regence standard silver valueppo plan policy individual ... · quan tr Ñ ng v Å ÿkqÿqjnêkr »...

Regence BlueCross BlueShield of Oregonis an Independent Licensee of the BlueCross andBlueShield Association the BlueCross and BlueShieldAssociation

Regence Standard Silver ValuePPO Plan Policy

Individual Group Number: 38003001

2017 Medical Benefits

01012017.02PF12LNoticeNDMARegence_OR_UT

DISCRIMINATION IS AGAINST THE LAW Regence complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Regence does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Regence:

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

o Qualified sign language interpreters

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

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

o Qualified interpreters

o Information written in other languages If you need these services, contact us at 888-344-6347. If you believe that Regence has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our civil rights coordinator at M/S CS B32B, P.O. Box 1271, Portland, OR 97207-1271, phone: 888-344-6347, TTY: 711, email: [email protected]. Please indicate you wish to file a civil rights grievance. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance our Civil Rights Coordinator is available to help you. 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, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

HELP IN OTHER LANGUAGES

The following translations help people who do not read English understand their rights and responsibilities and who to call for help. Including these translations is a federal requirement for all health plans sold on the state or federal marketplaces.

Spanish: Este aviso tiene informacin importante. Regence cumple con las leyes de derechos civiles federales aplicables y no discrimina sobre la base de raza, color, nacionalidad, edad, discapacidad o sexo. Este aviso tiene informacin importante sobre su solicitud o cobertura. Busque las fechas importantes en este aviso. Es posible que tenga que tomar alguna accin en un determinado plazo para mantener su cobertura de salud o ayuda con los costos. Usted tiene derecho a obtener esta informacin y otra informacin sobre su solicitud o cobertura, en su propio idioma y sin costo. Llame al 888-344-6347. (TTY: 711)


Chinese Traditional: Regence

888-344-6347 711

Vietnamese: Thng bo ny c Thng tin Quan trng. Regence tun th lut php Lin bang v quyn cng dn hin hnh v khng phn bit i x theo chng tc, mu da, ngun gc quc gia, tui, khuyt tt hoc gii tnh. Thng bo ny c thng tin quan trng v n ng k hoc bo him ca qu v. Tm nhng ngy chnh trong thng bo ny. Qu v c th cn hnh ng trc mt s thi hn duy tr bo him sc khe ca mnh hoc c gip c tnh ph. Qu v c quyn ly thng tin ny v thng tin khc v n ng k hoc bo him, bng ngn ng ca mnh min ph. Gi s 888-344-6347. (TTY: 711)

Korean: . Regence

, , , , , .

.

.

.

. 888-344-6347

. (TTY: 711)

Russian: . Regence

, , , ,

.

. ,

. ,

,

. ,

. 888-344-6347. (TTY: 711)

Tagalog: Ang Abiso na ito ay may Mahalagang Impormasyon. Ang Regence ay sumusunod sa mga naaangkop na Pederal na batas sa mga karapatang sibil at hindi nagdidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan, o kasarian. Ang abiso na ito ay may mahalagang impormasyon tungkol sa iyong aplikasyon o coverage. Hanapin ang mga importanteng petsa sa abiso na ito. Maaaring kailangan mong gumawa ng hakbang hanggang sa mga partikular na takdang araw upang mapanatili mo ang iyong coverage sa kalusugan o tulong sa mga gastusin. May karapatan kang makuha ang impormasyong ito, at iba pang impormasyon tungkol sa iyong aplikasyon o coverage, sa iyong sariling wika nang walang bayad. Tumawag sa 888-344-6347. (TTY: 711)


Ukrainian: . Regence , , , , . . . , , , . , - , . : 888-344-6347 (: 711).

Mon-Khmer, Cambodian: Regence 888-344-6347 ( TTY 711)

Japanese: Regence

888-344-6347(TTY: 711)

Amharic: Regence

888-344-6347 (-

711)

Cushite/Oromo: Beeksisni kun odeeffannoo barbaachisaa qabatee jira. Regence Ulaagaa seera mirga Siivilii Federaalaa kan guutuu fi sanyii, bifa, lammummaa, umrii, miidhama qaamaa ykn saala irratti hundaaee addaan hinqoodne dha. Beeksisni kun iyyannoo ykn haguuggii kara keessan irratti odeeffannoo barbaachisaa qabatee jira. Guyyoota furtuu beeksisa kana keessa jiran ilaalaa. Haguuggii fayyaa ykn gargaarsa keessan eeggachuuf hanga dhuma yeroo taeetti tarkanfii tae gatii bastanii fudhachuu qabdu. Odeeffannoo kana fi waaee iyyannoo ykn haguuggii keessanii kaffaltii tokko malee afaan keessaniin argachuuf mirga qabdu. Bilbilaa 888-344-6347. (TTY: 711)


Arabic:

Regence . .

. . .

. ) 6347-344-888 . (711 :

Punjabi: Regence , , , , , - , 888-344-6347 (TTY: 711) German: Diese Mitteilung enthlt wichtige Informationen. Regence hlt die

Grundrechte der USA ein und es finden keine Diskriminierungen aufgrund von Rasse,

Hautfarbe, nationaler Herkunft, Alter, Behinderung oder Geschlecht statt. Diese Mitteilung

enthlt wichtige Informationen ber Ihren Antrag oder die entsprechende

Versicherungsdeckung. Beachten Sie wichtige Fristen in dieser Mitteilung. Sie mssen

unter Umstnden Manahmen innerhalb bestimmter Fristen ergreifen, um Ihren

Krankenversicherungsschutz zu erhalten oder eine Kostenerstattung zu erhalten. Sie

haben das Recht, diese Informationen und andere Informationen ber Ihren Antrag oder

Ihren Versicherungsschutz kostenlos in Ihrer Sprache zu erhalten. Rufen Sie folgende

Nummer an 888-344-6347. (Fernschreiber: 711)

Laotian: . Regence , , , , . . . . . 888-344-6347. (TTY: 711)

1

OO0117PSSLVID

IntroductionRegence BlueCross BlueShield of Oregon

Street Address:100 SW Market StreetPortland, OR 97201

Claims Address:P.O. Box 30805

Salt Lake City, UT 84130-0805

Customer Service/Correspondence Address:P.O. Box 1271, M/S C7APortland, OR 97207-1271

Appeals Address:P.O. Box 1408

Lewiston, ID 83501

As You read this Policy, please keep in mind that references to "You" and "Your" refer toboth the Policyholder and Enrolled Dependents. The terms "We," "Us" and "Our" refer toRegence BlueCross BlueShield of Oregon and the term "Policyholder" means a personwho is enrolled for coverage under a Regence BlueCross BlueShield of Oregon healthinsurance Policy, and whose name appears on the records of Regence BlueCrossBlueShield of Oregon as the individual to whom this Policy was issued. Policyholderdoes not mean a dependent under this Policy. Other terms are defined in the DefinitionsSection at the back of this Policy or where they are first used and are designated by thefirst letter being capitalized.

POLICYThis Policy is a Health Benefit Plan for individuals and their families. This Policydescribes benefits effective January 1, 2017, for the Policyholder and EnrolledDependents. This Policy provides the evidence and a description of the terms andbenefits of coverage. This Policy, including Your application, endorsements andattached papers constitutes the entire contract. This Policy replaces any policy, plandescription or certificate previously issued by Us and makes it void.

Regence BlueCross BlueShield of Oregon, an independent licensee of the Blue Crossand Blue Shield Association, agrees to provide benefits for Medically Necessaryservices as described in this Policy, subject to all of the terms, conditions, exclusionsand limitations in this Policy, including endorsements affixed hereto. This agreementis in consideration of the premium payments hereinafter stipulated and in furtherconsideration of the application and statements currently on file with Us and signed bythe Policyholder for and on behalf of the Policyholder and/or any Enrolled Dependentslisted in this Policy, which are hereby referred to and made a part of this Policy.

