Plan Summary

Plan V-A PPP RX4
$100 Deductible
90/70/70% Coinsurance

Effective Date: August 1, 2012

Benefit Summary
Annual Maximum Benefit
$2,000,000
Deductible per calendar year
$100 Per Claimant
$300 Per Family (3 times the Claimant amount)
Category 1 Maximum coinsurance per
$500 Per Claimant
calendar year
$1,000 Per Family (2 times the Claimant amount)
Category 2 & 3 Maximum coinsurance per
$1,500 Per Claimant
calendar year
$3,000 Per Family (2 times the Claimant amount)
After the maximum coinsurance is met, the
100% for the remainder of the calendar year except where noted
Plan pays

Understanding Your Benefits
Your health coverage is insured by CIS, but administered by Regence BlueCross BlueShield of Oregon. This means that
CIS, not Regence BlueCross BlueShield of Oregon, pays for your covered medical services and supplies. For Customer
Service contact: 1 (866) 240-9580
Once you have satisfied any applicable deductible or copayment, the Plan will begin to pay benefits for covered services
in any calendar year. Your deductible applies for all services unless otherwise specified. Copayments do not count
toward the deductible.
Once you have satisfied any applicable deductible and any applicable copayment, the Plan pays a percentage of the
allowed amount for covered services. When payment is less than 100%, you pay the remaining percentage. This is your
Coinsurance (Claimant Responsibility).
You can meet the maximum coinsurance by payments of coinsurance for all categories. Any amounts you pay for non-
covered services, deductible, copayments or amounts in excess of the allowed amount do not apply toward the maximum
coinsurance.
There are two maximum coinsurance amounts, one for Category 1 benefits, and another maximum coinsurance amount
for Category 2 and 3 benefits combined.
At myRegence.com, you'l find all your health and wellness resources in one place. Advise, Navigate, Reward:
www.myRegence.com offers comprehensive, health-related information designed to help advise members on health
care and lifestyle options, navigate them through the health care system and reward those who make healthier choices.
Important Information Regarding Preventive Care: Benefits will be covered under the preventive care benefit if services
are in accordance with age limits and frequency guidelines according to, and as recommended by, the United States
Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices of the Centers for Disease
Control and Prevention (CDC) or Health Resources and Services Administration (HRSA). In the event any of these bodies
adopts a new or revised recommendation, this plan has up to one year before coverage of the related services must be
available and effective under this benefit. For a list of services covered under this benefit, please visit
www.myRegence.com. (From there, select "My Navigator", then "Benefits", then "Preventive Care.") Covered services that
do not meet this criteria will be covered the same as any other illness or injury.

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You Select Your Provider and Control Your Out-of-Pocket Expenses
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 beyond any deductible, copayment, and/or coinsurance for covered
services. You can find a list of providers at the Claims Administrator Website, www.myRegence.com (From there,
select, "My Navigator," then "Provider Search."), or by calling Customer Service.
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 the Claims Administrator may negotiate larger discounts with preferred providers that will
result in lower out-of-pocket amounts for you. Choosing this category means you will not be billed for balances beyond
any deductible, copayment, and/or coinsurance for covered services.
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.

