Complete

CIS (CityCounty Insurance Services)




Plan V-A PPP Rx4


Effective August 1, 2012





Employee Benefit Plan with Family Protection

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Introduction


Regence BlueCross BlueShield of Oregon

100 SW Market Street
Portland, OR 97207

P.O. Box 30805
Salt Lake City, UT 84130-0805

Welcome to participation in the self-funded group health plan (hereafter referred to as "Plan") provided for
You by Your employer and CIS. CIS has chosen Regence BlueCross BlueShield of Oregon to administer
claims for Your group health plan. Throughout this Booklet, CIS may be referred to as the "Plan Sponsor"
or "Plan Administrator."
EMPLOYER PAID BENEFITS
Your Plan is an employer-sponsored benefits plan administered by Regence BlueCross BlueShield of
Oregon (usually referred to as the "Claims Administrator" in this Booklet). This means that Your employer
and CIS, not Regence BlueCross BlueShield of Oregon, pays for Your covered medical services and
supplies. Your claims will be paid only after CIS provides Regence BlueCross BlueShield of Oregon with
the funds to pay Your benefits and pay all other charges due under the Plan. The Claims Administrator
provides administrative claims payment services only and does not assume any financial risk or obligation
with respect to claims.
Because of their extensive experience and reputation of service, Regence BlueCross BlueShield of
Oregon has been chosen as the Claims Administrator of Your Plan.
The following pages are the Booklet, the written description of the terms and benefits of coverage
available under the Plan. This Booklet describes benefits effective August 1, 2012, or the date after that
on which Your coverage became effective. This Booklet replaces any plan description, Booklet or
certificate previously issued by Regence BlueCross BlueShield of Oregon and makes it void.
As You read this Booklet, please keep in mind that references to "You" and "Your" refer to both the
Participant and Beneficiaries (except that in the Who Is Eligible, How To Enroll And When Coverage
Begins, When Coverage Ends, COBRA Continuation, and Other Continuation Options sections, the terms
"You" and "Your" mean the Participant only). The term "Agreement" refers to the administrative services
contract between the Plan Sponsor and the Claims Administrator.
Other terms are defined in the Definitions Section at the back of this Booklet or where they are first used
and are designated by the first letter being capitalized.
Federal law mandates coverage for certain breast reconstruction services in connection with a covered
mastectomy. See Women's Health and Cancer Rights in the General Provisions Section of this Booklet
for details.
Statement of Rights Under the Newborns' and Mothers' Health Protection Act: Under federal law,
group health plans and health insurance issuers offering group health insurance coverage generally may
not restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by
cesarean section. However, the plan or issuer may pay for a shorter stay if the attending Provider (e.g.,
Your Physician, nurse midwife, or Physician assistant), after consultation with the mother, discharges the
mother or newborn earlier.
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Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that
any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or
newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a Physician or other health care
provider obtain preauthorization for prescribing a length of stay of up to 48 hours (or 96 hours). However,
to use certain Providers or facilities, or to reduce Your out-of-pocket costs, You may be required to obtain
preauthorization. For information on preauthorization, contact Your Claims Administrator.
Notice of Privacy Practices: Regence BlueCross BlueShield of Oregon has a Notice of Privacy
Practices that is available by calling Customer Service or visiting the Web site at:
www.myRegence.com. (Select "Privacy Policy" at the bottom of the home page.)
CONTACT INFORMATION
Customer Service: 1 (866) 240-9580
And visit the Claims Administrator's Web site at: www.myRegence.com.
Using Your Booklet
This Plan, administered by Regence, provides You with great benefits that are quickly accessible and
easy to understand, thanks to broad access to Providers and innovative tools. With this health care
coverage, You will discover more personal freedom to make informed health care decisions, as well as
the assistance You need to navigate the health care system.
YOU SELECT YOUR PROVIDER AND CONTROL YOUR OUT-OF-POCKET EXPENSES
Your Plan gives You broad access to Providers and allows You to control Your out-of-pocket expenses,
such as Copayments and Coinsurance, for each Covered Service. Here's how it works - You control Your
out-of-pocket expenses by choosing Your Provider under three choices called: "Category 1," "Category 2"
and "Category 3."