2

OO0117PSSLVID

EXAMINATION OF POLICYIf, after examination of this Policy, the Policyholder is not satisfied for any reason withthis Policy, the above named Policyholder will be entitled to return this Policy within10 days after its delivery date. If the Policyholder returns this Policy to Us within thestipulated 10-day period, such Policy will be considered void as of the original EffectiveDate and the Policyholder generally will receive a refund of premiums paid, if any. (Ifbenefits already paid under this Policy exceed the premiums paid by the Policyholder,We will be entitled to retain the premiums paid and the Policyholder will be required torepay Us for the amount of benefits paid in excess of premiums.)

MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008This coverage complies with the Mental Health Parity and Addiction Equity Act of 2008.

ESSENTIAL HEALTH BENEFITSThis coverage complies with the essential health benefits in the following ten categories:ambulatory patient services; emergency services; hospitalization; maternity andnewborn care; mental health and substance use disorder services, including behavioralhealth treatment; prescription drugs; rehabilitative and habilitative services and devices;laboratory services; preventive and wellness services including chronic diseasemanagement; and pediatric services, including vision care.

RISK-SHARING ARRANGEMENTS WITH PROVIDERSThis plan includes "risk-sharing" arrangements with Physicians who provide servicesto the Insureds of this plan. Under a risk-sharing arrangement, the Providers thatare responsible for delivering health care services are subject to some financial riskor reward for the services they deliver. Additional information on Our risk-sharingarrangements is available upon request by calling Customer Service at the numberlisted below.

NOTICE OF PRIVACY PRACTICESRegence BlueCross BlueShield of Oregon has a Notice of Privacy Practices that isavailable by calling Customer Service or visiting the Web site listed below.

CONTACT INFORMATIONCustomer Service: 1 (888) 675-6570

(TTY: 711)

And visit Our Web site at: www.Regence.com

For assistance in a language other than English, please call the Customer Servicetelephone number.

Angela DowlingPresident

3

OO0117PSSLVID

Regence BlueCross BlueShield of Oregon

Jim WaltonVice President, SalesRegence BlueCross BlueShield of Oregon

4

OO0117PSSLVID

Using Your Regence Standard Silver ValuePPO Plan PolicyYOUR PARTNER IN HEALTH CARERegence BlueCross BlueShield of Oregon is pleased that You have chosen Us as Yourpartner in health care. It's important to have continued protection against unexpectedhealth care costs. Thanks to the purchase of Regence Standard Silver Plan ValuePPOPlan, You have coverage that's affordable and provided by a partner You can trust intimes when it matters most.

Regence Standard Silver Plan ValuePPO Plan provides You with great benefits thatare quickly accessible and easy to understand, thanks to broad access to Providersand innovative tools. With Regence Standard Silver Plan ValuePPO Plan health carecoverage, You will discover more personal freedom to make informed health caredecisions, as well as the assistance You need to navigate the health care system.

We have contracted with respected Providers to provide Our Insureds with the besthealth care possible. Regence Standard Silver Plan ValuePPO Plan provides You withgreat benefits that are quickly accessible and easy to understand, and valuable tools toassist You in navigating the health care system.

You may change Your Plan if You experience a qualifying event described under thespecial enrollment provision. Beyond this, You cannot change Your Plan until the nextopen enrollment period.

YOU SELECT YOUR PROVIDER AND CONTROL YOUR OUT-OF-POCKETEXPENSESRegence Standard Silver Plan ValuePPO Plan allows You to control Your out-of-pocketexpenses, such as Copayments and Coinsurance, for each Covered Service. Here'show it works - You control Your out-of-pocket expenses by choosing Your Providerunder two choices called: "In-Network" and "Out-of-Network."

In-Network. You choose to see an In-Network Provider and save the most in Yourout-of-pocket expenses. Choosing this provider option means You will not be billedfor balances beyond any Deductible, Copayment and/or Coinsurance for CoveredServices.

Out-of-Network. You choose to see an Out-of-Network Provider and Your out-of-pocket expenses will generally be higher than an In-Network Provider. Also, choosingthis provider option means You may be billed for balances beyond any Deductible,Copayment and/or Coinsurance. This is sometimes referred to as balance billing.

For each benefit in this Policy, We indicate the payment amount for each provider optionYou might use. See the Definitions Section of this Policy for a complete description ofIn-Network and Out-of-Network. You can go to www.Regence.com for further Providernetwork information.

ADDITIONAL MEMBERSHIP ADVANTAGESWhen You purchased Regence Standard Silver Plan ValuePPO, You were provided withmore than just great coverage. You also acquired Regence membership, which offersadditional valuable services. The advantages of Regence membership include access

5

OO0117PSSLVID

to personalized health care planning information, health-related events and innovativehealth-decision tools, as well as a team dedicated to Your personal health care needs.You also have access to www.Regence.com, an interactive environment that canhelp You navigate Your way through health care decisions. THESE ADDITIONALVALUABLE SERVICES ARE A COMPLEMENT TO THE INDIVIDUAL POLICY, BUTARE NOT INSURANCE. Go to www.Regence.com. It is a health power source that can help You lead a

healthy lifestyle, become a well-informed health care shopper and increase the valueof Your health care dollar. Have Your member card handy to log on. Use the securemember Web site to:

- view recent claims, benefits, and coverage;- find a contracting Provider;- participate in online wellness programs and use tools to estimate upcoming health care costs;- identify Participating Pharmacies;- find alternatives to expensive medicines;- learn about prescriptions for various Illnesses; and- compare medications based upon performance and cost, as well as discover how to receive

discounts on prescriptions.

GUIDANCE AND SERVICE ALONG THE WAYThis Policy was designed to provide information and answers quickly and easily. Besure to understand Your benefits before You need them. You can learn more about theunique advantages of Regence Standard Silver Plan ValuePPO health care coverageand the rewards of Regence membership throughout this Policy, some of whichare highlighted here. We realize that You may still have some questions about YourRegence Standard Silver Plan ValuePPO health care coverage, so please contact Us ifYou do.

Learn more and receive answers about Your coverage or any other plan thatWe offer. Just call 1 (888) 675-6570 to talk with one of Our Customer Servicerepresentatives. Phone lines are open Monday-Friday 6 a.m. - 6 p.m. You may alsovisit Our Web site at: www.Regence.com.

BlueCard Program. Learn how to have access to care through the BlueCardProgram. This unique program enables You to access Hospitals and Physicianswhen traveling outside the four-state area Regence serves (Idaho, Oregon, Utah andWashington), as well as receive care in 200 countries around the world.

OO0117PSSLVID

Table of ContentsUNDERSTANDING YOUR BENEFITS........................................................................................................ 1

MAXIMUM BENEFITS..............................................................................................................................................1OUT-OF-POCKET MAXIMUM................................................................................................................................. 1COPAYMENTS......................................................................................................................................................... 2PERCENTAGE PAID UNDER THIS POLICY (COINSURANCE)............................................................................2DEDUCTIBLES.........................................................................................................................................................2INPATIENT NON-EMERGENCY ADMISSIONS AT NONPARTICIPATING FACILITIES.........................................3HOW CALENDAR YEAR BENEFITS RENEW........................................................................................................3

