2017 DECISION GUIDE Regence Medicare Advantage HMO Plan for Clackamas, Marion and Polk counties in Oregon and Clark county in Washington Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association Y0062_MAHMODG17 ACCEPTED OR-HMO-002-2017
Need to find a primary care provider? Call one of our Medicare plan advisors at 1-844-REGENCE (734-3623) (TTY: 711) or use the Find a Doctor link at regence.com/medicare
With an HMO plan, you work with a primary care provider who coordinates your care with a wide variety of specialists who all work for the same provider network and are used to working as a team a team that collaborates, communicates and focuses on your care. And you ll always be involved in making decisions about your health and your treatment because you re the most important member of the team. Get the benefits you need to keep yourself healthy with no deductibles and low copays. $0 monthly premium $0 medical deductible $0 prescription drug deductible $0 copay on Select Care drugs Low primary care copay Free fitness membership Worldwide coverage for urgent and emergency care Annual physical exam Annual routine eye exam Routine vision hardware Referrals This plan requires that you choose a primary care provider (PCP). To see a specialist or receive other services, you ll need to have a referral from your PCP. When dealing with referrals, always make sure: Your specialists and hospitals are in-network Your referrals are approved Your doctor requests prior authorization for your medical services and procedures Prior authorization Some medical services and procedures require prior authorization from Regence before you receive treatment. This process helps you: Understand your treatment options and any related risks Ensure coverage of a specific procedure, treatment or service that is supported by best available evidence Avoid inappropriate or unnecessary medical treatment and costs For additional information about prior authorization, you can talk with your provider, or visit regence.com/medicare. OR-HMO-002-2017 1
Regence delivers the service, reliability and value you expect from a Blue Plan. As a locally owned non-profit, we put our members first. Quality provider networks. We partner with quality provider networks to help you get efficient, coordinated care. Our Oregon HMO network has over 6,200 doctors, 224 facilities and 12 hospitals. You can be confident that Regence and your doctors work together to improve your health and simplify your life. Dental, vision and hearing benefits. Add extra benefits such as dental, vision and hearing to your HMO plan to support your overall health. See page 5 and the Summary of Benefits for more information. 2 OR-HMO-002-2017
Travel with complete peace of mind. When you arrange cashless access with a participating provider or hospital through the BlueCard Worldwide Service Center, you ll only pay the out-of-pocket expenses (copays and coinsurance) that you would normally pay for urgent and emergency care under your HMO plan. Part D prescription drug coverage is not available outside the United States and its territories. Low out-of-pocket costs. Our HMO plan has no deductibles, low primary care office visit copay and low copays on most generic drugs. Prescription drug savings. You pay only two times your monthly copay for a three - month supply of drugs on Tiers 1 and 2; drugs on Tier 3 are only two and a half times your monthly copay. Tier 6 Select Care drugs are available at no cost. OR-HMO-002-2017 3
HMO medical benefits. Medical Benefits Service area Regence BlueAdvantage HMO Clackamas, Marion, Polk, Clark (WA) Monthly premium $0 Annual medical deductible $0 Out-of-pocket maximum $6,700 In-Network Primary care office visit $10 Specialist office visit $35 Chiropractic services $20 X-rays doctor s office or independent imaging center $15 X-rays ambulatory surgical center/hospital $30 Lab services doctor s office or independent lab $15 Lab services ambulatory surgical center/hospital $30 Inpatient hospital Days 1 4: $395 per day Outpatient surgery ambulatory surgery center $225 Outpatient surgery hospital 20% Emergency room (waived if admitted within 48 hours) $75 Urgent care $50 Ambulance $275 Durable medical equipment 20% Premiums do not apply to the medical out - of - pocket maximum. All cost - sharing amounts for covered medical services accumulate toward the out - of - pocket maximum except for preventive and comprehensive dental services, routine vision services, routine hearing services and prescription drugs. 4 OR-HMO-002-2017
HMO medical benefits. Medical Benefits Regence BlueAdvantage HMO In-Network Medicare-covered preventive services $0 Annual physical exam $0 Routine vision exam $15 Routine vision hardware The Silver&Fit Program Lenses covered 100%, up to $65 allowed for frames or contact lenses Included at no additional charge Optional Benefits In-Network Regence DH Option Available for HMO plan only Monthly premium $39 Preventive dental Comprehensive dental 50% coinsurance, up to $500 allowed per year 50% coinsurance, up to $1,000 allowed per year Routine hearing exam $45 Hearing aid $699 copay (per aid) Flyte 700 $999 copay (per aid) Flyte 900 Routine vision exam and hardware must be received from a Vision Service Plan (VSP) provider to be eligible for coverage. Only one pair of lenses and eyeglass frames or one pair of contact lenses allowed per year. Lenses and frames must be purchased at the same visit. See Summary of Benefits for details. Visit vsp.com to search for a provider in your area. Routine hearing exam and hearing aids must be obtained from a TruHearing provider to be eligible for coverage. See Summary of Benefits for details. OR-HMO-002-2017 5
Prescription drugs. Prescription Drug Benefits Regence BlueAdvantage HMO Annual Rx deductible $0 Stage 1: Initial coverage stage 1-month supply (in-network retail pharmacy) Tier 1: Preferred generics $3 Tier 2: Generics $8 Tier 3: Preferred brands $47 Tier 4: Non-preferred drugs 40% Tier 5: Specialty drugs 33% Tier 6: Select Care drugs $0 3-month supply (in-network retail or mail-order pharmacy) Tier 1: Preferred generics $6 Tier 2: Generics $16 Tier 3: Preferred brands $117.50 Tier 4: Non-preferred drugs 40% Tier 5: Specialty drugs Not applicable; limited to a 30-day supply Tier 6: Select Care drugs $0 Stage 2: Coverage gap stage (after prescription costs reach $3,700) Generic drugs You pay 51% Brand-name drugs You pay 40% Stage 3: Catastrophic coverage stage (after you have paid $4,950 out of pocket) Generic drugs You pay the greater of $3.30 or 5% Brand-name drugs You pay the greater of $8.25 or 5% 6 OR-HMO-002-2017
