Group Enrollment Guide

Transcription

1 Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association Group Enrollment Guide

2

3 WHAT YOU NEED TO KNOW ABOUT PREVENTIVE HEALTH CARE COVERAGE Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association Wondering what preventive care services are covered by your health plan? As you re probably aware, the federal health care reform law passed in 2010 requires insurers to include specific preventive care services in their benefit plans. Regence supports that initiative. In fact, Regence plans already provided benefits for many preventive care services, as we have long believed that preventive care and early detection are key to the long-term health and well-being of our members. This brochure explains preventive care eligibility and shows which services are available to you and the family members covered by your plan. Who s eligible for these preventive services? To be eligible for these preventive services, you must first be covered by a current Regence policy. Benefits for the federally required preventive services: Are not required in grandfathered policies, which are essentially policies that were in effect on March 23, 2010, as long as few or no benefit changes have been made to them (please note that Regence has chosen to retain grandfathered status for a very limited number of policies) May be covered by grandfathered plans that have chosen to include the benefit May apply to retiree-only plans Apply to Association plans at the Association s plan renewal date 1 Evidence-based preventive guidelines are developed and validated by the following government entities: United States Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA). What preventive services are covered? Regence follows government guidelines to determine which preventive services we cover 1. These guidelines are updated periodically to reflect new scientific and medical advances. Additionally, current services could be revised and subject to different limitations; thus, benefits are subject to change. New guidelines will be implemented within one year of the recommendation s publication. You can learn more details about these services at healthcare.gov, including recommended child and adolescent immunization schedules. What is the coinsurance/copay for these preventive services? The services listed in this brochure will be paid at 100% (no deductibles, coinsurance or copays) when you see preferred or participating providers (Category 1 or Category 2) or in-network providers. Deductibles and/or coinsurance may apply when you see other providers. To find out if you re eligible for preventive coverage, call the Customer Service number on the back of your member card or go to the Contact Us link at regence.com.

4 Covered preventive services Men Women Pregnant Women Children (0-17) Health screenings, counseling and services for: Adult abdominal aortic aneurysm Alcohol misuse Suggested guidelines Screening is covered once per lifetime for men age 65 and over if they have ever smoked. Screening and behavioral counseling intervention covered for adults age 19 and older. Anemia (iron deficiency) Screening covered up to age 21, and pregnant women. ü ü ü ü Bacteriuria (urinary tract infection) Screening for asymptomatic pregnant women. ü Blood pressure Screening covered for adults age 18 and older. ü ü Breast cancer Screening for women age 40 and older and those at increased risk. Mammograms only. ü Breast cancer chemoprevention Counseling for women at increased risk. ü Breastfeeding equipment Manual and electric breastfeeding pumps are covered when purchased or rented from a licensed provider. Off-the-shelf pumps from a retail outlet are not covered. Hospital-grade pumps are not covered. See Note 1. ü Breastfeeding - lactation support and counseling Lactation support and counseling are covered when provided by a licensed provider. Breastfeeding supplies Initial breastfeeding supplies provided with a breastfeeding pump. See Note 1. ü Cervical cancer Screening for sexually active women. ü Chlamydia infection Screening for infection. ü Cholesterol Screening for men age 35 and older and men ages who are at increased risk for coronary heart disease. Screening for women age 45 and older and those ü ü ü who are at increased risk for coronary heart disease. Colorectal cancer Screening for those age 50 and older, once every 5 years for a sigmoidoscopy and every 10 years for a colonoscopy, fecal occult blood testing annually. ü ü Congenital hypothyroidism Screening for newborns. ü Contraceptive education and training Education and training on contraceptive methods. See Notes 1 and 2. ü ü Contraceptive devices - implants, cervical caps, intrauterine devices (IUDs), diaphragms Generic contraceptive devices are covered. When no generic exists, a brand is covered. If a generic becomes available, the brand will no longer be covered under Preventive Care. Insertion of a device is covered under Preventive Care. Removal is covered at regular plan benefits if a Family Planning benefit applies. See Notes 1 and 2. Depression screening Screening during wellness exams. ü ü ü Diabetes (Type 2) Screening for adults with sustained high blood pressure. ü ü Diabetes (Gestational) Screening for pregnant women between 24 and 28 weeks of gestation and the first pre-natal visit for pregnant women at high risk for diabetes. See Note 1. ü Diet behavioral counseling Counseling for adults with hyperlipidemia and other risk factors. ü ü Genetic risk assessment and BRCA (breast For women with family risk of breast and ovarian cancer. cancer susceptibility) mutation counseling ü Gonorrhea medication Preventive medication for the eyes of newborns. ü Gonorrhea screening Screening for males up to age 21 and all females. ü ü ü Hearing One screening in the first year of life for newborns. ü ü ü ü ü ü ü

