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

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For more information, call one of our

Plan’s Medicare sales representatives,

8 a.m. to 5 p.m., Monday through Friday

toll-free: 1-844-REGENCE

(1-844-734-3623)

TTY users should call 711

OR CALL YOUR INSURANCE AGENT.

Either way, there’s plenty of help available if you have questions.

GET STARTED

READ.

This booklet gives you all the tools you need to make an informed decision in choosing a Regence Medicare Advantage Plan. It provides important information you need to evaluate your options and find the plan that best fits your needs. It has easy-to- read charts that compare benefits, gives you information about additional programs and benefits you can enjoy as a Regence BlueCross BlueShield of Oregon member and provides directions for how to enroll.

CALL.

If you need additional help, or if you would prefer an in-person meeting with one of our Plan’s Medicare sales

representatives, call us at 1-844-REGENCE (1-844-734-3623) from 8 a.m. to 5 p.m., Monday through Friday. TTY users should call 711.

ATTEND.

We offer free informational meetings for you to learn more about our Medicare Advantage plans. For the most current list of meetings in your area, visit regence.com/medicare.

GO ONLINE.

A wealth of information is available at your fingertips at regence.com/medicare.You can search for your provider in our network and check our formulary (list of covered prescription drugs) for the prescription drugs you take.

2015

Regence Medicare Advantage

PPO Plans

DECISION GUIDE

Regence BlueCross BlueShield of Oregon

is an Independent Licensee of the Blue Cross and Blue Shield Association Y0062_07978 Approved

08497-or/07-14

P.O. Box 1271

Portland, OR 97207-1271 regence.com/medicare

OR | PPO | 2015

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For more information, call one of our

Plan’s Medicare sales representatives,

8 a.m. to 5 p.m., Monday through Friday

toll-free: 1-844-REGENCE

(1-844-734-3623)

TTY users should call 711

GET STARTED

READ.

CALL.

ATTEND.

GO ONLINE.

2015

Regence Medicare Advantage

PPO Plans

DECISION GUIDE

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OR | PPO | 2015

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MEDICARE MADE EASY

Are you confused about how Medicare benefits work? Unsure if you’re

covered when you're traveling? Are you effectively using all of your benefits

to support your health?

Regence BlueCross BlueShield of Oregon makes it easy to choose, and use,

your Medicare Advantage plan. You can access all your benefits with one

member identification card and virtually no paperwork. Should you have a

question or need assistance, our customer service team is only a phone

call away.

Regence Medicare Advantage Plans combine all of the benefits of Original

Medicare Parts A (hospital) and B (physician), and in some cases Part D

prescription drug coverage, into one easy-to-use plan. You also get extra

benefits and programs beyond what Original Medicare has to offer.

1 Get EXTRA BENEFITS and PROGRAMS

OR | PPO | 2015

u

Worldwide coverage

for urgent and emergency care. Travel without worrying about access to care if you need it with the BlueCard Worldwide® program.

u

Large national PPO provider network

through the Blue Medicare

Advantage PPO Network Sharing Program and no referrals needed to see a provider of your choice.

u

SilverSneakers® Fitness program.

Receive a free fitness membership and access to more than 11,000 participating locations across the country. Unable to get to a SilverSneakers location? A home fitness kit is available to help you get fit at home or on the go.

u

Regence Advice24.

Get the medical advice you need from a registered nurse any time, day or night, using our toll-free medical advice line.

u

My Advocate.

Find out if you qualify for, but are not receiving, assistance with medical costs, heating bills, meal programs or other programs and social services.

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Regence

MedAdvantage + Rx

CLASSIC (PPO)

Regence

MedAdvantage + Rx

ENHANCED (PPO)

Regence

MedAdvantage

BASIC (PPO) (no Rx)

●_$

₀

medical deductible

●_$

₁₅

primary care copay

● Freedom to see any provider across the United States

● No referrals required

● In-network travel benefits

● Routine eye exam

● Vision hardware

● Preventive dental

●_$

₀

medical deductible

●_$

₁₀

primary care copay

●_$

₀

prescription drug deductible

● Vision hardware

● Hearing aid benefit

●_$

₀

medical deductible

●_$

₁₅

primary care copay

● Vision hardware

All PPO plan members receive:

●

Worldwide emergency

and urgent care when you travel domestically or abroad

●

_Vision:

One routine eye exam per year

●

Annual physical exam:

An annual physical exam with no copay, coinsurance or deductible, in addition to the Medical Annual Wellness Visit

●

Hearing aid:

Up to $500 annually for Regence MedAdvantage + Rx Enhanced (PPO) members

●

Vision hardware:

An allowance toward the purchase of glasses, lenses and contact lenses

●

Preventive dental:

Up to $500 annually for preventive dental services, such as twice-yearly cleanings, X-rays and preventive dental exams

NEW! Additional dental coverage

available for PPO plan members

Regence PPO members can receive restorative dental services such as oral

surgery, extractions and implants with no deductible. This optional dental coverage is available for an additional premium. See the Summary of Benefits for details.

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OR | PPO | 2015

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WE HAVE YOU COVERED

across the country and around the world!

Travel the world with complete peace of mind.

Through the BlueCard Worldwide program, you have access to medical assistance services and doctors and hospitals in more than 200 countries and territories around the world.¹ When you receive care from a participating provider, you’ll pay the out-of-pocket expenses (deductible, copay and coinsurance) that you would normally pay under your PPO plan.

Get in-network benefits across the country—a special

advantage for Regence PPO members.

Regence PPO plan members can see any Medicare-contracted provider anywhere in the United States. When traveling outside the service area, PPO members will also receive in-network benefits by seeing Medicare Advantage PPO Blue Cross® and/or Blue Shield®-contracted providers through the Blue Medicare Advantage PPO Network Program available in 35 states across the country.²

In-network coverage Out-of-network coverage

PUERTO RICO Michigan

Wyoming

Finding a Blue Medicare Advantage PPO provider is easy. Download the Blue National Doctor & Hospital Finder App at bcbs.com/mobile, or use the National Doctor and Hospital Finder at provider.bcbs.com.

1Part D prescription drug coverage is not available outside the United States and its territories.

2The Medicare Advantage PPO Network Sharing Program is only available with Regence Medicare Advantage PPO plans.

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Feel better and healthier–regardless of your

current fitness level.

Get fit, have fun and make friends by using your SilverSneakers membership. You’ll have access to more than 11,000 participating fitness facility locations across the country where on-site staff members can help you meet your wellness goals. Locations offer amenities such as exercise equipment and SilverSneakers fitness classes that are designed specifically for active older adults and are taught by certified instructors (classes and amenities vary by location). Don’t have access to a participating fitness location? SilverSneakers will send you a home fitness kit that contains tools to achieve a healthier lifestyle at home or on the go.

Regence Advice24.

Get the medical advice you need from a registered nurse any time, day or night, using our toll-free medical advice line.

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OR | PPO | 2015

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Save money when you fill a three-month supply

of your maintenance medication prescriptions.

Take advantage of greater savings and convenience for your ongoing prescription needs when you order a three-month supply of your maintenance medications from an in-network retail pharmacy or mail-order pharmacy. You pay only two times your monthly copay for a three-month supply of generic drugs; brand-name prescriptions are only two and a half times your monthly copay. You can get prescription drugs shipped to your home through our network mail order delivery program. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail order pharmacy receives the order. Should a prescription drug order not arrive within the estimated time frame, help is available from Customer Service at 1 (800) 541-8981 from 8 a.m. to 8 p.m. Monday through Friday (from October 1 through February 14, our telephone hours are 8 a.m. to 8 p.m., seven days a week). TTY users should call 711.

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OR | PPO | 2015

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1

2 Search for your provider in our network.

Check our formulary for your prescription drugs.

Search for providers and view our formulary online at regence.com/medicare.

Call us at 1-844-REGENCE (1-844-734-3623). TTY users should call 711. Our Plan’s Medicare sales representatives are happy to answer your questions, find a doctor or look up your medication for you.

●

₃ Review our plans and identify the one with

the benefits that are most important to you.

Each plan has different premiums, copays and out-of-pocket maximums. Review the highlights of our Medicare Advantage plans in the pages that follow. A comprehensive list of benefits can be found in the Summary of Benefits that is included in this packet.