MEDICAL BENEFITS...................................................................................................................................4CALENDAR YEAR OUT-OF-POCKET MAXIMUM................................................................................................. 4COPAYMENTS AND COINSURANCE.................................................................................................................... 4CALENDAR YEAR DEDUCTIBLES.........................................................................................................................4PREVENTIVE CARE AND IMMUNIZATIONS......................................................................................................... 5OFFICE OR URGENT CARE FACILITY VISITS ILLNESS OR INJURY............................................................. 6OTHER PROFESSIONAL SERVICES.....................................................................................................................7AMBULANCE SERVICES........................................................................................................................................ 9AMBULATORY SURGICAL CENTER......................................................................................................................9APPROVED CLINICAL TRIALS.............................................................................................................................. 9BIOFEEDBACK...................................................................................................................................................... 10BLOOD BANK........................................................................................................................................................ 10CARDIAC REHABILITATION................................................................................................................................. 10CHILD ABUSE MEDICAL ASSESSMENT............................................................................................................ 11DENTAL HOSPITALIZATION................................................................................................................................. 11DETOXIFICATION.................................................................................................................................................. 12DIABETES SUPPLIES AND EQUIPMENT............................................................................................................12DIABETIC EDUCATION......................................................................................................................................... 12DURABLE MEDICAL EQUIPMENT.......................................................................................................................12EMERGENCY ROOM (INCLUDING PROFESSIONAL CHARGES).....................................................................13FAMILY PLANNING................................................................................................................................................14GENETIC TESTING...............................................................................................................................................14HABILITATIVE SERVICES.....................................................................................................................................14HEARING AIDS......................................................................................................................................................15HOME HEALTH CARE.......................................................................................................................................... 15HOSPICE CARE.................................................................................................................................................... 16HOSPITAL CARE INPATIENT AND OUTPATIENT............................................................................................16MATERNITY CARE................................................................................................................................................ 17MEDICAL FOODS (PKU).......................................................................................................................................17MENTAL HEALTH OR SUBSTANCE USE DISORDER SERVICES.....................................................................17NEWBORN CARE..................................................................................................................................................19NUTRITIONAL COUNSELING...............................................................................................................................20ORTHOTIC DEVICES............................................................................................................................................ 20OUTPATIENT KIDNEY DIALYSIS..........................................................................................................................20PEDIATRIC VISION............................................................................................................................................... 21PRESCRIPTION MEDICATIONS...........................................................................................................................22PROSTHETIC DEVICES........................................................................................................................................31REHABILITATIVE SERVICES................................................................................................................................ 31REPAIR OF TEETH............................................................................................................................................... 32SKILLED NURSING FACILITY (SNF) CARE........................................................................................................ 32TELEHEALTH......................................................................................................................................................... 33TELEMEDICINE..................................................................................................................................................... 33TOBACCO USE CESSATION................................................................................................................................33TRANSPLANTS......................................................................................................................................................34

ACCIDENTAL DEATH BENEFIT............................................................................................................... 34BENEFIT.................................................................................................................................................................34EXCLUSIONS.........................................................................................................................................................35GENERAL PROVISIONS.......................................................................................................................................35

OO0117PSSLVID

DEFINITIONS......................................................................................................................................................... 36

GENERAL EXCLUSIONS.......................................................................................................................... 37SPECIFIC EXCLUSIONS.......................................................................................................................................37

POLICY AND CLAIMS ADMINISTRATION...............................................................................................43PREAUTHORIZATION........................................................................................................................................... 43MEMBER CARD.....................................................................................................................................................44SUBMISSION OF CLAIMS AND REIMBURSEMENT...........................................................................................44OUT-OF-AREA SERVICES....................................................................................................................................47BLUECARD WORLDWIDE.................................................................................................................................. 49NONASSIGNMENT................................................................................................................................................ 50CLAIMS RECOVERY............................................................................................................................................. 50LEGAL ACTION..................................................................................................................................................... 51RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION AND MEDICAL RECORDS..................... 51LIMITATIONS ON LIABILITY................................................................................................................................. 52RIGHT OF REIMBURSEMENT AND SUBROGATION RECOVERY.................................................................... 52COORDINATION OF BENEFITS...........................................................................................................................54

APPEAL PROCESS...................................................................................................................................60EXTERNAL APPEAL - IRO................................................................................................................................... 61EXPEDITED APPEALS..........................................................................................................................................62INFORMATION....................................................................................................................................................... 63DEFINITIONS SPECIFIC TO THE APPEAL PROCESS.......................................................................................64

WHO IS ELIGIBLE, HOW TO APPLY AND WHEN COVERAGE BEGINS..............................................66WHEN COVERAGE BEGINS................................................................................................................................ 66NEWLY ELIGIBLE DEPENDENTS........................................................................................................................ 68SPECIAL ENROLLMENT.......................................................................................................................................68OPEN ENROLLMENT PERIOD.............................................................................................................................69DOCUMENTATION OF ELIGIBILITY.....................................................................................................................69DEFINITIONS SPECIFIC TO WHO IS ELIGIBLE, HOW TO APPLY AND WHEN COVERAGE BEGINSSECTION................................................................................................................................................................ 69

WHEN COVERAGE ENDS........................................................................................................................ 70GUARANTEED RENEWABILITY AND POLICY TERMINATION.......................................................................... 70MILITARY SERVICE...............................................................................................................................................70WHAT HAPPENS WHEN YOU ARE NO LONGER ELIGIBLE............................................................................. 70NONPAYMENT OF PREMIUM.............................................................................................................................. 70GRACE PERIOD....................................................................................................................................................71TERMINATION BY YOU........................................................................................................................................ 71WHAT HAPPENS WHEN YOUR ENROLLED DEPENDENTS ARE NO LONGER ELIGIBLE............................. 71OTHER CAUSES OF TERMINATION................................................................................................................... 72MEDICARE SUPPLEMENT................................................................................................................................... 73

GENERAL PROVISIONS........................................................................................................................... 74PREMIUMS.............................................................................................................................................................74CHOICE OF FORUM.............................................................................................................................................74GOVERNING LAW AND BENEFIT ADMINISTRATION........................................................................................74MODIFICATION OF POLICY................................................................................................................................. 74NO WAIVER........................................................................................................................................................... 75NOTICES................................................................................................................................................................ 75RELATIONSHIP TO BLUE CROSS AND BLUE SHIELD ASSOCIATION............................................................ 75REPRESENTATIONS ARE NOT WARRANTIES.................................................................................................. 76TIME LIMIT ON CERTAIN DEFENSES.................................................................................................................76WHEN BENEFITS ARE AVAILABLE..................................................................................................................... 76WOMEN'S HEALTH AND CANCER RIGHTS....................................................................................................... 76

DEFINITIONS..............................................................................................................................................77DISCLOSURE STATEMENT PATIENT PROTECTION ACT.....................................................................82

OO0117PSSLVID

WHAT ARE MY RIGHTS AND RESPONSIBILITIES AS AN INSURED OF REGENCE BLUECROSSBLUESHIELD OF OREGON?................................................................................................................................82HOW DO I ACCESS CARE IN THE EVENT OF AN EMERGENCY?.................................................................. 82HOW WILL I KNOW IF MY BENEFITS CHANGE OR ARE TERMINATED?....................................................... 83WHAT HAPPENS IF I AM RECEIVING CARE AND MY DOCTOR IS NO LONGER A CONTRACTINGPROVIDER?........................................................................................................................................................... 83HOW CAN I PARTICIPATE IN THE DEVELOPMENT OF YOUR CORPORATE POLICIES ANDPRACTICES?......................................................................................................................................................... 84WHAT ARE YOUR PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT CRITERIA?.........................84HOW ARE IMPORTANT DOCUMENTS (SUCH AS MY MEDICAL RECORDS) KEPT CONFIDENTIAL?...........85MY NEIGHBOR HAS A QUESTION ABOUT THE POLICY THAT HE HAS WITH YOU AND DOESN'T SPEAKENGLISH VERY WELL. CAN YOU HELP?.......................................................................................................... 85WHAT ADDITIONAL INFORMATION CAN I GET FROM YOU UPON REQUEST?.............................................85

1

OO0117PSSLVID

Understanding Your BenefitsIn this section, You will discover information to help You understand what We mean byYour Maximum Benefits, Deductibles, Copayments, Coinsurance and Out-of-PocketMaximum. Other terms are defined in the Definitions Section at the back of this Policy orwhere they are first used and are designated by the first letter being capitalized.

While this Understanding Your Benefits Section defines these types of cost-sharingelements, You need to refer to the Medical Benefits Section to see exactly how they areapplied and to which benefits they apply.

