2025 cis copay h rx9-cis vision-a- cis copay alt care.pdf

CIS Copay Plan H Alternative Care Benefits Summary Effective January 1, 2025

These medical plans are insured by CIS but administered by Regence BlueCross BlueShield (BCBS) of Oregon. This means that CIS, not Regence BCBS, pays for your covered medical services and supplies.

Copay Plan H

Deductible Per Calendar Year $1,500 Individual $4,500 Family

Out-of-Pocket Maximum Per Calendar Year

Category 1 & 2 - Preferred and Participating Provider (includes deductible and medical copays but does not include prescription copays)

$3,500 Individual $8,500 Family

Category 3 - Non-Preferred Provider (includes deductible and medical copays but does not include prescription copays)

$5,500 Individual $12,500 Family

Medical Services Member Pays Member Pays

Category 1 - Preferred Category 2 - Category 3 -

Participating Non-Preferred

Preventive Care Services Routine well-baby care, physical examinations, health screenings, and immunizations (for a list of covered services, visit our website regence.com, hover over “Member dashboard” at the top, select Preventive Care from the drop down)

0% for Category 1 & 2 (deductible waived) 40% for Category 3 (after deductible)

Professional Services After Deductible – Member Pays

Office visits for illness or injury, mental/behavioral health or substance use disorder (primary care, specialist, naturopath, urgent/immediate care center or virtual care)

$5 copay for first 3 visits for Primary Care, Behavioral

Health and Virtual Care visits

$20 copay for additional office visits

(deductible waived)

40%

Outpatient laboratory, radiology, and diagnostic procedures $0 up to first $400

(deductible waived) then 20%

40%

Maternity care 20% 40% Therapeutic injections including allergy shots 20% 40%

Hospital/Facility Services After Deductible - Member Pays

Ambulatory Surgical Center 10% (20% for all other facilities) 40%

Emergency room care (including professional charges) 20% after $100 copay (copay waived if admitted) Inpatient/outpatient surgery and surgeon fees 20% 40%

Inpatient mental/behavioral health & substance use disorder 20% 20% - Category 2 40%- Category 3

Skilled Nursing Facility – 120 inpatient days per year 20% 40% Other Services After Deductible - Member Pays

Ambulance 20% Rehabilitation Services: Inpatient: Unlimited / Outpatient: 77 visits per year (visit limit shared with Neurodevelopmental therapy) 20% 40%

Hearing Aids - applies to children 18 years or younger or children 19 to 25 enrolled in an accredited education institution

20% (deductible waived)

40% (deductible waived)

Home health care - 180 visits per year 20% 40%

Hospice – 14 respite days per lifetime 0% (deductible waived) 40%

Durable Medical Equipment 20% 40% Weight Management/Nutritional Counseling and Bariatric Surgery: 0%

(deductible waived) 40% - Weight management and nutritional counseling visits Four visits per year

- Bariatric surgery may be covered to treat morbid obesity (participant must meet participation requirements) Limited to one surgery per claimant lifetime

$1,000 copay then 20% (does not accumulate towards the out-of-pocket maximum)

$1,000 copay then 40% (does not accumulate towards the out-of-pocket maximum)

Prescription Medication Benefit If you need drugs to treat your illness or condition, your prescription drug coverage is administered through Express Scripts (ES). Please visit Express Scripts’ web site at www.express-scripts.com or contact their customer service at 1 (800) 496-4182.

Regence BlueCross BlueShield of Oregon assumes no liability for the accuracy of your prescription drug benefits information.

At the Pharmacy (30-day supply) Member Pays

Mail Order thru the Express Scripts Pharmacy Program (90-day supply)

Member Pays

Individual deductible per calendar year No deductible Out-of-pocket maximum each calendar year $2,500 per person/$7,500 per family Generic drugs $10 copay $20 copay Preferred brand drugs $40 copay $80 copay Non-Preferred brand drugs $100 copay $200 copay Accredo Specialty Pharmacy (30-day supply) Specialty Generic $50 copay N/A Specialty Preferred brand drugs $100 copay N/A Specialty Non-Preferred brand drugs $200 copay N/A

Limitations and Exceptions

Out-of-pocket limit $2,500 / claimant / year. Coverage is limited to 30-day supply retail or 90-day supply mail order. Long-term medication fills at participating retail pharmacies may be filled for up to a 90-day supply and will follow the mail order copayment structure. Visit Express Scripts’ website for details. Specialty drug coverage is limited to a 30-day supply and must be filled through Accredo Specialty Pharmacy.

