Regence MedAdvantage Retiree Rate Sheet Utah Valley University Retirees

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Regence MedAdvantage Retiree Rate SheetUtah Valley University RetireesJanuary 1, 2021 - December 31, 2021PlanRegence MedAdvantage Rx Primary (PPO)Regence MedAdvantage Rx Classic w/ Comp Dental (PPO) You must continue to pay your Medicare Part B premium.Rate changes are effective January 1 of each yearRate 0 45

Regence BlueCross BlueShield of UtahMedAdvantage (PPO) Enrollment Request FormPO Box 1827Medford, OR 975011 (888) 319-8904TTY 711Fax Number: 1 (888) 335-2988 PLEASE PRINT IN INK Please provide the following information:Employer or Trust Name: Utah Valley University RetireesPlease check which plan you want to enroll in: Regence MedAdvantage Rx Primary (PPO)Requested Effective Date:— —MMDDYYYY Regence MedAdvantage Rx Classic w/ Comp Dental (PPO)LAST NameFIRST NameMrs.Middle Initital Mr. Mrs. Ms.Birthdate: (mm/dd/yyyy)Sex:Home Phone Number M FPermanent Residence Street Address (P.O. Box is not allowed):CityMedicare Number (Required)StateZIP CodeMailing Address (only if different from your Permanent Residence Address):Street Address:CityEmergency Contact:StatePhone Number:ZIP CodeRelationship to You:Your e-mail address:By providing your email, you give permission to be contacted about future Medicare news and planinformation via email. You may opt out of email communication at any time.Employer or Trust Name:Utah Valley UniversityForm 5364UT-UVU - Page 1 of 5 (Eff. 1/2021) v1Page 1 of 5*F5364.XOR0EN02200105*Please continue on next page*F5364.XOR0EN10200105*

If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the SocialSecurity Administration. You will be responsible for paying this extra amount in addition to your plan premium.You will be billed directly by Medicare or the Railroad Retirement Board. DO NOT pay Regence MedAdvantagethe Part D-IRMAA.People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify,Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annualdeductibles, and co-insurance. Additionally, those who qualify won’t have a coverage gap or a late enrollmentpenalty. Many people are eligible for these savings and don’t even know it. For more information about thisextra help, contact your Social Security office, or call Social Security at 1 (800) 772-1213. TTY users shouldcall 1 (800) 325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or partof your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount thatMedicare doesn’t cover. You can pay your monthly plan premium (including any late enrollment penaltythat you currently have or may owe) by mail each month or by having it deducted from your bankaccount.Please select a premium payment option: Get a bill (A billing statement will be sent in the mail) Electronic funds transfer (EFT) from your bank account each month. Please enclose a preprinted VOIDEDcheck or provide the following:Account Holder Name:If Account Holder name is NOT the name of the applicant on this application, please sign below toauthorize deductions: Bank Routing Number:Bank Account Number:Account Type: Checking SavingsIf you don’t select a payment option, you will get a bill each month.Employer or Trust NameUtah Valley UniversityForm 5364UT - UVU - Page 2 of 5 (Eff. 1/2021) v1Page 2 of 5*F5364.XOR0EN02200205*Please continue on next page*F5364.XOR0EN10200205*

Please read and answer these important questions1. Do you have End Stage Renal Disease (ESRD)? Yes No2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federalemployee health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will youhave other prescription drug coverage in addition to Regence MedAdvantage? Yes NoIf “yes”, please list your other coverage:Name of the other coverage:ID Number for this coverage:Group Number for this coverage:3. Do you or your spouse work? Yes No4. Are you the retiree? Yes No5. Are you a resident in a long-term care facility, such as a nursing home? Yes NoIf “yes” please provide the following information:Name of Institution:Address & Phone Number of Institution (number and street):Please contact Regence MedAdvantage at 1 (888) 319-8904 (TTY users should call 711) if you needinformation in another format. Our telephone hours are from 8:00 a.m. to 8:00 p.m., Monday through Friday.From October 1 through February 14, our office hours are 8:00 a.m. to 8:00 p.m., seven days a week.Please choose the name of a Primary Care Physician (PCP), clinic, or health center:First and Last Name of PCP:PCP Address:PCP Phone Number:Employer or Trust Name:Utah Valley UniversityForm 5364UT - UVU- Page 3 of 5 (Eff. 1/2021) v1Page 3 of 5*F5364.XOR0EN02200305*Please continue on next page*F5364.XOR0EN10200305*