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OR | PPO | 2015

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SERVICE AREAS AND PREMIUMS

Clark

Benton

Clackamas Clatsop ^Columbia

Coos

Curry

Douglas

Hood River

Jackson Josephine

Lane Lincoln

Linn Marion

Multnomah

Polk Tillamook

Wasco Washington

Yamhill

Clackamas, Columbia, Lane, Multnomah, Washington Regence MedAdvantage Basic (PPO) (no Rx) $31 Regence MedAdvantage + Rx Classic (PPO) $44 Regence MedAdvantage + Rx Enhanced (PPO) $188

Clatsop, Hood River, Lincoln, Tillamook, Wasco Regence MedAdvantage Basic (PPO) (no Rx) $87 Regence MedAdvantage + Rx Classic (PPO) $102 Regence MedAdvantage + Rx Enhanced (PPO) $208 Benton, Clark (WA), Coos, Curry, Douglas, Jackson, Josephine, Linn, Marion, Polk, Yamhill

Regence MedAdvantage Basic (PPO) (no Rx) $58 Regence MedAdvantage + Rx Classic (PPO) $82 Regence MedAdvantage + Rx Enhanced (PPO) $208

Review our plans and identify the one with

the benefits that are most important to you.

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Medical

Benefits

Regence

MedAdvantage + Rx

CLASSIC (PPO)

Regence

MedAdvantage + Rx

ENHANCED (PPO)

Regence

MedAdvantage

BASIC (PPO) (no Rx)

Monthly premium Varies, see page 6 Varies, see page 6 Varies, see page 6 Annual medical

deductible¹ ^$0 ^$0 ^$0

Out-of-pocket

maximum $3,400 in-network

$5,100 combined $2,500 in-network

$4,500 combined $3,400 in-network

$5,100 combined

Network În Ôut În Ôut În Ôut

Preventive services and screenings (including an Annual Wellness Visit)

$0

Primary care office visit $15 $25 $10 $20 $15 $25

Specialist office visit $35 $45 $25 $35 $35 $45

X-rays $0 30% $0 10% $0 30%

Lab services $0 $0 $0 $0 $0 $0

Inpatient hospital ^{Days 1-4:} per day$400

Days 1-4: per day$500

Outpatient surgery – ambulatory surgery

center ^$200 ^$250 ^$75 ^$125 ^$200 ^$250

Outpatient surgery –

hospital ^$250 ^$350 ^$200 ^$300 ^$250 ^$350

Emergency room $65 (in or out of network, waived if admitted within 48 hours)

Urgent care $30 $30 $30 $30 $30 $30

Durable medical

equipment ^20% ^30% ^10% ^20% ^20% ^30%

Skilled nursing facility (days 1-100; no benefit after 100 days)

$40

per day per day^$70 per day^$40 per day^$60 per day^$40 per day^$70

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OR | PPO | 2015

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PPO BENEFIT HIGHLIGHTS

9

OR | PPO | 2015

Medical

Benefits

Regence

MedAdvantage + Rx

CLASSIC (PPO)

Regence

MedAdvantage + Rx

ENHANCED (PPO)

Regence

MedAdvantage

BASIC (PPO) (no Rx)

Additional Benefits and Programs

Network În Ôut În Ôut În Ôut

Annual physical exam $0

Hearing aid No coverage Up to $500 allowed per

year, in or out of network No coverage Routine eye exam

(one per year)¹ ^$35 ^$35 ^$25 ^$25 ^$35 ^$35

Routine vision

hardware Up to $100 allowed per

year, in or out of network Up to $200 allowed per

year, in or out of network Up to $100 allowed per year, in or out of network Preventive dental

(cleanings and X-rays) 50%, up to $500 allowed per year, in or out of network Comprehensive dental

(optional, additional

premium applies) 50%, up to $1,000 allowed per year, in or out of network SilverSneakers

Fitness program Included in plan at no additional cost Part D prescription

drug coverage Included in plan; see page 10 for details No coverage

1Routine vision care must be received from a Vision Service Plan (VSP) provider to be eligible for in-network cost sharing. Visit vsp.com to search for a provider in your area.

