asante 2020 benefit summaries & legal notices · 2019. 12. 29. · mily per calend ar year....
TRANSCRIPT
-
> Summary of Benefits and Coverage
– Asante PPO Health Plan, Asante Savings Health Plan, Asante Reimbursement Health Plan & Asante Flexible Workforce Health Plan
> Annual Required Notices
> Summary of Material Modification
> Notice of Privacy Practices
> Continuation Coverage Rights Under Cobra
> Medicare Notice of Creditable Coverage
> New Health Insurance Marketplace Coverage
> Where To Get Help
ASANTE2020 BENEFIT SUMMARIES & LEGAL NOTICES
-
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e: W
hat t
his
Pla
n C
over
s &
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d:
01/0
1/20
20 –
12/
31/2
020
AS
AN
TE
PP
O H
EA
LT
H P
LA
N
Co
vera
ge
for:
Indi
vidu
al a
nd E
ligib
le F
amily
| P
lan
Typ
e: P
PO
1 o
f 8
Cla
ims
Adm
inis
trat
or: R
egen
ce B
lueC
ross
Blu
eShi
eld
of O
rego
n
OO
0120
SC
LAX
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n. T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es. N
OT
E:
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely.
T
his
is o
nly
a s
um
mar
y. F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge, o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e, g
o to
reg
ence
.com
or
call
1 (8
88)
344-
8235
. F
or g
ener
al d
efin
ition
s of
com
mon
term
s, s
uch
as a
llow
ed a
mou
nt, b
alan
ce b
illin
g, c
oins
uran
ce, c
opay
men
t, de
duct
ible
, pro
vide
r, o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y.
You
can
vie
w th
e G
loss
ary
at h
ealth
care
.gov
/sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
:
Wh
at is
th
e o
vera
ll d
edu
ctib
le?
Asa
nte
pref
erre
d ne
twor
k an
d R
egen
ce n
etw
ork
prov
ider
s: $
500
indi
vidu
al /
$1,0
00 fa
mily
per
cal
enda
r ye
ar. R
egen
ce li
mite
d ne
twor
k pr
ovid
ers:
$2,
000
indi
vidu
al /
$4,0
00 fa
mily
per
cal
enda
r ye
ar. O
ut-o
f-ne
twor
k: $
2,50
0 in
divi
dual
/ $4
,000
fam
ily p
er c
alen
dar
year
. The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers,
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate.
Gen
eral
ly, y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay. I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an, e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
.
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le?
Yes
. Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
"ded
uctib
le d
oes
not a
pply
" or
as
"No
char
ge."
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven'
t yet
met
th
e de
duct
ible
am
ount
. But
a c
opay
men
t or
coin
sura
nce
may
app
ly.
For
exa
mpl
e, th
is p
lan
cove
rs c
erta
in p
reve
ntiv
e se
rvic
es w
ithou
t cos
t sh
arin
g an
d be
fore
you
mee
t you
r de
duct
ible
. See
a li
st o
f cov
ered
pr
even
tive
serv
ices
at h
ealth
care
.gov
/cov
erag
e/pr
even
tive
-car
e-be
nefit
s/.
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s?
No.
Y
ou d
on't
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es.
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n?
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers:
$2,
500
indi
vidu
al /
$5,0
00 fa
mily
per
cal
enda
r ye
ar. *
Reg
ence
net
wor
k pr
ovid
ers:
$3,
500
indi
vidu
al /
$7,0
00 fa
mily
per
cal
enda
r ye
ar. R
egen
ce li
mite
d ne
twor
k pr
ovid
ers:
$7,
500
indi
vidu
al /
$15,
000
fam
ily p
er c
alen
dar
year
. The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers,
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate.
Out
-of-
netw
ork:
$8,
250
indi
vidu
al /
$16,
500
fam
ily p
er c
alen
dar
year
. *T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned.
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es. I
f you
hav
e ot
her
fam
ily m
embe
rs in
this
pla
n, th
ey h
ave
to m
eet
thei
r ow
n ou
t-of
-poc
ket l
imits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et.
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
?
Pre
miu
ms,
bal
ance
-bill
ed c
harg
es, a
nd h
ealth
car
e th
is
plan
doe
sn't
cove
r.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don'
t cou
nt to
wa
rd th
e ou
t-of
-po
cket
lim
it.
-
2 o
f 8
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er?
Y
es. A
sant
e pr
ovid
ers.
See
reg
ence
.com
/go/
OR
/Pre
ferr
ed
or c
all 1
(88
8) 3
44-8
235
for
a lis
t of n
etw
ork
prov
ider
s.