Please read and sign on page 5By completing this enrollment application, I agree to the following:Regence BlueCross BlueShield of Utah MedAdvantage is a Medicare Advantage plan and has a contractwith the Federal government. I will need to keep my Medicare Parts A and B. I can be in only oneMedicare Advantage plan at a time and I understand that my enrollment in this plan willautomatically end my enrollment in another Medicare health plan or prescription drug plan. It is myresponsibility to inform you of any prescription drug coverage that I have or may get in the future. Iunderstand that if I don’t have Medicare prescription drug coverage, or creditable prescription drugcoverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicareprescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once Ienroll, I may leave this plan or make changes only at certain times of the year when an enrollment period isavailable (Example: October 15 - December 7 of every year), or under certain special circumstances.Once I am a member of Regence MedAdvantage, I have the right to appeal plan decisions about paymentor services if I disagree. I will read the Evidence of Coverage document from Regence MedAdvantage whenI get it to know which rules I must follow in order to receive coverage with this Medicare Advantage plan.I understand that beginning on the date Regence MedAdvantage coverage begins, using services in-networkcan cost less than using services out-of-network, except for emergency or urgently needed services or outof-area dialysis services. If medically necessary, Regence MedAdvantage provides refunds for all coveredbenefits, even if I get services out-of-network. Services authorized by Regence MedAdvantage and otherservices contained in my Regence MedAdvantage Evidence of Coverage document will be covered. Withoutauthorization, NEITHER MEDICARE NOR REGENCE MEDADVANTAGE WILL PAY FOR THE SERVICES.Katie Keil - 000000407115 - 0105076-0004Tina Davis - 000000407104 - 0108057-0000Employer or Trust NameUtah Valley UniversityForm 5364UT - UVU- Page 4 of 5 (Eff. 1/2021) v1Page 4 of 5*F5364.XOR0EN02200405*Please continue on next page*F5364.XOR0EN10200405*

I understand that if I am getting assistance from a sales agent, broker, or other individual employed byor contracted with Regence MedAdvantage, he/she may be paid based on my enrollment in RegenceMedAdvantage.Counseling services may be available in my state to provide advice concerning Medicare supplementinsurance or other Medicare Advantage or Prescription Drug plan options and concerning medical assistancethrough the state Medicaid program and the Medicare Savings Program.Release of Information: By joining this Medicare health plan, I acknowledge that the Medicare health planwill release my information to Medicare and other plans as is necessary for treatment, payment and healthcare operations. I also acknowledge that Regence MedAdvantage will release my information including myprescription drug event data to Medicare, who may release it for research and other purposes which followall applicable Federal statutes and regulations. I also allow the plan’s doctors and clinics or anyone else withmedical or other relevant information about me to give Medicare or their agents the information needed torun the Medicare program. The information on this enrollment form is correct to the best of my knowledge.I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.I understand that my signature (or the signature of the person authorized to act on my behalf under the lawsof the State where I live) on this application means that I have read and understand the contents of thisapplication. If signed by an authorized individual (as described above), this signature certifies that 1) thisperson is authorized under State law to complete this enrollment and 2) documentation of this authority isavailable upon request by Regence MedAdvantage or by Medicare. Your Signature*: Date:month/day/year*If you are the authorized representative, you must sign above and provide the following information:Name:Relationship to enrollee:Address:Phone Number:Office Use OnlyName of staff member/agent/broker (if assisted in enrollment):Plan ID#:Effective Date of Coverage:ICEP/IEP:AEP:SEP (type):Not Eligible:Regence MedAdvantage is a PPO with a Medicare contract. Enrollment in Regence MedAdvantage depends oncontract renewal.Employer or Trust NameUtah Valley UniversityForm 5364UT - UVU - Page 5 of 5 (Eff. 1/2021) v1Page 5 of 5*F5364.XOR0EN02200505**F5364.XOR0EN10200505*