Specialty medications filled at a retail pharmacy are subject to 100% copayment/coinsurance, and this amount does not accumulate towards the out-of-pocket maximum.

Certain preventive items and services as defined by the Affordable Care Act are covered at zero-dollar cost share. Product Selection Cost – If you request and obtain a brand name drug when a generic equivalent is available, you are responsible for the applicable copayment plus the cost difference between the brand name drug and the generic drug.

http://www.express-scripts.com/

Please note: This benefit summary provides a brief description of your health care plan benefits and is not a guarantee of payment. For a detailed description of your plan benefits, visit www.regence.com on or after January 1, 2025. You must set up an account to review your specific plan booklet.

Other services included in your CIS medical plan Contact Information Hinge Health - Hinge Health provides all the tools you need to get moving again from the comfort of your home. You’ll get exercise therapy tailored to your condition and a personal care team of experts. Best of all, there's no additional cost to you.

To learn more, please call 1 (855) 902-2777 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on Hinge Health.

Lantern (formerly SurgeryPlus) – A comprehensive surgical program that provides a personalized concierge experience from dedicated Care Advocates and access to quality-centric health care through a network of credentialed surgeons. By using the SurgeryPlus benefit, you may also save money through reduced financial responsibility.

To learn more, please call (833) 633-0511, go to cisbenefit.surgeryplus.com, or email cisbenefits@surgeryplus.com

MDLIVE (Telehealth) - With MDLIVE’s telehealth service, you can see a doctor or therapist from home, work or on the go, 24/7/365. Board-certified doctors visit with you by phone or secure video to treat non-emergency medical conditions. They can diagnose symptoms, prescribe medication, and send prescriptions to your pharmacy.

To learn more, please call 1 (888) 725-3097 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on MDLIVE

Chronic Condition Coaching supports and educates members with chronic conditions including hypertension, diabetes, COPD, CAD, CHF, asthma and obesity.

To learn more, please call 1 (866) 865-6725.

BeyondWell - A comprehensive well-being solution for members that integrates wellness activities, goals, rewards and challenges into a single location for a holistic wellness offering.

To learn more, please call 1 (866) 865-6725 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on BeyondWell

Case Management - Supports and educates members with serious illnesses or injuries.

To learn more, please call 1 (866) 543-5765 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on Care Management

Pregnancy Program (Childbirth to Newborn resources).

To learn more, please call 1 (888) 569-2229 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on Pregnancy Program.

BlueCard Program (Out of Area Services) – access hospital and physicians when outside the four-state area Regence services (Oregon, Idaho, Utah and Washington) as well as receive care in 200 countries around the world.

Find a provider near you at www.regence.com or call 1 (800)

810-BLUE (2583).

Additional Medical Services

Alternative Care Services Acupuncture and Chiropractic Spinal Manipulations

No deductible, any provider - $20 Copay – Maximum allowance of 12 visits per calendar year for Acupuncture and 20 visits per calendar year for Chiropractic Spinal Manipulations.

http://www.regence.com/ http://www.regence.com/ http://www.regence.com/ http://www.regence.com/

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2025 – 12/31/2025 CIS Copay Plan H with Alternative Care Coverage for: Individual and Eligible Family | Plan Type: PPO

Claims Administrator: Regence BlueCross BlueShield of Oregon

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to https://regence.com or call 1 (888) 370-6159. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary.

You can view the Glossary at healthcare.gov/sbc-glossary or call 1 (888) 370-6159 to request a copy. Please Note: Your medical plan is provided and insured by CIS, but administered by Regence BlueCross BlueShield of Oregon. This means that CIS, not Regence BlueCross BlueShield of Oregon, pays for your covered medical services and supplies.

Important Questions Answers Why This Matters:

What is the overall deductible?

$1,500 individual / $4,500 family per calendar year.

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Are there services covered before you meet your deductible?

Yes. Certain preventive care and those services listed below as "deductible does not apply." "No charge" means $0 copayment or 0% coinsurance, regardless of deductible applicability

This plan covers some items and services even if you haven't yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits/.

Are there other deductibles for specific services?

No. You don't have to meet deductibles for specific services.

What is the out-of-pocket limit for this plan?

Preferred provider & participating provider:

$3,500 individual / $8,500 family per calendar year.

Non-participating provider: $5,500 individual / $12,500 family per calendar year.

The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is not included in the out-of-pocket limit?

Premiums, prescription drug out-of-pocket limit, balance-billing charges, and health care this plan doesn't cover.

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Will you pay less if you use a network provider?

Yes. See https://regence.com/go/OR/Preferred or call 1 (888) 370-6159 for a list of network providers.