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
th
e pl
an's
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
er's
cha
rge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
. Be
awar
e, y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch 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,
& 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
k/R
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,
& 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
T/P
ET
sc
ans,
MR
Is)
15
% c
oins
uran
ce
30%
coi
nsur
ance
40
% c
oins
uran
ce
If y
ou
nee
d d
rug
s to
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
e.co
m/g
o/dr
uglis
t/20
20/O
R/3
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
en's
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy.
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
nd/o
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,
& 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
(e.g
., 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
an/s
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
k/R
egen
ce n
etw
ork/
Reg
ence
lim
ited
netw
ork
offic
e/ur
gent
car
e vi
sit.
If y
ou
hav
e a
ho
spit
al
stay
Fac
ility
fee
(e.g
., ho
spita
l roo
m)
15%
coi
nsur
ance
30
% c
oins
uran
ce
40%
coi
nsur
ance
50
% c
oins
uran
ce fo
r O
ut-o
f-ne
twor
k pr
ovid
ers,
af
ter
dedu
ctib
le.
Phy
sici
an/s
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
k/R
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,
& 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 (
i.e. u
ltras
ound
).
Mat
erni
ty c
over
age
for
depe
nden
t chi
ldre
n is
on
ly c
over
ed in
the
case
of c
ompl
icat
ions
.
Chi
ldbi
rth/
deliv
ery
prof
essi
onal
ser
vice
s 15
% c
oins
uran
ce
30%
coi
nsur
ance
40
% c
oins
uran
ce
Chi
ldbi
rth/
deliv
ery
faci
lity
serv
ices
15
% c
oins
uran
ce
30%
coi
nsur
ance
40
% c
oins
uran
ce
If y
ou
nee
d h
elp
re
cove
rin
g o
r h
ave
oth
er
spec
ial h
ealt
h n
eed
s
Hom
e he
alth
car
e 15
% c
oins
uran
ce
30%
coi
nsur
ance
40
% c
oins
uran
ce
50%
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s,
afte
r de
duct
ible
. Li
mite
d to
100
vis
its /
year
.
Reh
abili
tatio
n se
rvic
es
$10
copa
y /
outp
atie
nt v
isit,
de
duct
ible
doe
s no
t ap
ply;
15
% c
oins
uran
ce /
inpa
tient
ser
vice
s
$25
copa
y /
outp
atie
nt v
isit,
de
duct
ible
doe
s no
t ap
ply;
30
% c
oins
uran
ce /
inpa
tient
ser
vice
s
$75
copa
y /
outp
atie
nt v
isit,
de
duct
ible
doe
s no
t app
ly;
40%
coi
nsur
ance
/ in
patie
nt s
ervi
ces
50%
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s,
afte
r de
duct
ible
. C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
k/R
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
k/R
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,
& 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
n's
eye
exam
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Chi
ldre
n's
glas
ses
Not
cov
ered
N
ot c
over
ed
Not
cov
ered
N
one
Chi
ldre
n's
dent
al
chec
k-up
N
ot c
over
ed
Not
cov
ered
N
ot c
over
ed
Non
e
Exc
lud
ed S
ervi
ces
& O
ther
Co
vere
d S
ervi
ces:
Ser
vice
s Y
ou
r P
lan
Gen
eral
ly D
oes
NO
T C
ove
r (C
hec
k yo
ur
po
licy
or
pla
n d
ocu
men
t fo
r m
ore
info
rmat
ion
an
d a
list
of
any
oth
er e
xclu
ded
ser
vice
s.)
•
Acu
punc
ture
(pr
ovid
ed b
y an
acu
punc
turis
t)
•
Bar
iatr
ic s
urge
ry
•
Chi
ropr
actic
car
e
•
Cos
met
ic s
urge
ry, e
xcep
t con
geni
tal a
nom
alie
s
•
Den
tal c
are
(Adu
lt)
•
Long
-ter
m c
are
•
Non
-em
erge
ncy
care
whe
n tr
ave
ling
outs
ide
the
U.S
.
•
Priv
ate-
duty
nur
sing
(ex
cept
as
prov
ided
for
hom
e he
alth
)
•
Rou
tine
eye
care
(A
dult)
•
Rou
tine
foot
car
e
•
Wei
ght l
oss
prog
ram
s, u
nles
s re
quire
d by
law
Oth
er C
ove
red
Ser
vice
s (L
imit
atio
ns
may
ap
ply
to
th
ese
serv
ices
. T
his
isn
't a
com
ple
te li
st. P
leas
e se
e yo
ur
pla
n d
ocu
men
t.)
