

harm

acie

s an

d 40

c

oins

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ce u

p to

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t a R

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axim

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k pr

escr

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age

is n

ot c

over

ed

You

are

res

pons

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for

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diffe

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cos

t bet

wee

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disp

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and-

nam

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nd th

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add

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to th

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tow

ard

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dedu

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t be

pro

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Asa

nte

Out

patie

nt P

harm

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s F

or a

ll ot

her

spec

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dru

gs t

he fi

rst f

ill m

ust b

e pr

ovid

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t A

sant

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utpa

tient

Pha

rmac

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If A

sant

e O

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P

harm

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e un

able

to fi

ll th

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ill c

oord

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fill

thro

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peci

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Pha

rmac

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leas

e re

fer

to m

y H

R fo

r a

list o

f med

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req

uire

the

first

fil

l at A

sant

e O

utpa

tient

Pha

rmac

ies

Pre

ferr

ed b

rand

dr

ugs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

crip

tion

35

coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

escr

iptio

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c

oins

uran

ce u

p to

$12

0 m

axim

um

mai

l ord

er

pres

crip

tion

Not

cov

ered

Bra

nd d

rugs

30

coi

nsur

ance

up

to $

100

max

imum

30

-day

ret

ail

pres

crip

tion

30

coi

nsur

ance

up

to $

300

max

imum

90

-day

ret

ail

pres

crip

tion

40

coi

nsur

ance

up

to $

200

max

imum

re

tail

pres

crip

tion

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coi

nsur

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up

to $

600

max

imum

m

ail o

rder

pr

escr

iptio

n

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cov

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Spe

cial

ty d

rugs

R

efer

to g

ener

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pref

erre

d br

and

and

bran

d dr

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Ref

er to

gen

eric

pr

efer

red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

4 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

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(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

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(Yo

u w

ill p

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he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

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(Yo

u w

ill p

ay t

he

mo

st)

surg

ery

cent

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Phy

sici

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on

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10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

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netw

ork

prov

ider

s

If y

ou

nee

d im

med

iate

m

edic

al a

tten

tio

n

Em

erge

ncy

room

ca

re

15

coi

nsur

ance

15

c

oins

uran

ce

15

coi

nsur

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15

c

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uran

ce fo

r O

ut-o

f-ne

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k pr

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ncy

med

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tr

ansp

orta

tion

Not

app

licab

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20

coi

nsur

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20

c

oins

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ce

20

coi

nsur

ance

for

Out

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ork

prov

ider

s

Urg

ent c

are

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

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50

c

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uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

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If y

ou

hav

e a

ho

spit

al

stay

Fac

ility

fee

(eg

ho

spita

l roo

m)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

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Phy

sici

ans

urge

on

fees

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

If y

ou

nee

d m

enta

l h

ealt

h b

ehav

iora

l hea

lth

o

r su

bst

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ab

use

se

rvic

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Out

patie

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serv

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10

coi

nsur

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of

fice

visi

t 10

c

oins

uran

ce fo

r al

l oth

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ervi

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15

coi

nsur

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for

prof

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and

30

c

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r fa

cilit

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40

coi

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50

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Inpa

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ser

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s 10

c

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uran

ce

15

coi

nsur

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for

prof

essi

onal

and

30

c

oins

uran

ce fo

r fa

cilit

y

40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

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If y

ou

are

pre

gn

ant

Offi

ce v

isits

10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

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for

Out

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ork

prov

ider

s

Cos

t sha

ring

does

not

app

ly to

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pre

vent

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serv

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Dep

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f ser

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co

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ded

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are

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th

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Mat

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case

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deliv

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prof

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rvic

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10

coi

nsur

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15

c

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ce

40

coi

nsur

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Chi

ldbi

rth

deliv

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faci

lity

serv

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10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

5 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

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ou

nee

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elp

re

cove

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g o

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oth

er

spec

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ealt

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Hom

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alth

car

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c

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30

coi

nsur

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40

c

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Lim

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to 1

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Reh

abili

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n se

rvic

es

10

coi

nsur

ance

30

c

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ce

40

coi

nsur

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50

coi

nsur

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for

Out

-of-

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prov

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s

Inpa

tient

lim

ited

to 3

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up to

60

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seve

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head

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utpa

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to

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phy

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rapy

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rapy

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serv

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Hab

ilita

tion

serv

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10

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ce

30

coi

nsur

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40

c

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50

coi

nsur

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health

Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been

performed Surgery and reconstruction of the other breast as necessary to provide

a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event

For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)

Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075

Asante Health PlanAnnual Required Notices

To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)

Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others

The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits

toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020

The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger

The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks

1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen

2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program

If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA

If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts

The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower

Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year

Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health

If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status

The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor

Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment

Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs

In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately

You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate

If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995

Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not

discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender

Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio

accessible electronic formats and other formats) bull Asante provides free language services to people whose primary

language is not English including o Qualified interpreters o Information written in other languages

If you need these services contact Alicia Lorenz at the phone number or email address listed below

If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)

You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)

Complaint forms are available at hhsgovocrofficefileindexhtml

20HR011

This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020

Asante Health Plan changesPlan names  Asante Health Plan 1 is being

renamed Asante PPO Health Plan  Asante Health Plan 2 is being

renamed Asante Savings HealthPlan or HSA

  Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA

For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use

Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers

A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles  The deductibles for the new

Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family

Out-of-pocket maximums  There will no longer be separate

out-of-pocket maximums forprescription drug expenses

Rx expenses will be counted toward the medical out-of-pocket maximums

  The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family

Copay and coinsurance changes  The office visit copay for primary

care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)

  The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)

  The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50

Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles  The deductibles for the four

categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family

Out-of-pocket maximums  The out-of-pocket maximums for the

four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family

Copay and coinsurance changes  The office visit coinsurance for

primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)

The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)

  The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50

Health Savings Account  The HSA contribution limit has

increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage

Employer contributions to the HSA Asante contributes to your HSA

if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled

Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four

categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family

Out-of-pocket maximums There will no longer be separate

out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums

Whatrsquos new for 2020

The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family

Copay and coinsurance changes The office visit copay for primary

care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)

The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)

The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50

Employer contributions to the HRA Asante contributes to your HRA

account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents

Other changes In the Asante Reimbursement

Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations

In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers

Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan

(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)

Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit

All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet

All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply

A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible

Dental plan changes The Willamette Dental plan will have

a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year

There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan

Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits

Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012

Critical illness and accident plans Certain insurance policies are

available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505

Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information

This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025

All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services

We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization

How We May Use and Disclose Your Protected Health Information

Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories

For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use

For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments

For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes

To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us

As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws

Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it

The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage

This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System

The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees

What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage

If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen

1 Your hours of employment are reduced or

2 Your employment ends for any reason other than your gross misconduct

If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens

1 Your spouse dies

2 Your spousersquos hours of employment are reduced

3 Your spousersquos employment ends for any reason other than his or her gross misconduct

4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or

5 You become divorced or legally separated from your spouse

Continuation Coverage Rights Under Cobra

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens

1 The parent-employee dies

2 The parent-employeersquos hours of employment are reduced

3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct

4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)

5 The parents become divorced or legally separated or

6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo

Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan

When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event

You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to

Asante Health System

How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended

Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov

If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)

Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator

Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Updated 91418 ND

PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is

eligible for coverage please contact us so that we can provide them with this notice

Important Notice from Asante About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug

coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice

There are two important things you need to know about your current coverage and Medicarersquos

prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium

2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan

When Can You Join A Medicare Drug Plan

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th

However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan

You should also know that if you drop or lose your current coverage with Asante and donrsquot join a

Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later

Page 2

If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join

For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time

If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by

Medicare in the next 12 months this notice doesnrsquot apply to you

For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos

how to get more information about Medicare prescription drug plans

Visit wwwmedicaregov

Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048

For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)

Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)

4 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

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xcep

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ns

amp O

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Imp

ort

ant

Info

rmat

ion

Asa

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Pre

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ed

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rovi

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ou

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pay

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e $1

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ctib

le d

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y

$150

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ay

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ible

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ply

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ible

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ly

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r O

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le

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ance

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Out

-of-

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ork

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r de

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t app

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ach

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ork

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e vi

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ility

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l roo

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30

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ce

40

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ance

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ce fo

r O

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ce a

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se

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ices

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nt s

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copa

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ffice

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le d

oes

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pply

15

c

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ce fo

r al

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er s

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ffice

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ctib

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oes

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15

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r pr

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nsur

ance

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ffice

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ctib

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ly

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-of-

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nce

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ified

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r de

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s 15

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uran

ce

15

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nsur

ance

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essi

onal

and

30

c

oins

uran

ce fo

r fa

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y

40

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c

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uran

ce fo

r O

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k pr

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af

ter

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ctib

le

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f 8

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Med

ical

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Nee

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Wh

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ou

Will

Pay

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ion

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Imp

ort

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rmat

ion

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Pre

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ed

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rk P

rovi

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(Y

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rk

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vid

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ill p

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ited

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ce v

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-of-

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ork

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r de

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reve

ntiv

e se

rvic

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ding

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the

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of s

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ces

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nce

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tible

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app

ly M

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re m

ay in

clud

e te

sts

and

serv

ices

des

crib

ed

else

whe

re in

the

SB

C (

ie u

ltras

ound

)

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erni

ty c

over

age

for

depe

nden

t chi

ldre

n is

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ly c

over

ed in

the

case

of c

ompl

icat

ions

Chi

ldbi

rth

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ery

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essi

onal

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vice

s 15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

Chi

ldbi

rth

deliv

ery

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lity

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ices

15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

If y

ou

nee

d h

elp

re

cove

rin

g o

r h

ave

oth

er

spec

ial h

ealt

h n

eed

s

Hom

e he

alth

car

e 15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

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ork

prov

ider

s

afte

r de

duct

ible

Li

mite

d to

100

vis

its

year

Reh

abili

tatio

n se

rvic

es

$10

copa

y

outp

atie

nt v

isit

de

duct

ible

doe

s no

t ap

ply

15

c

oins

uran

ce

inpa

tient

ser

vice

s

$25

copa

y

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atie

nt v

isit

de

duct

ible

doe

s no

t ap

ply

30

c

oins

uran

ce

inpa

tient

ser

vice

s

$75

copa

y

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atie

nt v

isit

de

duct

ible

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s no

t app

ly

40

coi

nsur

ance

in

patie

nt s

ervi

ces

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

outp

atie

nt v

isit

only

Inp

atie

nt s

ervi

ces

are

cove

red

at th

e co

insu

ranc

e sp

ecifi

ed a

fter

dedu

ctib

le

Inpa

tient

lim

ited

to 3

0 da

ys (

up to

60

days

for

seve

re h

ead

or s

pina

l cor

d in

jury

) y

ear

O

utpa

tient

lim

ited

to 8

0 vi

sits

ye

ar

Incl

udes

phy

sica

l the

rapy

occ

upat

iona

l the

rapy

an

d sp

eech

ther

apy

serv

ices

Hab

ilita

tion

serv

ices

$10

copa

y

outp

atie

nt v

isit

de

duct

ible

doe

s no

t ap

ply

15

c

oins

uran

ce

inpa

tient

ser

vice

s

$25

copa

y

outp

atie

nt v

isit

de

duct

ible

doe

s no

t ap

ply

30

c

oins

uran

ce

inpa

tient

ser

vice

s

$75

copa

y

outp

atie

nt v

isit

de

duct

ible

doe

s no

t app

ly

40

coi

nsur

ance

in

patie

nt s

ervi

ces

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

C

opay

men

t app

lies

to e

ach

Asa

nte

pref

erre

d ne

twor

kR

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

outp

atie

nt v

isit

only

Inp

atie

nt s

ervi

ces

are

cove

red

at th

e co

insu

ranc

e sp

ecifi

ed a

fter

dedu

ctib

le

Out

patie

nt n

euro

deve

lopm

enta

l the

rapy

is li

mite

d to

60

visi

ts

year

N

euro

deve

lopm

enta

l the

rapy

is li

mite

d to

se

rvic

es fo

r in

divi

dual

s th

roug

h ag

e 17

6 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

Incl

udes

phy

sica

l the

rapy

occ

upat

iona

l the

rapy

an

d sp

eech

ther

apy

serv

ices

Ski

lled

nurs

ing

care

N

ot a

pplic

able

20

c

oins

uran

ce

20

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

af

ter

dedu

ctib

le

Lim

ited

to 9

0 in

patie

nt d

ays

yea

r

Dur

able

med

ical

eq

uipm

ent

Not

app

licab

le

20

coi

nsur

ance

20

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

Hos

pice

ser

vice

s 15

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

ible

R

espi

te c

are

is li

mite

d to

14

days

lif

etim

e

If y

ou

r ch

ild n

eed

s d

enta

l o

r ey

e ca

re

Chi

ldre

ns

eye

exam

N

ot c

over

ed

Not

cov

ered

N

ot c

over

ed

Non

e

Chi

ldre

ns

glas

ses

Not

cov

ered

N

ot c

over

ed

Not

cov

ered

N

one

Chi

ldre

ns

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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fill

