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2022 Regence Medicare Advantage Plan InformationThank you for your interest in applying for the Regence BlueShield of Washington Medicare Advantage plan. Beloware links to the items which are part of the Enrollment Packet you would receive if we were to mail it to you. Pleasetake note and make sure to review the information. You will be receiving an “Enrollment Verification Letter” fromRegence BlueShield within 15 calendar days of receipt of the enrollment request.Enrollment Packet – click links below to download and save documentsStar Rating: HMO / PPOApply OnlineSummary of Benefits: Core Rx / Primary Rx & Classic Rx / Enhanced Rx / Valiance HMO / Align HMO & HMO /BlueAdvantage HMO & HMO Provider SearchPharmacy SearchFormularyInitial Enrollment Period (IEP)If you are new to Medicare, you can enroll during your Initial Enrollment Period (IEP); the three months before,the month of, and the three months after your Part B effective date. Once you have been enrolled in a MedicarePlan, you can only make changes during the Annual Enrollment Period (AEP). Please be aware of the AEP dates arenow October 15th to December 7th. This will give you a January 1st effective date for your new plan.Annual Enrollment Period (AEP)Applications must be signed and dated on, or between October 15th and December 7th. If they are signed prior toOctober 15th they will be returned to you with a new application. If they are received after December 7th, you willnot be able to change plans until the next AEP for January of the following year.Special Enrollment Period (SEP)There are a number of reasons for Special Enrollments; Loss of a job that provides benefits, death of a spousewho's plan provided benefits, moving to an area where your old plan is not available, etc Once you submit your application to us, we will review your application for completeness and accuracy before we submit it tothe company. You may fax, upload, email or mail your application in to CDA Insurance:CDA Insurance LLCPO Box 26540Eugene, Oregon 97402Fax: 1.541.284.2994 or 888.632.5470Secure File Upload: Click hereEmail: cs@cda-insurance.comIf you should have any questions on the application, please call a licensed insurance agent at 1.800.884.2343 or 1.541.434.9613.Our website: https://medicare-washington.comY0062 MULTIPLAN CDA INSURANCE Washington 2022 (Pending)

Regence BlueAdvantage HMORegence BlueAdvantage HMO Plus2022 Summary of Benefitsfor residents of King, Kitsap, Pierce, and SnohomishcountiesFor more informationVisit our website at regence.com/medicare.Prospective members call 1-844-734-3623 (TTY: 711) 8 a.m. to 5 p.m., Monday through Friday.Current HMO members call 1-855-522-8896 (TTY: 711). Customer Service hours are 8 a.m. to 8 p.m., Mondaythrough Friday (October 1 through March 31, our telephone hours are from 8 a.m. to 8 p.m., seven days a week).Regence BlueShield serves select counties in the state of Washington and is an Independent Licensee of the BlueCross and Blue Shield Association.Regence is an HMO/PPO/PDP plan with a Medicare contract. Enrollment in Regence depends on contract renewal.Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.This document is available electronically and may be available in other formats.H1997 SB22WAM M

What you need to know about this bookThe information listed is a summary of what we cover and what you pay. It does not list every service, coveragelimitation or exclusion. A complete list of covered services can be found in our Evidence of Coverage (EOC) onour website at regence.com/medicare or by calling 1-855-522-8896 (TTY: 711) to request a copy.You must choose a primary care provider (PCP) from the plan’s provider network when you enroll in an HMOplan.To join a Regence Medicare Advantage plan, you must be entitled to Medicare Part A, be enrolled in MedicarePart B, and live in our service area of King, Kitsap, Pierce, and Snohomish counties.Out-of-network/noncontracted providers are under no obligation to treat Regence members, except inemergency situations. Please call our Customer Service number or see your Evidence of Coverage for moreinformation, including the cost-sharing that applies to out-of-network services.Utilization Management (UM) is the way we review the type and amount of care you're getting. This involveslooking at the setting for your care and its medical necessity. Clinical professionals make decisions based on ourclinical review criteria, guidelines, and medical policies. Examples of UM procedures include pre-service review(prior authorization), concurrent review (including urgent concurrent review) and post-service review. Find moreinformation in our Member FAQ on regence.com/medicare/resources/faq.Cost-sharing may be less if you qualify for Extra Help. To find out if you qualify, call the Social SecurityAdministration at 1-800-772-1213 (TTY: 1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday.If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare &You 2022 handbook. View it online at medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-6334227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of AmericanSpecialty Health Incorporated (ASH). Silver&Fit is a registered trademark of ASH and used with permissionherein. Other names may be trademarks of their respective owners.American Specialty Health Incorporated, Lively, MDLIVE, Mom’s Meals, Medline, Papa, Inc., TruHearing andVSP Vision Care are separate companies that provide services to Regence members.2 HMO