MAXIMUM BENEFITSSome benefits for Covered Services may have a specific Maximum Benefit. For thoseCovered Services, We will provide benefits until the specified Maximum Benefit (whichmay be a number of days, visits, services, supplies or specified time period) has beenreached. Allowed Amounts for Covered Services provided are also applied toward theDeductible and against any specific Maximum Benefit that is expressed in this Policy asa number of days, visits, services or supplies. Refer to the Medical Benefits Section inthis Policy to determine if a Covered Service has a specific Maximum Benefit.

OUT-OF-POCKET MAXIMUMYou can meet the Out-of-Pocket Maximum by payments of Deductible, Copaymentsand Coinsurance as specifically indicated in the Medical Benefits Section. There aretwo Out-of-Pocket Maximum amounts: one for In-Network benefits and another for Out-of-Network benefits. The Medical Benefits Section describes this more fully, but in thisPolicy, the term is referred to simply as "the Out-of-Pocket Maximum." An Insuredspayment of any Deductible, Copayment and/or Coinsurance for emergency roomservices, pediatric vision, Prescription Medications and benefits listed in the MedicalBenefits Section that show under the Provider "All" will apply toward the In-Network Out-of-Pocket Maximum amount. Additionally, services provided by a Provider that has aneffective participating contract with Us but is not designated as an In-Network Provider(as further defined in the Definitions Section at the back of this Policy) will apply to theIn-Network Out-of-Pocket Maximum amount. Any amounts You pay for non-CoveredServices or amounts in excess of the Allowed Amount do not apply toward the Out-of-Pocket Maximum. You will continue to be responsible for amounts that do not applytoward the Out-of-Pocket Maximum, even after You reach this Policy's Out-of-PocketMaximum.

Once You reach the Out-of-Pocket Maximum, benefits subject to the Out-of-PocketMaximum will be paid at 100 percent of the Allowed Amount for the remainder of theCalendar Year. The Copayment and/or Coinsurance for some benefits of this Policy donot change to a higher payment level or apply to the Out-of-Pocket Maximum. Thoseexceptions are specifically noted in the Medical Benefits Section of this Policy.

There are two Family Out-of-Pocket Maximum amounts: one for In-Network benefitsand another for Out-of-Network benefits. The Family Out-of-Pocket Maximumfor a Calendar Year is satisfied when two or more Family members' Deductibles,Copayments and Coinsurance for Covered Services for that Calendar Year total and

2

OO0117PSSLVID

meet the Family's Out-of-Pocket Maximum amount. One Insured may not contributemore than the individual Deductible amount. Any amounts You pay for non-CoveredServices, Copayments or amounts in excess of the Allowed Amount do not counttoward the Deductible.

COPAYMENTSA Copayment means a fixed dollar amount that You must pay directly to a providerof services or supplies, including medications or, each time You receive a specifiedservice or medication (as applicable). The Copayment will be the lesser of the fixeddollar amount or the Allowed Amount for the service or medication. Refer to the MedicalBenefits Section to understand what Copayments You are responsible for.

PERCENTAGE PAID UNDER THIS POLICY (COINSURANCE)Once You have satisfied any applicable Deductible and any applicable Copayment, Wepay a percentage of the Allowed Amount for Covered Services You receive, up to anyMaximum Benefit. When Our payment is less than 100 percent, You pay the remainingpercentage (this is Your Coinsurance). Your Coinsurance will be based upon the lesserof the billed charges or the Allowed Amount. The percentage We pay varies, dependingon the kind of service or supply You received and who rendered it.

We do not reimburse Providers for charges above the Allowed Amount. However, anIn-Network Provider will not charge You for any balances for Covered Services beyondYour Deductible, Copayment and/or Coinsurance amount. Out-of-Network Providers,however, may bill You for any balances over Our payment level in addition to anyDeductible, Copayment and/or Coinsurance amount. See the Definitions Section fordescriptions of Providers.

DEDUCTIBLESWe will begin to pay benefits for Covered Services in any Calendar Year only after anInsured satisfies the Calendar Year Deductible. There are two Deductible amounts: onefor In-Network benefits and another for Out-of-Network benefits. The Medical BenefitsSection describes this more fully, but in this Policy, the term is referred to simply as"the Deductible." An Insured satisfies the Deductible by incurring a specific amountof expense for Covered Services during the Calendar Year for which the AllowedAmounts total the Deductible. An Insureds Deductible amount, if any, paid towardCovered Services listed in the Medical Benefits Section for emergency room services,Prescription Medications and Covered Services that show under the Provider "All" willapply toward the In-Network Deductible amount. Additionally, services provided by aProvider that has an effective participating contract with Us but is not designated asan In-Network Provider (as further defined in the Definitions Section at the back of thisPolicy) will apply to the In-Network Deductible amount.

There are two Family Calendar Year Deductible amounts: one for In-Network benefitsand another for Out-of-Network benefits. The Family Calendar Year Deductible issatisfied when two or more covered Family members' Allowed Amounts for CoveredServices for that Calendar Year total and meet the Family Deductible amount. OneInsured may not contribute more than the individual Deductible amount.

3

OO0117PSSLVID

We do not pay for services applied toward the Deductible. Refer to the Medical BenefitsSection to see if a particular service is subject to the Deductible. Any amounts You payfor non-Covered Services, Copayments or amounts in excess of the Allowed Amount donot count toward the Deductible.

INPATIENT NON-EMERGENCY ADMISSIONS AT NONPARTICIPATING FACILITIESThe maximum Allowed Amount for facility charges of an inpatient non-emergencyadmission to a Nonparticipating Facility is $3,000 per day. In addition to Deductible and/or Coinsurance, You may be billed for the balance of billed charges, including any billedamount in excess of this maximum Allowed Amount, and the balance of billed chargeswill not apply to any Out-of-Pocket Maximum.

An admission will be non-emergency unless it is precipitated by emergency servicesfor an Emergency Medical Condition. Emergency services include a medical screeningexamination within the capability of a Hospital emergency department, ancillary servicesroutinely available to it to evaluate an Emergency Medical Condition, and furthermedical examination and treatment within the capabilities of the Hospital staff andfacilities.

An inpatient admission to a Nonparticipating Facility that begins as an emergency shallbe regarded as an emergency admission through discharge and therefore will not besubject to the $3,000 per day maximum Allowed Amount.

HOW CALENDAR YEAR BENEFITS RENEWMany provisions in this Policy (for example, Deductibles, Out-of-Pocket Maximum andcertain benefit maximums) are calculated on a Calendar Year basis. Each January 1,those Calendar Year maximums begin again.

Some benefits in this Policy have a separate Maximum Benefit based upon an Insured'sLifetime and do not renew every Calendar Year. Those exceptions are specifically notedin the benefits sections of this Policy.

4

OO0117PSSLVID

Medical BenefitsIn this section, You will learn about Your Policy's benefits and how Your coverage paysfor Covered Services. There are no referrals required before You can use any of thebenefits of this coverage. For Your ease in finding the information regarding benefitsmost important to You, We have listed these benefits alphabetically, with the exceptionof the Preventive Care and Immunizations, Office or Urgent Care Facility Visits andOther Professional Services benefits.

All covered benefits are subject to the limitations, exclusions and provisions of thisPolicy. To be covered, medical services and supplies must be Medically Necessaryfor the treatment of an Illness or Injury (except for any covered preventive care). Also,a Provider practicing within the scope of his or her license must render the service.Please see the Definitions Section in the back of this Policy for descriptions of MedicallyNecessary and of the kinds of Providers who deliver Covered Services.

A Health Intervention may be medically indicated or otherwise be Medically Necessary,yet not be a Covered Service in this Policy.

If benefits in this Policy change while You are in the Hospital (or any other facility asan inpatient), coverage will be provided based upon the benefit in effect when the staybegan.

NOTE: You are required to obtain preauthorization from Us in advance of allinpatient services received from non-contracted Providers or a penalty will apply. Refer to the Preauthorization provision of the Policy and Claims AdministrationSection for requirements and exceptions.