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harm

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for

a lis

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med

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req

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first

fill

at A

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Pha

rmac

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rand

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25

coi

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up

to $

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ce u

p to

$60

max

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up

to $

60 m

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c

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Bra

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30

coi

nsur

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up

to $

100

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-day

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pres

crip

tion

30

coi

nsur

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up

to $

300

max

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90

-day

ret

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pres

crip

tion

40

coi

nsur

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up

to $

200

max

imum

re

tail

pres

crip

tion

40

coi

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up

to $

600

max

imum

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ail o

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pr

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cov

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Spe

cial

ty d

rugs

R

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to g

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pref

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and

and

bran

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Ref

er to

gen

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pr

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red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

4 o

f 8

Co

mm

on

Med

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Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

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Pre

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mo

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ou

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Fac

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fee

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-of-

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r de

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Phy

sici

ans

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10

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nsur

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50

c

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ers

af

ter

dedu

ctib

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If y

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nee

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med

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m

edic

al a

tten

tio

n

Em

erge

ncy

room

car

e $1

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opay

vi

sit

dedu

ctib

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not

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$150

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ay

visi

t de

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tion

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licab

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20

coi

nsur

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20

c

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ce

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coi

nsur

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prov

ider

s

afte

r de

duct

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Urg

ent c

are

$10

copa

y v

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de

duct

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doe

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ply

$25

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de

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ply

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copa

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de

duct

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doe

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50

coi

nsur

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for

Out

-of-

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prov

ider

s

afte

r de

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C

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ach

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eur

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car

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sit

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al

stay

Fac

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fee

(eg

ho

spita

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c

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10

coi

nsur

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coi

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50

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af

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dedu

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ehav

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r pr

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faci

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netw

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coin

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afte

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Inpa

tient

ser

vice

s 10

c

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ce

15

coi

nsur

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for

prof

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and

30

c

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uran

ce fo

r fa

cilit

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40

coi

nsur

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50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

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af

ter

dedu

ctib

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5 o

f 8

Co

mm

on

Med

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Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

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xcep

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Imp

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ant

Info

rmat

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rovi

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Pro

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Offi

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c

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ap

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d se

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C (

ie

ultr

asou

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cov

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ser

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coi

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40

c

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Chi

ldbi

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deliv

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faci

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serv

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10

c

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ce

30

coi

nsur

ance

40

c

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ce

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ou

nee

d h

elp

re

cove

rin

g o

r h

ave

oth

er

spec

ial h

ealt

h n

eed

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e he

alth

car

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c

oins

uran

ce

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coi

nsur

ance

40

c

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ce

50

coi

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ance

for

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netw

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ider

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ter

dedu

ctib

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to 1

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ye

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Reh

abili

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es

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de

duct

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c

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in

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ider

s

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fter

dedu

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tient

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to 3

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up to

60

days

for

seve

re h

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jury

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rapy

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rapy

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year

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rapy

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se

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r in

divi

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6 o

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Co

mm

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Med

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nt

Ser

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ou

May

Nee

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Wh

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ou

Will

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rapy

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Dur

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re

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ompa

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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k pr

ovid

ers

and

Reg

ence

lim

ited

netw

ork

prov

ider

s cr

oss

accu

mul

ate

Gen

eral

ly y

ou m

ust p

ay a

ll of

the

cost

s fr

om p

rovi

ders

up

to th

e de

duct

ible

am

ount

bef

ore

this

pla

n be

gins

to p

ay I

f you

hav

e ot

her

fam

ily m

embe

rs o

n th

e po

licy

the

over

all f

amily

ded

uctib

le m

ust b

e m

et b

efor

e th

e pl

an b

egin

s to

pay

Are

th

ere

serv

ices

co

vere

d

bef

ore

yo

u m

eet

you

r d

edu

ctib

le

Yes

Cer

tain

pre

vent

ive

care

and

thos

e se

rvic

es li

sted

be

low

as

ded

uctib

le d

oes

not a

pply

or

as

No

char

ge

Thi

s pl

an c

over

s so

me

item

s an

d se

rvic

es e

ven

if yo

u ha

ven

t ye

t met

th

e de

duct

ible

am

ount

But

a c

opay

men

t or

coin

sura

nce

may

app

ly F

or

exam

ple

this

pla

n co

vers

cer

tain

pre

vent

ive

serv

ices

with

out c

ost

shar

ing

and

befo

re y

ou m

eet y

our

dedu

ctib

le S

ee a

list

of c

over

ed

prev

entiv

e se

rvic

es a

t hea

lthca

reg

ovc

ove

rage

pre

vent

ive-

care

-be

nefit

s

Are

th

ere

oth

er d

edu

ctib

les

for

spec

ific

ser

vice

s

No

Y

ou d

ont

have

to m

eet d

educ

tible

s fo

r sp

ecifi

c se

rvic

es

Wh

at is

th

e o

ut-

of-

po

cket

lim

it

for

this

pla

n

Asa

nte

pref

erre

d ne

twor

k pr

ovid

ers

$2

000

indi

vidu

al

(sin

gle

cove

rage

) $

300

0 fa

mily

per

cal

enda

r ye

ar

Reg

ence

net

wor

k pr

ovid

ers

$3

000

indi

vidu

al (

sing

le

cove

rage

) $

600

0 fa

mily

per

cal

enda

r ye

ar R

egen

ce

limite

d ne

twor

k pr

ovid

ers

$6

000

indi

vidu

al (

sing

le

cove

rage

) $

120

00 fa

mily

per

cal

enda

r ye

ar T

he o

ut-o

f-po

cket

lim

it am

ount

s fo

r A

sant

e pr

efer

red

netw

ork

prov

ider

s R

egen

ce n

etw

ork

prov

ider

s an

d R

egen

ce

limite

d ne

twor

k pr

ovid

ers

cros

s ac

cum

ulat

e O

ut-o

f-ne

twor

k $

800

0 in

divi

dual

$1

400

0 fa

mily

per

cal

enda

r ye

ar

The

Reg

ence

net

wor

k ou

t-of

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ket l

imit

for

The

out

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pock

et li

mit

is th

e m

ost y

ou c

ould

pay

in a

yea

r fo

r co

vere

d se

rvic

es

If yo

u ha

ve o

ther

fam

ily m

embe

rs in

this

pla

n th

e ov

eral

l fam

ily o

ut-o

f-po

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lim

it m

ust b

e m

et

2 o

f 7

med

ical

and

pre

scrip

tion

bene

fits

are

com

bine

d

Wh

at is

no

t in

clu

ded

in t

he

ou

t-o

f-p

ock

et li

mit

Pre

miu

ms

bal

ance

-bill

ed c

harg

es a

nd h

ealth

car

e th

is

plan

doe

snt

cove

r

Eve

n th

ough

yo

u pa

y th

ese

expe

nses

th

ey d

ont

coun

t tow

ard

the

out-

of-p

ocke

t lim

it

Will

yo

u p

ay le

ss if

yo

u u

se a

n

etw

ork

pro

vid

er

Yes

Asa

nte

prov

ider

s S

ee

rege

nce

com

go

OR

Pre

ferr

ed o

r ca

ll 1

(888

) 34

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for

a lis

t of n

etw

ork

prov

ider

s

Thi

s pl

an u

ses

a pr

ovid

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etw

ork

You

will

pay

less

if y

ou u

se a

pro

vide

r in

the

plan

s n

etw

ork

You

will

pay

the

mos

t if y

ou u

se a

n o

ut-o

f-ne

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k pr

ovid

er a

nd

you

mig

ht r

ecei

ve a

bill

from

a p

rovi

der

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diffe

renc

e be

twee

n th

e pr

ovid

ers

ch

arge

and

wha

t you

r pl

an p

ays

(bal

ance

bill

ing)

Be

awar

e y

our

netw

ork

prov

ider

mig

ht u

se a

n ou

t-of

-net

wor

k pr

ovid

er fo

r so

me

serv

ices

(su

ch a

s la

b w

ork)

Che

ck w

ith y

our

prov

ider

bef

ore

you

get s

ervi

ces

Do

yo

u n

eed

a r

efer

ral t

o s

ee

a sp

ecia

list

N

o

You

can

see

the

spec

ialis

t you

cho

ose

with

out a

ref

erra

l

A

ll co

paym

ent a

nd c

oins

uran

ce c

osts

sho

wn

in th

is c

hart

are

afte

r yo

ur d

educ

tible

has

bee

n m

et i

f a d

educ

tible

app

lies

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

vis

it a

hea

lth

car

e p

rovi

der

s o

ffic

e o

r cl

inic

Prim

ary

care

vis

it to

trea

t an

inju

ry o

r ill

ness

10

c

oins

uran

ce

15

coi

nsur

ance

Not

app

licab

le fo

r pr

imar

y ca

re v

isits

40

c

oins

uran

ce

reta

il cl

inic

vis

it

40

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

Cov

erag

e in

clud

es p

rimar

y ca

re v

isits

at a

ret

ail c

linic

C

over

age

for

acup

unct

ure

and

chi

ropr

actic

spi

nal

man

ipul

atio

ns is

sub

ject

to 2

0 c

oins

uran

ce fo

r R

egen

ce n

etw

ork

Reg

ence

lim

ited

netw

ork

prov

ider

s an

d 40

c

oins

uran

ce fo

r ou

t-of

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wor

k pr

ovid

ers

Li

mite

d to

$2

000

yea

r fo

r ac

upun

ctur

e an

d $2

000

ye

ar fo

r sp

inal

man

ipul

atio

ns

Coi

nsur

ance

app

lies

to th

e ou

t-of

-poc

ket l

imit

Spe

cial

ist v

isit

10

coi

nsur

ance

15

c

oins

uran

ce

40

coi

nsur

ance

Pre

vent

ive

care

scr

eeni

ng

imm

uniz

atio

n N

o ch

arge

N

o ch

arge

N

o ch

arge

You

may

hav

e to

pay

for

serv

ices

that

are

nt

prev

entiv

e A

sk y

our

prov

ider

if th

e se

rvic

es n

eede

d ar

e pr

even

tive

The

n ch

eck

wha

t you

r pl

an w

ill p

ay fo

r

Sub

ject

to p

reve

ntiv

e ca

re g

uide

lines

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y b

lood

wor

k)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

50

coi

nsur

ance

for

Out

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netw

ork

prov

ider

s

Imag

ing

(CT

PE

T

scan

s M

RIs

)