You pay the least if you use a provider in the preferred network. You pay more if you use a provider in the participating network. You will pay the most if you use a non-participating provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware, your network provider might use a non-participating provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral to see a specialist?

No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common Medical Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information

Preferred Provider (You pay the least)

Participating Provider

(You pay more)

Non-participating Provider

(You pay the most)

If you visit a health care provider's office or clinic

Primary care visit to treat an injury or illness

$5 copay / upfront office visit, deductible does not apply;

$20 copay / additional office visit (after upfront limit), deductible does not apply;

20% coinsurance for other services

40% coinsurance 40% coinsurance First 3 upfront office visits / year.

Limit is for primary care and behavioral health visits combined.

Specialist visit

$20 copay / office visit, deductible does not apply;

20% coinsurance for other services

40% coinsurance 40% coinsurance None

Preventive care/screening/ immunization

No charge, deductible does not apply

No charge, deductible does not apply

40% coinsurance

You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

If you have a test Diagnostic test (x-ray, blood work)

No charge, deductible does not apply for the first $400 / year, then 20% coinsurance for outpatient services;

40% coinsurance 40% coinsurance

Once outpatient diagnostic tests and imaging combined reach $400 / year, services are covered at the coinsurance specified for preferred providers only. All other services are covered at the coinsurance specified, after deductible.

Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information

Preferred Provider (You pay the least)

Participating Provider

(You pay more)

Non-participating Provider

(You pay the most)

20% coinsurance for inpatient services

Imaging (CT/PET scans, MRIs)

No charge, deductible does not apply for the first $400 / year, then 20% coinsurance for outpatient services;

20% coinsurance for inpatient services

40% coinsurance 40% coinsurance

If you need drugs to treat your illness or condition

Specialty generic drugs & generic drugs

Not applicable, refer to the participating provider column.

$50 copay 30-day / specialty generic prescription through Accredo Specialty Pharmacy;

$10 copay 30-day / retail prescription;

$20 copay 90-day / mail order prescription

Not covered

Out-of-pocket limit: $2,500 claimant / $7,500 family / year.

30-day supply / retail prescription 90-day supply / mail order prescription Long term medication fills at participating retail pharmacies may be filled for up to a 90-day supply and will follow the mail order copayment structure.

Visit Express Scripts website for details.

30-day supply / specialty drug prescription Specialty drug coverage is limited to a 30-day supply and must be filled through Accredo Specialty Pharmacy. Specialty drugs filled at a retail pharmacy are subject to 100% copayment / coinsurance, and this amount does not accumulate towards the out-of-pocket limit.

Certain preventive items and services as defined by the Affordable Care Act are covered at zero-dollar cost share.

Preferred brand drugs

Not applicable, refer to the participating provider column.

$40 copay 30-day / retail prescription;

$80 copay 90-day / mail order prescription

Not covered

Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information

Preferred Provider (You pay the least)

Participating Provider

(You pay more)

Non-participating Provider

(You pay the most)

Your prescription drug coverage is administered through Express Scripts (ES).

Please visit Express Scripts' web site at www.express-scripts.com or contact their customer service at 1 (800) 496-4182.

Regence BlueCross BlueShield of Oregon assumes no liability for the accuracy of your prescription drug benefits information.

Non-Preferred Brand drugs

Not applicable, refer to the participating provider column.

$100 copay 30-day / retail prescription;

$200 copay 90-day / mail order prescription

Not covered

No charge, deductible does not apply for certain preventive drugs, contraceptives and immunizations at a participating pharmacy.

Production Selection Cost – If you request and obtain a brand name drug when a generic equivalent is available, you will be charged a penalty equal to the cost difference between the brand name drug and the generic drug.

Preferred specialty drugs & specialty drugs

Not applicable, refer to the participating provider column.

$100 copay 30-day / preferred specialty prescription;

$200 copay 30-day / specialty prescription;

Specialty drugs must be filled through Accredo Specialty Pharmacy.

Not covered

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

10% coinsurance for ambulatory surgery centers;

20% coinsurance for all other facilities

40% coinsurance 40% coinsurance

None

Physician/surgeon fees

10% coinsurance for ambulatory surgery center physicians;

20% coinsurance for all other physicians

40% coinsurance 40% coinsurance

Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information

Preferred Provider (You pay the least)

Participating Provider

(You pay more)

Non-participating Provider

(You pay the most)

If you need immediate medical attention

Emergency room care

20% coinsurance after $100 copay / visit

20% coinsurance after $100 copay / visit

20% coinsurance after $100 copay / visit

Copayment applies to facility charge for each visit (waived if admitted), whether or not the deductible has been met.