•
Hab
ilita
tion
serv
ices
•
Hea
ring
aids
for
indi
vidu
als
up to
age
19,
or
indi
vidu
als
19 y
ears
of a
ge u
p to
age
26
and
enro
lled
in a
sec
onda
ry s
choo
l or
an a
ccre
dite
d ed
ucat
iona
l ins
titut
ion
•
Infe
rtili
ty tr
eatm
ent
-
7 o
f 8
Yo
ur
Rig
hts
to
Co
nti
nu
e C
ove
rag
e: T
here
are
age
ncie
s th
at c
an h
elp
if yo
u w
ant t
o co
ntin
ue y
our
cove
rage
afte
r it
ends
. The
con
tact
info
rmat
ion
for
thos
e ag
enci
es
is: t
he U
.S. D
epar
tmen
t of L
abor
, Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
dol
.gov
/ebs
a/he
alth
refo
rm, o
r th
e U
.S. D
epar
tmen
t of H
ealth
and
H
uman
Ser
vice
s, C
ente
r fo
r C
onsu
mer
Info
rmat
ion
and
Insu
ranc
e O
vers
ight
at 1
(87
7) 2
67-2
323
x615
65 o
r cc
iio.c
ms.
gov
or y
our
stat
e in
sura
nce
depa
rtm
ent.
You
may
al
so c
onta
ct th
e pl
an a
t 1 (
888)
344
-823
5. O
ther
cov
erag
e op
tion
s m
ay b
e av
aila
ble
to y
ou to
o, in
clud
ing
buyi
ng in
divi
dual
insu
ranc
e co
vera
ge th
roug
h th
e H
ealth
In
sura
nce
Mar
ketp
lace
. For
mor
e in
form
atio
n ab
out t
he M
arke
tpla
ce, v
isit
Hea
lthC
are.
gov
or c
all 1
(80
0) 3
18-2
596.
Y
ou
r G
riev
ance
an
d A
pp
eals
Rig
hts
: T
here
are
age
ncie
s th
at c
an h
elp
if yo
u ha
ve a
com
plai
nt a
gain
st y
our
plan
for
a de
nial
of a
cla
im. T
his
com
plai
nt is
cal
led
a gr
ieva
nce
or a
ppea
l. F
or m
ore
info
rmat
ion
abou
t you
r rig
hts,
look
at t
he e
xpla
natio
n of
ben
efits
you
will
rec
eive
for
that
med
ical
cla
im. Y
our
plan
doc
umen
ts a
lso
prov
ide
com
plet
e in
form
atio
n to
sub
mit
a cl
aim
, app
eal,
or a
grie
vanc
e fo
r an
y re
ason
to y
our
plan
. For
mor
e in
form
atio
n ab
out
your
rig
hts,
this
not
ice,
or
assi
stan
ce,
cont
act t
he p
lan
at 1
(88
8) 3
44-8
235
or v
isit
rege
nce.
com
or
the
U.S
. Dep
artm
ent o
f Lab
or, E
mpl
oye
e B
enef
its S
ecur
ity A
dmin
istr
atio
n at
1 (
866)
444
-327
2 or
do
l.gov
/ebs
a/he
alth
refo
rm. Y
ou m
ay a
lso
cont
act t
he O
rego
n D
ivis
ion
of F
inan
cial
Reg
ulat
ion
by c
allin
g (5
03)
947
-798
4 or
the
toll
free
mes
sage
line
at 1
(88
8) 8
77-
4894
; by
writ
ing
to th
e O
rego
n D
ivis
ion
of F
inan
cial
Reg
ulat
ion,
Con
sum
er A
dvoc
acy
Uni
t, P
.O. B
ox 1
4480
, Sal
em, O
R 9
7309
-040
5; th
roug
h th
e In
tern
et a
t: df
r.or
egon
.gov
/get
help
/Pag
es/fi
le-a
-com
plai
nt.a
spx;
or
by E
-mai
l at:
DF
R.In
sura
nceH
elp@
oreg
on.g
ov.
Do
es t
his
pla
n p
rovi
de
Min
imu
m E
ssen
tial
Co
vera
ge?
Yes
If
you
don'
t hav
e M
inim
um E
ssen
tial C
over
age
for
a m
onth
, you
'll h
ave
to m
ake
a pa
ymen
t whe
n yo
u fil
e yo
ur ta
x re
turn
unl
ess
you
qual
ify fo
r an
exe
mpt
ion
from
the
requ
irem
ent t
hat y
ou h
ave
heal
th c
over
age
for
that
mon
th.
Do
es t
his
pla
n m
eet
the
Min
imu
m V
alu
e S
tan
dar
ds?
Yes
If
your
pla
n do
esn'
t mee
t the
Min
imum
Val
ue S
tand
ards
, you
may
be
elig
ible
for
a pr
emiu
m ta
x cr
edit
to h
elp
you
pay
for
a pl
an th
roug
h th
e M
arke
tpla
ce.