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

ance

3 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

cov

erag

e

is a

vaila

ble

at

rege

nce

com

go

drug

list2

020

OR

3tie

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Gen

eric

dru

gs

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tail

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tail

pres

crip

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$15

copa

y r

etai

l pr

escr

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0 co

pay

mai

l or

der

pres

crip

tion

Not

cov

ered

Ded

uctib

le d

oes

not a

pply

for

drug

s sp

ecifi

cally

de

sign

ated

as

prev

entiv

e fo

r tr

eatm

ent o

f chr

onic

di

seas

es th

at a

re o

n th

e O

ptim

um V

alue

Med

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ion

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C

over

age

is li

mite

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a 3

0-da

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ret

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p to

90

-day

sup

ply

at A

sant

e O

utpa

tient

Pha

rmac

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or

thro

ugh

Reg

ence

mai

l ord

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No

char

ge fo

r F

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s c

ontr

acep

tives

an

d ce

rtai

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even

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drug

s an

d im

mun

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ions

at a

pa

rtic

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ing

phar

mac

y

Cov

erag

e in

clud

es c

ompo

und

med

icat

ions

at 3

0

coin

sura

nce

up to

$10

0 m

axim

um a

t Asa

nte

Out

patie

nt P

harm

acie

s an

d 40

c

oins

uran

ce u

p to

$2

00 m

axim

um a

t a R

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ce p

artic

ipat

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reta

il ph

arm

acy

ref

er to

you

r pl

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r fu

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form

atio

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Mai

l-ord

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resc

riptio

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5 c

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uran

ce u

p to

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0 m

axim

um O

ut-o

f-ne

twor

k pr

escr

iptio

n dr

ug c

over

age

is n

ot c

over

ed

You

are

res

pons

ible

for

the

diffe

renc

e in

cos

t bet

wee

n a

disp

ense

d br

and-

nam

e dr

ug a

nd th

e eq

uiva

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neric

dru

g in

add

ition

to th

e co

paym

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ndo

r co

insu

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he c

ost d

iffer

entia

l bet

wee

n ge

neric

an

d br

and-

nam

e dr

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accr

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tow

ard

the

dedu

ctib

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firs

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sele

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peci

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ay b

e pr

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at a

par

ticip

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tail

phar

mac

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dditi

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fills

mus

t be

pro

vide

d at

Asa

nte

Out

patie

nt P

harm

acie

s F

or a

ll ot

her

spec

ialty

dru

gs t

he fi

rst f

ill m

ust b

e pr

ovid

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t A

sant

e O

utpa

tient

Pha

rmac

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If A

sant

e O

utpa

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P

harm

acie

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e un

able

to fi

ll th

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ill c

oord

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e a

fill

thro

ugh

a R

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peci

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Pha

rmac

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leas

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fer

to m

y H

R fo

r a

list o

f med

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req

uire

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first

fil

l at A

sant

e O

utpa

tient

Pha

rmac

ies

Pre

ferr

ed b

rand

dr

ugs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

crip

tion

35

coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

escr

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c

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uran

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p to

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0 m

axim

um

mai

l ord

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pres

crip

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Not

cov

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Bra

nd d

rugs

30

coi

nsur

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up

to $

100

max

imum

30

-day

ret

ail

pres

crip

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30

coi

nsur

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up

to $

300

max

imum

90

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ret

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pres

crip

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40

coi

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up

to $

200

max

imum

re

tail

pres

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max

imum

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ail o

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pr

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cov

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Spe

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rugs

R

efer

to g

ener

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and

bran

d dr

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Ref

er to

gen

eric

pr

efer

red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

su

rger

y ce

nter

) 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

4 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

rk

Pro

vid

er

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Lim

ited

N

etw

ork

Pro

vid

er

(Yo

u w

ill p

ay t

he

mo

st)

Phy

sici

ans

urge

on

fees

10

c

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uran

ce

15

coi

nsur

ance

40

c

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uran

ce

50

coi

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for

Out

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ork

prov

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s

If y

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med

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m

edic

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erge

ncy

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15

coi

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c

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15

coi

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15

c

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Em

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ncy

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app

licab

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20

coi

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20

c

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20

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for

Out

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Urg

ent c

are

10

coi

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30

c

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ce

40

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ut-o

f-ne

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ou

hav

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ho

spit

al

stay

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fee

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ho

spita

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m)

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coi

nsur

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30

c

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ce

40

coi

nsur

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50

c

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uran

ce fo

r O

ut-o

f-ne

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Phy

sici

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fees

10

c

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uran

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15

coi

nsur

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40

c

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50

coi

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for

Out

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prov

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s

If y

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nee

d m

enta

l h

ealt

h b

ehav

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l hea

lth

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r su

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use

se

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Out

patie

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serv

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10

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nsur

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of

fice

visi

t 10

c

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r al

l oth

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15

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for

prof

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and

30

c

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40

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Inpa

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c

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15

coi

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for

prof

essi

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and

30

c

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uran

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r fa

cilit

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40

coi

nsur

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50

c

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uran

ce fo

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f-ne

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ovid

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If y

ou

are

pre

gn

ant

Offi

ce v

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10

c

oins

uran

ce

15

coi

nsur

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40

c

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50

coi

nsur

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for

Out

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prov

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Cos

t sha

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

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ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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$15

copa

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etai

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pay

mai

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pres

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Not

cov

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Ded

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pply

for

drug

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sign

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Pha

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up to

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d 40

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axim

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over

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is n

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Pha

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peci

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Pha

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to m

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req

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first

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Pha

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Pre

ferr

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dr

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up

to $

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etai

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p to

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max

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to $

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Bra

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up

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30

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tail

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Spe

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R

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Ref

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drug

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N

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If y

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Fac

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fee

(eg

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10

c

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30

coi

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40

c

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50

coi

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Out

-of-

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prov

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s

4 o

f 7

Co

mm

on

Med

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Eve

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Ser

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s Y

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May

Nee

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Wh

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ou

Will

Pay

Lim

itat

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s E

xcep

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Imp

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rmat

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Pre

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Net

wo

rk P

rovi

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(Yo

u w

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he

leas

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Reg

ence

Net

wo

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Pro

vid

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he

leas

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Reg

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Lim

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N

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he

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surg

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Phy

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10

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15

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40

c

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Out

-of-

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prov

ider

s

If y

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nee

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med

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m

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Em

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15

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15

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Em

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20

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Out

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Urg

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coi

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30

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40

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ho

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al

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Fac

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fee

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ho

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10

coi

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30

c

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ce

40

coi

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50

c

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uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

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Phy

sici

ans

urge

on

fees

10

c

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uran

ce

15

coi

nsur

ance

40

c

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uran

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50

coi

nsur

ance

for

Out

-of-

netw

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prov

ider

s

If y

ou

nee

d m

enta

l h

ealt

h b

ehav

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l hea

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r su

bst

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ab

use

se

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Out

patie

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serv

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10

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nsur

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of

fice

visi

t 10

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r al

l oth

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15

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for

prof

essi

onal

and

30

c

oins

uran

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r fa

cilit

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40

coi

nsur

ance

50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

ers

Inpa

tient

ser

vice

s 10

c

oins

uran

ce

15

coi

nsur

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for

prof

essi

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and

30

c

oins

uran

ce fo

r fa

cilit

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40

coi

nsur

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50

c

oins

uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

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If y

ou

are

pre

gn

ant

Offi

ce v

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10

c

oins

uran

ce

15

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

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for

Out

-of-

netw

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prov

ider

s

Cos

t sha

ring

does

not

app

ly to

cer

tain

pre

vent

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serv

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n th

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f ser

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s a

co

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ded

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ay a

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Mat

erni

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may

incl

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d se

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escr

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th

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BC

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ultr

asou

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Mat

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over

age

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depe

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ldre

n is

onl

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vere

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case

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com

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Chi

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deliv

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prof

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se

rvic

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10

coi

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15

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40

coi

nsur

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Chi

ldbi

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deliv

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faci

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serv

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10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

5 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

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ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Yo

u w

ill p

ay t

he

leas

t)

Reg

ence

Net

wo

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Pro

vid

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(Yo

u w

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ay t

he

leas

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Reg

ence

Lim

ited

N

etw

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Pro

vid

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(Yo

u w

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ay t

he

mo

st)

If y

ou

nee

d h

elp

re

cove

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g o

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ave

oth

er

spec

ial h

ealt

h n

eed

s

Hom

e he

alth

car

e 10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

Lim

ited

to 1

00 v

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ye

ar

Reh

abili

tatio

n se

rvic

es

10

coi

nsur

ance

30

c

oins

uran

ce

40

coi

nsur

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50

coi

nsur

ance

for

Out

-of-

netw

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prov

ider

s

Inpa

tient

lim

ited

to 3

0 da

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up to

60

days

for

seve

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head

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spin

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Incl

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phy

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rapy

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rapy

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sp

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ther

apy

serv

ices

Hab

ilita

tion

serv

ices

10

c

oins

uran

ce

30

coi

nsur

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40

c

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ce

50

coi

nsur

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for

Out

-of-

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prov

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s

Out

patie

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rapy

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20

c

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Out

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40

c

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f 7

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pla

n w

ould

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r co

sts

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EX

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cov

ered

ser

vice

s

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avin

g a

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y (9

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ths

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ldbi

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nal S

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ty S

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ld p

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nsur

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t isn

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Exa

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Th

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no

t a

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or

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atm

ents

sho

wn

are

just

exa

mpl

es o

f how

this

pla

n m

ight

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er m

edic

al c

are

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r ac

tual

cos

ts w

ill b

e di

ffere

nt d

epen

ding

on

the

actu

al c

are

you

rece

ive

the

pric

es y

our

prov

ider

s ch

arge

and

man

y ot

her

fact

ors

Foc

us o

n th

e co

st s

harin

g am

ount

s (d

educ

tible

s c

opay

men

ts a

nd c

oins

uran

ce)

and

excl

uded

ser

vice

s un

der

the

plan

Use

this

info

rmat

ion

to c

ompa

re th

e po

rtio

n of

co

sts

you

mig

ht p

ay u

nder

diff

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t he

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ns P

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rage

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mpl

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re b

ased

on

self-

only

cov

erag

e

NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health

Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been

performed Surgery and reconstruction of the other breast as necessary to provide

a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event

For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)

Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075

Asante Health PlanAnnual Required Notices

To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)

Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others

The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits

toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020

The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger

The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks

1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen

2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program

If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA

If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts

The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower

Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year

Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health

If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status

The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor

Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment

Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs

In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately

You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate

If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995

Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not

discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender

Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio

accessible electronic formats and other formats) bull Asante provides free language services to people whose primary

language is not English including o Qualified interpreters o Information written in other languages

If you need these services contact Alicia Lorenz at the phone number or email address listed below

If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)

You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)

Complaint forms are available at hhsgovocrofficefileindexhtml

20HR011

This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020

Asante Health Plan changesPlan names  Asante Health Plan 1 is being

renamed Asante PPO Health Plan  Asante Health Plan 2 is being

renamed Asante Savings HealthPlan or HSA

  Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA

For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use

Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers

A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles  The deductibles for the new

Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family

Out-of-pocket maximums  There will no longer be separate

out-of-pocket maximums forprescription drug expenses

Rx expenses will be counted toward the medical out-of-pocket maximums

  The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family

Copay and coinsurance changes  The office visit copay for primary

care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)

  The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)

  The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50

Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles  The deductibles for the four

categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family

Out-of-pocket maximums  The out-of-pocket maximums for the

four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family

Copay and coinsurance changes  The office visit coinsurance for

primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)

The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)

  The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50

Health Savings Account  The HSA contribution limit has

increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage

Employer contributions to the HSA Asante contributes to your HSA

if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled

Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four

categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family

Out-of-pocket maximums There will no longer be separate

out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums

Whatrsquos new for 2020

The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family

Copay and coinsurance changes The office visit copay for primary

care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)

The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)

The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50

Employer contributions to the HRA Asante contributes to your HRA

account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents

Other changes In the Asante Reimbursement

Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations

In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers

Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan

(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)

Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit

All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet

All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply

A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible

Dental plan changes The Willamette Dental plan will have

a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year

There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan

Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits

Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012

Critical illness and accident plans Certain insurance policies are

available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505

Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information

This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025

All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services

We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization

How We May Use and Disclose Your Protected Health Information

Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories

For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use

For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments

For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes

To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us

As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws

Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it

The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage

This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System

The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees

What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage

If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen

1 Your hours of employment are reduced or

2 Your employment ends for any reason other than your gross misconduct

If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens

1 Your spouse dies

2 Your spousersquos hours of employment are reduced

3 Your spousersquos employment ends for any reason other than his or her gross misconduct

4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or

5 You become divorced or legally separated from your spouse

Continuation Coverage Rights Under Cobra

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens

1 The parent-employee dies

2 The parent-employeersquos hours of employment are reduced

3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct

4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)