Emergency medical transportation

20% coinsurance 20% coinsurance 20% coinsurance

None

Urgent care

$20 copay / visit, deductible does not apply;

20% coinsurance for other services

40% coinsurance 40% coinsurance

If you have a hospital stay

Facility fee (e.g., hospital room)

20% coinsurance 40% coinsurance 40% coinsurance

None Physician/surgeon fees

20% coinsurance 40% coinsurance 40% coinsurance

If you need mental health, behavioral health, or substance abuse services

Outpatient services

$5 copay / upfront office or psychotherapy visit, deductible does not apply;

$20 copay / additional office or psychotherapy visit (after upfront limit), deductible does not apply;

No charge, deductible does not apply for other services

$20 copay / office or psychotherapy visit, deductible does not apply;

No charge, deductible does not apply for other services

40% coinsurance First 3 upfront visits / year.

Limit is for primary care and behavioral health visits combined.

Inpatient services 20% coinsurance 20% coinsurance 40% coinsurance None

Event

Services You May Need

What You Will Pay

Limitations, Exceptions, & Other Important Information

Preferred Provider (You pay the least)

Participating Provider

(You pay more)

Non-participating Provider

(You pay the most)

If you are pregnant

Office visits 20% coinsurance 40% coinsurance 40% coinsurance Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply.

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

Childbirth/delivery professional services

20% coinsurance 40% coinsurance 40% coinsurance

Childbirth/delivery facility services

20% coinsurance 40% coinsurance 40% coinsurance

If you need help recovering or have other special health needs

Home health care 20% coinsurance 40% coinsurance 40% coinsurance 180 visits / year

Rehabilitation services

20% coinsurance 40% coinsurance 40% coinsurance 77 outpatient visits / year for all habilitation and outpatient rehabilitation services Includes physical therapy, occupational therapy, speech therapy and neurodevelopmental therapy services.

Habilitation services 20% coinsurance 40% coinsurance 40% coinsurance

Skilled nursing care 20% coinsurance 40% coinsurance 40% coinsurance 120 inpatient days / year

Durable medical equipment

20% coinsurance 40% coinsurance 40% coinsurance None

Hospice services No charge, deductible does not apply

No charge, deductible does not apply

40% coinsurance 14 respite inpatient or outpatient days / lifetime

If your child needs dental or eye care

Children's eye exam Not covered Not covered Not covered

None Children's glasses Not covered Not covered Not covered

Children's dental check-up

Not covered Not covered Not covered

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)

• Cosmetic surgery, except congenital anomalies

• Dental care

• Infertility treatment

• Long-term care

• Private-duty nursing

• Routine eye care

• Routine foot care, except for diabetic patients

• Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)

• Abortion

• Acupuncture, 12 visits / year

• Bariatric surgery, 1 surgery / lifetime

• Chiropractic care, 20 visits / year

• Hearing aids (individuals up to age 26), 1 per ear / year

• Non-emergency care when traveling outside the U.S.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform, or the U.S. Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1 (877) 267-2323 ext. 61565 or cciio.cms.gov or your state insurance department. You may also contact the plan at 1 (888) 370-6159. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call 1 (800) 318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the plan at 1 (888) 370-6159 or visit regence.com or the U.S. Department of Labor, Employee Benefits Security Administration at 1 (866) 444-3272 or dol.gov/ebsa/healthreform. You may also contact the Oregon Division of Financial Regulation by calling 1 (503) 947-7984 or the toll-free message line at 1 (888) 877-4894; by writing to the Oregon Division of Financial Regulation, Consumer Advocacy Unit, P.O. Box 14480, Salem, OR 97309-0405; through the Internet at: dfr.oregon.gov/help/complaints-licenses/Pages/file-complaint.aspx; or by E-mail at: DFRInsuranceHelp@oregon.gov.

Does this plan provide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1 (888) 370-6159.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)

◼ The plan's overall deductible $1,500 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20%

This EXAMPLE event includes services like:

Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay:

Cost Sharing

Deductibles $1,500

Copayments $0

Coinsurance $2,000

What isn't covered

Limits or exclusions $60

The total Peg would pay is $3,560

Managing Joe's Type 2 Diabetes (a year of routine in-network care of a well-controlled condition)

◼ The plan's overall deductible $1,500 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20%

This EXAMPLE event includes services like:

Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)

Total Example Cost $5,600

In this example, Joe would pay:

Cost Sharing

Deductibles $800

Copayments $800

Coinsurance $0

What isn't covered

Limits or exclusions $200

The total Joe would pay is $1,800

Mia's Simple Fracture (in-network emergency room visit and follow up care)

◼ The plan's overall deductible $1,500 ◼ Specialist copayment $20 ◼ Hospital (facility) coinsurance 20% ◼ Other coinsurance 20%

This EXAMPLE event includes services like:

Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)

Total Example Cost $2,800

In this example, Mia would pay:

Cost Sharing

Deductibles $1,500

Copayments $200

Coinsurance $100

What isn't covered

Limits or exclusions $0

The total Mia would pay is $1,800

The plan would be responsible for the other costs of these EXAMPLE covered services.