CALENDAR YEAR OUT-OF-POCKET MAXIMUMIn-NetworkPer Insured: $6,850Per Family: $13,700

Out-of-NetworkUnlimited

COPAYMENTS AND COINSURANCECopayments and Coinsurance are listed in the tables for Covered Services for eachapplicable benefit.

CALENDAR YEAR DEDUCTIBLESIn-NetworkPer Insured: $2,500Per Family: $5,000

Out-of-NetworkPer Insured: $10,000Per Family: $20,000

You do not need to meet any Deductible before receiving benefits for:

5

OO0117PSSLVID

In-Network Preventive Care and Immunizations; In-Network Office or Urgent Care Facility Visits Illness or Injury; In-Network Diabetes Management Associated with Pregnancy; In-Network medical colonoscopy associated with positive fecal test; In-Network Diabetic Education; In-Network outpatient Habilitative Services; In-Network outpatient therapy visits for Mental Health or Substance Use Disorder

Services; In-Network Nutritional Counseling; Pediatric Vision services; In-Network outpatient Rehabilitative Services; and In-Network Telehealth.Furthermore, You do not need to meet the Deductible when You fill CoveredPrescription Medications.

PREVENTIVE CARE AND IMMUNIZATIONSBenefits will be covered under this Preventive Care and Immunizations benefit, not anyother provision in this Policy, if services are in accordance with age limits and frequencyguidelines according to, and as recommended by, the United States Preventive ServiceTask Force (USPSTF), the Health Resources and Services Administration (HRSA),or by the Advisory Committee on Immunization Practices of the Centers for DiseaseControl and Prevention (CDC). In the event any of these bodies adopts a new orrevised recommendation, this plan has up to one year before coverage of the relatedservices must be available and effective under this benefit. For a list of services coveredunder this benefit, please visit www.Regence.com or contact Customer Service at1 (888) 675-6570. You can also visit the HRSA Web site at: http://www.hrsa.gov/womensguidelines/ for womens preventive services guidelines, and the USPSTF Website at: http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations for a list of A and B preventive services. NOTE: Covered Servicesthat do not meet these criteria will be covered the same as any other Illness or Injury.

In addition to Covered Services for Preventive Care and Immunizations by an In-Network Provider, Covered Services for Preventive Care and Immunizations providedby a Provider that has any form of participating contract to provide services and suppliesto Our Insureds in accordance with the provisions of this coverage, will be covered asan In-Network benefit as explained below.

Provider: In-Network Provider: Out-of-NetworkPayment: We pay 100% of the AllowedAmount.

Payment: After Deductible, We pay 50% ofthe Allowed Amount and You pay balanceof billed charges. Your 50% payment of theAllowed Amount will be applied toward theOut-of-Pocket Maximum.

We cover preventive care services provided by a professional Provider or facility.Preventive care services include routine well-baby care, routine physical examinations,routine well-women's care, routine immunizations and routine health screenings. Also

6

OO0117PSSLVID

included is Provider counseling for tobacco use cessation and Generic Medicationsprescribed for tobacco use cessation. See the Prescription Medications benefit in thisPolicy for a description of how to obtain Generic Medications. Coverage for all suchservices is provided only for preventive care as designated above (which designationmay be modified from time to time). Covered expenses do not include immunizationsif the Insured receives them only for purposes of travel, occupation or residence in aforeign country.

We cover one non-Hospital grade breast pump (including its accompanying supplies)per pregnancy at the In-Network benefit level when obtained from a Provider (includinga Durable Medical Equipment supplier). Alternatively, a comparable breast pumpmay be obtained from approved non-Providers in lieu of a Provider. Benefits for acomparable breast pump obtained from an approved non-Provider will be covered upto the In-Network benefit level and limited to Reasonable Charges. An approved non-Provider may include, but is not limited to, retailers, wholesalers or commercial vendors.To find an approved non-Provider, instructions for claiming benefits or for additionalinformation on Covered Services, please visit Our Web site at www.Regence.com orcontact Customer Service at 1 (888) 675-6570.

Additionally, We cover all United States Food and Drug Administration (FDA)approved contraceptive and sterilization methods for women in accordance withHRSA recommendations. These include female condoms, diaphragm with spermicide,sponge with spermicide, cervical cap with spermicide, spermicide, oral contraceptives(combined pill, mini pill, and extended/continuous use pill), contraceptive patch, vaginalring, contraceptive shot/injection, emergency contraceptives (both levonorgestrel- andulipristal acetate-containing products), intrauterine devices (both copper and those withprogestin), implantable contraceptive rod, surgical implants and surgical sterilization.Please visit Our Web site at www.Regence.com for Our preferred contraceptiveproducts covered under the Prescription Medications benefit.

OFFICE OR URGENT CARE FACILITY VISITS ILLNESS OR INJURYProvider: In-Network Provider: Out-of-Network

Primary Physicianor Practitioner

Payment: After $35 Copayment pervisit, We pay 100% of the AllowedAmount.

Payment: After Deductible,We pay 50% of the AllowedAmount and You paybalance of billed charges.Your 50% payment of theAllowed Amount will beapplied toward the Out-of-Pocket Maximum.

Specialist Payment: After $70 Copayment pervisit, We pay 100% of the AllowedAmount.

Payment: After Deductible,We pay 50% of the AllowedAmount and You paybalance of billed charges.Your 50% payment of theAllowed Amount will be

7

OO0117PSSLVID

applied toward the Out-of-Pocket Maximum.

Urgent CareFacility

Payment: After $70 Copayment pervisit, We pay 100% of the AllowedAmount.

Payment: After Deductible,We pay 50% of the AllowedAmount and You paybalance of billed charges.Your 50% payment of theAllowed Amount will beapplied toward the Out-of-Pocket Maximum.

We cover visits in the office, home, urgent care facility or Hospital outpatient departmentonly for treatment of Illness or Injury. All other professional services performed in theoffice, not billed as an office visit, or that are not related to the actual visit (separatefacility fees billed in conjunction with the office visit for example) are not consideredan office visit under this benefit. For example, We will pay for a surgical procedureperformed in the office according to the Other Professional Services benefit.

OTHER PROFESSIONAL SERVICES

Provider: In-Network Provider: Out-of-Network

Payment: After Deductible, We pay 70%and You pay 30% of the Allowed Amount.Your 30% payment will be applied towardthe Out-of-Pocket Maximum.


We cover services and supplies provided by a professional Provider subject to theDeductible and Coinsurance and any specified limits as explained in the followingparagraphs:

Medical ServicesWe cover professional services, second opinions and supplies, including the servicesof a Provider whose opinion or advice is requested by the attending Provider, thatare generally recognized and accepted non-surgical procedures for diagnostic ortherapeutic purposes in the treatment of Illness or Injury. Covered services and suppliesalso include those to treat a congenital anomaly, foot care associated with diabetes,and osteopathic manipulative treatment of disorders of the musculoskeletal system,as well as dental and orthodontic services that are for the treatment of craniofacialanomalies and are Medically Necessary to restore function. A "craniofacial anomaly"is a physical disorder, identifiable at birth, that affects the bony structures of the faceor head, including, but not limited to, cleft palate, cleft lip, craniosynotosis, craniofacialmicrosomia and Treacher Collins syndrome. Coverage is not provided under this benefitfor the treatment of temporomandibular joint disorder or developmental maxillofacialconditions that result in overbite, crossbite, malocclusion or similar developmentalirregularities of the teeth.

Breast, Pelvic and Pap Smear Examinations

8

OO0117PSSLVID

We cover breast, pelvic and Pap smear examinations not covered under the PreventiveCare and Immunizations benefit.

Diabetes Management Associated with PregnancyManagement of a pregnant Insureds diabetes from the date of conception through sixweeks postpartum (for each pregnancy) that is Medically Necessary and a CoveredService is not subject to any Copayments, Coinsurance or Deductible when provided byan In-Network Provider.

Diagnostic ProceduresWe cover services for diagnostic procedures including cardiovascular testing,pulmonary function studies, stress test, sleep studies and neurology/neuromuscularprocedures.