5 The parents become divorced or legally separated or

6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo

Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan

When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event

You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to

Asante Health System

How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended

Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov

If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)

Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator

Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Updated 91418 ND

PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is

eligible for coverage please contact us so that we can provide them with this notice

Important Notice from Asante About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug

coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice

There are two important things you need to know about your current coverage and Medicarersquos

prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium

2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan

When Can You Join A Medicare Drug Plan

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th

However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan

You should also know that if you drop or lose your current coverage with Asante and donrsquot join a

Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later

Page 2

If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join

For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time

If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by

Medicare in the next 12 months this notice doesnrsquot apply to you

For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos

how to get more information about Medicare prescription drug plans

Visit wwwmedicaregov

Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048

For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)

Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)

5 o

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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Pre

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afte

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Y

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Ask

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Med

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Ser

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May

Nee

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Will

Pay

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you

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Mor

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Med

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Ser

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Nee

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Wh

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50

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Co

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Med

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Eve

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Ser

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May

Nee

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Wh

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ou

Will

Pay

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Imp

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ompa

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mig

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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Med

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to c

ompa

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co

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mig

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ay u

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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ervi

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Do

yo

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spec

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A

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care

vis

it to

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10

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15

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nsur

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app

licab

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r pr

imar

y ca

re v

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it

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Out

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prov

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and

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is s

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20

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Reg

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mite

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to $

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ear

for

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Spe

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Pre

vent

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care

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imm

uniz

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o ch

arge

N

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You

may

hav

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pay

for

serv

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that

are

nt

prev

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e A

sk y

our

prov

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if th

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ou

hav

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test

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x-ra

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30

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40

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for

Out

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prov

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s

Imag

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(CT

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scan

s M

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)

10

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nsur

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30

c

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40

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f 7

Co

mm

on

Med

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Eve

nt

Ser

vice

s Y

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Nee

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Wh

at Y

ou

Will

Pay

Lim

itat

ion

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amp O

ther

Imp

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wo

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N

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Pro

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u w

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mo

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If y

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you

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Mor

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drug

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vaila

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rege

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com

go

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Gen

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Cov

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med

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at 3

0

coin

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up to

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d 40

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e pr

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t A

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to m

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first

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Pre

ferr

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rand

dr

ugs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

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c

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ce u

p to

$60

max

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90

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up

to $

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axim

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mai

l ord

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Bra

nd d

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nsur

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up

to $

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max

imum

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-day

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30

coi

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up

to $

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max

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90

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up

to $

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tail

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Ref

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gen

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pr

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bran

d an

d br

and

drug

s ab

ove

N

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over

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If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

4 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

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tio

ns

amp O

ther

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nte

Pre

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wo

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Lim

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N

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vid

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mo

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surg

ery

cent

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Phy

sici

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10

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15

coi

nsur

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40

c

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50

coi

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for

Out

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ork

prov

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s

If y

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med

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m

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tio

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ncy

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15

coi

nsur

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app

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20

c

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Urg

ent c

are

10

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ho

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ce

40

coi

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50

c

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ce fo

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ut-o

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sici

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fees

10

c

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15

coi

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40

c

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50

coi

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for

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prov

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s

If y

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d m

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ehav

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use

se

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patie

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of

fice

visi

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c

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15

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30

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40

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Inpa

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15

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for

prof

essi

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and

30

c

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uran

ce fo

r fa

cilit

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40

coi

nsur

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50

c

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uran

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ou

are

pre

gn

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Offi

ce v

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10

c

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uran

ce

15

coi

nsur

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40

c

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coi

nsur

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for

Out

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prov

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s

Cos

t sha

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40

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Chi

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10

c

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ce

30

coi

nsur

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40

c

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uran

ce

5 o

f 7

Co

mm

on

Med

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Eve

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Ser

vice

s Y

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May

Nee

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Wh

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ou

Will

Pay

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nte

Pre

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leas

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Reg

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wo

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Pro

vid

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leas

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Reg

ence

Lim

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N

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vid

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mo

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Hom

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coi

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30

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coi

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s

Inpa

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to 3

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health

Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been

performed Surgery and reconstruction of the other breast as necessary to provide

a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event

For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)

Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075

Asante Health PlanAnnual Required Notices

To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)

Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others

The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits

toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020

The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger

The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks

1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen

2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program

If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA

If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts

The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower

Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year

Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health

If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status

The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor

Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment

Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs

In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately

You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate

If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995

Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not

discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender

Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio

accessible electronic formats and other formats) bull Asante provides free language services to people whose primary

language is not English including o Qualified interpreters o Information written in other languages

If you need these services contact Alicia Lorenz at the phone number or email address listed below

If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)

You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)

Complaint forms are available at hhsgovocrofficefileindexhtml

20HR011

This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020

Asante Health Plan changesPlan names  Asante Health Plan 1 is being

renamed Asante PPO Health Plan  Asante Health Plan 2 is being

renamed Asante Savings HealthPlan or HSA

  Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA

For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use

Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers

A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles  The deductibles for the new

Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family

Out-of-pocket maximums  There will no longer be separate

out-of-pocket maximums forprescription drug expenses

Rx expenses will be counted toward the medical out-of-pocket maximums

  The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family

Copay and coinsurance changes  The office visit copay for primary

care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)

  The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)

  The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50

Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles  The deductibles for the four

categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family

Out-of-pocket maximums  The out-of-pocket maximums for the

four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family

Copay and coinsurance changes  The office visit coinsurance for

primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)

The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)

  The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50

Health Savings Account  The HSA contribution limit has

increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage

Employer contributions to the HSA Asante contributes to your HSA

if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled

Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four

categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family

Out-of-pocket maximums There will no longer be separate

out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums

Whatrsquos new for 2020

The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family

Copay and coinsurance changes The office visit copay for primary

care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)

The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)

The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50

Employer contributions to the HRA Asante contributes to your HRA

account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents

Other changes In the Asante Reimbursement

Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations

In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers

Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan

(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)

Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit

All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet

All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply

A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible

Dental plan changes The Willamette Dental plan will have

a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year

There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan

Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits

Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012

Critical illness and accident plans Certain insurance policies are

available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505

Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information

This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025

All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services

We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization

How We May Use and Disclose Your Protected Health Information

Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories

For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use

For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments

For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes

To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us

As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws

Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it

The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage

This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System

The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees

What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage

If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen

1 Your hours of employment are reduced or

2 Your employment ends for any reason other than your gross misconduct

If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens

1 Your spouse dies

2 Your spousersquos hours of employment are reduced

3 Your spousersquos employment ends for any reason other than his or her gross misconduct

4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or

5 You become divorced or legally separated from your spouse

Continuation Coverage Rights Under Cobra

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens

1 The parent-employee dies

2 The parent-employeersquos hours of employment are reduced

3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct

4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)

5 The parents become divorced or legally separated or

6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo

Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan

When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event

You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to

Asante Health System

How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended

Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov

If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)

Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator

Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Updated 91418 ND

PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is

eligible for coverage please contact us so that we can provide them with this notice

Important Notice from Asante About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug

coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice

There are two important things you need to know about your current coverage and Medicarersquos

prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium

2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan

When Can You Join A Medicare Drug Plan

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th

However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan

You should also know that if you drop or lose your current coverage with Asante and donrsquot join a

Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later

Page 2

If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join

For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time

If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by

Medicare in the next 12 months this notice doesnrsquot apply to you

For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos

how to get more information about Medicare prescription drug plans

Visit wwwmedicaregov

Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048

For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)

Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)

6 o

f 8

Co

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8 o

f 8

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wo

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es)

Reh

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phys

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ther

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T

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ost

$1

925

In

th

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xam

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wo

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pay

Cos

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Ded

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$500

Cop

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$1

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$2

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Wha

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Th

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$9

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Ab

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Th

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no

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cost

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or

Tre

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wn

are

just

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this

pla

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cov

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are

You

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tual

cos

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ill b

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ffere

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ding

on

the

actu

al c

are

you

rece

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the

pric

es y

our

prov

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s ch

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and

man

y ot

her

fact

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Foc

us o

n th

e co

st s

harin

g am

ount

s (d

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s c

opay

men

ts a

nd c

oins

uran

ce)

and

excl

uded

ser

vice

s un

der

the

plan

Use

this

info

rmat

ion

to c

ompa

re th

e po

rtio

n of

co

sts

you

mig

ht p

ay u

nder

diff

eren

t hea

lth p

lans

Ple

ase

note

thes

e co

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xam

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are

bas

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lf-on

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over

age

NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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isits

$7

5 co

pay

ret

ail

clin

ic v

isit

de

duct

ible

doe

s no

t app

ly

40

coi

nsur

ance

fo

r al

l oth

er

serv

ices

40

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

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C

opay

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ach

Asa

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twor

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etw

ork

Reg

ence

lim

ited

netw

ork

offic

e vi

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onl

y A

ll ot

her

serv

ices

that

ar

e no

t bill

ed a

s an

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ce v

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are

cove

red

at th

e co

insu

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e sp

ecifi

ed a

fter

dedu

ctib

le

Cov

erag

e fo

r ac

upun

ctur

e an

d ch

iropr

actic

sp

inal

man

ipul

atio

ns is

sub

ject

to $

25

copa

ymen

t for

Reg

ence

net

wor

k pr

ovid

ers

Reg

ence

lim

ited

netw

ork

prov

ider

s an

d 50

c

oins

uran

ce fo

r ou

t-of

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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

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ns

Coi

nsur

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app

lies

to th

e ou

t-of

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ket l

imit

Spe

cial

ist v

isit

$10

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

10

c

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ce fo

r al

l oth

er s

ervi

ces

$25

copa

y o

ffice

vi

sit

dedu

ctib

le d

oes

not a

pply

15

c

oins

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ce fo

r al

l oth

er s

ervi

ces

$75

copa

y o

ffice

vi

sit

dedu

ctib

le

does

not

app

ly

40

coi

nsur

ance

fo

r al

l oth

er

serv

ices

Pre

vent

ive

care

scr

eeni

ng

imm

uniz

atio

n N

o ch

arge

N

o ch

arge

N

o ch

arge

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

afte

r de

duct

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Y

ou m

ay h

ave

to p

ay fo

r se

rvic

es th

at a

ren

t pr

even

tive

Ask

you

r pr

ovid

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the

serv

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ne

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are

pre

vent

ive

The

n ch

eck

wha

t you

r pl

an w

ill p

ay fo

r S

ubje

ct to

pre

vent

ive

care

3 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

Info

rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

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Pro

vid

er

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u w

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he

leas

t)

Reg

ence

Lim

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N

etw

ork

Pro

vid

er

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u w

ill p

ay t

he

mo

st)

guid

elin

es

If y

ou

hav

e a

test

Dia

gnos

tic te

st (

x-ra

y

bloo

d w

ork)

10

c

oins

uran

ce

30

coi

nsur

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40

c

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uran

ce

50

coi

nsur

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for

Out

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netw

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prov

ider

s

afte

r de

duct

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Im

agin

g (C

TP

ET

sc

ans

MR

Is)

10

c

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30

coi

nsur

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40

c

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uran

ce

If y

ou

nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

itio

n

Mor

e in

form

atio

n ab

out

pres

crip

tion

drug

cov

erag

e

is a

vaila

ble

at

rege

nce

com

go

drug

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020

OR

3tie

r

Gen

eric

dru

gs

$5 c

opay

30

-day

re

tail

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crip

tion

$10

copa

y 9

0-da

y re

tail

pres

crip

tion

$15

copa

y r

etai

l pr

escr

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n $2

0 co

pay

mai

l or

der

pres

crip

tion

Not

cov

ered

Ded

uctib

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oes

not a

pply

Li

mite

d to

a 3

0-da

y su

pply

ret

ail a

nd u

p to

90-

day

supp

ly a

t Asa

nte

Out

patie

nt P

harm

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s or

th

roug

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ail o

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N

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FD

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mun

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ticip

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arm

acy

C

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com

poun

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edic

atio

ns a

t 30

c

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uran

ce u

p to

$10

0 m

axim

um a

t A

sant

e O

utpa

tient

Pha

rmac

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and

40

co

insu

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to $

200

max

imum

at a

Reg

ence

pa

rtic

ipat

ing

reta

il ph

arm

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ref

er to

yo

ur p

lan

for

furt

her

info

rmat

ion

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l-ord

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nsur

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up

to $

120

max

imum

Out

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netw

ork

pres

crip

tion

drug

cov

erag

e is

not

co

vere

d

You

are

res

pons

ible

for

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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