Pre-enrollment checklistBefore making an enrollment decision, it is important that you fully understand our benefits and rules. If youhave any questions, you can call and speak to a customer service representative at 1-855-522-8896.Understanding the BenefitsReview the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for whichyou routinely see a doctor. Visit regence.com/medicare or call 1-855-522-8896 to view a copy of the EOC.Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. Ifthey are not listed, it means you will likely have to select a new doctor.Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in thenetwork. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.Understanding Important RulesIn addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. Thispremium is normally taken out of your Social Security check each month.Benefits, premiums and/or copayments/coinsurance may change on January 1, 2023.Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors whoare not listed in the provider directory).3 HMO

Medical BenefitsPlan costs & informationRegenceBlueAdvantage HMORegenceBlueAdvantage HMO PlusPlan numberH1997-009H1997-002 0 48 0 0 6,500 5,900Medical benefitsRegenceBlueAdvantage HMORegenceBlueAdvantage HMO PlusInpatient hospital coverage1,3Days 1-5: 350 / dayDays 1-4: 390 / dayNumber of days allowed per stay is unlimited.Days 6 : 0 / dayDays 5 : 0 / dayFor wound care 40 45For observation 90 90For all other services 375 325For wound care 40 45For all other services 300 250Primary care provider 0 0Specialist 40 45 0 0Monthly plan premiumYou must continue to pay your Medicare PartB premium.Annual deductibleThe amount you pay for medical servicesbefore the plan begins to pay. Deductibleamounts reset every January 1.Maximum out-of-pocket responsibilityAnnual limit on your out- of-pocket costs forPart A (hospital) and Part B (medical)services. Does not include prescription drugs.Outpatient hospital services¹Ambulatory surgery center services1Doctor visits3Preventive careCost-sharing may apply if you receive otherservices during your preventive care visit.Emergency careCopay waived if admitted to the hospital within 9048 hours. 90Urgently needed services 45 401- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.3- Services may require a physician referral.4 HMO

RegenceBlueAdvantage HMORegenceBlueAdvantage HMO PlusHbA1C testing 0 0Lab services1 20 20 20 20 20 20 0 0 25020%Medical hearing exam 40 45Routine hearing2Exam: 0Exam: 0Hearing aids: 699 or 999per aidHearing aids: 699 or 999per aidMedical dental services 40 45Preventive and diagnostic dentalservices2 0; 1,000 benefit limit peryear for covered services 0; no limit for coveredservicesAvailable only as an optionalsupplemental benefit.Available only as an optionalsupplemental benefit.Medical vision services 0 0Routine vision2Exam: 0Exam: 0Lenses: 0Lenses: 0Frames or contact lenses: 100 allowance per yearFrames or contact lenses: 100 allowance per yearDays 1-5: 350 / dayDays 1-4: 390 / dayDays 6-190: 0 / dayDays 5-190: 0 / dayMedical benefitsDiagnostic services/labs/imagingOutpatient x-raysDiagnostic tests and procedures1Diagnostic mammographyDiagnostic radiology (MRI, CT, etc.)1Hearing servicesIn-network coverage through TruHearing.Hearing aids covered only if obtained fromTruHearing. 1 per ear, per year.Dental servicesCovers preventive and diagnostic exams,bitewing and diagnostic x-rays, cleanings, andfluoride twice per year, full- mouth orpanoramic x-rays once every 3 years, andcertain periodontal services as needed.Restorative dental services2Covers crowns, dentures, partials, bridges,implants, restorations, endodontics,periodontics, and oral surgery.Vision servicesIn-network coverage through VSP VisionCare. Lenses limited to standard basic singlevision, lined bifocal, lined trifocal or lenticular.1 pair of lenses and frames or a singlepurchase of contact lenses per year.Mental health services1Inpatient psychiatric hospitalThere is a 190-day lifetime maximum.Outpatient therapy (individual and group) 40 401- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.3- Services may require a physician referral.5 HMO

Medical benefitsRegenceBlueAdvantage HMORegenceBlueAdvantage HMO PlusSkilled nursing facility1Days 1-20: 0 / dayDays 1-20: 0 / dayUp to 100 days covered per benefit period.Days 21-55: 188 / dayDays 21-52: 188 / dayDays 56-100: 0 / dayDays 53-100: 0 / day 40 40 260 275Not coveredNot covered20%20%AcupunctureLimited to treatment of chronic low back pain. 20 20ChiropracticLimited to manipulation of the spine to correcta subluxation. 20 20 20 20Chiropractic2Combined limit of 18 visits per year. 20 20Massage therapy2Limit of 6 visits per year, up to 60 minutes pervisit. 20 20Naturopathy2Limit of 6 visits per year. 20 20In addition to the Medicare Annual WellnessVisit. 0 0Bathroom safety devices2 100 allowance every year 100 allowance every yearDurable medical equipment (DME)120%20%Fitness program2 0 0Fitness program membership, home fitness kitwith options such as a complimentary activitytracker, health coaching and more.Provided exclusively throughSilver&FitProvided exclusively throughSilver&FitPhysical therapy1Includes occupational therapy and speechlanguage therapy.Ambulance (air/ground)1Copay applies for each one-way transport.TransportationMedicare Part B drugs1Usually administered by a provider.Alternative care (Medicare-covered)Alternative care (Additional covered)Acupuncture2Annual physical exam1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.3- Services may require a physician referral.6 HMO