MEDICARE RETIREE GROUP PLANSREGENCE MEDADVANTAGE RX PRIMARY (PPO)REGENCE MEDADVANTAGE RX CLASSIC (PPO) W/COMP DENTAL2021of Benefits2021SummarySummaryof Benefitsfor members with employer groups based in Utah

The information listed is a summary of what we cover and what you pay. It does not list every service,coverage limitation or exclusion. A complete list of services we cover is found in our Evidence ofCoverage (EOC). Call 1-888-319-8904 (TTY: 711) to request a copy of the plan’s EOC.Regence MedAdvantage RxPrimary (PPO)Annual deductibleMedical 0Prescription 0 (Tiers 1,2) 200 (Tiers 3,4,5)Maximum out-of-pocket responsibility 5,900 in-network 10,000 combined in- and out-of-networkIn-networkOut-of-networkDays 1-4: 400 / dayDays 5 : 0 / dayDays 1 : 50%Ambulatory surgery center services1For wound care 4550%For all other services 30050%Outpatient hospital services¹For wound care 4550%For observation 9050%For all other services 35050%Doctor visitsPrimary care provider 550%Specialist 4550%Preventive care 050%Emergency care 90 90Urgently needed services 45 45Inpatient hospital coverage11- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.2 PPO

To join a Regence Medicare Advantage Retiree Group Plan, you must be entitled to MedicarePart A, be enrolled in Medicare Part B, be eligible for your employer’s retiree plan and live within theUnited States. As long as you are eligible for your employer’s retiree plan, you will have coverage inany state you live in (excluding U.S. territories). See other important plan information on page 12.Regence MedAdvantage RxClassic (PPO) w/Comp DentalWhat you should knowAmount you pay for health care services beforeyour health plan begins to pay. Deductibleamounts reset every calendar year on January 1. 0 0 (Tiers 1,2) 150 (Tiers 3,4,5) 5,500 in-network 10,000 combined in- and out-of-networkAnnual limit on your out-of-pocket costs for Part A(hospital) and Part B (medical) services. Does notinclude prescription drugs.In-networkOut-of-networkDays 1-4: 350 / dayDays 5 : 0 / dayDays 1 : 50% 4050% 22550% 4050% 9050% 30050% 050% 4050% 050%Cost-sharing may apply if you receive otherservices during your preventive care visit. 90 90Copay waived if admitted to the hospital within48 hours. 40 40There is no limit/maximum to number of days.1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.PPO 3

Regence MedAdvantage RxPrimary bs/imagingLab services1 0 - 2050%Outpatient X-rays 2050%Diagnostic tests and procedures1 2050%Diagnostic radiology (MRI, CT, etc.)120%50%Hearing servicesMedical hearing exam 4550%Routine hearing exam2 0 150Hearing aids (1 per ear, per year)2 699 or 999 per aidNot coveredDental servicesMedical dental services 4550%Preventive dental services2 050%Comprehensive dental services - diagnostic2 050%Comprehensive dental services - restorative2Not coveredNot coveredVision servicesMedical vision services 050%Routine vision exam2 050%Routine vision hardware2Lenses: 0Frames or contactlenses: 100 allowanceper yearLenses: 50%Frames or contactlenses: 100 allowanceper year1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.4 PPO