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dru

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add

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to th

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paym

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firs

t fill

for

sele

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peci

alty

dru

gs m

ay b

e pr

ovid

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t a p

artic

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ing

reta

il ph

arm

acy

ad

ditio

nal f

ills

mus

t be

prov

ided

at A

sant

e O

utpa

tient

Pha

rmac

ies

For

all

othe

r sp

ecia

lty

drug

s th

e fir

st fi

ll m

ust b

e pr

ovid

ed a

t Asa

nte

Out

patie

nt P

harm

acie

s If

Asa

nte

Out

patie

nt

Pha

rmac

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are

una

ble

to fi

ll th

ey w

ill

coor

dina

te a

fill

thro

ugh

a R

egen

ce S

peci

alty

P

harm

acy

Ple

ase

refe

r to

my

HR

for

a lis

t of

med

icat

ions

that

req

uire

the

first

fill

at A

sant

e O

utpa

tient

Pha

rmac

ies

Pre

ferr

ed b

rand

dru

gs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

ret

ail

pres

crip

tion

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coi

nsur

ance

up

to $

60 m

axim

um

reta

il pr

escr

iptio

n 35

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ce u

p to

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0 m

axim

um

mai

l ord

er

pres

crip

tion

Not

cov

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Bra

nd d

rugs

30

coi

nsur

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up

to $

100

max

imum

30

-day

ret

ail

pres

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tion

30

coi

nsur

ance

up

to $

300

max

imum

90

-day

ret

ail

pres

crip

tion

40

coi

nsur

ance

up

to $

200

max

imum

re

tail

pres

crip

tion

40

coi

nsur

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up

to $

600

max

imum

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ail o

rder

pr

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iptio

n

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cov

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Spe

cial

ty d

rugs

R

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to g

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erre

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Ref

er to

gen

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pr

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red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

4 o

f 8

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

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ion

Asa

nte

Pre

ferr

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Net

wo

rk P

rovi

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(Y

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will

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th

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ast)

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ence

Net

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Pro

vid

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ery

Fac

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bula

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40

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Out

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prov

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sici

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10

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af

ter

dedu

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If y

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med

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edic

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tten

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Em

erge

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room

car

e $1

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opay

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sit

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t de

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itted

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med

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tr

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tion

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app

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ance

20

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ce

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for

Out

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ider

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afte

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Urg

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are

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copa

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de

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for

Out

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prov

ider

s

afte

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lies

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ach

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Reg

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lim

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gent

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sit

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ou

hav

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ho

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al

stay

Fac

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10

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nsur

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30

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ce

40

coi

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50

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af

ter

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sici

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on fe

es

10

coi

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15

c

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40

coi

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50

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f-ne

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af

ter

dedu

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If y

ou

nee

d m

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ealt

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ehav

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r su

bst

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ab

use

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Out

patie

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ces

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y o

ffice

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sit

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l oth

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copa

y o

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sit

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r pr

ofes

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30

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sit

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40

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fo

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for

Out

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coin

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Inpa

tient

ser

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s 10

c

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ce

15

coi

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for

prof

essi

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and

30

c

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ce fo

r fa

cilit

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40

coi

nsur

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50

c

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uran

ce fo

r O

ut-o

f-ne

twor

k pr

ovid

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af

ter

dedu

ctib

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5 o

f 8

Co

mm

on

Med

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Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

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rmat

ion

Asa

nte

Pre

ferr

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Net

wo

rk P

rovi

der

(Y

ou

will

pay

th

e le

ast)

Reg

ence

Net

wo

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Pro

vid

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u w

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Reg

ence

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vid

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u w

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pre

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Offi

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10

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40

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prov

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type

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15

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40

c

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Chi

ldbi

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deliv

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faci

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40

c

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ave

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rapy

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rapy

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10

c

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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Med

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Pay

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15

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prov

ider

s

If y

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Inpa

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pre

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Offi

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coi

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Out

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Chi

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5 o

f 7

Co

mm

on

Med

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Eve

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Ser

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s Y

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May

Nee

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Wh

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Pay

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Pre

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Hom

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-of-

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der

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plan

Use

this

info

rmat

ion

to c

ompa

re th

e po

rtio

n of

co

sts

you

mig

ht p

ay u

nder

diff

ere

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ealth

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only

cov

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

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ost y

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pay

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yea

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yo

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plan

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Che

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get s

ervi

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Do

yo

u n

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N

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can

see

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spec

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l

A

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bee

n m

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app

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Co

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Med

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Ser

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Nee

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Wh

at Y

ou

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Pay

Lim

itat

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amp O

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Imp

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wo

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Prim

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care

vis

it to

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inju

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r ill

ness

10

c

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uran

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15

coi

nsur

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app

licab

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r pr

imar

y ca

re v

isits

40

c

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ce

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vis

it

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Out

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netw

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prov

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Cov

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es p

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y ca

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at a

ret

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linic

C

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for

acup

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and

chiro

prac

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pina

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ions

is s

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20

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for

Reg

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net

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ce li

mite

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ovid

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and

40

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for

out-

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s

Lim

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to $

200

0 y

ear

for

acup

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and

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for

spin

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pplie

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the

out-

of-p

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it

Spe

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10

coi

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15

c

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Pre

vent

ive

care

scr

eeni

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imm

uniz

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n N

o ch

arge

N

o ch

arge

N

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You

may

hav

e to

pay

for

serv

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that

are

nt

prev

entiv

e A

sk y

our

prov

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if th

e se

rvic

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eede

d ar

e pr

even

tive

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n ch

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wha

t you

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to p

reve

ntiv

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re g

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lines

If y

ou

hav

e a

test

Dia

gnos

tic te

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x-ra

y b

lood

wor

k)

10

coi

nsur

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30

c

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uran

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40

coi

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50

coi

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for

Out

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prov

ider

s

Imag

ing

(CT

PE

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scan

s M

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)

10

coi

nsur

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30

c

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40

coi

nsur

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3 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

ort

ant

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rmat

ion

Asa

nte

Pre

ferr

ed

Net

wo

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rovi

der

(Yo

u w

ill p

ay t

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leas

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ence

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wo

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Pro

vid

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u w

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he

leas

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Reg

ence

Lim

ited

N

etw

ork

Pro

vid

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(Yo

u w

ill p

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he

mo

st)

If y

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nee

d d

rug

s to

tre

at

you

r ill

nes

s o

r co

nd

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n

Mor

e in

form

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out

pres

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drug

cov

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vaila

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at

rege

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com

go

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Gen

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cov

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Ded

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for

drug

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sign

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as

prev

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r tr

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f chr

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at a

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n th

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sant

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pa

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phar

mac

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Cov

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es c

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und

med

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ions

at 3

0

coin

sura

nce

up to

$10

0 m

axim

um a

t Asa

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Out

patie

nt P

harm

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d 40

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p to

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is n

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You

are

res

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for

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add

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to th

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spec

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he fi

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e pr

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t A

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sant

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harm

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peci

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to m

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r a

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first

fil

l at A

sant

e O

utpa

tient

Pha

rmac

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Pre

ferr

ed b

rand

dr

ugs

25

coi

nsur

ance

up

to $

30 m

axim

um

30-d

ay r

etai

l pr

escr

iptio

n 25

c

oins

uran

ce u

p to

$60

max

imum

90

-day

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ail

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up

to $

60 m

axim

um

reta

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c

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p to

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axim

um

mai

l ord

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pres

crip

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cov

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Bra

nd d

rugs

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nsur

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up

to $

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max

imum

30

-day

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ail

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30

coi

nsur

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up

to $

300

max

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90

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pres

crip

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40

coi

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up

to $

200

max

imum

re

tail

pres

crip

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nsur

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up

to $

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imum

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ail o

rder

pr

escr

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cov

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Spe

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ty d

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R

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to g

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and

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d dr

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Ref

er to

gen

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pr

efer

red

bran

d an

d br

and

drug

s ab

ove

N

ot c

over

ed

If y

ou

hav

e o

utp

atie

nt

surg

ery

Fac

ility

fee

(eg

am

bula

tory

10

c

oins

uran

ce

30

coi

nsur

ance

40

c

oins

uran

ce

50

coi

nsur

ance

for

Out

-of-

netw

ork

prov

ider

s

4 o

f 7

Co

mm

on

Med

ical

Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

ns

amp O

ther

Imp

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ant

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rmat

ion

Asa

nte

Pre

ferr

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Net

wo

rk P

rovi

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u w

ill p

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he

leas

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ence

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wo

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Pro

vid

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(Yo

u w

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leas

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ence

Lim

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N

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Pro

vid

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u w

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mo

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surg

ery

cent

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sici

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on

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10

c

oins

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15

coi

nsur

ance

40

c

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uran

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50

coi

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for

Out

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netw

ork

prov

ider

s

If y

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nee

d im

med

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m

edic

al a

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tio

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erge

ncy

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ca

re

15

coi

nsur

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c

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15

coi

nsur

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15

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uran

ce fo

r O

ut-o

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ncy

med

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tion

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app

licab

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coi

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20

c

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for

Out

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prov

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s

Urg

ent c

are

10

coi

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30

c

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ce

40

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50

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ut-o

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ou

hav

e a

ho

spit

al

stay

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fee

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ho

spita

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30

c

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ce

40

coi

nsur

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50

c

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uran

ce fo

r O

ut-o

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ovid

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Phy

sici

ans

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on

fees

10

c

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uran

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15

coi

nsur

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40

c

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50

coi

nsur

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for

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netw

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prov

ider

s

If y

ou

nee

d m

enta

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ealt

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ehav

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o

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bst

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use

se

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patie

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of

fice

visi

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c

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15

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40

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Inpa

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15

coi

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for

prof

essi

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and

30

c

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uran

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r fa

cilit

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40

coi

nsur

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50

c

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uran

ce fo

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ovid

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ou

are

pre

gn

ant

Offi

ce v

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10

c

oins

uran

ce

15

coi

nsur

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40

c

oins

uran

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nsur

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for

Out

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prov

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s

Cos

t sha

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pre

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co

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ded

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Mat

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Chi

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faci

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serv

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10

c

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ce

30

coi

nsur

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40

c

oins

uran

ce

5 o

f 7

Co

mm

on

Med

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Eve

nt

Ser

vice

s Y

ou

May

Nee

d

Wh

at Y

ou

Will

Pay

Lim

itat

ion

s E

xcep

tio

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ther

Imp

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rmat

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Asa

nte

Pre

ferr

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wo

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rovi

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u w

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he

leas

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Reg

ence

Net

wo

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Pro

vid

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u w

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he

leas

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Reg

ence

Lim

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N

etw

ork

Pro

vid

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u w

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mo

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Hom

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alth

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to 1

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10

coi

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30

c

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coi

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prov

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Inpa

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to 3

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rapy

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rapy

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In

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NONDISCRIMINATION NOTICE

0101201704PF12LNoticeNDMARegence

Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Regence does not exclude people or treat them differently because of race color national origin age disability or sex Regence Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio and accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages If you need these services listed above please contact Medicare Customer Service 1-800-541-8981 (TTY 711) Customer Service for all other plans 1-888-344-6347 (TTY 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with our civil rights coordinator below Medicare Customer Service Civil Rights Coordinator MS B32AG PO Box 1827 Medford OR 97501 1-866-749-0355 (TTY 711) Fax 1-888-309-8784 medicareappealsregencecom Customer Service for all other plans Civil Rights Coordinator MS CS B32B PO Box 1271 Portland OR 97207-1271 1-888-344-6347 (TTY 711) CSregencecom

You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

Language assistance

0101201704PF12LNoticeNDMARegence

ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten

servicios gratuitos de asistencia linguumliacutestica Llame al

1-888-344-6347 (TTY 711)