Category 1. You choose to see a preferred Provider and save the most in Your out-of-pocket
expenses. Choosing this category means You will not be billed for balances for Covered Services
beyond any Deductible, Copayment and/or Coinsurance.

Category 2. You choose to see a participating Provider and Your out-of-pocket expenses will
generally be higher than if You choose Category 1 because larger discounts with preferred Providers
may be negotiated that will result in lower out-of-pocket amounts for You. Choosing this category
means You will not be billed for balances for Covered Services beyond any Deductible, Copayment
and/or Coinsurance.

Category 3. You choose to see a Provider that does not have a participating contract with the Claims
Administrator and Your out-of-pocket expenses will generally be higher than Category 1. Also,
choosing this category 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 Booklet, the Provider You may choose and Your payment amount for each
Category is indicated. Categories 1, 2 and 3 are also in the Definitions Section of this Booklet. You can
go to www.myRegence.com for further Provider network information. (From there, select "My
Navigator," then "Provider Search.")
ADDITIONAL PARTICIPATION ADVANTAGES
Your Plan offers You access to valuable services. The advantages of Regence involvement as the
Claims Administrator include admission to personalized health care planning information, health-related
events and innovative health-decision tools, as well as a team dedicated to Your personal health care
needs. You also have access to www.myRegence.com, powered by the Regence Engine, an interactive
environment that can help You navigate Your way through health care decisions. THESE ADDITIONAL
VALUABLE SERVICES ARE A COMPLEMENT TO THE GROUP HEALTH PLAN, BUT ARE NOT
INSURANCE.
CIS, 800000000, EFF DATE 080112

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Go to www.myRegence.com. Have Your Plan identification card handy to log on. Use the Web site
to view recent claims, get health guidance and support, get access to local events, and use tools for
annual planning. It is a health power source that can help You lead a healthy lifestyle, become a well-
informed health care shopper and increase the value of Your health care dollar.

Go to www.regencerx.com or www.myRegence.com. Here You can identify Participating
Pharmacies, find alternatives to expensive medicines, learn about prescriptions for various Illnesses
and even compare medications based upon performance and cost, as well as discover how to receive
discounts on prescriptions.
GUIDANCE AND SERVICE ALONG THE WAY
This Booklet was designed to provide information and answers quickly and easily. Be sure to understand
Your benefits before You need them. You can learn more about the unique advantages of Your health
care coverage throughout this Booklet, some of which are highlighted here. If You have questions about
Your health care coverage, please contact the Claims Administrator.

Learn more and receive answers about Your coverage. Just call Customer Service: 1 (866) 240-
9580 to talk with one of the Claims Administrator's Customer Service representatives. Phone lines
are open Monday-Friday 6 a.m. - 6 p.m. You may also visit the Claims Administrator's Web site at:
www.myRegence.com.

Case Management. You can request that a case manager be assigned or You may be assigned a
case manager to help You and Your Physician best use Your benefits and navigate the health care
system in the best way possible. Case managers assess Your needs, develop plans, coordinate
resources and negotiate with Providers. Call Case Management at 1 (866) 543-5765.