Lan
gu
age
Acc
ess
Ser
vice
s:
Spa
nish
(E
spañ
ol):
Par
a ob
tene
r as
iste
ncia
en
Esp
añol
, lla
me
al 1
(88
8) 3
44-8
235.
––
––––
––––
––––
––––
––––
To
see
exam
ples
of h
ow th
is p
lan
mig
ht c
over
cos
ts fo
r a
sam
ple
med
ical
situ
atio
n, s
ee th
e ne
xt s
ectio
n.––
––––
––––
––––
––––
––––
-
8 o
f 8
The
pla
n w
ould
be
resp
onsi
ble
for
the
othe
r co
sts
of th
ese
EX
AM
PLE
cov
ered
ser
vice
s.
Peg
is H
avin
g a
Bab
y (9
mon
ths
of in
-net
wor
k pr
e-na
tal c
are
and
a ho
spita
l del
iver
y)
Mia
's S
imp
le F
ract
ure
(in-n
etw
ork
emer
genc
y ro
om v
isit
and
follo
w
up c
are)
Man
agin
g J
oe'
s ty
pe
2 D
iab
etes
(a y
ear
of r
outin
e in
-net
wor
k ca
re o
f a w
ell-
cont
rolle
d co
nditi
on)
◼ T
he
pla
n's
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30%
◼
Oth
er c
oin
sura
nce
30
%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
S
peci
alis
t offi
ce v
isits
(pr
enat
al c
are)
C
hild
birt
h/D
eliv
ery
Pro
fess
iona
l Ser
vice
s C
hild
birt
h/D
eliv
ery
Fac
ility
Ser
vice
s D
iagn
ostic
test
s (u
ltras
ound
s an
d bl
ood
wor
k)
Spe
cial
ist v
isit
(ane
sthe
sia)
T
ota
l Exa
mp
le C
ost
$1
2,80
0 In
th
is e
xam
ple
, Peg
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$0
Coi
nsur
ance
$3
,000
Wha
t isn
't co
vere
d
Lim
its o
r ex
clus
ions
$6
0
Th
e to
tal P
eg w
ou
ld p
ay is
$3
,560
◼ T
he
pla
n's
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30%
◼
Oth
er c
oin
sura
nce
30
%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
P
rimar
y ca
re p
hysi
cian
offi
ce v
isits
(in
clud
ing
dise
ase
educ
atio
n)
Dia
gnos
tic te
sts
(blo
od w
ork)
P
resc
riptio
n dr
ugs
D
urab
le m
edic
al e
quip
men
t (gl
ucos
e m
eter
) T
ota
l Exa
mp
le C
ost
$7
,400
In
th
is e
xam
ple
, Jo
e w
ou
ld p
ay:
Cos
t Sha
ring
Ded
uctib
les
$102
Cop
aym
ents
$5
39
Coi
nsur
ance
$1
,858
Wha
t isn
't co
vere
d
Lim
its o
r ex
clus
ions
$2
55
Th
e to
tal J
oe
wo
uld
pay
is
$2,7
54
◼ T
he
pla
n's
ove
rall
ded
uct
ible
$5
00
◼ S
pec
ialis
t co
pay
men
t $2
5 ◼
Ho
spit
al (
faci
lity)
co
insu
ran
ce
30%
◼
Oth
er c
oin
sura
nce
30
%
Th
is E
XA
MP
LE
eve
nt
incl
ud
es s
ervi
ces
like:
E
mer
genc
y ro
om c
are
(incl
udin
g m
edic
al
supp
lies)
D
iagn
ostic
test
(x-
ray)
D
urab
le m
edic
al e
quip
men
t (cr
utch
es)
Reh
abili
tatio
n se
rvic
es (
phys
ical
ther
apy)
T
ota
l Exa
mp
le C
ost
$1
,925
In
th
is e
xam
ple
, Mia
wo
uld
pay
:
Cos
t Sha
ring
Ded
uctib
les
$500
Cop
aym
ents
$1
75
Coi
nsur
ance
$2
95
Wha
t isn
't co
vere
d
Lim
its o
r ex
clus
ions
$0
Th
e to
tal M
ia w
ou
ld p
ay is
$9
70
Ab
ou
t th
ese
Co
vera
ge
Exa
mp
les:
Th
is is
no
t a
cost
est
imat
or.
Tre
atm
ents
sho
wn
are
just
exa
mpl
es o
f how
this
pla
n m
ight
cov
er m
edic
al c
are.