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Prescription

Drug

Coverage

Regence

MedAdvantage + Rx

CLASSIC (PPO)

Regence

MedAdvantage + Rx

ENHANCED (PPO)

Annual Rx Deductible $210 $0

STAGE 1: Initial Coverage Stage

1-Month supply

(in-network retail pharmacy)

Tier 1: Preferred generics $8 $5

Tier 2: Non-preferred generics $15 $12

Tier 3: Preferred brands $45 $45

Tier 4: Non-preferred brands $95 $95

Tier 5: Specialty drugs 27% 33%

3-Month supply

(in-network retail pharmacy or mail-order pharmacy)

Tier 1: Preferred generics $16 $10

Tier 2: Non-preferred generics $30 $24

Tier 3: Preferred brands $112.50 $112.50

Tier 4: Non-preferred brands $237.50 $237.50

Tier 5: Specialty drugs Not applicable; limited to a 30-day supply

STAGE 2: Coverage Gap Stage

(after prescription costs reach $2,960)

Generic drugs You pay 65%

Brand drugs You pay 45%

STAGE 3: Catastrophic Coverage Stage

(after you have paid $4,700 out of pocket)

Generic drugs You pay the greater of 5% or $2.65

Brand drugs You pay the greater of 5% or $6.60

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OR | PPO | 2015

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THE COVERAGE GAP

How it works

STAGE 1:

Initial Coverage Coverage Gap ^{STAGE 2:} Catastrophic Coverage ^{STAGE 3:}

After you pay your annual deductible (if applicable), you pay a copay or coinsurance for each prescription you fill.

Your plan pays the rest until the total that you and the plan pay reaches $2,960.

After your total drug costs reach $2,960, you pay 65% of the cost of generic prescription drugs and 45% of the cost of most brand-name prescription drugs until your total out-of- pocket prescription drug costs reach $4,700.

Total out-of-pocket costs are the amounts paid by you in the first two stages plus any applicable drug manufacturer discounts applied in the Coverage Gap stage.

After your total drug costs reach $4,700, you pay the greater of 5% coinsurance or $2.65 copay for generic drugs, and the greater of 5% coinsurance or $6.60 copay for brand-name drugs.

Your plan pays the rest of the cost of your prescription drugs for the rest of the calendar year (through December 31, 2015).

• •

You pay a little

Plan pays most _•

You pay most

Plan pays a little_• _• _•

You pay a little Plan pays most

Need extra help with prescription drug costs?

To determine if you qualify for extra help from Medicare to pay for your prescription drug premiums and costs, call the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday (TTY users should call 1-800-325-0778); or your State Medicaid Office.

$

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Enrolling is easy:

ENROLL BY PHONE.

Have one of our Plan’s Medicare sales representatives enroll you over the phone by calling 1-844-REGENCE (1-844-734-3623). TTY users should call 711.

ENROLL ONLINE.

Enjoy the convenience of applying online. Visit regence.com/medicare and follow the instructions for

applying online.

ENROLL BY MAIL.

An enrollment application is included in this packet or you can visit regence.com/medicare and download an enrollment application.

●

1.

Complete and sign your application. Verify that the information from your Medicare card is listed correctly on your enrollment application, or make a copy of your Medicare card and attach it to your enrollment application.

2.

Use the postage-paid return envelope included in this information packet to mail your completed and signed application.

Applications can also be mailed to: PO Box 1827, B32M, Medford, OR 97501. Please make sure you have sufficient postage.

3.

Do not send any payment with your enrollment application.

Regence BlueCross BlueShield of Oregon is a Medicare Advantage plan with a Medicare contract. Enrollment in Regence BlueCross BlueShield of Oregon depends on contract

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For more information, call one of our

Plan’s Medicare sales representatives,

8 a.m. to 5 p.m., Monday through Friday

toll-free: 1-844-REGENCE

(1-844-734-3623)

TTY users should call 711

OR CALL YOUR INSURANCE AGENT.

Either way, there’s plenty of help available if you have questions.

GET STARTED

READ.

CALL.

ATTEND.

GO ONLINE.

2015

Regence Medicare Advantage

PPO Plans

DECISION GUIDE

Regence BlueCross BlueShield of Oregon

is an Independent Licensee of the Blue Cross and Blue Shield Association

Y0062_07978 Approved OR | PPO | 2015

P.O. Box 1271

Portland, OR 97207-1271 regence.com/medicare 08497-or/07-14