注意如果您使用繁體中文您可以免費獲得語言

援助服務請致電 1-888-344-6347 (TTY 711)

CHUacute Yacute Nếu bạn noacutei Tiếng Việt coacute caacutec dịch vụ hỗ

trợ ngocircn ngữ miễn phiacute dagravenh cho bạn Gọi số 1-888-

344-6347 (TTY 711)

주의 한국어를 사용하시는 경우 언어 지원

서비스를 무료로 이용하실 수 있습니다 1-888-

344-6347 (TTY 711) 번으로 전화해 주십시오

PAUNAWA Kung nagsasalita ka ng Tagalog maaari

kang gumamit ng mga serbisyo ng tulong sa wika nang

walang bayad Tumawag sa 1-888-344-6347 (TTY

711)

ВНИМАНИЕ Если вы говорите на русском языке

то вам доступны бесплатные услуги перевода

Звоните 1-888-344-6347 (телетайп 711)

ATTENTION Si vous parlez franccedilais des services

daide linguistique vous sont proposeacutes gratuitement

Appelez le 1-888-344-6347 (ATS 711)

注意事項日本語を話される場合無料の言語支

援をご利用いただけます1-888-344-6347

（TTY711）までお電話にてご連絡ください

tirsquogo Dineacute

Bizaad saad

1-888-344-6347 (TTY 711)

FAKATOKANGArsquoI Kapau lsquooku ke Lea-

Fakatonga ko e kau tokoni fakatonu lea lsquooku nau fai

atu ha tokoni tarsquoetotongi pea te ke lava lsquoo marsquou ia

harsquoo telefonimai mai ki he fika 1-888-344-6347 (TTY

711)

OBAVJEŠTENJE Ako govorite srpsko-hrvatski

usluge jezičke pomoći dostupne su vam besplatno

Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa

oštećenim govorom ili sluhom 711)

បរយតន បរើសនជាអនកនយាយ ភាសាខមែរ បសវាជនយខននកភាសា បោយមនគតឈន ល គអាចមានសរាររបរ ើអនក ចរ ទរសពទ 1-888-344-

6347 (TTY 711)

ਧਿਆਨ ਧਿਓ ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਿ ਹ ਤਾ ਭਾਸ਼ਾ ਧ ਿ ਚ

ਸਹਾਇਤਾ ਸ ਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਿ ਹ 1-888-344-

6347 (TTY 711) ਤ ਕਾਲ ਕਰ

ACHTUNG Wenn Sie Deutsch sprechen stehen

Ihnen kostenlose Sprachdienstleistungen zur

Verfuumlgung Rufnummer 1-888-344-6347 (TTY 711)

ማስታወሻ- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል በሚከተለው ቁጥር

ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው- 711)

УВАГА Якщо ви розмовляєте українською

мовою ви можете звернутися до безкоштовної

служби мовної підтримки Телефонуйте за

номером 1-888-344-6347 (телетайп 711)

धयान दिनहोस तपारइल नपाली बोलनहनछ भन तपारइको दनदतत भाषा सहायता सवाहर

दनिःशलक रपमा उपलबध छ फोन गनहोस 1-888-344-6347 (दिदिवारइ

711

ATENȚIE Dacă vorbiți limba romacircnă vă stau la

dispoziție servicii de asistență lingvistică gratuit

Sunați la 1-888-344-6347 (TTY 711)

MAANDO To a waawi [Adamawa] e woodi ballooji-

ma to ekkitaaki wolde caahu Noddu 1-888-344-6347

(TTY 711)

โปรดทราบ ถาคณพดภาษาไทย คณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-888-344-6347 (TTY 711)

ໂປດຊາບ ຖາວາ ທານເວ າພາສາ ລາວ

ການບ ລ ການຊວຍເຫ ອດານພາສາ ໂດຍບ ເສຽຄາ ແມນມ ພອມໃຫທານ

ໂທຣ 1-888-344-6347 (TTY 711)

Afaan dubbattan Oroomiffaa tiif tajaajila gargaarsa

afaanii tola ni jira 1-888-344-6347 (TTY 711) tiin

bilbilaa

شمای برا گانیرا بصورتی زبان لاتیتسه دیکنی مصحبت فارسی زبان به اگر توجه

دیریبگ تماس (TTY 711) 6347-344-888-1 با باشدی م فراهم

6347-344-888-1ملحوظة إذا كنت تتحدث فاذكر اللغة فإن خدمات المساعدة اللغویة تتوافر لك بالمجان اتصل برقم

TTY 711)هاتف الصم والبكم )رقم

This document provides you with important notices and information about the Asante Health Plan Womenrsquos health and cancer rights Special enrollment rights Newborn and motherrsquos health protection Premium assistance under Medicaid and the Childrenrsquos Health

Insurance Program (CHIP) Notice about womenrsquos health and cancer rights in the Asante Health PlanThe Womenrsquos Health and Cancer Rights Act of 1998 requires group health plans to cover certain expenses relating to a mastectomy The Asante Health Plan complies with this law and will cover the following Medical and surgical charges directly related to a mastectomy Reconstruction of the breast on which the mastectomy has been

performed Surgery and reconstruction of the other breast as necessary to provide

a symmetrical appearance Prosthetic devices relating to such breast reconstruction Treatment of physical complications arising from a mastectomy These benefits will be provided subject to the same deductibles co-pays and co-insurance provisions applicable to other medical and surgical benefits provided under the plan If you have any questions regarding this law please contact the Asante Human Resources Department at (541) 789-4551 or Regence at (866) 344-8235 Notice about special enrollment rights in the Asante Health PlanLoss of other coverage If you declined enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependentsrsquo other coverage) You do not need to wait for the next open enrollment period You must request enrollment within 30 days after your or your dependentsrsquo other coverage ends (or after the employer stops contributing toward the other coverage) New dependent by marriage birth adoption or placement for adoption If you have a new dependent as a result of marriage birth adoption or placement for adoption you may be able to enroll yourself and your dependents without waiting for the next open enrollment period You must request enrollment within 30 days after the marriage birth adoption or placement for adoption Individuals who become eligible for state premium assistance subsidy If you declined enrollment for yourself or your dependents (including your spouse) you may enroll yourself or your dependent(s) in this plan if (1) The family loses its Medicaid or CHIP coverage because its employment situation improves the family can then sign up for employer-sponsored coverage without having to wait for the open enrollment period and experiencing a gap in coverage (2) A child becomes eligible for Medicaid or CHIP and has access to employer-sponsored coverage which the state wishes to subsidize through a premium assistance option the family may then sign up immediately and does not have to wait for the open enrollment period Enrollment must be requested within 60 days following the date of the eligibility event

For information on eligibility for coverage either through Medicaid or Oregonrsquos CHIP program (typically administered through the Oregon Health Plan) please contact the Department of Human Services (DHS)

Oregon Department of Human Services Office of Medical Assistance ProgramsPhone (503) 945-5772 Toll-free (800) 527-5772 TTY (800) 375-2863 Email dhsinfostateorusWebsite oregongovOHAhealthplanPagesindexaspx Address 500 Summer St NE E37 Salem OR 97301-1079 To request special enrollment or obtain more information contact the Asante Human Resources Department at (541) 789-4551 Notice about newbornsrsquo and mothersrsquo health protectionGroup health plans and health insurance issuers generally may not under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section However federal law generally does not prohibit the motherrsquos or newbornrsquos attending provider after consulting with the mother from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable) In any case plans and issuers may not under federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours) Notice about premium assistance under Medicaid and the Childrenrsquos Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and yoursquore eligible for health coverage from your employer your state may have a premium assistance program that can help pay for coverage using funds from their Medicaid or CHIP programs If you or your children arenrsquot eligible for Medicaid or CHIP you wonrsquot be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the health insurance marketplace For more information visit healthcaregov If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below contact your state Medicaid or CHIP office to find out if premium assistance is available If you or your dependents are not currently enrolled in Medicaid or CHIP and you think you or any of your dependents might be eligible for either of these programs contact your state Medicaid or CHIP office or dial (877) KIDS NOW or insurekidsnowgov to find out how to apply If you qualify ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan If you or your dependents are eligible for premium assistance under Medicaid or CHIP and are eligible under your employer plan your employer must allow you to enroll in your employer plan if you arenrsquot already enrolled This is called a ldquospecial enrollmentrdquo opportunity and you must request coverage within 60 days of being determined eligible for premium assistance If you have questions about enrolling in your employer plan contact the Department of Labor at askebsadolgov or call (866) 444-EBSA (3272) If you live in Oregon you may be eligible for assistance paying your employer health plan premiums If you reside in another state please contact Asante Human Resources at (541) 789-4551 The following is current as of Jan 31 2020 Contact your state for more information on eligibilityOREGON mdash Medicaid healthcareoregongovPhone (800) 699-9075

Asante Health PlanAnnual Required Notices

To see if any other states have added a premium assistance program since July 31 2019 or for more information on special enrollment rights contact either US Department of Labor Employee Benefits Security Administration dolgovebsa | (866) 444-EBSA (3272) US Department of Health and Human Services Centers for Medicare amp Medicaid Servicescmshhsgov | (877) 267-2323 menu option 6 ext 61565 OMB Control Number 1210-0137 (expires 1312023)

Notice regarding Asante Wellness ProgramsAsante Wellness Programs are voluntary wellness programs available to employees and their spouses participating in one of the Asante medical plan options (ldquoMedical Planrdquo) The programs are administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease including the Americans with Disabilities Act of 1990 the Genetic Information Nondiscrimination Act of 2008 and the Health Insurance Portability and Accountability Act as applicable among others

The three Asante Wellness Programs The first Asante Wellness Program gives the employee premium credits

toward the Medical Plan premiums otherwise payable by the employee in the following calendar year To earn this incentive you must complete two tasks in the current calendar year To earn the premium credit for 2021 for example you must complete the tasks during 2020

The first task is to complete a voluntary online Healthy Lifestyle Assessment on MyChart that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (eg cancer diabetes or heart disease) The second task is to complete an on-site biometric screening or have an off-site preventive medical exam that includes biometric testing for height weight waist circumference blood pressure total cholesterol and HDL cholesterol If your spouse also completes these two tasks your premium credits will be larger

The second Asante Wellness Program provides incentives of up to $600 in annual contributions to the employeersquos health reimbursement account (HRA) or health savings account (HSA) These incentives are available if the employee or spouse completes one of following five tasks

1 Have one of the following medical exams wellness exam weight screen vision or dental exam colorectal cancer screen mammogram womenrsquos health exam prostate or skin cancer screen

2 Complete the Livongo Diabetes Program 3 Attend two Asante-sponsored webinars on mental health issues 4 Attend an Asante-sponsored financial health program 5 Complete an Asante-approved tobacco cessation program

If the employee or spouse is participating in the Asante Savings Health Plan or the Asante Reimbursement Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $300 contribution into either the employeersquos HRA or HSA If both the employee and spouse complete one of the required tasks the employee will receive a $600 contribution into either the employeersquos HRA or HSA

If the employee or spouse is participating the Asante PPO Health Plan and the employee or spouse completes one of the required tasks the employee will receive a $75 contribution into the employeersquos HRA If both the employee and spouse complete one of the required tasks the employee will receive a $150 contribution into the employeersquos HRA These contributions are in addition to any other contribution that Asante makes to these accounts

The third Asante Wellness Program provides a $25 gift card to employees who complete an online health risk assessment through Regence Empower

Rules applicable to all three wellness programsYou are not required to complete the Healthy Lifestyle Assessment the Regence Empower health risk assessment or other tasks listed above or to participate in the blood tests or other parts of the biometric screening or a medical examination However only employees and spouses who choose to complete the required tasks will receive an incentive in the following calendar year

Spouses who participate in the Asante Wellness Programs must complete an authorization form prior to beginning the program This form is available from Asante Employee Health

If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive under any of the Asante Wellness Programs you may be entitled to a reasonable accommodation or an alternative standard If you think you might be unable to meet a standard for an incentive you can earn the incentive by different means You may request a reasonable accommodation or an alternative standard by contacting the Asante HRBenefits at (541) 789-4551 We will work with you (and if you wish your doctor) to find a program with the same incentive that is right for you and your health status