5 Covered preventive services Men Women Pregnant Women Children (0-17) Hepatitis B Screening for pregnant women. ü HIV Screening and counseling during wellness exams for sexually active women. Screening during wellness exams for men, women and children at increased risk. ü ü ü HPV Screening for women from age 30, every 3 years. See Note 1. ü Interpersonal and domestic violence Screening and counseling during wellness exams. See Note 1. ü Lead screening Screening up to age 21. ü ü ü Metabolic screening Screening up to age 2 months. ü Obesity Screening and counseling for age 6 and older. ü ü ü Oral health Risk assessment for preschool children. ü Osteoporosis Screening for women age 65 and older and all women at increased risk. ü Phenylketonuria (PKU) Newborn screening for genetic disorders. ü RH(D) incompatibility Screening for pregnant women. ü Sexually transmitted infection (STI) Counseling during wellness exams. ü ü ü Sickle cell Screening for children up to 12 months old. ü Sterilization Sterilization is covered. See Notes 1 and 2. ü Syphilis Screening for those at increased risk and those up to age 21; also includes pregnant women. ü ü ü ü Tobacco use Counseling and interventions. Does not include programs or classes. See also Tobacco use below. ü ü ü Tuberculosis Skin test for children. ü Vision Screening for children age 3 up to age 5. ü Immunization vaccines - please consult your physician for frequency Diphtheria, pertussis, tetanus (DPT) ü ü ü Haemophilus influenzae type b (Hib) ü Hepatitis A ü ü ü Hepatitis B ü ü ü Herpes zoster (shingles) Age 60 and older. ü ü Human papillomavirus (HPV) Up to age 27. ü ü ü Inactivated poliovirus ü Influenza ü ü ü Measles, mumps, rubella (MMR) ü ü ü Meningococcal ü ü ü Pneumococcal ü ü ü Rotavirus ü Varicella ü ü ü

6 Covered preventive services Men Women Pregnant Women Children (0-17) Prescription medications Only the types of prescription medications listed below are covered under Preventive Care. Medications require a prescription. Over-the-counter products are not covered. Get the most value for your health care dollar with preferred medications. Learn more at regencerx.com/learn/covered. Aspirin use for the prevention of For men age and women age cardiovascular disease ü ü Contraceptive injectables Generic contraceptive injectables. See Notes 1 and 2. ü ü Contraceptive pills Generic contraceptive pills. See Notes 1 and 2. ü ü Contraceptive products-topical Diaphragms and patches. See Notes 1, 2 and 3. ü ü Emergency contraceptive products Generic contraceptive pills. See Notes 1, 2 and 3. ü ü Fluoride supplements For children 6 months through age 6 without sufficient fluoride ü Folic acid supplements For all women planning or capable of pregnancy. ü ü Iron supplements For children age 6-12 months at increased risk - drops only. ü Tobacco use Generic tobacco cessation medications. ü ü Wellness exams Suggested guidelines Well-child exams For children through 17 years of age. ü Annual physical exams Ages 18 and over. ü ü Notes: 1. This benefit is available upon renewal of your plan, on or after August 1, This benefit may not be available to members of groups who have applied for a religious exemption from contraceptive coverage. 3. Generic contraceptives are covered. When no generic exists, a formulary brand is covered. If a generic becomes available, the formulary brand will no longer be covered under Preventive Care. Have questions? Call the Customer Service number on the back of your member card or go to the Contact Us link at regence.com rep04976-or / Regence BlueCross BlueShield of Oregon, all rights reserved.