You
r ac
tual
cos
ts w
ill b
e di
ffere
nt d
epen
ding
on
the
actu
al c
are
you
rece
ive,
the
pric
es y
our
prov
ider
s ch
arge
, and
man
y ot
her
fact
ors.
Foc
us o
n th
e co
st s
harin
g am
ount
s (d
educ
tible
s, c
opay
men
ts a
nd c
oins
uran
ce)
and
excl
uded
ser
vice
s un
der
the
plan
. Use
this
info
rmat
ion
to c
ompa
re th
e po
rtio
n of
co
sts
you
mig
ht p
ay u
nder
diff
eren
t hea
lth p
lans
. Ple
ase
note
thes
e co
vera
ge e
xam
ples
are
bas
ed o
n se
lf-on
ly c
over
age.
-
NONDISCRIMINATION NOTICE
01012017.04PF12LNoticeNDMARegence
Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Regence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Regence: Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, and accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages If you need these services listed above, please contact: Medicare Customer Service 1-800-541-8981 (TTY: 711) Customer Service for all other plans 1-888-344-6347 (TTY: 711) If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our civil rights coordinator below: Medicare Customer Service Civil Rights Coordinator MS: B32AG, PO Box 1827 Medford, OR 97501 1-866-749-0355, (TTY: 711) Fax: 1-888-309-8784 [email protected] Customer Service for all other plans Civil Rights Coordinator MS CS B32B, P.O. Box 1271 Portland, OR 97207-1271 1-888-344-6347, (TTY: 711) [email protected]
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
-
Language assistance
01012017.04PF12LNoticeNDMARegence
ATENCIÓN: si habla español, tiene a su disposición
servicios gratuitos de asistencia lingüística. Llame al
1-888-344-6347 (TTY: 711).
注意：如果您使用繁體中文，您可以免費獲得語言
援助服務。請致電 1-888-344-6347 (TTY: 711)。
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ
trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-
344-6347 (TTY: 711).
주의: 한국어를 사용하시는 경우, 언어 지원
서비스를 무료로 이용하실 수 있습니다. 1-888-
344-6347 (TTY: 711) 번으로 전화해 주십시오.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari
kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-888-344-6347 (TTY:
711).
ВНИМАНИЕ: Если вы говорите на русском языке,
то вам доступны бесплатные услуги перевода.
Звоните 1-888-344-6347 (телетайп: 711).
ATTENTION : Si vous parlez français, des services
d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-888-344-6347 (ATS : 711)
注意事項：日本語を話される場合、無料の言語支
援をご利用いただけます。1-888-344-6347
（TTY:711）まで、お電話にてご連絡ください。
ti’go Diné
Bizaad, saad
1-888-344-6347 (TTY: 711.)
FAKATOKANGA’I: Kapau ‘oku ke Lea-
Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai
atu ha tokoni ta’etotongi, pea te ke lava ‘o ma’u ia.
ha’o telefonimai mai ki he fika 1-888-344-6347 (TTY:
711)
OBAVJEŠTENJE: Ako govorite srpsko-hrvatski,
usluge jezičke pomoći dostupne su vam besplatno.
Nazovite 1-888-344-6347 (TTY- Telefon za osobe sa
oštećenim govorom ili sluhom: 711)
ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 1-888-344-6347 (TTY: 711)។
ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡ ੇਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-888-344-6347 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।
ACHTUNG: Wenn Sie Deutsch sprechen, stehen
Ihnen kostenlose Sprachdienstleistungen zur
Verfügung. Rufnummer: 1-888-344-6347 (TTY: 711)
ማስታወሻ:- የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፤ በሚከተለው ቁጥር
ይደውሉ 1-888-344-6347 (መስማት ለተሳናቸው:- 711)፡፡
УВАГА! Якщо ви розмовляєте українською
мовою, ви можете звернутися до безкоштовної
служби мовної підтримки. Телефонуйте за
номером 1-888-344-6347 (телетайп: 711)
ध्यान दिनहुोस्: तपार्इलं ेनेपाली बोल्नहुुन्छ भने तपार्इकंो दनदतत भाषा सहायता सेवाहरू
दनिःशलु्क रूपमा उपलब्ध छ । फोन गनुुहोस ्1-888-344-6347 (दिदिवार्इ:
711
ATENȚIE: Dacă vorbiți limba română, vă stau la
dispoziție servicii de asistență lingvistică, gratuit.
Sunați la 1-888-344-6347 (TTY: 711)
MAANDO: To a waawi [Adamawa], e woodi ballooji-
ma to ekkitaaki wolde caahu. Noddu 1-888-344-6347
(TTY: 711)
โปรดทราบ: ถา้คุณพดูภาษาไทย คุณสามารถใชบ้ริการช่วยเหลือทางภาษาไดฟ้รี โทร 1-888-344-6347 (TTY: 711)
ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ, ແມ່ນມີ ພ້ອມໃຫ້ທ່ານ.