NONDISCRIMINATION NOTICE

11022024_Regence_ID_OR_UT_NDMA

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 less favorably because of race, color, national origin, age, disability, or sex.

Regence:

Provides people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:

• Qualified sign language interpreters

• Written information in other formats (large print, audio, accessible electronic formats, other formats).

Provides free language assistance services to people whose primary language is not English, which may include:

• Qualified interpreters

• Information written in other languages.

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, contact the Civil Rights Coordinator.

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. You can file a grievance in person or by mail, fax, or email.

If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

Customer Service Civil Rights Coordinator PO Box 1106 Lewiston, ID 83501-1106 Phone: 1-888-344-6347, (TTY: 711) Fax: 1-888-309-8784 Email: CS@regence.com

Medicare Customer Service Phone: 1-800-541-8981 (TTY: 711) Email: medicareappeals@regence.com

VSP Customer Service Phone: 1-844-299-3041

TTY: 1-800-428-4833

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, available 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, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

mailto:CS@regence.com mailto:medicareappeals@regence.com https://ocrportal.hhs.gov/ocr/portal/lobby.jsf http://www.hhs.gov/ocr/office/file/index.html

Language assistance

11022024_Regence_ID_OR_UT_NDMA

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 ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧ ਿੱ ਚ

ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ 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 दिनुहोस्: तपारं्इले नेपाली बोल्नुहुन्छ भने तपारं्इको

दनम्ति भाषा सहायता सेवाहरू दनिः शुल्क रूपमा उपलब्ध छ ।

फोन गनुुहोस् 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: ถา้คณุพูดภาษาไทย คณุสามารถใชบ้รกิารชว่ยเหลอืทางภาษาไดฟ้ร ี โทร 1-888-

344-6347 (TTY: 711)

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. 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.

شما ی برا گانیرا بصورتی زبان لاتیتسه د،یکن ی مصحبت فارسی زبان به اگر: توجه

.د یریبگ تماس (TTY: 711) 6347-344-888-1 با. باشد ی 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

Regence Member

Earn up to

$150 in rewards for healthy activities:

Download BeyondWell app

Connect a device or app

Verified steps through device

Personal challenges

Self-guided programs

Dental exams

Vision exams

Flu shot, COVID-19 vaccinations

Health assessment

Preventive screenings

Regence BabyWiseSM program

BeyondWell is a comprehensive lifestyle program that integrates wellness activities, goals, rewards and more into a single place. The result is a truly personalized well-being experience that is tailored to your unique needs.

Earn up to $150 per year in rewards - act now!

> Gift cards earned must be self-claimed by December 31 each year.

> Unclaimed rewards will be forfeited.

Our BeyondWell program is available now and continues into 2025–and Regence members and eligible spouses can earn up to $150 in electronic gift cards. Engage throughout each year to maximize your rewards!

Flip to learn more about our 2025 program

Regence members

1. From a computer, log into your CIS Health Manager at regence.com

2. Scroll down to the programs listed and select BeyondWell.

3. If this is your first year participating, you'll need to register and accept the Terms of Use.

If you are asked for a code during registration | CODE: CIS

Get started today!

Take your well-being journey with you anywhere, anytime! Download the BeyondWell app now.

$5

Elevate Your Health, One Step at a Time with

CHS-670343-21/09-REG

®BeyondWell 2024

1. $1 per 10,000 steps; max $2 daily. Steps will not carry over from day to day. Max $25 per quarter for this activity.

2. This activity is tracked through claims. There will be processing time for these items, so it may take up to 8 weeks to see the credit in your account.

3. Qualifying preventive exams include: annual well-visit, pelvic exam, colorectal cancer screening, PSA and routine mammogram.

* Amazon.com is not a sponsor of this promotion. Except as required by law, Amazon.com Gift Cards cannot be transferred for value or redeemed for cash. For complete terms and conditions, see www.amazon.com/gc-legal. All Amazon ®, ™ & © are IP of Amazon.com, Inc.

BeyondWell is a separate and independent company that provides services for Regence members.

Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association.