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

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Table of Contents
UNDERSTANDING YOUR BENEFITS ........................................................................................................ 1
MAXIMUM BENEFITS .............................................................................................................................. 1
MAXIMUM COINSURANCE ..................................................................................................................... 1
COPAYMENTS ......................................................................................................................................... 1
PERCENTAGE PAID UNDER THE PLAN (COINSURANCE) ................................................................. 2
DEDUCTIBLES ......................................................................................................................................... 2
HOW CALENDAR YEAR BENEFITS RENEW ........................................................................................ 2
MEDICAL BENEFITS ................................................................................................................................... 3
ANNUAL MAXIMUM BENEFIT ................................................................................................................. 3
CALENDAR YEAR DEDUCTIBLES ......................................................................................................... 3
CALENDAR YEAR MAXIMUM COINSURANCE ...................................................................................... 3
COPAYMENTS AND COINSURANCE ..................................................................................................... 3
PREVENTIVE CARE AND IMMUNIZATIONS .......................................................................................... 4
OFFICE VISITS - ILLNESS OR INJURY ................................................................................................. 5
OTHER PROFESSIONAL SERVICES ..................................................................................................... 5
AMBULANCE SERVICES......................................................................................................................... 6
BLOOD BANK ........................................................................................................................................... 6
CHIROPRACTIC CARE ............................................................................................................................ 6
DENTAL HOSPITALIZATION ................................................................................................................... 7
DETOXIFICATION .................................................................................................................................... 7
DIABETIC EDUCATION ........................................................................................................................... 7
DIABETES SUPPLIES AND EQUIPMENT ............................................................................................... 7
DURABLE MEDICAL EQUIPMENT .......................................................................................................... 7
EMERGENCY ROOM (INCLUDING PROFESSIONAL CHARGES) ....................................................... 8
FAMILY PLANNING .................................................................................................................................. 8
GENETIC TESTING ................................................................................................................................. 8
HEARING AIDS FOR CLAIMANTS 18 YEARS OF AGE OR YOUNGER, OR CHILDREN 19 YEARS
OF AGE OR OLDER ................................................................................................................................. 9
HOME HEALTH CARE ............................................................................................................................. 9
HOSPICE CARE ....................................................................................................................................... 9
HOSPITAL CARE - INPATIENT, OUTPATIENT AND AMBULATORY SERVICE FACILITY ............... 10
MATERNITY CARE ................................................................................................................................ 10
MEDICAL FOODS (PKU) ....................................................................................................................... 11
MENTAL HEALTH OR CHEMICAL DEPENDENCY SERVICES ........................................................... 11
NEWBORN CARE .................................................................................................................................. 12
NUTRITIONAL COUNSELING ............................................................................................................... 12
ORTHOTIC DEVICES ............................................................................................................................ 12
PROSTHETIC DEVICES ........................................................................................................................ 13
REHABILITATION SERVICES ............................................................................................................... 13
REPAIR OF TEETH ................................................................................................................................ 13
SKILLED NURSING FACILITY (SNF) CARE ......................................................................................... 14
TELEMEDICINE ..................................................................................................................................... 14
TEMPOROMANDIBULAR JOINT (TMJ) DISORDERS .......................................................................... 14
TRANSPLANTS ...................................................................................................................................... 15
WEIGHT MANAGEMENT AND OBESITY TREATMENT - TURNING POINT...................................... 16
PRESCRIPTION MEDICATION BENEFITS ............................................................................................... 18
CALENDAR YEAR DEDUCTIBLE .......................................................................................................... 18
COPAYMENTS AND COINSURANCE ................................................................................................... 18
CALENDAR YEAR MAXIMUM COINSURANCE .................................................................................... 18
COVERED PRESCRIPTION MEDICATIONS ........................................................................................ 18
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GENERAL PRESCRIPTION MEDICATION BENEFITS INFORMATION (NETWORK, SUBMISSION
OF CLAIMS AND MAIL-ORDER) ........................................................................................................... 19
PREAUTHORIZATION ........................................................................................................................... 20
LIMITATIONS ......................................................................................................................................... 20
EXCLUSIONS ......................................................................................................................................... 21
DEFINITIONS ......................................................................................................................................... 22
CARE MANAGEMENT AND WELLNESS PROGRAMS ........................................................................... 24
CASE MANAGEMENT ........................................................................................................................... 24