7 Finding a doctor is quick and easy! GIVE OUR ONLINE PROVIDER DIRECTORY A TRY Finding a doctor online takes just seconds. Whether you want to know if your doctor is in your network or need to find a new one, our online provider directory can help. Browse our database 1. Go to regence.com. 2. Click on Find a Provider at the top right of the screen. 3. Enter your ZIP code. 4. Provide a clinic name or specialty (optional). Then click Search. Find a specific doctor 1. Go to Advanced Search. 2. Make a selection under Provider Type. 3. Key the provider s last name into the Name field under Provider Options. 4. Enter your location. Create a list of providers 1. Make a selection under Provider Type. 2. Choose a specialty from the drop-down box that appears under your selection. 3. Under Provider Options, choose your network from the Network Affiliation drop-down box. 4. Choose language or gender if you have a preference. 5. Enter your location. Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association Let us know if we can help Customer Service can also assist you with your doctor or pharmacy search, and tell you whether yours is in the network. Just give us a call at one of the following numbers: Regence HSA Healthplan 2.0 SM : 1 (877) Regence Innova, Regence Engage SM : 1 (888) or / The Regence Group, all rights reserved.

8

9 Regence has covered ACROSS THE COUNTRY AND AROUND THE WORLD. The BlueCard Program With coverage from Regence, you take your health care benefits with you across the country and around the world. The BlueCard Program gives you access to doctors and hospitals nearly everywhere, so you ll have peace of mind knowing that you can always find the health care provider you need. Choices Your Regence membership gives you a world of choices. Through the BlueCard Worldwide Program, you re free to choose doctors and hospitals that best suit you and your family in more than 200 countries and territories around the world. Designed to save money In most cases, when you travel or live outside the Regence service area, you can take advantage of savings the local Blue Plan has negotiated with providers in the area where you are. For covered services, you should not have to pay any amount above these negotiated rates. You should also not have to pay amounts above any applicable out-of-pocket expenses. BlueCard Program Advantages Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association PROVIDER CHOICE BENEFIT CONSISTENCY BILLING PROTECTION EASE OF ACCESS You have access to more than 85% of providers and 96% of hospitals nationwide. BlueCard ensures that you receive in-network benefits when choosing participating providers of any Blue Cross and/or Blue Shield Plan. Accessing a Blue Cross and/or Blue Shield Plan participating provider ensures that you are not responsible for any balance billed amount. It s quick and easy to locate a participating provider at bcbs.com or by calling ( BLUE).

10 How it works You see a provider outside the Regence service area Participating provider provides care for you Local Blue Plan prices the claim and submits it to Regence Local Blue Plan pays provider Processes the claim and authorizes payment Sends an explanation of benefits to you To learn more about the BlueCard program, call your local Blue Plan or visit regence.com. BlueCard and BlueCard Worldwide are registered service marks of the Blue Cross and Blue Shield Association or / The Regence Group, all rights reserved.

11 myregence.com Everything you ve always wanted to know about your health. In one place. Imagine a place where you can find answers and support for all of your health needs. myregence.com is your complete source of health and wellness information. And it s simple to understand. So whether you want to get started on an exercise program, need tips on eating healthier, or just want to know if we ve paid your claim, visit myregence.com today. Advise Consider health care decisions, explore treatment options and plan ahead for financial needs. Compare cost and quality of hospitals, clinics and providers. Research treatment options and out-of-pocket cost estimates. Learn about medical conditions, medications and cost-saving generics. Explore and enjoy health articles, videos and podcasts. Navigate Discover tools that help you track your your coverage and make informed decisions about your health care. Review details about your coverage. Manage your claims online and eliminate paper Explanation of Benefits. Find a doctor or specialist and read patient reviews online or on your mobile device. Create a secure, confidential Personal Health Record. Discuss a variety of important health and wellness topics on My Community, a nationwide social networking site. Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association Reward Healthy living has its own rewards, but Regence Rewards points can help. Earn points for browsing our health news, podcasts and videos. Receive points for healthy everyday activities such as eating fruits and veggies and walking the dog, or joining an online wellness program. Redeem points for an Amazon.com gift card.

12 myregence.com Want more value for your health care dollars? Log on to myregence.com and discover online resources and interactive experiences focused on your health. It s easy to join and you ll earn 5,000 points with Regence Rewards just for registering. Become an informed health care consumer. Log on today and earn 5,000 points. Simply use the information on your member card and follow these steps. 1. Go to myregence.com. 2. Click New Member Registration. 3. Complete the required My Member Account Information fields. The name, member and group numbers you enter must match your member card. 4. Create a user name and secure password. 5. Click Register and Login. Take a confidential General Health Assessment. Earn up to 10,000 points. Learn how you ve been managing your health to date, and get practical tips on how to improve your health and well-being. Manage stress and get into shape. Earn 5,000 points at completion. Reach for a healthy lifestyle with wellness programs on Weight Loss, Healthier Diet, Stress Relief, Healthy Aging, going Smoke-Free and more. Keep your health history at your fingertips. Earn up to 6,000 points. Create a secure, confidential record of your medical history with the Personal Health Record tool. Input your own information about allergies, immunizations, emergency contacts and more. Get social in My Community. Earn up to 2,400 points. Join the conversation and earn points for posting in My Community an online health and wellness social networking site where members nationwide are talking, asking questions of our experts, following bloggers and receiving support in achieving their goals. What are you waiting for? Register now at myregence.com! rep or / Regence BlueCross BlueShield of Oregon, all or rights reserved. / 6-08