Regence MedAdvantage RxClassic (PPO) w/Comp DentalIn-networkOut-of-network 0 - 1050% 1050% 1050%20%50% 4050% 0 150 699 or 999 per aidNot covered 4050%What you should knowLower copay amount applies to HbA1C testing;higher copay applies to all other lab services.Routine hearing services provided by TruHearing for in-network coverage. Hearing aids coveredonly if obtained from TruHearing. 050%Covers preventive exams, bitewing X-rays,cleanings and topical fluoride two times percalendar year. Full-mouth X-rays covered onceevery three years. 050%Covers diagnostic exams and intraoral-periapicalX-rays two times per calendar year.50%; 1,000 benefitlimit per calendar year50%; 1,000 benefitlimit per calendar yearCovers crowns, dentures, partials, bridges,implants, restorations, endodontics, periodonticsand oral surgery. 050% 050%Lenses: 0Frames or contactlenses: 100 allowanceper yearLenses: 50%Frames or contactlenses: 100 allowanceper yearRoutine vision services provided by VSP VisionCare for in-network coverage. Covered lensesinclude basic single-vision, lined bifocal, linedtrifocal or lenticular lenses. One pair of lenses/frames or single purchase of contact lenses peryear.1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.PPO 5

Regence MedAdvantage RxPrimary (PPO)In-networkOut-of-networkDays 1-4: 400 / dayDays 1-190: 50%Mental health services1InpatientDays 5-190: 0 / dayOutpatient therapy (individual and group) 4050%Skilled nursing facility1Days 1-20: 0 / dayDays 1-100: 50%Days 21-100: 167 / dayPhysical therapy1 3050%Ambulance (air/ground)1 275 275TransportationNot coveredNot coveredMedicare Part B drugs120%50%Acupuncture (Medicare-covered) 2050%Chiropractic (Medicare-covered) 2050%Chiropractic (additional)2 2050%Annual physical exam 050%Fitness program (Silver&Fit )² 0Not coveredChronic health status 0Not coveredPost-discharge 0Not coveredAlternative careMeal delivery service21- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.6 PPO

Regence MedAdvantage RxClassic (PPO) w/Comp DentalIn-networkOut-of-networkDays 1-4: 350 / dayDays 1-190: 50%Days 5-190: 0 / day 4050%Days 1-20: 0 / dayDays 1-100: 50%Days 21-100: 160 / dayWhat you should knowThere is a 190-day lifetime maximum.Up to 100 days covered per benefit period. 2550%Includes occupational therapy and speechlanguage therapy. 275 275Copay applies for each one-way transport.Not coveredNot covered20%50% 2050% 2050%Limited to manipulation of the spine to correct asubluxation. 2050%Up to 18 visits (for Primary plan) or 24 visits (forClassic plan) per year. 050%In addition to the Medicare Annual Wellness Visit. 0Not coveredFitness center membership, home fitness optionsincluding a complimentary Fitbit, weekly healthcoaching and more. 0Not covered 0Not coveredUsually administered in a hospital setting, likechemotherapy drugs.Limited to treatment of chronic low back pain.Requires enrollment in care management program.Chronic health: 2 meals/day for 56 days, 112-meallimit.Post-discharge: 2 meals per day, 28 days, 56-meallimit.1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.PPO 7

Regence MedAdvantage RxPrimary (PPO)In-networkOut-of-networkPalliative care and support2 050%Personal emergency response system (PERS)2 0Not coveredMedicare-covered 4550%Diabetic routine foot care2 050%Virtual companionship2 0Not coveredVirtual visits (telehealth) 550%Podiatry services1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.8 PPO

Regence MedAdvantage RxClassic (PPO) w/Comp DentalIn-networkWhat you should knowOut-of-network 050%Includes care planning, pain/symptom managementand counseling services for patients, caregivers andfamilies in case of serious illness. 0Not coveredBenefit includes device and monthly monitoringservices. 4050% 050%Limit of 6 visits per year. 0Not coveredVirtual support services by phone. Limit of 4 visitsper month; up to 60 minutes per visit. 050%Medical and mental health services provided byMDLIVE or other provider by phone or video.1- Services may require prior authorization. 2- Services do not apply to the out-of-pocket maximum.PPO 9