How your drug coverage works. Stage 1: Initial Coverage Stage 2: Coverage Gap Stage 3: Catastrophic Coverage You pay a little Plan pays most You pay some Plan pays some You pay a little Plan pays most After you pay your annual deductible (if your plan has one), you pay a copay or coinsurance for each prescription you fill. Your plan pays the rest. You enter the coverage gap when the total amount you and your plan pay for covered drugs reaches $3,700. After you and your plan spend $3,700, you pay 51% of the plan s price for generic prescription drugs and 40% of the plan s price for brand-name prescription drugs. You enter catastrophic coverage when your total out-of-pocket reaches $4,950. Only the amount you ve paid in Stages 1 and 2 and the brand-name drug discount paid by the drug company count toward the total out - of - pocket. After your total out-of-pocket reaches $4,950, you pay the greater of 5% coinsurance or $3.30 copay for generic drugs, and the greater of 5% coinsurance or $8.25 copay for brand-name drugs. Your plan pays the rest of the cost of your prescription drugs for the rest of the calendar year (until Dec. 31). How we cover medications We organize covered prescription medications into six tiers, and a copay or coinsurance is assigned to each tier. What you pay depends on which tier your medication falls into. The formulary Our list of covered brand-name and generic prescription medications is selected and regularly reviewed by a committee of doctors and pharmacists. Formulary medications are chosen for effectiveness, value and safety not just price. Save with generics Generics typically cost a lot less than brand-name medications and work just as well. So ask your doctor if a generic version of your medication is right for you. Prior authorization Some brand-name medications require prior authorization. Generics typically don t require prior authorization, so switching to a generic can eliminate the need for review. If you need to obtain prior authorization, your doctor or pharmacist can call or fax in the request. Visit regence.com/medicare to: Find a network pharmacy near you Learn about your medication choices See if your medication needs prior authorization or has limitations or restrictions OR-HMO-002-2017 7
Member perks. Regence Advice24 nurse line Make a toll-free and confidential call if you can t decide between going to the ER or calling your doctor. Registered nurses are ready 24/7 to answer questions and assess symptoms or injuries. regence.com You ll find 24-hour access to your coverage and claims, and you can find a doctor near home or work in minutes. Providers are even reviewed by other Regence members. Our library of articles, videos and interactive tools help you brush up on nutrition and get current information on medications and other health topics. My Advocate Find out if you qualify for, but are not receiving, assistance with medical costs, heating bills, meal programs or other programs and social services. Case management We can help if you face a difficult medical situation. Case managers experienced registered nurses and social workers will answer questions and work closely with you and your doctor on a personal treatment plan. They also work with disease and behavioral specialists to help with chemical dependency, depression and other chronic conditions. Disease management If you re dealing with a chronic illness, like diabetes or heart disease, managing your condition is a good way to maintain or improve your quality of life. Our registered nurses help you understand your condition, create a personalized care plan and communicate with your doctor as a part of your health care team. Annual in-home health evaluation This service from a licensed health practitioner is designed to support and complement your regular doctor s care to help you maintain or improve your health. The Silver&Fit Program Being active can improve the quality of your life for years to come. With the Silver&Fit program, you can go to participating fitness clubs and exercise centers at no cost. 8 OR-HMO-002-2017
Ready to enroll? Call us. Our Medicare plan advisors are ready to help you find a doctor, look up your medications or locate an informational meeting in your area. They can even take your application over the phone. Just call 1-844 - REGENCE (734-3623) (TTY: 711) 8 a.m. to 5 p.m., Monday Friday. Information at your fingertips. Visit regence.com/medicare and use our provider search tool, view the medications on our formulary or find an informational meeting near you. Ready to enroll? Just follow the instructions for applying online.
Need answers? Call us. Speak to one of our Medicare plan advisors. Toll-free: 1-844-REGENCE (734-3623) (TTY: 711) 8 a.m. to 5 p.m. Monday Friday Need extra help with prescription drug costs? To determine if you qualify for extra help from Medicare to pay for your prescription drug premiums and costs, call the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday Friday (TTY users should call 1-800-325-0778); or your State Medicaid Office. Mail-order pharmacy. You can get prescription drugs shipped to your home through our network mail-order delivery service. To refill your mailorder prescriptions, please contact us 14 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail-order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact us at 1-855-522-8896 (TTY: 711), from 8 a.m. to 8 p.m. Monday Friday (from October 1 February 14, our telephone hours are 8 a.m. to 8 p.m., seven days a week) or visit regence.com/medicare. Privacy policy. View the annual notice of member rights regarding privacy practices and how we protect your information at regence.com/medicare. Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-541-8981 (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 1-800-541-8981 (TTY: 711). Regence BlueCross BlueShield of Oregon is a Medicare Advantage plan with a Medicare contract. Enrollment in Regence BlueCross BlueShield of Oregon depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premium. The Silver&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH and used with permission herein. 2016 Regence BlueCross BlueShield of Oregon. P.O. BOX 1271 PORTLAND, OR 97207-1271 REGENCE.COM/MEDICARE REG-91987-16/08-16-OR-002