Medical ColonoscopyMedical colonoscopy (and all associated services, such as anesthesia and pathology)performed as a result of a positive fecal test for an Insured age 50 or older is notsubject to any Copayments, Coinsurance, or Deductible when provided by an In-Network Provider. Preventive colonoscopies are covered under the Preventive Care andImmunizations benefit. All other colonoscopies, including for those Insureds at high-risk,are covered subject to the Deductible, Copayment and/or Coinsurance.

Professional InpatientWe cover professional inpatient visits for Illness or Injury. If pre-arranged proceduresare performed by an In-Network Provider and You are admitted to an In-NetworkHospital, We will cover associated services (for example, anesthesiologist, radiologist,pathologist, surgical assistant, etc.) provided by an Out-of-Network Provider at the In-Network benefit level. However, an Out-of-Network Provider may bill You for balancesbeyond any Deductible, Copayment and/or Coinsurance. Please contact CustomerService for further information and guidance.

Radiology and LaboratoryWe cover services for treatment of Illness or Injury. This includes, but is not limited to,Medically Necessary mammography services not covered under the Preventive Careand Immunizations benefit.

Surgical ServicesWe cover surgical services and supplies including cochlear implants and the services ofa surgeon, an assistant surgeon and an anesthesiologist.

Therapeutic InjectionsWe cover therapeutic injections and related supplies when given in a professionalProvider's office.

A selected list of Self-Administrable Injectable Medications is covered under thePrescription Medications benefit.

9

OO0117PSSLVID

AMBULANCE SERVICESProvider: All

Payment: After Deductible, We pay 70% and You pay 30% of the Allowed Amount.Your 30% payment of the Allowed Amount will be applied toward the Out-of-PocketMaximum.We cover ambulance services to the nearest Hospital equipped to provide treatment,when any other form of transportation would endanger Your health and the purpose ofthe transportation is not for personal or convenience purposes. Covered ambulanceservices include licensed ground and air ambulance Providers.

AMBULATORY SURGICAL CENTERProvider: In-Network Provider: Out-of-Network



We cover outpatient services and supplies of an Ambulatory Surgical Center (includingservices of staff Providers) for Injury and Illness.

APPROVED CLINICAL TRIALSWe cover Your Routine Patient Costs in connection with an Approved Clinical Trial inwhich You are enrolled and participating subject to the Deductible, Coinsurance and/orCopayments, the maximum Allowed Amount for inpatient non-emergency admission ata Nonparticipating Facility and Maximum Benefits as specified in the Medical Benefitsand Prescription Medications benefits in this Policy. Additional specified limits are asfurther defined. If an In-Network Provider is participating in the Approved Clinical Trialand will accept You as a trial participant, these benefits will be provided only if Youparticipate in the Approved Clinical Trial through that Provider. If the Approved ClinicalTrial is conducted outside Your state of residence, You may participate and benefits willbe provided in accordance with the terms for other covered out-of-state care.

DefinitionsIn addition to the definitions in the Definitions Section, the following definitions apply tothis Approved Clinical Trials benefit:

Approved Clinical Trial means a clinical trial that is a study or investigation:

Approved or funded by one or more of:

- The National Institutes of Health (NIH), the CDC, The Agency for Health Care Research andQuality, The Centers for Medicare & Medicaid, or a cooperative group or center of any of thoseentities or of the Department of Defense (DOD) or the Department of Veterans Affairs (VA);

- A qualified non-governmental research entity identified in guidelines issued by the NIH for centerapproval grants; or

- The VA, DOD, or Department of Energy, provided it is reviewed and approved through a peerreview system that the Department of Health and Human Services has determined both is

10

OO0117PSSLVID

comparable to that of the NIH and assures unbiased review of the highest scientific standards byqualified individuals without an interest in the outcome of the review; or

Conducted under an investigational new drug application reviewed by the Food andDrug Administration or that is a drug trial exempt from having an investigational newdrug application.

Routine Patient Costs means items and services that typically are Covered Services foran Insured not enrolled in a clinical trial, but do not include:

An Investigational item, device, or service that is the subject of the Approved ClinicalTrial unless it would be covered for that indication absent a clinical trial;

Items and services provided solely to satisfy data collection and analysis needs andnot used in the direct clinical management of the Insured;

A service that is clearly inconsistent with widely accepted and established standardsof care for the particular diagnosis; or

Services, supplies or accommodations for direct complications or consequences ofthe Approved Clinical Trial.

BIOFEEDBACKWe cover biofeedback to treat migraine headaches or urinary incontinence up to tenvisits combined per Member Lifetime, subject to the Deductible, Coinsurance and/orCopayments as specified in the Medical Benefits of this Policy. For example, We willpay for office visits according to the Office or Urgent Care Facility Visits Illness orInjury benefit. We do not cover biofeedback for other conditions. Biofeedback visits thatare applied toward any Deductible will be applied against the Maximum Benefit limit onthese services.

BLOOD BANKProvider: All

Payment: After Deductible, We pay 70% and You pay 30% of the Allowed Amount.Your 30% payment of the Allowed Amount will be applied toward the Out-of-PocketMaximum.We cover the services and supplies of a blood bank, excluding storage costs.

CARDIAC REHABILITATIONWe cover Medically Necessary phase I (inpatient) and up to 36 visits per MemberLifetime for phase II (short-term outpatient) cardiac rehabilitation services associatedwith a cardiac rehabilitation exercise program. Coverage is subject to the Deductible,Coinsurance and/or Copayments as specified in the Medical Benefits of this Policy.For example, We will pay for office visits according to the Office or Urgent CareFacility Visits Illness or Injury benefit. We do not cover phase III (long-termoutpatient) services. Outpatient cardiac rehabilitation visits that are applied towardany Deductible will be applied against the Maximum Benefit limit on these services.The maximum Allowed Amount for facility charges during a non-emergency admissionat a Nonparticipating Facility for or including phase I (inpatient) cardiac rehabilitationservices is $3,000 per day.

11

OO0117PSSLVID

CHILD ABUSE MEDICAL ASSESSMENTWe cover Child Abuse Medical Assessments including those services provided byan Oregon Community Assessment Center in conducting a Child Abuse MedicalAssessment of a child enrolled on this plan subject to the Deductible, Coinsurance and/or Copayments and Maximum Benefits, if any, as specified in the Medical Benefits ofthis Booklet. The services include, but are not limited to, a forensic interview and MentalHealth treatment.

DefinitionsIn addition to the definitions in the Definitions Section, the following definitions apply tothis Child Abuse Medical Assessment benefit:

Child Abuse Medical Assessment means an assessment by or under the direction of alicensed Physician or other licensed health care professional trained in the evaluation,diagnosis and treatment of child abuse. Child Abuse Medical Assessment includes thetaking of a thorough medical history, a complete physical examination and an interviewfor the purpose of making a medical diagnosis, determining whether or not the child hasbeen abused and identifying the appropriate treatment or referral for follow-up for thechild.

Community Assessment Center means a neutral, child-sensitive community-basedfacility or service Provider to which a child from the community may be referred toreceive a thorough Child Abuse Medical Assessment for the purpose of determiningwhether the child has been abused or neglected.

DENTAL HOSPITALIZATIONProvider: In-Network Provider: Out-of-Network


Payment: After Deductible, We pay 50% ofthe Allowed Amount* and You pay balanceof billed charges. Your 50% payment of theAllowed Amount* will be applied toward theOut-of-Pocket Maximum.

*For inpatient non-emergency admissionat a Nonparticipating Facility, the maximumAllowed Amount for facility charges is$3,000 per day.

We cover inpatient and outpatient services and supplies for hospitalization for DentalServices (including anesthesia), if hospitalization in an Ambulatory Surgical Center orHospital is necessary to safeguard Your health. Other than anesthesia, benefits are notavailable for services received in a dentist's office.

12

OO0117PSSLVID

DETOXIFICATIONProvider: In-Network Provider: Out-of-Network




We cover Medically Necessary detoxification.