DISEASE MANAGEMENT ...................................................................................................................... 24
SPECIAL BEGINNINGS ......................................................................................................................... 24
REGENCE HEALTH COACHSM ............................................................................................................. 24
GENERAL EXCLUSIONS .......................................................................................................................... 25
PREEXISTING CONDITIONS ................................................................................................................ 25
SPECIFIC EXCLUSIONS ....................................................................................................................... 25
CLAIMS ADMINISTRATION ...................................................................................................................... 30
PLAN IDENTIFICATION CARD .............................................................................................................. 30
SUBMISSION OF CLAIMS AND REIMBURSEMENT ............................................................................ 30
OUT-OF-AREA SERVICES .................................................................................................................... 32
BLUECARD WORLDWIDE(R) .................................................................................................................. 34
NONASSIGNMENT ................................................................................................................................ 34
CLAIMS RECOVERY.............................................................................................................................. 34
RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION AND MEDICAL RECORDS ...... 35
LIMITATIONS ON LIABILITY.................................................................................................................. 35
RIGHT OF REIMBURSEMENT AND SUBROGATION RECOVERY ..................................................... 36
COORDINATION OF BENEFITS ........................................................................................................... 37
RESOLVING YOUR CONCERNS .............................................................................................................. 42
EXTERNAL APPEAL - IRO .................................................................................................................... 42
EXPEDITED APPEALS .......................................................................................................................... 43
INFORMATION ....................................................................................................................................... 44
DEFINITIONS SPECIFIC TO THE GRIEVANCE AND APPEAL PROCESS ......................................... 45
WHO IS ELIGIBLE, HOW TO ENROLL AND WHEN COVERAGE BEGINS ............................................ 47
INITIALLY ELIGIBLE, WHEN COVERAGE BEGINS ............................................................................. 47
NEWLY ELIGIBLE DEPENDENTS ........................................................................................................ 48
SPECIAL ENROLLMENT ....................................................................................................................... 48
ANNUAL ENROLLMENT PERIOD ......................................................................................................... 49
DOCUMENTATION OF ELIGIBILITY ..................................................................................................... 49
ADMINISTRATIVE AND ELIGIBILITY APPEALS ................................................................................... 49
WHEN COVERAGE ENDS ......................................................................................................................... 51
AGREEMENT TERMINATION ............................................................................................................... 51
WHAT HAPPENS WHEN YOU ARE NO LONGER ELIGIBLE .............................................................. 51
TERMINATION OF YOUR EMPLOYMENT OR YOU ARE OTHERWISE NO LONGER ELIGIBLE ..... 51
NONPAYMENT ....................................................................................................................................... 51
FAMILY AND MEDICAL LEAVE ............................................................................................................. 51
MILITARY LEAVE OF ABSENCE ........................................................................................................... 52
LEAVE OF ABSENCE ............................................................................................................................ 52
MID-YEAR STATUS CHANGES ............................................................................................................ 53
WHAT HAPPENS WHEN YOUR BENEFICIARIES ARE NO LONGER ELIGIBLE ............................... 53
OTHER CAUSES OF TERMINATION .................................................................................................... 54
CERTIFICATES OF CREDITABLE COVERAGE ................................................................................... 54
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COBRA CONTINUATION OF COVERAGE ............................................................................................... 55
OTHER CONTINUATION OPTIONS .......................................................................................................... 56
IF YOU RETIRE ...................................................................................................................................... 56
STRIKE OR LOCKOUT .......................................................................................................................... 56
WORKERS' COMPENSATION CLAIM .................................................................................................. 57
GENERAL PROVISIONS ........................................................................................................................... 58
CHOICE OF FORUM .............................................................................................................................. 58
GOVERNING LAW ................................................................................................................................. 58
PLAN SPONSOR IS AGENT .................................................................................................................. 58
LEGAL OR ARBITRATION PROCEEDINGS ......................................................................................... 58
NO WAIVER ........................................................................................................................................... 58
NOTICES ................................................................................................................................................ 58
RELATIONSHIP TO BLUE CROSS AND BLUE SHIELD ASSOCIATION ............................................. 58
REPRESENTATIONS ARE NOT WARRANTIES .................................................................................. 59
WHEN BENEFITS ARE AVAILABLE ..................................................................................................... 59
WOMEN'S HEALTH AND CANCER RIGHTS ........................................................................................ 59
DEFINITIONS.............................................................................................................................................. 60

CIS, 800000000, EFF DATE 080112

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