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CIS Copay Plan E Benefits Summary Effective January 1, 2025 These medical plans are insured by CIS but administered by Regence BlueCross BlueShield (BCBS) of Oregon. This means that CIS, not Regence BCBS, pays for your covered medical services and supplies. Copay Plan E Deductible Per Calendar Year $250 Individual $750 Family Out-of-Pocket Maximum Per Calendar Year Category 1 & 2 - Preferred and Participating Provider (includes deductible and medical copays but does not include prescription copays) $2,250 Individual $4,750 Family Category 3 - Non-Preferred Provider (includes deductible and medical copays but does not include prescription copays) $4,250 Individual $8,750 Family Medical Services Member Pays Member Pays Category 1 - Preferred Category 2 - Category 3 - Participating Non-Preferred Preventive Care Services Routine well-baby care, physical examinations, health screenings, and immunizations (for a list of covered services, visit our website regence.com, hover over “Member dashboard” at the top, select Preventive Care from the drop down) 0% for Category 1 & 2 (deductible waived) 40% for Category 3 (after deductible) Professional Services After Deductible – Member Pays Office visits for illness or injury, mental/behavioral health or substance use disorder (primary care, specialist, naturopath, urgent/immediate care center or virtual care) $5 copay for first 3 visits for Primary Care, Behavioral Health and Virtual Care visits $20 copay for additional office visits (deductible waived) 40% Outpatient laboratory, radiology, and diagnostic procedures $0 up to first $400 (deductible waived) then 20% 40% Maternity care 20% 40% Therapeutic injections including allergy shots 20% 40% Hospital/Facility Services After Deductible - Member Pays Ambulatory Surgical Center 10% (20% for all other facilities) 40% Emergency room care (including professional charges) 20% after $100 copay (copay waived if admitted) Inpatient/outpatient surgery and surgeon fees 20% 40% Inpatient mental/behavioral health & substance use disorder 20% 20% - Category 2 40%- Category 3 Skilled Nursing Facility – 120 inpatient days per year 20% 40% Other Services After Deductible - Member Pays Ambulance 20% Rehabilitation Services: Inpatient: Unlimited / Outpatient: 77 visits per year (visit limit shared with Neurodevelopmental therapy) 20% 40% Hearing Aids - applies to children 18 years or younger or children 19 to 25 enrolled in an accredited education institution 20% (deductible waived) 40% (deductible waived) Home health care - 180 visits per year 20% 40% Hospice – 14 respite days per lifetime 0% (deductible waived) 40% Durable Medical Equipment 20% 40% Weight Management/Nutritional Counseling and Bariatric Surgery: 0% (deductible waived) 40% - Weight management and nutritional counseling visits Four visits per year - Bariatric surgery may be covered to treat morbid obesity (participant must meet participation requirements) Limited to one surgery per claimant lifetime $1,000 copay then 20% (does not accumulate towards the out-of-pocket maximum) $1,000 copay then 40% (does not accumulate towards the out-of-pocket maximum) ---PAGE BREAK--- Prescription Medication Benefit If you need drugs to treat your illness or condition, your prescription drug coverage is administered through Express Scripts (ES). Please visit Express Scripts’ web site at www.express-scripts.com or contact their customer service at 1 (800) 496-4182. Regence BlueCross BlueShield of Oregon assumes no liability for the accuracy of your prescription drug benefits information. At the Pharmacy (30-day supply) Member Pays Mail Order thru the Express Scripts Pharmacy Program (90-day supply) Member Pays Individual deductible per calendar year No deductible Out-of-pocket maximum each calendar year $2,500 per person/$7,500 per family Generic drugs $10 copay $20 copay Preferred brand drugs $40 copay $80 copay Non-Preferred brand drugs $100 copay $200 copay Accredo Specialty Pharmacy (30-day supply) Specialty Generic $50 copay N/A Specialty Preferred brand drugs $100 copay N/A Specialty Non-Preferred brand drugs $200 copay N/A Limitations and Exceptions Out-of-pocket limit $2,500 / claimant / year. Coverage is limited to 30-day supply retail or 90-day supply mail order. Long-term medication fills at participating retail pharmacies may be filled for up to a 90-day supply and will follow the mail order copayment structure. Visit Express Scripts’ website for details. Specialty drug coverage is limited to a 30-day supply and must be filled through Accredo Specialty Pharmacy. Specialty medications filled at a retail pharmacy are subject to 100% copayment/coinsurance, and this amount does not accumulate towards the out- of-pocket maximum. Certain preventive items and services as defined by the Affordable Care Act are covered at zero-dollar cost share. Product Selection Cost – If you request and obtain a brand name drug when a generic equivalent is available, you are responsible for the applicable copayment plus the cost difference between the brand name drug and the generic drug. ---PAGE BREAK--- Please note: This benefit summary provides a brief description of your health care plan benefits and is not a guarantee of payment. For a detailed description of your plan benefits, visit www.regence.com on or after January 1, 2025. You must set up an account to review your specific plan booklet. Other services included in your CIS medical plan Contact Information Hinge Health - Hinge Health provides all the tools you need to get moving again from the comfort of your home. You’ll get exercise therapy tailored to your condition and a personal care team of experts. Best of all, there's no additional cost to you. To learn more, please call 1 (855) 902-2777 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on Hinge Health. Lantern (formerly SurgeryPlus) – A comprehensive surgical program that provides a personalized concierge experience from dedicated Care Advocates and access to quality-centric health care through a network of credentialed surgeons. By using the SurgeryPlus benefit, you may also save money through reduced financial responsibility. To learn more, please call (833) 633-0511, go to cisbenefit.surgeryplus.com, or email [EMAIL REDACTED] MDLIVE (Telehealth) - With MDLIVE’s telehealth service, you can see a doctor or therapist from home, work or on the go, 24/7/365. Board-certified doctors visit with you by phone or secure video to treat non-emergency medical conditions. They can diagnose prescribe medication, and send prescriptions to your pharmacy. To learn more, please call 1 (888) 725-3097 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on MDLIVE Chronic Condition Coaching supports and educates members with chronic conditions including hypertension, diabetes, COPD, CAD, CHF, asthma and obesity. To learn more, please call 1 (866) 865-6725. BeyondWell - A comprehensive well-being solution for members that integrates wellness activities, goals, rewards and challenges into a single location for a holistic wellness offering. To learn more, please call 1 (866) 865-6725 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on BeyondWell Case Management - Supports and educates members with serious illnesses or injuries. To learn more, please call 1 (866) 543-5765 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on Care Management Pregnancy Program (Childbirth to Newborn resources). To learn more, please call 1 (888) 569-2229 or sign on to the CIS Health Manager at www.regence.com. Scroll down to Resources and click on Pregnancy Program. BlueCard Program (Out of Area Services) – access hospital and physicians when outside the four-state area Regence services (Oregon, Idaho, Utah and Washington) as well as receive care in 200 countries around the world. Find a provider near you at www.regence.com or call 1 (800) 810-BLUE (2583). Additional Medical Services