DIABETES SUPPLIES AND EQUIPMENTWe cover supplies and equipment for the treatment of diabetes. Please refer to theOther Professional Services, Diabetic Education, Durable Medical Equipment, OrthoticDevices or Prescription Medications benefits in this Policy for coverage details of suchcovered supplies and equipment.

NOTE: In-Network coverage of diabetes supplies is not subject to any Copayments,Coinsurance, or Deductible.

DIABETIC EDUCATIONProvider: In-Network Provider: Out-of-Network

Payment: We pay 100% of the AllowedAmount.


We cover services and supplies for diabetic self-management training and education ifprovided by Providers with expertise in diabetes. Nutritional therapy is covered underthe Nutritional Counseling benefit.

DURABLE MEDICAL EQUIPMENTProvider: In-Network Provider: Out-of-Network



13

OO0117PSSLVID

Limit: one pair of glasses (frames and lenses) or contact lenses per Insured perCalendar Year to correct visual defect due to severe medical or surgical problemsuch as stroke, neurological disease, trauma or eye surgery other than refractiveprocedures.

Limit: one synthetic wig per Insured per Calendar Year. For reimbursement, You mustsubmit a Prescription Order from Your Provider and an itemized purchase receiptindicating the type of wig and the charges for it.Durable Medical Equipment means an item that can withstand repeated use, is primarilyused to serve a medical purpose, is generally not useful to a person in the absenceof Illness or Injury and is appropriate for use in the Insured's home. Examples includeinsulin pumps and insulin pump supplies, oxygen equipment and wheelchairs. Wigs,glasses or contact lenses that are applied toward any Deductible will be applied againstthe Maximum Benefit limit on these services. Durable Medical Equipment is not coveredif it serves solely as a comfort or convenience item.

Alternatively, We cover Durable Medical Equipment up to the In-Network benefit leveland limited to Reasonable Charges when obtained from an approved non-Provider.An approved non-Provider may include, but is not limited to, retailers, wholesalers orcommercial vendors. To verify eligible Durable Medical Equipment, find an approvednon-Provider, instructions for claiming benefits or for additional information on CoveredServices, please visit Our Web site at www.Regence.com or contact Customer Serviceat 1 (888) 675-6570.

EMERGENCY ROOM (INCLUDING PROFESSIONAL CHARGES)Provider: In-Network Provider: Out-of-Network


Payment: After In-Network Deductible,We pay 70% of the Allowed Amount andYou pay balance of billed charges. Your30% payment of the Allowed Amount willbe applied toward the In-Network Out-of-Pocket Maximum.

We cover emergency room services and supplies, including outpatient charges forpatient observation and medical screening exams that are required for the stabilizationof a patient experiencing an Emergency Medical Condition. For the purpose of thisbenefit, "stabilization" means to provide Medically Necessary treatment: 1) to assure,within reasonable medical probability, no material deterioration of an EmergencyMedical Condition is likely to occur during, or to result from, the transfer of the Insuredfrom a facility; and 2) in the case of a covered Insured, who is pregnant, to performthe delivery (including the placenta). Emergency room services do not need to bepreauthorized. If admitted to an Out-of-Network Hospital directly from the emergencyroom, services will be covered at the In-Network benefit level. However, an Out-of-Network Provider may bill You for balances beyond any Deductible, Copayment and/or Coinsurance. Please contact Customer Service for further information and guidance.See the Hospital Care benefit in this Medical Benefits Section for coverage of inpatientHospital admissions.

14

OO0117PSSLVID

FAMILY PLANNINGProvider: In-Network Provider: Out-of-Network



We cover certain professional Provider contraceptive services and supplies not coveredunder the Preventive Care and Immunizations benefit, including, but not limited to,vasectomy. See the Prescription Medications benefit for coverage of prescriptioncontraceptives.

Womens contraceptive methods, sterilization procedures, and patient education andcounseling services in accordance with any frequency guidelines according to, and asrecommended by the USPSTF, HRSA and CDC are covered under the Preventive Careand Immunizations benefit.

GENETIC TESTINGProvider: In-Network Provider: Out-of-Network



HABILITATIVE SERVICESInpatient Services

Provider: In-Network Provider: Out-of-NetworkPayment: After Deductible, We pay 70%and You pay 30% of the Allowed Amount.Your 30% payment will be applied towardthe Out-of-Pocket Maximum.



Outpatient ServicesProvider: In-Network Provider: Out-of-Network

Payment: After $35 Copayment per visit,We pay 100% of the Allowed Amount.


15

OO0117PSSLVID

Inpatient limit: 30 days per Insured per Calendar Year (up to 60 days per CalendarYear for head or spinal cord Injury).Outpatient limit: 30 visits combined per Insured per Calendar Year (up to 30 additionalvisits per condition may be considered for treatment of neurologic conditions whencriteria for supplemental services are met)We cover inpatient and outpatient habilitative services and devices that help a personkeep, learn, or improve skills and functioning for daily living (habilitative services) andare not services for a Mental Health Condition or Substance Use Disorder. Examplesinclude therapy for a child who is not walking or talking at the expected age. Theseservices and devices may include physical and occupational therapy, speech-languagepathology and other services and devices for people with disabilities in a variety ofinpatient or outpatient settings.

Habilitative services for Mental Health Conditions or Substance Use Disorders are notsubject to a visit limit. Such services are covered under the Mental Health or SubstanceUse Disorder Services benefit.

Habilitative services that are applied toward any Deductible will be applied against theMaximum Benefit limit on these services.

HEARING AIDSProvider: In-Network Provider: Out-of-Network



Limit: two hearing aids per Insured every four Calendar YearsWe cover hearing aids when necessary for the treatment of hearing loss. For thepurpose of this benefit, "hearing aid" means any nondisposable, wearable instrument ordevice designed to aid or compensate for impaired human hearing and any necessaryear mold, part, attachments or accessory for the instrument or device. Hearing aids thatare applied toward any Deductible will be applied against the Maximum Benefit limit onthese services. This coverage does not include routine hearing examinations or the costof batteries or cords.

HOME HEALTH CAREProvider: In-Network Provider: Out-of-Network



We cover home health care when provided by a licensed agency or facility for homehealth care. Home health care includes all services for patients that would be coveredif the patient were in a Hospital or Skilled Nursing Facility. Durable Medical Equipment

16

OO0117PSSLVID

associated with home health care services is covered under the Durable MedicalEquipment benefit of this Policy.

HOSPICE CAREProvider: In-Network Provider: Out-of-Network



Limit: 30 inpatient or outpatient respite care days per Insured Lifetime (limited to amaximum of five consecutive respite days at a time)We cover hospice care when provided by a licensed hospice care program. A hospicecare program is a coordinated program of home and inpatient care, available 24 hoursa day. This program uses an interdisciplinary team of personnel to provide comfort andsupportive services to a patient and any family members who are caring for a patient,who is experiencing a life threatening disease with a limited prognosis. These servicesinclude acute, respite and home care to meet the physical, psychosocial and specialneeds of a patient and his or her family during the final stages of Illness. Respite care:We cover respite care to provide continuous care of the Insured and allow temporaryrelief to family members from the duties of caring for the Insured. Respite days thatare applied toward any Deductible will be applied against the Maximum Benefit limit onthese services. Durable Medical Equipment associated with hospice care is coveredunder the Durable Medical Equipment benefit in this Policy.

HOSPITAL CARE INPATIENT AND OUTPATIENTProvider: In-Network Provider: Out-of-Network




We cover inpatient and outpatient services and supplies of a Hospital for Injury andIllness (including services of staff Providers billed by the Hospital). Room and board islimited to the Hospital's average semiprivate room rate, except where a private room isdetermined to be necessary. If admitted to an Out-of-Network Hospital directly from theemergency room, services will be covered at the In-Network benefit level. However, anOut-of-Network Provider may bill You for balances beyond any Deductible, Copaymentand/or Coinsurance. Please contact Customer Service for further information andguidance. See the Emergency Room benefit in this Medical Benefits Section for

17

OO0117PSSLVID

coverage of emergency services, including medical screening exams, in a Hospital'semergency room.