BeyondWell is not insurance, but it is offered in addition to your medical plan to help you get information and support when you need it.

Below you'll see all the ways you and your qualified spouse on the Regence health plan can earn up to $150 each in Amazon.com* electronic gift cards in 2025.

When steps are logged from your synced device, you earn credit.

$1 per 10,000 steps.1

Verified steps through device$1

Complete a preventive vision exam through CIS VSP and earn $30.2

Get a qualifying preventive exam and earn this incentive once per year.2 , 3

Preventive exam

$30 Vision exam

$30

Download the BeyondWell app$5

Download and log in to the BeyondWell app after creating your account online and earn $5.

Get your flu shot, COVID-19 vaccination or booster and earn $20 once per year.2

$15 Personal challenge

Challenge yourself to improve lifestyle habits and earn $15 per challenge (up to $45 annually).

$5 Sync a device or app

Our platform syncs with over 100 different devices. Earn this credit once per year.

The health assessment will help personalize your experience.

Earn this incentive once per year.

Health assessment$25

Complete a preventive dental exam through CIS (Delta) Dental, Kaiser Dental, or Willamette Dental and earn $30.2

Dental exam$30

Attend a webinar$15

Attend a webinar hosted by your EAP or BeyondWell and earn $15 each (up to $60 annually).

Complete any interactive self-guided program and earn $30 (up to $60 annually).

Interactive self-guided program$30

Regence Pregnancy Program

Enroll and participate in the Regence Pregnancy program and earn this incentive once per year.2

$50

Enroll and engage in Chronic Condition Coaching in 2025 and earn a $50 incentive! If you are eligible for the program you will be outreached to directly.

Chronic condition coaching$50

$20 Flu or COVID-19 Vaccination

Register your account on regence.com and earn $5.

$5 Register on Regence.com

Feb 4 @ 10:00am

Apr 10 @ 1:00pm Aug 19 @ 9:00am Nov14 @ 2:00pm

EAP Webinars Healthy Heart, Healthy Mind Mindfulness Based Stress Reduction Coping Strategies for Caregivers Holiday Stress

BeyondWell Webinars Food For Your Heart Feb 11 @ 11:30am

Health Myths & Facts- Mental Health May 15 @ 11:30am

Eating for Gut Health Aug 14 @ 11:30am

Plan for Good Health Dec 11@ 11:30am

Your one-stop shop for managing your health

With the CIS Health Manager on regence.com, you can find important health information in one place, customized for you. Use your computer, phone or tablet to easily access health benefits, telehealth and behavioral health resources, explanations of benefits, wellness tools and much more.

BeyondWellSM

Wellness activities, goal setting and rewards are all in one place for a personalized well-being experience.

Telehealth Chat by phone or video with in-network providers who offer this service. Reach out to your doctor or clinic to find out if they provide virtual care.

Pregnancy program Get support from caring professionals throughout your pregnancy with our maternity management program. A nurse will reinforce your doctor’s or midwife’s care and answer questions 24/7.

Healthy Benefits The CIS Healthy Benefits program provides financial assistance for certain weight management and tobacco cessation programs.

Start with your CIS Health Manager!

Download the Regence app or go to regence.com to create an account.

All you need is your member ID card to get started.

Hinge Health Take control of your joint and back pain through virtual muscle and joint support. Join the thousands of people who have cut their pain through easy-to-do 15-minute exercise therapy sessions.

If you’re considering surgery, Hinge Health also gives you an option to access in-network surgeons and a care advocate to guide you through care and recovery to get you to the finish line.

VSP: Vision Your vision plan uses the VSP Choice network of providers. View your benefits, find a provider, get special offers and shop for eyewear.

Express Scripts Express Scripts provides prescription drug coverage. Sign in to the CIS Health Manager for more information.

MDLIVE

With MDLIVE, you can securely chat with a doctor by phone or video, 24/7 wherever you are.

Mental health support If you're feeling low or in need of support, we can help you find the right care. Many therapists and psychiatrists offer both in-person and virtual appointments, so you can get care just how you need it. Your plan also includes additional options for virtual therapy and virtual substance use disorder treatment.

REG-OR-860116-24/08

© 2024 Regence BlueCross BlueShield of Oregon

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 1-888-344-6347 (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).

Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association

Regence BlueCross BlueShield of Oregon 200 SW Market Street, 11th Floor | Portland, OR 97201

BeyondWell is a separate company that provides health information services.

Hinge Health is a separate company that provides virtual physical therapy services.