The information from your Healthy Lifestyle Assessment the Regence Empower health risk assessment your biometric screening medical exams or any other medical tests that are a part of the Asante Wellness Programs will provide you with information to help you understand your current health and potential health risks and in some cases may also be used to offer you services through the Asante Wellness Programs You also are encouraged to share your results or concerns with your own doctor

Protections from disclosure of medical informationThe medical information received as part of the Asante Wellness Programs is subject to the privacy and security rules of a federal law called HIPAA We are required by HIPAA and other applicable law to maintain the privacy and security of your personally identifiable health information Although the Asante Wellness Programs and Asante may use aggregate information Asante collects to design a program based on identified health risks in the workplace the Asante Wellness Programs will never disclose any of your personal information either publicly or to your employer except as necessary to respond to a request from you for a reasonable accommodation needed to participate in an Asante Wellness Program or as otherwise expressly permitted by law Medical information that personally identifies you that is provided in connection with the Asante Wellness Programs will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment

Your health information will not be sold exchanged transferred or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the Asante Wellness Programs You will not be asked or required to waive the confidentiality of your health information as a condition of participating in the Asante Wellness Programs or receiving an incentive Anyone who receives your information for purposes of providing you services as part of the Asante Wellness Programs will abide by the same confidentiality requirements The only individuals who will receive your personally identifiable health information are those who will provide you with services under the Asante Wellness Programs

In addition all medical information obtained through the Asante Wellness Programs will be maintained separately from your personnel records Information stored electronically will be encrypted and no information you provide as part of the Asante Wellness Programs will be used in making any employment decision Appropriate precautions will be taken to avoid any data breach In the event a data breach occurs involving information you provide in connection with the wellness program we will notify you immediately

You may not be discriminated against in employment if you decide not to participate in one or more aspects of the Asante Wellness Programs or because of the medical information you provide as part of participating in the Asante Wellness Programs You will not be subjected to retaliation if you choose not to participate

If you have questions or concerns regarding this notice or about protections against discrimination and retaliation please contact Asante Health Promotion at (541) 789-4995

Notice of non-discrimination Asante complies with applicable federal civil rights laws and does not

discriminate on the basis of race color national origin age disability or gender Asante does not exclude people or treat them differently because of race color national origin age disability or gender

Asante provides free aids and services that allow people with disabilities to communicate effectively with caregivers and others in the organization including o Qualified sign language interpreters o Written information in other formats (large print audio

accessible electronic formats and other formats) bull Asante provides free language services to people whose primary

language is not English including o Qualified interpreters o Information written in other languages

If you need these services contact Alicia Lorenz at the phone number or email address listed below

If you believe that Asante has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or gender you can file a grievance with Alicia Lorenz director of employee and labor relations2635 Siskiyou Blvd Medford OR 97504(541) 789-4227 (phone) (541) 789-4509 (fax) alicialorenzasanteorg (email)

You can file a grievance in person or by mail fax or email If you need help filing a grievance Alicia Lorenz director of employee and labor relations is available to help You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services200 Independence Ave SW Room 509F HHH BuildingWashington DC 20201 | (800) 368ndash1019 (800) 537ndash7697 (TDD)

Complaint forms are available at hhsgovocrofficefileindexhtml

20HR011

This document describes in summary fashion the changes being made to the Asante Employee Benefits Plan (the ldquoPlanrdquo) beginning Jan 1 2020 it amends the terms of the 2018 Summary Plan Description for the Plan Important changes to certain benefits under the Plan as described below go into effect on Jan 1 2020

Asante Health Plan changesPlan names  Asante Health Plan 1 is being

renamed Asante PPO Health Plan  Asante Health Plan 2 is being

renamed Asante Savings HealthPlan or HSA

  Asante Health Plan 3 is beingrenamed Asante ReimbursementHealth Plan or HRA

For all Asante health plans there will be an additional category of network providers (new Category 3) called theRegence Limited Network so there willbe four different categories of providers that health plan participants may use

Category 1 Asante Preferred NetworkCategory 2 Regence NetworkCategory 3 Regence Limited NetworkCategory 4 Out-of-network providers

A list of providers in the first three categories will be made available to persons participating in the healthplan Providers not in the first threecategories are considered Category 4Out-of-network providers Deductibles out-of-pocketmaximums and copaycoinsurance changesAsante PPO Health Plan (formerly Asante Health Plan 1)Deductibles  The deductibles for the new

Category 3 Regence LimitedNetwork providers and the newdeductibles for Category 4Out-of-network providers areCategory 3 $2000 individual$4000 familyCategory 4 $2500 individual$4000 family

Out-of-pocket maximums  There will no longer be separate

out-of-pocket maximums forprescription drug expenses

Rx expenses will be counted toward the medical out-of-pocket maximums

  The out-of-pocket maximums forthe new Category 3 RegenceLimited Network providers andthe new out-of-pocket maximumsfor Category 4 Out-of-networkproviders areCategory 3 $7500 individual$15000 familyCategory 4 $8250 individual $16500 family

Copay and coinsurance changes  The office visit copay for primary

care specialty and urgent careproviders in the Category 1 AsantePreferred Network is reduced to$10 (deductible waived)

  The office visit copay for specialtyand urgent care providers in the newCategory 3 Regence LimitedNetwork is $75 (deductible waived)

  The coinsurance for lab andinpatientoutpatient professional andfacility services for each category ofproviders isCategory 1 15Category 2 15 professional30 facilityCategory 3 40Category 4 50

Asante Savings Health Plan (formerly Asante Health Plan 2)Deductibles  The deductibles for the four

categories of providers areCategory 1 $1400 individual$2800 familyCategory 2 $1400 individual$2800 familyCategory 3 $3500 individual$7000 familyCategory 4 $4500 individual$9000 family

Out-of-pocket maximums  The out-of-pocket maximums for the

four categories of providers areCategory 1 $2000 individual$3000 familyCategory 2 $3000 individual$6000 familyCategory 3 $6000 individual$12000 familyCategory 4 $8000 individual$14000 family

Copay and coinsurance changes  The office visit coinsurance for

primary care and specialty providers in the Category 1 Asante Preferred Network is reduced to 10 (after deductible is met)

The office visit coinsurance forspecialty and urgent care providersin the new Category 3 RegenceLimited Network is 40 (afterdeductible is met)

  The coinsurance for lab andinpatientoutpatient professional andfacility services (after deductible)foreach category of providers isCategory 1 10Category 2 15 professional30 facilityCategory 3 40Category 4 50

Health Savings Account  The HSA contribution limit has

increased to allow employees up toage 54 to contribute as muchas $3550 annually for employee- only coverage and $7100 foremployees covering dependentsEmployees who turn age 55 in 2020or are older can contribute up toanadditional $1000 for either typeof coverage

Employer contributions to the HSA Asante contributes to your HSA

if you are a full-time employeeenrolled in the Asante SavingsHealth Plan These contributions for2020 will increase to $300 per yearfor full-time employees enrolled inemployee-only coverage and to $600for full-time employees who also havedependents enrolled

Asante Reimbursement Health Plan (formerly Asante Health Plan 3)Deductibles The deductibles for the four

categories of providers areCategory 1 $1000 individual$2000 familyCategory 2 $1500 individual$3000 familyCategory 3 $3000 individual$6000 familyCategory 4 $4000 individual$7000 family

Out-of-pocket maximums There will no longer be separate

out-of-pocket maximums forprescription drug expenses Rxexpenses will be counted toward themedical out-of-pocket maximums

Whatrsquos new for 2020

The out-of-pocket maximums for thenew Category 3 Regence LimitedNetwork providers and the newout-of-pocket maximums forCategory 4 Out-of-networkproviders areCategory 3 $7000 individual$14000 familyCategory 4 $8000 individual$16000 family

Copay and coinsurance changes The office visit copay for primary

care specialty and urgent care providers in the Category 1 Asante Preferred Network is reduced to $10 (deductible waived)

The office visit copay for specialtyand urgent care providers in the new Category 3 Regence Limited Network is $75 (deductible waived)

The coinsurance for lab andinpatientoutpatient professional and facility services for each category of providers is Category 1 10 Category 2 15 professional 30 facilityCategory 3 40 Category 4 50

Employer contributions to the HRA Asante contributes to your HRA

account if you are a full-time employee enrolled in the Asante Reimbursement Health Plan These contributions for 2020 will increase to $300 per year for full-time employees enrolled in employee-only coverage and to $600 for full-time employees and their enrolled dependents

Other changes In the Asante Reimbursement

Health Plan there will be an office visit copay (deductible waived) rather than coinsurance for acupuncture and chiropractic spinal manipulations

In the Asante PPO Health Plan andthe Asante Reimbursement Health Plan there will be an office visit copay (deductible waived) for outpatient neurodevelopmentalrehabilitation coverage for Category 2 Regence Network providers

Under the pharmacy benefit forall three Asante Health Plans certain opioid antagonists such as naloxone (Narcan) intended to treat opioid overdose will be covered The cost share is $0 (deductible waived) for the Asante Reimbursement Health Plan

(formerly Asante Health Plans 1 and 3) and $0 (after deductible) for the Asante Savings Health Plan (formerly Asante Health Plan 2)

Self-administrable hemophiliaclotting factor drugs are covered as specialty medications under the pharmacy benefit for all Asante Health Plans Plan participants will experience no change in terms of the dose or factor drug used The only differences are (1) the factor drugs will be shipped from the Plansrsquo specialty pharmacy to the patientrsquos home rather than the Plan participantrsquos receiving the drugs in the providerrsquos office or at a home infusion pharmacy and (2) the factor drugs will now be covered as specialty medications under the pharmacy benefit rather than as therapeutic injections under the medical benefit

All three Asante Health Plans willhave coverage for foot care associated with diabetes including foot care due to hazards of a systemic condition causing severe circulatory dysfunction or diminished sensation in the legs or feet

All three Asante Health Plans willhave coverage for gene therapyand adoptive cellular therapyregardless of whether such therapyis provided by a Center of Excellenceprovider Travel benefits may not apply

A new benefit category is beingadded to all Asante Health Planstitled Preventive Care of SpecifiedChronic Conditions This includescoverage for the medical servicesassociated with certain diagnosesThe deductible is waived thencovered at applicable coinsurancefor the Regence Network andRegence Limited Network Out ofnetwork benefits are covered atregular plan cost shares Prescriptionmedications that can help preventillnesses and conditions for peoplewho have risk factors are includedin the Optimum Value MedicalList or OVML The medications onthe OVML are not subject to theapplicable deductible

Dental plan changes The Willamette Dental plan will have

a new benefit for dental implant surgery This benefit will be covered up to an annual benefit maximum of $1500 limited to one implant per year

There will be a 29 increase in thesemimonthly contribution amount forthe Willamette Dental plan

Life and disability plansBasic life insurance and accidental death and dismemberment or ADampD supplemental life insurance short-term disability and long-term disability The short-term disability plan will have a 60-day benefit waiting period (applies only to late applicants) These benefits will be provided through insurance purchased from The Standard rather than Reliance Standard The Standard will serve as the claims administrator and reviewer for these benefits

Disability life and ADampD claimStandard Insurance CompanyPO Box 2800Portland OR 97208(833) 760-7012

Critical illness and accident plans Certain insurance policies are

available to Asante employees The policies are not part of an Employee Retirement Income Security Act of 1974 or ERISA planor an employee welfare benefit plan sponsored by Asante In 2019 these policies were offered through MetLife Beginning Jan 1 2020 critical illness and accident insurance are available through The Standard Critical illness and accident claims Standard Insurance CompanyPO Box 85508Lincoln NE 68501-5508(866) 851-5505

Questions If you have questions about these changes in benefits please contact your Plan administrator at (541) 789-4244 Employees can go to myHR (httpshrasanteorg) or asanteorgemployee-benefits for more information

This document serves as a Summary of Material Modifications under ERISA and amends the terms of the 2018 Summary Plan Description for the Plan and any other Summaries of Material Modifications to the Plan issued after the issuance of the 2018 Summary Plan Description Please note In the event of any discrepancy between this document and the 2018 Summary Plan Description the provisions of this document will govern 19HR025