If benefits in this Policy change while You or an Enrolled Dependent is in the Hospital(or any other facility as an inpatient), coverage will be provided based upon the benefitin effect when the stay began.

MATERNITY CAREProvider: In-Network Provider: Out-of-Network




We cover prenatal and postnatal maternity (pregnancy) care, childbirth (vaginal orcesarean), complications of pregnancy and related conditions. There is no limit forthe mother's length of inpatient stay. Where the mother is attended by a Provider,the attending Provider will determine an appropriate discharge time, in consultationwith the mother. See the Newborn Care benefit in this Medical Benefits Section tosee how the care of Your newborn is covered. Coverage also includes termination ofpregnancy for all Insureds. When provided by an In-Network Provider, any Copayments,Coinsurance, and Deductible do not apply to Medically Necessary Covered Services formanagement of a pregnant Insureds diabetes from the date of conception through sixweeks postpartum for each pregnancy.

Certain services such as screening for gestational diabetes; breastfeeding support,supplies and counseling are covered under Your Preventive Care benefit.

MEDICAL FOODS (PKU)Provider: In-Network Provider: Out-of-Network



We cover medical foods for inborn errors of metabolism including, but not limited to,formulas for Phenylketonuria (PKU). Other services and supplies such as office visitsand formula to treat severe intestinal malabsorption are otherwise covered under theappropriate provision in this Medical Benefits Section.

MENTAL HEALTH OR SUBSTANCE USE DISORDER SERVICESInpatient Services

18

OO0117PSSLVID




Outpatient Testing and Non-Therapy ServicesProvider: In-Network Provider: Out-of-Network



Outpatient Therapy VisitsProvider: In-Network Provider: Out-of-Network

Payment: After $35 Copayment per visit,We pay 100% of the Allowed Amount.


We cover inpatient and outpatient Mental Health and Substance Use Disorder Services,including Applied Behavioral Analysis (ABA) therapy services. Benefits include physicaltherapy, occupational therapy or speech therapy provided for treatment of a MentalHealth Condition.

DefinitionsIn addition to the definitions in the Definitions Section, the following definitions apply tothis Mental Health or Substance Use Disorder Services benefit:

Applied Behavioral Analysis means the design, implementation and evaluationof environmental modifications, using behavioral stimuli and consequences, toproduce significant improvement in human social behavior, including the use ofdirect observation, measurement and functional analysis of the relationship betweenenvironment and behavior. ABA therapy services must be provided by a licensedProvider qualified to prescribe and perform ABA therapy services. Providers mustsubmit individualized treatment plans and progress evaluations.

Habilitative means health care services and devices that help a person keep, learn orimprove skills and functioning for daily living. Examples include therapy for a child whois not walking or talking at the expected age. These services and devices may include

19

OO0117PSSLVID

physical and occupational therapy, speech-language pathology and other services anddevices for people with disabilities in a variety of inpatient or outpatient settings.

Mental Health and Substance Use Disorder Services mean Medically Necessaryoutpatient services, residential care, partial hospital program or inpatient servicesprovided by a licensed facility or licensed individuals with the exception of SkilledNursing Facility services (unless the services are provided by a licensed behavioralhealth provider for a covered diagnosis), home health services and court orderedtreatment (unless the treatment is determined by Us to be Medically Necessary). Theseservices include Habilitative services for Mental Health Conditions or Substance UseDisorders.

Mental Health Condition means any mental disorder covered by diagnostic categorieslisted in the most recent edition of the Diagnostic and Statistical Manual of MentalDisorders published by the American Psychiatric Association, including autism spectrumdisorders and Pervasive Developmental Disorder (PDD). Pervasive DevelopmentalDisorder means a neurological condition that includes Aspergers syndrome, autism,developmental delay, developmental disability or intellectual disability. Mental disordersthat accompany an excluded diagnosis are covered.

Substance Use Disorder means any substance-related disorder covered by diagnosticcategories listed in the most recent edition of the Diagnostic and Statistical Manual ofMental Disorders published by the American Psychiatric Association. Substance UseDisorder does not include addiction to or dependency on tobacco, tobacco products, orfoods.

NEWBORN CAREProvider: In-Network Provider: Out-of-Network




We cover services and supplies, under the newborn's own coverage, in connectionwith nursery care for the natural newborn or newly adoptive child of the Policyholder orPolicyholder's spouse. The newborn child must be eligible and enrolled as explainedlater in the Who Is Eligible, How to Apply and When Coverage Begins Section. Thereis no limit for the newborn's length of inpatient stay. For the purpose of this benefit,"newborn care" means the medical services provided to a newborn child following birthincluding well-baby Hospital nursery charges, unless otherwise covered under thePreventive Care and Immunizations benefit.

20

OO0117PSSLVID

NUTRITIONAL COUNSELINGProvider: In-Network Provider: Out-of-Network



ORTHOTIC DEVICESProvider: In-Network Provider: Out-of-Network



We cover benefits for the purchase of braces, splints, orthopedic appliances andorthotic supplies or apparatuses used to support, align or correct deformities or toimprove the function of moving parts of the body. We may elect to provide benefits fora less costly alternative item. We do not cover orthopedic shoes and off-the-shelf shoeinserts.

OUTPATIENT KIDNEY DIALYSISInitial Outpatient Treatment Period



When Your Physician prescribes outpatient kidney dialysis, regardless of Yourdiagnosis, We cover hemodialysis, peritoneal dialysis, and hemofiltration services andsupplies during an initial treatment period of 120 days, measured from the first day Youreceive dialysis treatment. This initial treatment period benefit is available once for eachcourse of continuous or related dialysis care, even if that course of treatment spans twoor more Calendar Years.

Supplemental Outpatient Treatment Period (Following Initial Outpatient Treatment Period)

21

OO0117PSSLVID

Provider: In-Network Provider: Out-of-NetworkPayment: After Deductible, We pay 125%of the Medicare allowed amount at thetime of service.

Payment: After Deductible, We pay 125%of the Medicare allowed amount at the timeof service.

If You are not enrolled in Medicare Part B:

Payment: After Deductible, We pay 125%of the Medicare allowed amount at the timeof service and You pay balance of billedcharges.

When Your Physician prescribes outpatient kidney dialysis, regardless of Yourdiagnosis, for a period that is longer than the initial treatment period, then beginningthe first day following completion of the initial treatment period, We cover outpatienthemodialysis, peritoneal dialysis, and hemofiltration services and supplies. Yourkidney diagnosis may make You Medicare-eligible and, if You are enrolled in additionalMedicare Part B on any basis and receive dialysis from a Medicare-participatingProvider, You will not be responsible for additional out-of-pocket expenses. For thepurpose of this benefit, Medicare allowed amount is the amount that a Medicare-contracted provider agrees to accept as full payment for a covered service. This is alsoreferred to as the provider accepting Medicare assignment.

PEDIATRIC VISIONWe cover benefits for vision care for Insureds under the age of 19. Coverage willbe provided for an Insured until the last day of the monthly period in which theInsured turns 19 years of age. Covered Services must be rendered by a Physicianor optometrist practicing within the scope of his or her license. Please note that theBlueCard Program detailed in the Policy and Claims Administration Section does notapply to vision hardware benefits provided under this Pediatric Vision benefit. We willpay benefits under this Pediatric Vision benefit, not any other provision in this Policy, if aservice or supply is covered under both.

Vision ExaminationProvider: In-Network Provider: Out-of-Network


Payment: We pay 100% of the AllowedAmount and You pay balance of billedcharges.

Limit: one routine eye examination per Insured per Calendar YearVision Hardware

Provider: AllPayment: We pay 50% and You pay 50% of the Allowed Amount.* Your 50% paymentof the Allowed

regence standard silver valueppo plan policy individual ... · quan tr Ñ ng v Å ÿkqÿqjnêkr »...

Documents