Prescription deductibleRegence MedAdvantage RxPrimary (PPO)Regence MedAdvantage RxClassic (PPO) w/Comp Dental 0 (Tiers 1,2) 200 (Tiers 3,4,5) 0 (Tiers 1,2) 150 (Tiers 3,4,5)Initial coverage (after deductible, what you pay until you and the plan pay 4,130 for prescription drugs)Tier 1: Preferred genericPreferred retailMail orderStandard retail1-month3-month1-month3-month 3 0 10 0 0 20 3 0 10 0 0 20 13 20 26 40 13 20 26 40 40 47 100 117.50 40 47 100 AN/ATier 2: GenericPreferred retail / mail orderStandard retailTier 3: Preferred brandPreferred retail / mail orderStandard retailTier 4: Non-preferred drugPreferred retail / mail orderStandard retailTier 5: SpecialtyPreferred retail / mail orderStandard retailCoverage gap (what you pay after you and your plan pay 4,130 for prescription drugs)Generic drugsYou pay 25%Brand-name drugsYou pay 25%Catastrophic coverage (what you pay after your total out-of-pocket costs reach 6,550)Generic drugsYou pay the greater of 3.70 or 5%Brand-name drugsYou pay the greater of 9.20 or 5%You may pay more than your copay or coinsurance amount if you get drugs from an out-of-networkpharmacy. Long-term care facility residents pay the same as at a standard retail pharmacy andare limited to a one-month supply (three-month supply is not available). Cost-sharing may changeif you qualify for Extra Help. To find out if you qualify, call the Social Security Administration at1-800-772-1213 (TTY: 1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday.10 PPO

Prescription costs in the coverage gapDeductibleMeet your plan’s prescription deductibleYou first need to meet your plan’s annual prescriptiondeductible. Your deductible amount resets everycalendar year on Jan. 1. There is no deductible forgeneric medications on Tiers 1 and 2.Pay the plan’s prescriptiondeductible ( 0 for Tiers 1 and 2)Initial coveragePay a copay or coinsurance for each fill until totalspent by you and plan reaches 4,130After you meet your deductible, you pay a copay orcoinsurance for each prescription until the amountyou and your plan spend on prescriptions reachesthe initial coverage limit. Then you enter the coveragegap. Not everyone will enter the coverage gap.Pay a copay or coinsurance untilprescription costs reach 4,130Coverage gapPay 25% of negotiated price for generic andbrand-name drugs until your prescription spendingreaches 6,550After the initial coverage limit is met, you enterthe coverage gap. You pay 25% of your plan’snegotiated price for generic and brand-name drugsuntil your spending on prescription drugs reachesthe total out-of-pocket threshold. Then you entercatastrophic coverage.Pay 25% until your total spendon prescriptions reaches 6,550Catastrophic coveragePay the greater of 5% or 3.70 for generic drugs;pay the greater of 5% or 9.20 for brand-name drugsWhen you enter catastrophic coverage, you pay onlya small amount for your covered drugs for the rest ofthe year. Your plan pays the rest.Pay 5% or 3.70 for genericsand 5% or 9.20 for brandname drugsPPO 11