13 Find your way around your Rx plan IN A FLASH. A quick guide to your RegenceRx prescription program Here s a quick reference sheet to help you better understand your prescription benefits and find the Rx information you need. It s one more tool you can use to navigate the health care system and make informed decisions about your care. Check it out! With more than 65,000 pharmacies in our network, it s easy to find one near you. Using your Rx benefits Simply present your Regence member card at the pharmacy, and the pharmacist will submit your claim online. The system will calculate the claim cost based on your pharmacy benefit, then the pharmacist will tell you how much you owe. Your member card Take a minute to look at your member card. It verifies that you have prescription coverage and gives our participating pharmacies everything they need in order to submit your claim online. If you have questions, just call us at the phone number on the back of your card. Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association Your deductible and copay If you have a plan with a pharmacy deductible, then you ll pay for each covered prescription in full until you ve met your deductible. (The pharmacist will still submit your claim as usual so that your purchase counts toward your deductible.) After you meet your deductible, then you ll simply pay your portion of the cost (copay/coinsurance). If you have a plan with a copay only (no deductible), then you ll just pay that amount for each covered prescription medication when you pick it up. You ll find your prescription deductible and copay amounts summarized in your benefits booklet on myregence.com.

14 Generics: another way to save You ll save money by using generic medications whenever possible. If the medication you need is not available in generic form, ask your doctor if another generic can be used to treat the same condition, or if there is a less expensive brand-name medication. Your doctor is the best person to determine the medication that s right for you. Prior authorization and our Generics First policy Some brand-name medications require prior authorization to ensure they re covered, such as antidepressant, diabetes, pain, heartburn and cholesterol medications. Go to regencerx.com and click on Prior Auth/Medication Quantities in the Learn About Medications section for a list of medications needing prior authorization. If you take one of these medications or keep one on hand to use as needed, then you ll need to do one of two things in order to be sure your medication will continue to be covered: 1. Try a generic first! Switch to a generic version of the brand-name medication you are taking. Just ask your pharmacist to fill your prescription with the generic rather than the brand-name. or 2. Get prior authorization for that brand-name medication. The brand-name medication might be denied if it hasn t been approved ahead of time. Ask your doctor or pharmacist to send a prior authorization request with your medical or medication history before your next refill. Your pharmacist may fax your prescription profile to 1 (888) or call 1 (800) Filing claims and getting reimbursed The pharmacist will file your claim for you, and we ll pay the pharmacy directly, so you won t have to worry about paperwork or getting reimbursed. In the rare event that you do need to file a claim, we make it painless. Just go to regencerx.com to download the proper claim form, or give us a call at the number on the back of your member card. If you misplace your member card, we ll replace it. Just call us toll-free at 1 (888) or visit myregence.com. Explore regencerx.com: a site devoted to your Rx benefits Visit regencerx.com for information specifically related to your RegenceRx prescription benefit. Use it to: Find a participating pharmacy Access our formulary Learn about your medication choices Preview medications to learn if they require prior authorization, or if they have any limitations or restrictions Print out a prescription claim form Go to myregence.com to make the most of all your benefits To discover all the advantages of your Regence membership beyond prescriptions, go to myregence.com. There you can view and manage details related to your medical and prescription coverage, explore events and rewards for healthy living, and plan ahead using our Health Cost Estimators. Maximize your benefit: Always show your member card to the pharmacy where you purchase your prescriptions rep03460-or / Regence BlueCross BlueShield of Oregon, all rights reserved.