MDLIVE is a separate company that provides telehealth services. Express Scripts and VSP do not provide Blue Cross Blue Shield services and are separate companies solely responsible for their products/services.

http://regence.com http://regence.com

If you or your loved one is facing a behavioral health challenge—from anxiety and depression to eating disorders or substance use—we want to make it easy to get care. You can find in-network providers at regence.com. (Some services aren’t available on all plans.)

Help is available. No referral is needed.

Customer Service is here for you Need more help finding the right care? Our compassionate team is ready to help.

Just give us a call at the number on the back of your member ID card.

Boulder Care is a separate company that provides substance abuse and addiction treatment services.

AbleTo and Talkspace are separate companies that provide mental health telehealth services.

Resource information is current as of June 2024.

Thoughts of suicide? Call 988—National Suicide and Crisis Lifeline—available 24/7.

OREGON

In-person care Go to regence.com to find a doctor and look for these in-network options:

• Private practitioners with a variety of expertise, such as psychiatrists, psychologists, social workers, licensed counselors and more

Virtual care

• AbleTo Therapy+ for an 8-week series of one-on-one therapy with digital support between sessions for ages 18 and up: AbleTo.com or 1-866-287-1802

• Array specializes in psychiatry and counseling services for ages 5 and up: arraybc.com

• Charlie Health for an Intensive Outpatient Program treating ages 11 to 34 with behavioral health needs:

charliehealth.com

• Equip for treatment of eating disorders for all ages:

equip.health

• NOCD specializes in treatment of obsessive-compulsive disorders for ages 6 and up: treatmyocd.com

• Talkspace specializes in counseling for general behavioral health needs for ages 13 and up, and psychiatry/medication management for ages 18 and up: talkspace.com

Substance use disorder

• Boulder Care for virtual outpatient treatment: boulder.care or 1-866-901-4860

• Hazelden Betty Ford for inpatient and outpatient services. Virtual care is also available:

hazeldenbettyford.org or 1-877-859-2124

Provider matching

• Headway for finding an in-network therapist and booking their next available virtual or in-person appointment for ages 6 and up: headway.co

Employee Assistance Program (EAP) Ask your HR team if your plan includes EAP. It quickly puts professional support in your hands without additional cost to you. Get a range of services to support your mental health, emotional well-being and life-balance needs.

Know your behavioral health options

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 1-888-344-6347 (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).

Regence BlueCross BlueShield of Oregon is an Independent Licensee of the Blue Cross and Blue Shield Association

Regence BlueCross BlueShield of Oregon 200 SW Market Street, 11th Floor | Portland, OR 97201

REG-OR-1009926-24/06

© 2024 Regence BlueCross BlueShield of Oregon http://regence.com https://www.ableto.com/ https://arraybc.com/ https://www.charliehealth.com/ https://equip.health/regence-members https://www.treatmyocd.com/ https://www.talkspace.com/coverage/insurance/regence https://www.boulder.care/ http://hazeldenbettyford.org/ https://headway.co/

Work/ Life Balance Services Canopy will help locate resources related to Eldercare, Childcare, Identity Theft, Housing, Pet Parent Support or anything else you may need.

Legal Call for a free consultation, and then receive a discount thereafter.

Financial Coaching Access to unlimited financial coaching to help you develop a plan to improve your financial wellbeing.

Confidential Coaching and Counseling access to masters-level counselors in person, over the phone, or online for concerns such as:

• Stress and Burnout

• Depression and Anxiety

• Relationships and Family

• Alcohol and Drug Use

WholeLife Directions Take a confidential survey and get connected to interactive tools to improve the way you feel.

Access in the EAP member site or search WholeLife Directions in the App Store or Google Play.

EAP Summary of Services Helping you get to your happy place The Employee Assistance Program (EAP) is a FREE and CONFIDENTIAL benefit that can assist you, your dependents, and household family members with any personal life problems, large or small.

Wellbeing Tools

• Fertility Health Support

• Online Legal Tools

• Will Kit Questionnaire

• Life Coaching

• Gym Membership Discounts

EAP Member Site Access innovative tools, chat for support, view videos and webinars, and more. Access at: my.canopywell.com, and register as a new user or log-in. Enter your company name when you register as:

Crisis Counselors are available 24/7/365 call: 800-433-2320 text: 503-850-7721 email: info@canopywell.com

Support for growing families and their journey.

Exclusive access for Canopy members:

• Free Fertility Health Consultation

• Discounted Fertility Health Check

• Connection to Fertility Preservation, Care, and Donation Services

• Free Educational Webinars and Events

• Adoption Resources

• Counseling Support

• Legal and Financial Guidance

Fertility Health and Family Building

Access your benefits:

call: 800-433-2320 text: 503-850-7721 email: info@canopywell.com online: my.canopywell.com

1. Register or Log In

a. Company code is CIS

2. Select the ‘My EAP Benefits’ tile

Your health plan may not cover Fertility Health and Family Growing services.