Important plan informationUsing in-network providersVirtual visits (telehealth)If you use a Regence MedAdvantage PPOnetwork provider, or a provider who participatesin the Blue Medicare Advantage PPO NetworkSharing Program, you will receive in-networkbenefits for covered services. If you reside in acounty or state that does not participate in theBlue Medicare Advantage PPO Network Program,you will still receive in-network benefits forcovered services as long as your chosen provideraccepts Medicare. If you choose to use an outof-network provider when an in-network provideris available, you may pay more for your services,except in urgent and emergency situations.Primary care and mental health visits are availableby mobile app, video or phone. For moreinformation or to schedule an appointment, callMDLIVE at 1-800-400-6354 (TTY: 711), 24 hoursa day, 7 days a week. Or visit mdlive.com.You can search for a participating providerat bcbs.com/find-a-doctor or call RegenceCustomer Service at 1-888-319-8904 (TTY: 711).Urgent and emergency care when you travelIf you travel outside the United States, the plancovers urgent care and medical emergencies inmore than 190 countries around the world. PartD prescription drug coverage is not availableoutside the United States and its territories.Routine hearing servicesFor more information about your routine hearingbenefits or to find a hearing provider, callTruHearing at 1-855-542-1711 (TTY: 711), 8 a.m.to 8 p.m. Monday through Friday. Or visittruhearing.com.Routine vision servicesFor more information about your routine visionbenefits or to find a vision provider, call VSPVision Care at 1-844-872-6065 (TTY: 1-800428-4833), 5 a.m. to 6 p.m. Pacific time, Mondaythrough Friday, or 7 a.m. to 5 p.m. Pacific time,Saturday and Sunday. Or visit vsp.com.12 PPOThe Silver&Fit programIncludes a basic membership at one or moreparticipating fitness centers, plus an expandedhome fitness program with two home fitnesskits, one Stay Fit kit (Fitbit, Garmin, yoga orstrength training), weekly 1-to-1 health coaching,and more. For more information or to signup, call Silver&Fit at 1-888-797-8086 (TTY: 711),5 a.m. to 6 p.m. Pacific time, Monday throughFriday. Or visit SilverandFit.com.Personal emergency response system (PERS)Receive a Lively Mobile Plus medical alertdevice and monthly monitoring per calendaryear when arranged by the plan. For moreinformation, call GreatCall at 1-800-358-9066(TTY: 711). Or visit greatcall.com/RegenceUT.Virtual companionshipEligible members are able to receive supportservices, such as grocery and pharmacy pick-up/delivery, technology assistance, phone visits andmore. For more information or to see if you qualify,call Papa Pals at 1-877-310-0303 (TTY: 711) 5 a.m.to 8 p.m. Pacific time, Monday through Friday, or5 a.m. to 5 p.m. Pacific time, Saturday and Sunday.Or visit Joinpapa.com/Regence.Meal delivery serviceNo-cost meals for chronic condition or posthospital stay nutritional support for those whoqualify and participate in the plan’s care/casemanagement program. Mom’s Meals deliversmeals to all 50 states plus U.S. territories. Formore information or to see if you qualify, callRegence Customer Service at 1-888-319-8904(TTY: 711).

Important information to know before you enrollBefore making an enrollment decision, it is important that you fully understand our benefits and rules. Ifyou have any questions, you can call and speak to a customer service representative at 1-888-319-8904.Understanding Important RulesUnderstanding the BenefitsReviewthethefull listbenefitsfound in foundthe EvidenceReviewfulloflistof benefitsin of Coverage(EOC), especially for those services for which youthe Evidence of Coverage (EOC), especiallyroutinely see a doctor. Call 1-888-319-8904 to request afor those services for which you routinelycopy of the plan’s EOC.see a doctor. Call 1-888-319-8904 torequest a copy of the plan’s EOC.Review the provider directory (or ask your doctor) toReview the provider directory (or ask yourmakesuredoctorsnow arethe network.doctor)to innotlisted,itmeansyouwilllikelythe network. If they are not listed,havetoselectnewdoctor.it means you awilllikelyhave to select aIn addition to any monthly plan premium, you must continue to pay your MedicareIn addition to any monthly plan premium, youPart B premium. This premium is normally taken out of your Socialmustcheckcontinueto pay your Medicare Part BSecurityeach month.premium. This premium is normally taken outof your Social Security check each month.Benefits,and/or copayments/cocopayments/co- insuranceBenefits, premiumspremiums and/ormaychangeonchangeJanuaryon1,January2022. 1, 2022.insurancemayOur plan allows you to see providers outside of our networkOur plan allows you to see providers outside(non-contractedHowever,while weof our yforcoveredservicesprovidedby a non-contractedHowever, while we will pay for coverednew doctor.provider,providerbymustagree to treatservicestheprovideda thepharmacyyou.Exceptthein anemergencyurgenttosituations,Review the pharmacy directory to make sureprovider,providermustoragreetreat you.youfor any he usepharmacyyou use formedicinesany prescriptionExcept in an emergency or urgent situations,inthe network.If theyou willmedicinesis inthepharmacynetwork. isIf notthe listed,pharmacyInnon-contractedaddition, you maypay a higherfor servicesprovidersmayco-paydeny care.likelyto selecta newyour prescriptions.receivedis nothavelisted,you willlikelypharmacyhave to forselectby non-contractedin-networkIn addition,you may pay providersa higher ifco-paya new pharmacy for your prescriptions.providersare available.for servicesreceived by non-contractedproviders if in-network providers are available.Covered preventive careOur plans cover the following Medicare-covered preventive services, along with any additionalpreventive services that Medicare approves during the contract year.Abdominal aortic aneurysmscreeningAlcohol misuse screeningsand counselingAnnual Wellness VisitBone mass measurements(bone density)Breast cancer screening(mammogram)Cardiovascular diseasescreeningsCardiovascular disease(behavioral therapy)Cervical and vaginal cancerscreeningColorectal cancer screenings(multi-target stool DNA test,barium enemas, colonoscopy,fecal occult blood test orflexible sigmoidoscopies)Depression screeningDiabetes screeningDiabetes self-managementtrainingGlaucoma testsHepatitis B virus (HBV)infection screeningHepatitis C screening testHIV screeningLung cancer screeningswith Low Dose ComputedTomography (LDCT)Medicare Diabetes PreventionProgram (MDPP)Nutrition therapy servicesObesity screenings andcounselingProstate cancer screeningsSexually transmitted infectionsscreening and counselingImmunizations for flu, hepatitis Band pneumococcusTobacco use cessationcounseling“Welcome to Medicare”preventive visit (one time)PPO 13