15 Get more value for your dollar WITH TIPS AND TOOLS from regencerx.com. Raise your pharmacy IQ. Control your medication costs. Your online Rx tools Load up on cost-saving ideas and health care knowledge with the user-friendly tools at regencerx.com. There you ll find a preferred medication list, a glossary of insurance terms, prior authorization information, a pharmacy locator, specialty program information, facts about generics and much more. Here are just a few of the tools that can help you make the most of every dollar: RxPrice Guide Become more informed about your medication costs and options. After you ve checked to see whether a medication is on our preferred medication list (also known as a formulary), you can use the RxPrice Guide to browse the costs of commonly prescribed medications. You ll get detailed pricing on brand-name medications and their generic alternatives. Health Calculators These online calculators can help you see health-minded behaviors from a financial perspective. You ll learn the cost of bad habits and the benefits of good choices. For instance, calculate the actual out-of-pocket cost of smoking, or estimate how long it might take to lose weight by doing your favorite activity. Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association ConsumerRx These educational summaries help you understand your medication options without the medical jargon. You ll find overviews of different conditions and the medications that are used to treat them, along with facts and tips to help you save money. Visit regencerx.com today, and take full advantage of all that RegenceRx has to offer or / 6-11

16

17 Prior authorization helps protect our members from harm and high costs. Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association Prior authorization is a small step that has a huge impact on safety and savings We sometimes need more information about a medication before we can cover it. We get that information through the prior authorization process. Not all medications need prior authorization. But for those that do, this process helps ensure that you get the best in safety and value. Here are some reasons a prescription might need prior authorization: It has been proven to benefit only a limited number of people Unusually large doses are requested for coverage Equally effective but more affordable generic options are available It s prescribed for conditions not covered by your health plan It hasn t been thoroughly tested by the scientific community or approved by the FDA for certain uses If your medication is on our prior authorization list, we ll need information from your doctor or pharmacist. When prior authorization works Our pharmacists and doctors tirelessly research medications for safety, effectiveness and overall value. We re committed to sharing this information with you through the prior authorization list. The prior authorization process is simple: Your doctor or pharmacist can request prior authorization by going to regencerx.com/pa, calling 1 (800) , or faxing 1 (800) Our team of clinical pharmacists and pharmacy technicians carefully reviews each request, taking into consideration our evidence-based reviews of scientific research. Any request that can t be approved is then reviewed by a physician medical director. We ll contact you, your doctor, and your pharmacy within two business days with our decision. If we find that the medication is the best value for your condition, the medication will generally be authorized. If not, the medication won t be covered. If your medication isn t covered, we ll share a clear explanation of our reasons, along with potential covered alternatives, if available. Your prior authorization support Naturally, you and your doctor are the best people to determine the medication that s right for you. If you have questions or concerns about prior authorization, we re here to help. Here s how you can reach us: To determine if a medication needs approval, visit and look under Learn About Medications. To review our medication policies, visit com/learn/policy/index.html. To speak to Pharmacy Customer Service, call 1 (800) or / 2-12