ໂທຣ 1-888-344-6347 (TTY: 711)
Afaan dubbattan Oroomiffaa tiif, tajaajila gargaarsa
afaanii tola ni jira. 1-888-344-6347 (TTY: 711) tiin
bilbilaa.
شمای برا گانیرا بصورتی زبان التیتسه د،یکنی مصحبت فارسی زبان به اگر: توجه
.دیریبگ تماس (TTY: 711) 6347-344-888-1 با. باشدی م فراهم
6347-344-888-1ملحوظة: إذا كنت تتحدث فاذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم
TTY: 711)هاتف الصم والبكم )رقم
-
Su
mm
ary
of
Ben
efit
s an
d C
ove
rag
e: W
hat t
his
Pla
n C
over
s &
Wha
t You
Pay
For
Cov
ered
Ser
vice
s C
ove
rag
e P
erio
d:
01/0
1/20
20 –
12/
31/2
020
AS
AN
TE
RE
IMB
UR
SE
ME
NT
HE
AL
TH
PL
AN
Co
vera
ge
for:
Indi
vidu
al a
nd E
ligib
le F
amily
| P
lan
Typ
e: P
PO
1 o
f 8
Cla
ims
Adm
inis
trat
or: R
egen
ce B
lueC
ross
Blu
eShi
eld
of O
rego
n O
O01
19S
CLA
X
Th
e S
um
mar
y o
f B
enef
its
and
Co
vera
ge
(SB
C)
do
cum
ent
will
hel
p y
ou
ch
oo
se a
hea
lth
pla
n. T
he
SB
C s
ho
ws
you
ho
w y
ou
an
d t
he
pla
n w
ou
ld s
har
e th
e co
st f
or
cove
red
hea
lth
car
e se
rvic
es. N
OT
E:
Info
rmat
ion
ab
ou
t th
e co
st o
f th
is p
lan
(ca
lled
th
e p
rem
ium
) w
ill b
e p
rovi
ded
sep
arat
ely.
T
his
is o
nly
a s
um
mar
y. F
or m
ore
info
rmat
ion
abou
t you
r co
vera
ge, o
r to
get
a c
opy
of th
e co
mpl
ete
term
s of
cov
erag
e, g
o to
reg
ence
.com
or
call
1 (8
88)
344-
8235
. F
or g
ener
al d
efin
ition
s of
com
mon
term
s, s
uch
as a
llow
ed a
mou
nt, b
alan
ce b
illin
g, c
oins
uran
ce, c
opay
men
t, de
duct
ible
, pro
vide
r, o
r ot
her
unde
rline
d te
rms
see
the
Glo
ssar
y.
You
can
vie
w th
e G
loss
ary
at h
ealth
care
.gov
/sbc
-glo
ssar
y or
cal
l 1 (
888)
344
-823
5 to
req
uest
a c
opy.
Imp
ort
ant
Qu
esti
on
s A
nsw
ers
Wh
y T
his
Mat
ters
:
Wh
at is
th
e o
vera
ll d
edu
ctib
le?
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers:
$1,
000
indi
vidu
al /
$2,0
00 fa
mily
per
cal
enda
r ye
ar. R
egen
ce n
etw
ork:
$1
,500
indi
vidu
al /
$3,0
00 fa
mily
per
cal
enda
r ye
ar.
Reg
ence
lim
ited
netw
ork
prov
ider
s: $
3,00
0 in
divi
dual
/ $6
,000
fam
ily p
er c
alen
dar
year
. Out
-of-
netw
ork:
$4
,000
indi
vidu
al /
$7,0
00 fa
mily
per
cal
enda
r ye
ar.
The
ded
uctib
le a
mou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers,
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate.
Gen
eral
ly, y
ou m
ust p
ay a
ll of
the
cost
s fr
om p
rovi
ders
up
to th
e de
duct
ible
am
ount
bef
ore
this
pla
n be
gins
to p
ay. I
f you
hav
e ot
her
fam
ily m
embe
rs o
n th
e pl
an, e
ach
fam
ily m
embe
r m
ust m
eet t
heir
own
indi
vidu
al d
educ
tible
unt
il th
e to
tal a
mou
nt o
f ded
uctib
le e
xpen
ses
paid
by
all f
amily
mem
bers
mee
ts th
e ov
eral
l fam
ily d
educ
tible
.
Are
th
ere
serv
ices
co
vere
d
bef
ore
yo
u m
eet
you
r d
edu
ctib
le?