NONDISCRIMINATION NOTICERegence complies with applicable Federal civil rights laws and does not discriminate on thebasis of race, color, national origin, age, disability, or sex. Regence does not exclude peopleor 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 effectivelywith us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, and accessible electronicformats, other formats)Provides free language services to people whose primary language is not English,such as: Qualified interpreters Information written in other languagesIf you need these services listed above,please contact:Medicare Customer Service1-800-541-8981 (TTY: 711)Customer Service for all other plans1-888-344-6347 (TTY: 711)If you believe that Regence has failed toprovide these services or discriminated inanother way on the basis of race, color,national origin, age, disability, or sex, you canfile a grievance with our civil rights coordinatorbelow:Medicare Customer ServiceCivil Rights CoordinatorMS: B32AG, PO Box 1827Medford, OR 975011-866-749-0355, (TTY: 711)Fax: 1-888-309-8784medicareappeals@regence.comCustomer Service for all other plansCivil Rights CoordinatorMS CS B32B, P.O. Box 1271Portland, OR 97207-12711-888-344-6347, (TTY: e01012018.04PF12LNoticeNDMARegence14 PPOYou can also file a civil rights complaint with theU.S. Department of Health and Human Services,Office for Civil Rights electronically through theOffice for Civil Rights Complaint Portal athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, orby mail or phone at:U.S. Department of Health and Human Services200 Independence Avenue SW,Room 509F HHH BuildingWashington, DC 202011-800-368-1019, 800-537-7697 (TDD).Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html.

Language assistanceATENCIÓN: si habla español, tiene a su disposiciónservicios gratuitos de asistencia lingüística. Llame al1-888-344-6347 (TTY: -344-6347 (TTY: 711)。 យ័ ស ក យ ែ រ, ស ួយែផ ក យ ល ច ស រ ក។ ចូ រ ទូ រស័ព 1-888-3446347 (TTY: 711)។ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਸ ਪੰ ਜਾਬੀ ਬੋਲਦੇ ਹੋ, ਤ ਭਾਸ਼ਾ ਿਵੱ ਚCHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗtrợ n

Regence BlueCross BlueShield of Utah MedAdvantage is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. . MEDICARE RETIREE GROUP PLANS REGENCE MEDADVANTAGE RX PRIMARY (PPO) REGENCE MEDADVANTAGE RX CLASSIC (PPO) W/COMP DENTAL: 2021 Summary of Benefits: 2 PPO Regence :