18

19 Prescription Prior Authorization Prior authorization helps ensure that covered medications provide the best safety and value. It is needed when a medication has only been proven to benefit a limited number of people or if unusually large doses are requested for coverage. These medications require prior authorization because alternatives may offer a better value Possible alternatives Cholesterol atorvastatin, Crestor simvastin (Zocor ), pravastatin (Pravachol ), lovastatin (Mevacor ) Lipitor, Livalo, Vytorin Depression Cymbalta, Pristiq, Viibryd Diabetes ACTOplus Met, Actos, Avandamet, Avandaryl, Avandia, Bydureon, Byetta, Duetact, Janumet, Janumet XR, Januvia, Jentadueto, Juvisync, Kombiglyze XR, Onglyza, Tradjenta, Victoza High Blood Pressure Benicar, Benicar HCT, Micardis, Micardis HCT Amturnide, Atacand, Atacand-HCT, Avalide, Avapro, Azor, Diovan, Diovan HCT, Edarbi, Exforge, Exforge HCT, Tekamlo, Tekturna, Tekturna HCT, Teveten, Teveten HCT, Tribenzor, Twynsta, Valturna Mental Health Abilify, Fanapt, Geodon, Invega, Latuda, Saphris, ziprasidone simvastin (Zocor ), pravastatin (Pravachol ), lovastatin (Mevacor ), Crestor bupropion SR (Wellbutrin SR ), bupropion XL 300mg (Wellbutrin XL ), fluoxetine (Prozac ), fluvoxamine maleate, mirtazapine (Remeron ), paroxetine (Paxil ), sertraline (Zoloft ) metformin (Glucophage ), glimepiride (Amaryl ), glipizide (Glucotrol ), glyburide (Diabeta ), insulin benazepril/hct (Lotensin/HCT ), captopril/hct (Capoten/ Captozide ), enalapril/hct (Vasotec/Vaseretic ), fosinopril/ HCT (Monopril/HCT ), lisinopril/hct (Zestril/Zestoretic, Prinivil/Prinzide ), losartan/hct (Cozaar/Hyzaar ), moexipril/ HCT (Univasc/Uniretic ), quinapril/hct (Accupril/Accuretic ), trandolapril (Mavik ) benazepril/hct (Lotensin/HCT ), captopril/hct(capoten/ Captozide ), enalapril/hct (Vasotec/Vaseretic ), fosinopril/ HCT (Monopril/HCT ), lisinopril/hct (Zestril/Zestoretic, Prinivil/ Prinzide ), losartan/hct (Cozaar/Hyzaar ), moexipril/hct (Univasc/ Uniretic ), quinapril/hct (Accupril/Accuretic ), trandolapril (Mavik ), Benicar, Benicar HCT, Micardis, Micardis HCT clozapine (Clozaril ), olanzapine (Zyprexa ), risperidone (Risperdal ), Seroquel, Seroquel XR Migraines Maxalt, Maxalt-MLT, Relpax sumatriptan (Imitrex ) Alsuma, Amerge, Axert, Frova, naratriptan HCL, Sumavel DosePro, Treximet, Zomig, Zomig-ZMT sumatriptan (Imitrex ), Maxalt, Maxalt-MLT, Relpax Multiple Sclerosis Extavia Avonex, Copaxone, Rebif Betaseron Avonex, Copaxone, Rebif, Extavia Nasal Steroids Beconase AQ, Nasonex, Omnaris, Qnasl, Rhinocort Aqua, Veramyst Pain and Inflammation Celebrex Stomach Acid lansoprazole, pantoprazole, Dexilant, Kapidex omeprazole (Prilosec ) flunisolide (Nasalide ), fluticasone (Flonase ), triamcinolone acetonide (Nasacort AQ) Generic non-steroidal anti-inflammatory medications (NSAIDs) such as: diclofenac (Voltaren ), etodolac (Lodine ), flurbiprofen (Ansaid ), ibuprofen (Motrin ), indomethacin (Indocin ), ketoprofen (Orudis ), nabumetone (Relafen ), naproxen (Naprosyn ), oxaprozin (Daypro ), piroxicam (Feldene ), salsalate (Disalcid ), sulindac (Clinoril ), tolmetin (Tolectin ) Aciphex, Nexium, Prevacid, Protonix, Vimovo omeprazole (Prilosec ), Dexilant, Kapidex Effective 04/12 NOTE: Our medication Prior Authorization List is subject to change. If the requested medication is authorized, there maybe limits to the amount of medication that is eligible for coverage. Please call our Customer Service Department if you have any questions.

20 Prescription Prior Authorization The Bottom Line Safety is our top priority and our prior authorization program helps you and your doctors choose quality medications that provide the most value. Some alternatives might also help you save money. These medications require prior authorization if prescribed above the maximum quantity Ambien CR (zolpidem tartrate er) Edluar Exalgo Imitrex (sumatriptan succinate) tablet Imitrex (sumatriptan succinate) injection Imitrex nasal spray Infergen injection Intermezzo Lunesta Opana ER Relenza Rozerem Tamiflu 30mg Tamiflu 45mg & 75mg Tamiflu 12mg/ml Maximum quantity per month unless otherwise specified 14 tablets 14 tablets 120 tablets 12 tablets 6 injections 6 canisters 12 injections 14 tablets 14 tablets 80 mg per day 10 discs (2 treatment courses) per 6 months 14 tablets 40 capsules (2 treatment courses) per 6 months 20 capsules (2 treatment courses) per 6 months 150ml (2 treatment courses) per 6 months These medications require prior authorization to determine if they can be covered for your medical condition Abstral Actiq Actonel Actonel with Calcium Adcirca Afinitor Amphetamine- Dextroamphetamine ER cap (Mfgs: Global, Barr/ Teva) Ampyra Arcalyst Atelvia Blood Glucose test strips and meters (Mfgs: Abbott, Lifescan/JJ, Roche) ciclopirox (solution) Cimzia CNL 8 Doryx Egrifta Embeda Enbrel Erivedge Fentora Firazyr Forteo Gilenya Gleevec Growth Hormone Humira Incivek Increlex Inlyta itraconazole Jakafi Kalydeco Kineret Lamisil Lazanda Letairis Lyrica Modafinil Nexavar Nuvigil Onsolis Orencia SQ injection Pegasys PEG-Intron PenLac Promacta Provigil Qualaquin Relistor Revatio Revlimid Savella Simponi Solodyn Sporanox Sprycel Subsys Sutent Sylatron Tarceva Tasigna terbinafine Tracleer Tykerb Tyvaso Vandetanib Ventavis Victrelis Votrient Xalkori Xenazine Xyrem Zavesca Zelboraf Zolinza ZolpiMist Zytiga NOTE: In addition to the above medications, there are limits to the amount of medication eligible for coverage for all prescriptions. These limits are based on your prescription benefit along with information from the FDA and scientific literature about maximum, safe, effective dosages