Yes
. Cer
tain
pre
vent
ive
care
and
thos
e se
rvic
es li
sted
be
low
as
"ded
uctib
le d
oes
not a
pply
" or
as
"No
char
ge."
Thi
s pl
an c
over
s so
me
item
s an
d se
rvic
es e
ven
if yo
u ha
ven'
t ye
t met
th
e de
duct
ible
am
ount
. But
a c
opay
men
t or
coin
sura
nce
may
app
ly. F
or
exam
ple,
this
pla
n co
vers
cer
tain
pre
vent
ive
serv
ices
with
out c
ost
shar
ing
and
befo
re y
ou m
eet y
our
dedu
ctib
le. S
ee a
list
of c
over
ed
prev
entiv
e se
rvic
es a
t hea
lthca
re.g
ov/c
over
age/
prev
entiv
e-ca
re-
bene
fits/
.
Are
th
ere
oth
er d
edu
ctib
les
for
spec
ific
ser
vice
s?
No.
Y
ou d
on't
have
to m
eet d
educ
tible
s fo
r sp
ecifi
c se
rvic
es.
Wh
at is
th
e o
ut-
of-
po
cket
lim
it
for
this
pla
n?
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers:
$2,
000
indi
vidu
al /
$4,0
00 fa
mily
per
cal
enda
r ye
ar. *
Reg
ence
net
wor
k pr
ovid
ers:
$3,
500
indi
vidu
al /
$7,0
00 fa
mily
per
ca
lend
ar y
ear.
Reg
ence
lim
ited
netw
ork
prov
ider
s:
$7,0
00 in
divi
dual
/ $1
4,00
0 fa
mily
per
cal
enda
r ye
ar.
The
out
-of-
pock
et li
mit
amou
nts
for
Asa
nte
pref
erre
d ne
twor
k pr
ovid
ers,
Reg
ence
net
wor
k pr
ovid
ers
and
Reg
ence
lim
ited
netw
ork
prov
ider
s cr
oss
accu
mul
ate.
O
ut-o
f-ne
twor
k: $
8,00
0 in
divi
dual
/ $1
6,00
0 fa
mily
per
ca
lend
ar y
ear.
*T
he R
egen
ce n
etw
ork
out-
of-p
ocke
t lim
it fo
r m
edic
al a
nd p
resc
riptio
n be
nefit
s ar
e co
mbi
ned.
The
out
-of-
pock
et li
mit
is th
e m
ost y
ou c
ould
pay
in a
yea
r fo
r co
vere
d se
rvic
es. I
f yo
u ha
ve o
ther
fam
ily m
embe
rs in
this
pla
n, th
ey h
ave
to m
eet t
heir
own
out-
of-
pock
et li
mits
unt
il th
e ov
eral
l fam
ily o
ut-o
f-po
cket
lim
it ha
s be
en m
et.
-
2 o
f 8
Wh
at is
no
t in
clu
ded
in t
he
ou
t-o
f-p
ock
et li
mit
?
Pre
miu
ms,
bal
ance
-bill
ed c
harg
es, a
nd h
ealth
car
e th
is
plan
doe
sn't
cove
r.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don'
t cou
nt to
war
d th
e ou
t-of
-poc
ket
limit.
Will
yo
u p
ay le
ss if
yo
u u
se a
n
etw
ork
pro
vid
er?
Yes
. Asa
nte
prov
ider
s. S
ee
rege
nce.
com
/go/
OR
/Pre
ferr
ed o
r ca
ll 1
(888
) 34
4-82
35
for
a lis
t of n
etw
ork
prov
ider
s.
Thi
s pl
an u
ses
a pr
ovid
er n
etw
ork.
You
will
pay
less
if y
ou u
se a
pro
vide
r in
the
plan
's n
etw
ork.
You
will
pay
the
mos
t if y
ou u
se a
n ou
t-of
-net
wor
k pr
ovid
er, a
nd
you
mig
ht r
ecei
ve a
bill
from
a p
rovi
der
for
the
diffe
renc
e be
twee
n th
e pr
ovid
er's
ch
arge
and
wha
t you
r pl
an p
ays
(bal
ance
bill
ing)
. Be
awar
e, y
our
netw
ork
prov
ider
mig
ht u
se a
n ou
t-of
-net
wor
k pr
ovid
er fo
r so
me
serv
ices
(su
ch a
s la
b w
ork)
. Che
ck w
ith y
our
prov
ider
bef
ore
you
get s
ervi
ces.
Do
yo
u n
eed
a r
efer
ral t
o s
ee
a sp
ecia
list?
N
o.
You
can
see
the
spec
ialis
t you
cho
ose
with
out a
ref
erra
l.