All Asante Health Plans will cover some ABA therapy under Mental Health and Substance Use Disorder Services

We reserve the right to change the terms of this Notice and to make new provisions regarding your protected health information that we maintain as allowed or required by law If we make any material change to this Notice we will provide you with a copy of our revised Notice of Privacy Practices You may also obtain a copy of the latest revised Notice by contacting our Corporate CompliancePrivacy Officer at the contact information provided above or on our website at httpsasanteultiprocom Except as provided within this Notice we may not disclose your protected health information without your prior authorization

How We May Use and Disclose Your Protected Health Information

Under the law we may use or disclose your protected health information under certain circumstances without your permission The following categories describe the different ways that we may use and disclose your protected health information For each category of uses or disclosures we will explain what we mean and present some examples Not every use or disclosure in a category will be listed However all of the ways we are permitted to use and disclose protected health information will fall within one of the categories

For Treatment We may use or disclose your protected health information to facilitate medical treatment or services by providers We may disclose medical information about you to providers including doctors nurses technicians medical students or other hospital personnel who are involved in taking care of you For example we might disclose information about your prior prescriptions to a pharmacist to determine if a pending prescription is inappropriate or dangerous for you to use

For Payment We may use or disclose your protected health information to determine your eligibility for Plan benefits to facilitate payment for the treatment and services you receive from health care providers to determine benefit responsibility under the Plan or to coordinate Plan coverage For example we may tell your health care provider about your medical history to determine whether a particular treatment is experimental investigational or medically necessary or to determine whether the Plan will cover the treatment We may also share your protected health information with a utilization review or precertification service provider Likewise we may share your protected health information with another entity to assist with the adjudication or subrogation of health claims or to another health plan to coordinate benefit payments

For Health Care Operations We may use and disclose your protected health information for other Plan operations These uses and disclosures are necessary to run the Plan For example we may use medical information in connection with conducting quality assessment and improvement activities underwriting premium rating and other activities relating to Plan coverage submitting claims for stop-loss (or excess-loss) coverage conducting or arranging for medical review legal services audit services and fraud amp abuse detection programs business planning and development such as cost management and business management and general Plan administrative activities The Plan is prohibited from using or disclosing protected health information that is genetic information about an individual for underwriting purposes

To Business Associates We may contract with individuals or entities known as Business Associates to perform various functions on our behalf or to provide certain types of services In order to perform these functions or to provide these services Business Associates will receive create maintain use andor disclose your protected health information but only after they agree in writing with us to implement appropriate safeguards regarding your protected health information For example we may disclose your protected health information to a Business Associate to administer claims or to provide support services such as utilization management pharmacy benefit management or subrogation but only after the Business Associate enters into a Business Associate Agreement with us

As Required by Law We will disclose your protected health information when required to do so by federal state or local law For example we may disclose your protected health information when required by national security laws or public health disclosure laws

Introduction You are receiving this notice because you have recently become covered under the Asante Benefit plan(s) (the Plan) This notice contains important information about your right to COBRA continuation coverage which is a temporary extension of coverage under the Plan This notice generally explains COBRA continuation coverage when it may become available to you and your family and what you need to do to protect the right to receive it

The right to COBRA continuation coverage was created by a federal law Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) COBRA continuation coverage can become available to you and to other members of your family who are covered under the Plan when you would otherwise lose your group health coverage It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage

This notice gives only a summary of your COBRA continuation coverage rights For more information about your rights and obligations under the Plan and under federal law you should either review the Planrsquos Summary Plan Description or get a copy of the Plan Document from the Plan AdministratorThe Plan Administrator isAsante Health System

The COBRA Administrator isAllegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

You may have other options available to you when you lose group health coverage For example you may be eligible to buy an individual plan through the Health Insurance Marketplace By enrolling in coverage through the Marketplace you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs Additionally you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spousersquos plan) even if that plan generally doesnrsquot accept late enrollees

What is COBRA Continuation CoverageCOBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a ldquoqualifying eventrdquo Specific qualifying events are listed later in the notice After a qualifying event COBRA continuation coverage must be offered to each person who is a ldquoqualified beneficiaryrdquo A qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying event Depending on the type of qualifying event employees spouses of employees and dependent children of employees may be qualified beneficiaries Under the Plan qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage

If you are an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because either one of the following qualifying events happen

1 Your hours of employment are reduced or

2 Your employment ends for any reason other than your gross misconduct

If you are the spouse of an employee you will become a qualified beneficiary if you will lose your coverage under the Plan because any of the following qualifying events happens

1 Your spouse dies

2 Your spousersquos hours of employment are reduced

3 Your spousersquos employment ends for any reason other than his or her gross misconduct

4 Your spouse becomes enrolled in Medicare (Part A Part B or both) or

5 You become divorced or legally separated from your spouse

Continuation Coverage Rights Under Cobra

Your dependent children will become qualified beneficiaries if they will lose coverage under the Plan because any of the following qualifying events happens

1 The parent-employee dies

2 The parent-employeersquos hours of employment are reduced

3 The parent-employeersquos employment ends for any reason other than his or her gross misconduct

4 The parent-employee becomes enrolled in Medicare (Part A Part B or both)

5 The parents become divorced or legally separated or

6 The child stops being eligible for coverage under the plan as a ldquodependent childrdquo

Sometimes filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event If a proceeding in bankruptcy is filed with respect to the Employer plan and that bankruptcy results in the loss of coverage of any retired employee covered under the plan the retired employee will become a qualified beneficiary The retired employeersquos spouse surviving spouse and dependent children will also become qualified beneficiaries if the employer bankruptcy results in the loss of their coverage under the Plan

When is COBRA Coverage AvailableThe plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred When the qualifying event is the end of employment or reduction of hours of employment death of the employee or enrollment of the employee in Medicare (Part A Part B or both) the employer must notify the Plan Administrator of the qualifying event In addition if the Plan provides retiree health coverage then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event

You Must Give Notice of Some Qualifying EventsFor the other qualifying events (divorce or legal separation of the employee and spouse or a dependent childrsquos losing eligibility for coverage as a dependent child) you must notify the Plan Administrator The Plan requires you to notify the Plan Administrator within 60 days after the qualifying event occurs You must send this notice to

Asante Health System

How is COBRA Coverage ProvidedOnce the Plan Administrator receives notice that a qualifying event has occurred COBRA continuation coverage will be offered to each of the qualified beneficiaries Each qualified beneficiary will have an independent right to elect COBRA continuation coverage Covered employees may elect COBRA continuation coverage on behalf of their spouses and parents may elect COBRA continuation coverage on behalf of their children For each qualified beneficiary who elects COBRA continuation coverage COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost depending on the nature of the Plan COBRA continuation coverage is a temporary continuation of coverage When the qualifying event is the death of the employee your divorce or legal separation or a dependent child losing eligibility as a dependent child COBRA continuation coverage lasts for up to 36 months When the qualifying event is the end of employment or reduction of the employeersquos hours of employment and the employee became entitled to Medicare benefits less than 18 months before the qualifying event COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement For example if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement which is equal to 28 months after the date of the qualifying event (36 months minus 8 months) Otherwise when the qualifying event is the end of employment or reduction of the employeersquos hours of employment COBRA continuation coverage generally lasts for only up to a total of 18 months There are two ways in which this 18-month period of COBRA continuation coverage can be extended

Disability extension of 18-month period of continuation coverageIf you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage for a total maximum of 29 months The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage This notice should be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event while receiving COBRA continuation coverage the spouse and dependent children in your family can get additional months of COBRA continuation coverage up to a maximum of 36 months This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies becomes entitled to Medicare benefits (under Part A Part B or both) or gets divorced or legally separated or if the dependent child stops being eligible under the Plan as a dependent child but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred In all of these cases you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event This notice must be sent to

Asante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Are there other coverage options besides COBRA Continuation CoverageYes Instead of enrolling in COBRA continuation coverage there may be other coverage options for you and your family through the Health Insurance Marketplace Medicaid or the group health plan coverage options (such as a spousersquos plan) through what is called a ldquospecial enrollment periodrdquo Some of these options may cost less than COBRA continuation coverage You can learn more about many of these options at wwwHealthCaregov

If You Have QuestionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below For more information about your rights under ERISA including COBRA the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans contact the nearest Regional or District Office of the US Department of Laborrsquos Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at wwwdolgovebsa (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSArsquos website)

Keep Your Plan Informed of Address ChangesIn order to protect your familyrsquos rights you should keep the Plan Administrator informed of any changes in the addresses of family members You should also keep a copy for your records of any notices you send to the Plan Administrator

Plan Contact InformationAsante Health System co Allegiance COBRA Services Inc PO Box 2097 Missoula MT 59806

Updated 91418 ND

PLEASE NOTE We are required by law to send this notice to all eligible employees and dependents eligible for coverage under the Asante Health Plan If you have an eligible dependent that does not reside with you but is

eligible for coverage please contact us so that we can provide them with this notice

Important Notice from Asante About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it This notice has information about prescription drug coverage with Asante and about your options under Medicarersquos prescription drug

coverage This information can help you decide whether or not you want to join a Medicare drug plan If you are considering joining you should compare your current coverage including which drugs are covered at what cost with the coverage and costs of the plans offering Medicare prescription drug coverage in your area Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice

There are two important things you need to know about your current coverage and Medicarersquos

prescription drug coverage 1 Medicare prescription drug coverage became available in 2006 to everyone with Medicare You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage All Medicare drug plans provide at least a standard level of coverage set by Medicare Some plans may also offer more coverage for a higher monthly premium

2 Asante has determined that the prescription drug coverage offered by Asante PPO Health Plan Asante Savings Health Plan Asante Reimbursement Health Plan and the Asante Flexible Workforce Health Plan is on average for all plan participants expected to pay out as much as standard Medicare prescription drug coverage will pay in 2020 and are therefore considered Creditable Coverage Because any existing Asante coverage is Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan

When Can You Join A Medicare Drug Plan

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th

However if you lose your current creditable prescription drug coverage through no fault of your own you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee you may also continue your employer coverage In this case the employer plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan If you waive or drop Asantersquos coverage Medicare will be your only payer You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the Asante plan

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan

You should also know that if you drop or lose your current coverage with Asante and donrsquot join a

Medicare drug plan within 63 continuous days after your current coverage ends you may pay a higher premium (a penalty) to join a Medicare drug plan later

Page 2

If you go 63 days or longer without creditable prescription drug coverage your monthly premium may go up by at least 1 of the Medicare base beneficiary premium per month for every month that you did not have that coverage For example if you go 19 months without coverage your premium may consistently be at least 19 higher than the Medicare base beneficiary premium You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage In addition you may have to wait until the following October to join

For More Information About This Notice Or Your Asante Health Plan Prescription Drug Coverage Contact Asante Human Resources 2635 Siskiyou Blvd Medford OR 97504 (541) 789-4243NOTE Yoursquoll get this notice each year You will also get it before the next period you can join a Medicare drug plan and if this coverage through Asante changes You also may request a copy of this notice at any time

If you or your family members arenrsquot currently covered by Medicare and wonrsquot become covered by

Medicare in the next 12 months this notice doesnrsquot apply to you

For More Information About Your Options Under Medicare Prescription Drug Coverage

More detailed information about Medicare plans that offer prescription drug coverage is in the ldquoMedicare amp Yourdquo handbook Medicare participants will get a copy of the handbook in the mail every year from Medicare You may also be contacted directly by Medicare prescription drug plans Herersquos

how to get more information about Medicare prescription drug plans

Visit wwwmedicaregov

Call your State Health Insurance Assistance Program (see a copy of the Medicare amp You handbookfor the telephone number) for personalized help

Call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048

For people with limited income and resources extra help paying for a Medicare prescription drug plan is available For information about this extra help visit Social Security on the web at wwwsocialsecuritygov or call 1-800-772-1213 (TTY 1-800-325-0778)

Remember Keep this notice If you decide to join one of the Medicare drug plans you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and therefore whether or not you are required to pay a higher premium (a penalty)