21 Facing a health challenge? YOUR PERSONAL CARE TEAM CAN HELP. Integrated Care Management When you re dealing with a health challenge, a helping hand can make all the difference. A Personal Care Team is ready to assist you with an ongoing medical condition, or serious illness or injury. The program provides easy access to one-on-one support at no extra cost to you. This program is not insurance, but is offered in addition to your medical plan to help you get information and support when you need it. Specialized support in times of need Imagine having a team of clinical health experts helping you manage a complex or chronic medical condition. That s what you ll experience with a Regence Personal Care Team. Our specialists utilize a holistic approach. We ll partner with you to develop a customized care plan that supports your health goals and specific challenges. You ll communicate directly with a designated nurse, social worker or care advocate. Behind the scenes you ll be supported by a team of experts. Together, we ll work with you and your doctors to manage your care. Teams can include certified case managers, pediatric and maternity nurses, behavioral health clinicians, transplant specialists, and others who understand you and what you re facing. Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association The goal is to get you the right care at the right time and help you achieve the best possible health. Who uses Integrated Care Management services? We provide support for a variety of medical concerns. Here are some real-life examples of members who ve been helped by a Personal Care Team: A pregnant mother who s just found out she s carrying triplets and feels overwhelmed by the challenges facing her family An 84-year-old man whose leg wounds were infected with antibiotic-resistant bacteria A 48-year-old man suffering from a lung disease who now receives intravenous treatment in the comfort of his own home A 17-year-old student whose kidney transplant saved her life

22 What you can expect A big-picture viewpoint of your health can lead to targeted interventions, extra support for managing medications, custom treatment plans and even suggestions for lifestyle changes. All of these can significantly impact your overall health. Expect your Personal Care Team to: We know that addressing potential health issues early on can mean better health outcomes in the long run. That s why a care advocate may reach out directly to you or a family member if it appears you could use some help. Need help or want to learn more? Call toll-free: 1 (866) Answer questions and provide information about your condition, illness or injury Be your advocate and help you navigate the health care system Work with your doctors and support your care plan Help you make informed decisions based on all your treatment options Make sure you re getting the most from your health care benefits Help you understand what actions you can take to improve your health or / The Regence Group, all rights reserved.

23 Feeling good doesn t have to cost a lot. Regence Advantages Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association As a Regence member, you can enjoy savings on the following health-related products and services. This discount program is offered to all Regence members at no additional cost (although some discounted programs offered by vendors may carry separate fees). Regence Advantages is not insurance but is offered in addition to your medical and/or dental plan(s) to help you stay healthy and live better. TruVision : Significant discounts are offered on laser vision correction procedures such as LASIK and PRK. Also, save 10% to 15% on mail-order contact lenses. TruHearing : TruHearing offers deep discounts on state-of-the-art digital hearing aids, and contracts with a national network of audiologists and hearing instrument specialists to provide lower costs on expert advice and service. It offers two programs to choose from TruHearing ValueAdd and TruHearing MemberPlus. Both include special health plan-contracted pricing on hearing aids, one-time loss or damage replacement for three years, a 45-day money back guarantee and 48 batteries per hearing aid purchased. Similar to warehouse memberships, TruHearing MemberPlus saves you an additional $300 to $1,100 on hearing aids for an annual membership fee of $108. QualSight : QualSight makes LASIK easy for members. You can save 40-50% off the national average price of Traditional LASIK or receive significant savings on procedures such as Custom Bladeless (all laser) LASIK. Find out if you are a potential candidate for this life-changing procedure today. Call 1 (866) to learn more or visit QualSight.com. Epic Dental: Purchase smile-protecting supplies at 25% off, including mouthwash, gums, mints and toothpaste. All items contain xylitol, a natural ingredient that fights cavities. CHP CAMaffinity Program: As a Regence member, you re eligible for the CHP CAMaffinity Program, which provides a 20% discount on complementary and alternative medicine (CAM) services offered through The CHP Group s growing network of chiropractors, acupuncturists, naturopathic physicians and massage therapists. Regence is completely independent from the companies that provide these products and services. Regence does not endorse or guarantee the products and services offered or their effectiveness. Regence reserves the right to change the program at any time without prior notice.