A
ll co
paym
ent a
nd c
oins
uran
ce c
osts
sho
wn
in th
is c
hart
are
afte
r yo
ur d
educ
tible
has
bee
n m
et, i
f a d
educ
tible
app
lies.
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s, E
xcep
tio
ns,
& O
ther
Imp
ort
ant
Info
rmat
ion
Asa
nte
Pre
ferr
ed
Net
wo
rk P
rovi
der
(Y
ou
will
pay
th
e le
ast)
Reg
ence
Net
wo
rk
Pro
vid
er
(Yo
u w
ill p
ay t
he
leas
t)
Reg
ence
Lim
ited
N
etw
ork
Pro
vid
er
(Yo
u w
ill p
ay t
he
mo
st)
If y
ou
vis
it a
hea
lth
car
e p
rovi
der
's o
ffic
e o
r cl
inic
Prim
ary
care
vis
it to
tr
eat a
n in
jury
or
illne
ss
$10
copa
y / o
ffice
vi
sit,
dedu
ctib
le d
oes
not a
pply
; $1
0 co
pay
/ ret
ail
clin
ic v
isit,
ded
uctib
le
does
not
app
ly;
10%
coi
nsur
ance
for
all o
ther
ser
vice
s
$25
copa
y / o
ffice
vi
sit,
dedu
ctib
le d
oes
not a
pply
; $2
5 co
pay
/ ret
ail
clin
ic v
isit,
ded
uctib
le
does
not
app
ly;
15%
coi
nsur
ance
for
all o
ther
ser
vice
s
Not
app
licab
le fo
r pr
imar
y ca
re v
isits
; $7
5 co
pay
/ ret
ail
clin
ic v
isit,
de
duct
ible
doe
s no
t app
ly;
40%
coi
nsur
ance
fo
r al
l oth
er
serv
ices
40%
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s,
afte
r de
duct
ible
. C
opay
men
t app
lies
to e
ach
Asa
nte
pref
erre
d ne
twor
k/R
egen
ce n
etw
ork/
Reg
ence
lim
ited
netw
ork
offic
e vi
sits
onl
y. A
ll ot
her
serv
ices
that
ar
e no
t bill
ed a
s an
offi
ce v
isit
are
cove
red
at th
e co
insu
ranc
e sp
ecifi
ed, a
fter
dedu
ctib
le.
Cov
erag
e fo
r ac
upun
ctur
e an
d ch
iropr
actic
sp
inal
man
ipul
atio
ns is
sub
ject
to $
25
copa
ymen
t for
Reg
ence
net
wor
k pr
ovid
ers/
Reg
ence
lim
ited
netw
ork
prov
ider
s an
d 50
% c
oins
uran
ce fo
r ou
t-of
-net
wor
k pr
ovid
ers.
Li
mite
d to
$2,
000
/ yea
r fo
r ac
upun
ctur
e an
d $2
,000
/ ye
ar fo
r sp
inal
man
ipul
atio
ns.
Coi
nsur
ance
app
lies
to th
e ou
t-of
-poc
ket l
imit.
Spe
cial
ist v
isit
$10
copa
y / o
ffice
vi
sit,
dedu
ctib
le d
oes
not a
pply
; 10
% c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$25
copa
y / o
ffice
vi
sit,
dedu
ctib
le d
oes
not a
pply
; 15
% c
oins
uran
ce fo
r al
l oth
er s
ervi
ces
$75
copa
y / o
ffice
vi
sit,
dedu
ctib
le
does
not
app
ly;
40%
coi
nsur
ance
fo
r al
l oth
er
serv
ices
Pre
vent
ive
care
/scr
eeni
ng/
imm
uniz
atio
n N
o ch
arge
N
o ch
arge
N
o ch
arge
50%
coi
nsur
ance
for
Out
-of-
netw
ork
prov
ider
s,
afte
r de
duct
ible
. Y
ou m
ay h
ave
to p
ay fo
r se
rvic
es th
at a
ren'
t pr
even
tive.
Ask
you
r pr
ovid
er if
the
serv
ices
ne
eded
are
pre
vent
ive.
The
n ch
eck
wha
t you
r pl
an w
ill p
ay fo
r. S
ubje
ct to
pre
vent
ive
care
-
3 o
f 8
Co
mm
on
Med
ical
Eve
nt
Ser
vice
s Y
ou
May
Nee
d
Wh
at Y
ou
Will
Pay
Lim
itat
ion
s, E
xcep
tio
ns,
& 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
T/P
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
list/2
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
en's
co
ntra
cept
ives
and
cer
tain
pre
vent
ive
drug
s an
d im
mun
izat
ions
at a
par
ticip
atin
g ph
arm
acy.
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