Please refer to your health plan summary for more information.

Parenting Support For Those With Furry Kids

• Concierge Support

• New Pet Parent

Resources

• Pet Insurance

Discounts

• Bereavement

Support Access your Pet Parent Benefits:

1. Go to my.canopywell.com 2.Register as a new user or log in

Use CIS as Company Code

3. Enter Pet Parent in the search bar

It’s free and confidential call: 800-433-2320 text: 503-850-7721 visit: canopywell.com

© 2023 Express Scripts. All Rights Reserved. CRP2309_427

Welcome to Express Scripts CIS and Express Scripts want you to know that Express Scripts manages your prescription plan. We care about your health and work to make medications safer and more affordable. We encourage you to take advantage of the services and resources available to help you and your dependents manage your pharmacy benefit. We look forward to serving you soon!

Why pay more? Make the move to a 3-month supply.

Under your prescription plan, you have the option to order 3-month supplies of long-term medications from certain participating retail pharmacies or through home delivery from Express Scripts® Pharmacy. 1

To start ordering a 3-month supply from Express Scripts® Pharmacy, register or log in at express-scripts.com. (Standard shipping is free with home delivery.2)

To find a retail pharmacy that participates in 3-month supplies, log in at express-scripts.com and choose Find a

Pharmacy from the menu under Prescriptions. The pharmacy can tell you how to transfer your prescription or start a new one. Search results will indicate whether a pharmacy is eligible to dispense up to a 3-month supply.

According to your plan, you can keep filling one month at a time, but you could miss out on convenience and savings.

1Long-term medications are taken for an ongoing condition, such as high blood pressure, high cholesterol and asthma.

2Cost of standard shipping is included as part of your prescription plan.

Accredo, your specialty pharmacy

Accredo is the Express Scripts specialty pharmacy. A specialty pharmacy provides medication and therapy for patients with serious, chronic conditions like cancer and hepatitis C. Accredo offers teams of pharmacists, nurses and clinicians who are specialty trained on your condition. This level of individualized, focused care gives you the most comprehensive, compassionate and customized care available.

Accredo offers many patient support services, including:

• Personal care and health advocacy assistance from patient care coordinators

• Coordination of financial assistance (availability varies by plan)

• Guidance for patients and caregivers for taking specialty medications most effectively

• All necessary ancillary supplies, such as syringes and sharps containers

Specialty medications must be filled through Accredo to receive coverage. To learn more about Accredo, please visit accredo.com.

CIS has partnered with SaveOnSP to provide a specialty pharmacy copayment assistance program. If you attempt to fill a specialty prescription that falls under this program, an Accredo representative will assist you with enrollment in the program by transferring you to SaveOnSP. More information about this program can be found in your plan booklet.

© 2023 Express Scripts. All Rights Reserved. CRP2309_427

Network retail pharmacies

Network pharmacies are retail pharmacies that are preferred by your prescription plan. Use them for prescriptions you need on a short-term basis, like an antibiotic to treat an infection. When you go to an in-network pharmacy for up to a 30-day supply of medication, you’ll typically pay less than at a retail pharmacy that’s out of your network.

To find an in-network pharmacy near you, go to express-scripts.com/CIS6 and select Locate a Pharmacy. Search results will indicate whether a pharmacy is eligible to dispense up to a 3-month supply. You may also log in at express-scripts.com and choose Find a Pharmacy from the menu under Prescriptions or call Express Scripts at

800.496.4182.

If you’re new to Regence BCBS coverage, be sure to show your new Express Scripts ID card at the pharmacy. You can also access your ID card by downloading the Express Scripts® mobile app. If you don’t show your ID card and instead choose to pay the entire cost of the medication, you must submit a claim form to Express Scripts for reimbursement. You’ll be reimbursed based on the covered medication’s contracted rate minus the appropriate copayment. This amount will be lower than the amount you paid out of pocket at the retail pharmacy.

If you need to transfer your prescription from an out-of-network pharmacy to an in-network pharmacy, just choose one of the following:

• Bring your prescription vial or container to an in-network pharmacy, and the pharmacist will transfer it.

• Call a pharmacy in your network, and ask the pharmacist to transfer your medication.

• Ask your doctor to send your prescription in to an in-network pharmacy using e-prescribing.

Manage your prescription

One of the great things about being an Express Scripts member is that you can manage your medication easily on your laptop, tablet, desktop or phone.