24 CHP Active and Healthy: CHP Active and Healthy is the discount program that gets you up, moving, and saving money! With discounts offered by thousands of participating vendors (e.g. health clubs, ski resorts, sporting events, museums, etc.) for a small annual fee, it s your source for great deals on healthy and fun activities. Banfield Pet Hospital: As a Regence member, you receive a waived enrollment fee for Banfield Pet Hospital s Optimum Wellness Plans, packages of preventive care that include annual blood work, vaccinations, de-worming, unlimited office visits, plus much more. Banfield is the largest veterinary hospital in the world with 800 hospitals in 43 states; most located inside PetSmart TM. Learn more at banfield.com/regence. Take Shape for Life : Save $25 or more on your first month s order! This safe weight management and health program uses clinically proven Medifast products and a personal health coach to provide one-on-one guidance and encouragement. The program helps you lose weight and manage disease and health through nutritional intervention, free access to health care professionals, educational materials, and the Habits of Health system. There are no hidden costs or start-up fees. Learn more at stayhealthy4ever.com. CorCell Saving Baby s Cord Blood : Cord blood stem cells are now being used to treat more than 70 diseases, and research is ongoing to find treatments for even more. Regence has partnered with CorCell to offer a $350 discount when you bank your baby s umbilical cord blood. Protect your child or give the gift of cord blood preservation to your grandchild, niece, nephew, friend or other loved one. Visit corcell.com for more information. HearPO : Receive a 40% discount on diagnostic services, including hearing exams, and significant savings on hearing aids. You ll enjoy a 60-day no-risk trial period; one-year followup care; a three-year warranty, including coverage for loss and damage; and free batteries (160 cells per hearing aid) all with a lowest-price guarantee. Everest, The First Nationwide Funeral Planning and Concierge Service: Save $50 off the enrollment fee for Everest s suite of funeral-planning services. With advisors available 24 hours a day, you ll get the information you need to make informed decisions about all funeral-related issues, within your budget, and with a funeral home of your choice. National Allergy Supply: Save 15% on products for non-drug allergy relief, including pillow and mattress encasings, air filtration products, asthma management tools, green cleaning products and personal care products. National Allergy Supply provides discount prices, outstanding service and a 60-day unconditional return policy with no restocking fees. EyeMed Vision Care : Save 35% on a complete pair of glasses (frames and lenses). Save 15% on non-disposable contacts and $10 on contact lens fittings. These discounts are available at leading retailers and many private practice locations. Jenny : Jenny Craig plans are personalized and offer one-on-one support from trained weight-loss consultants. With every Jenny Craig Program you ll receive weekly scheduled consultations, planned or personalized menus, and free online support at jennycraig.com. Choose from two special offers: A Free 30-day Program* 25% off a Premium Program* Beltone **: Receive a free screening, a 25% discount on Beltone hearing aids, a one-year supply of hearing-aid batteries and free follow-up visits and testing. Safe Beginnings : Save 15% on Safe Beginnings products, including safety gates, cabinet locks, outlet covers, window guards, and many other baby-proofing products Want to learn more? Go to myregence.com/advantages or regence.com/advantages * Plus the cost of food. Plus the cost of shipping, if applicable. Offer applies to initial membership fee only and is valid at participating centres in the United States, Canada and Puerto Rico and through Jenny Craig At Home. Each offer is a separate offer and can be used only once per person. Restrictions apply. ** Discounts through HearPO (also includes extended family), TruHearing and Beltone are available to members and their parents and grandparents rep05270-or / Regence BlueCross BlueShield of Oregon, all rights reserved.

25

26

27

28 04821-or /