Claimant
Claimant
Claimant
Covered Medical Services
Responsibility
Responsibility
Responsibility
(Per Claimant)
Category 1
Category 2
Category 3
Preventive Care
0%
0%
0%
Preventive care services include routine well-
(deductible waived)
(deductible waived)
(deductible waived)
baby care, routine physical examinations,
routine immunizations and routine health
screenings
Immunizations for adults and children
Professional Services
10%
30%
30%
Office visits for illness or injury
Laboratory, radiology and diagnostic
procedures
Surgery, inpatient visits and therapeutic
injections
Ambulance Services
10%
10%
10%
Blood Bank
10%
10%
10%
Chiropractic Care
10%
10%
10%
Limited to the treatment of musculoskeletal
disorders only
12 visit limit per calendar year
Does not apply toward maximum
coinsurance
Dental Hospitalization
10%
30%
30%
Durable Medical Equipment
10%
30%
30%
Emergency Room (Including Professional
$100 copay per visit
$100 copay per visit
$100 copay per visit
Charges)
and 10%
and 10%
and 10%
Copay applies to the facility charge, whether
or not the deductible has been met
Copay waived if admitted directly to a
hospital or facility on an inpatient basis
Genetic Testing
10%
30%
30%
Hearing Aids
10%
30%
30%
Hearing aids are limited to $4,300 every 4
calendar years
Covered for Claimants 18 years of age or
younger, or enrolled children 19 years of age
or older and enrolled in a secondary school
or an accredited educational institution.
The benefit amount is adjusted on January 1
of each year based on the Consumer Price
Index.
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Claimant
Claimant
Claimant
Covered Medical Services
Responsibility
Responsibility
Responsibility
(Per Claimant)
Category 1
Category 2
Category 3
Home Health Care
10%
10%
10%
180 visit limit per calendar year
0%
0%
0%
Hospice Care
(deductible waived)
(deductible waived)
(deductible waived)
Hospital Care
10%
30%
30%
Inpatient, Outpatient and Ambulatory Service
Facility
Maternity Care
10%
30%
30%
Mental Health/Chemical Dependency
10%
30%
30%
Services - Inpatient, Residential and
(deductible waived for
(deductible waived for
(deductible waived for
Outpatient
outpatient services)
outpatient services)
outpatient services)
Nutritional Counseling
0%
0%
0%
4 visit limit per Claimant lifetime
(deductible waived)
(deductible waived)
(deductible waived)
Orthotic Devices
10%
30%
30%
Prosthetic Devices
10%
30%
30%
Rehabilitation Services
10%
30%
30%
Inpatient: unlimited
Rehabilitation Services
10%
10%
10%
Outpatient: 77 visit limit per calendar year
Neurodevelopmental therapy (pervasive
developmental disorder) is limited to children
age 17 and under.
Repair of Teeth
10%
30%
30%
$1,000 per calendar year maximum benefit
when services are billed by a dentist
Damage or loss due to accidental injury
Skilled Nursing Facility (SNF) Care
10%
30%
30%
120 inpatient day limit per calendar year
Temporomandibular Joint (TMJ) Disorders
10%
30%
30%
Transplants
0%
30%
30%
24 month waiting period (you may receive
(deductible waived)
credit from your prior medical coverage)
Services do not accrue to coinsurance
maximum
Weight Management and Obesity Treatment
0%
0%
0%
- Turning Point
(deductible waived)
(deductible waived)
(deductible waived)
Weight management and obesity treatment



(includes health coaching, integrated care



coordination, nutritional counseling (up to 4



visits per calendar year), physician visits (up



to 4 visits per calendar year) and



coordination of care).







Bariatric surgery may be covered to treat morbid
$1,000 copay then
$1,000 copay then
$1,000 copay then
obesity. To learn more about Turning Point, call
10% after deductible
30% after deductible
30% after deductible
1 (800) 856-8543.

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Prescription Medication Benefits
A nationwide network of Participating Pharmacies is available to you. Pharmacies that participate in this network submit
claims electronically. You can find a list of Participating Pharmacies at the Claims Administrator Website,
www.RegenceRx.com or www.myRegence.com. (From there, select, "My Navigator," then "Provider Search," then
"Advanced Search.").
Individual deductible per calendar year
N/A
Individual maximum coinsurance per
$2,500 (calculated separately from your medical maximum coinsurance)
calendar year
Important note: You are not responsible for any applicable deductible, copayment and/or coinsurance when you fill
prescriptions at a Participating Pharmacy, for specific strengths or quantities of medications that are specifically designated
as preventive medications (including, but not limited to, aspirin, fluoride, iron and generic medications) or for immunizations.
The applicable deductible, copayment and/or coinsurance will apply when you fill these preventive medications and
immunizations at a Nonparticipating Pharmacy. You can find a list of such medications at www.myRegence.com. (From
there, select "My Navigator," then "Benefits," then "Preventive Care.")

Claimant
Claimant
Claimant
Covered Prescription Medication Services
Responsibility
Responsibility
Responsibility
(Per Claimant)
Non-Formulary
Generic
Formulary Brands
Brands
Prescription Medications From a Pharmacy

$5
$25
$50
34-day supply for each prescription
Injectable Medications From a Pharmacy or
Mail-Order Supplier
$5
$25
$50
30-day supply for each injectable medication
Medications From a Mail-Order Supplier

$10
$50
$100
90-day supply for each prescription
Self-Administrable Cancer Chemotherapy
Medication

$10
$50
$100
34-day supply for each prescription
Does not apply toward maximum coinsurance

Weight Management and Obesity Treatment - Turning Point Program
The Plan covers certain weight management services through a program called Turning Point. Turning Point coaches are
trained experts who will teach you the skills and give you the support you need to reach your weight loss, nutrition and
exercise goals. To learn more about Turning Point, call 1 (800) 856-8543.

Case Management
Receive one-on-one help and support in the event you have a serious or sudden illness or injury. An experienced,
compassionate case manager will serve as your personal advocate during a time when you need it most. Your case
manager is a licensed health care professional who will help you understand your treatment options, show you how to get the
most out of your available Plan benefits and work with your physician to support your treatment plan.
To learn more or to make a referral to case management, please call 1 (866) 543-5765.

Disease Management
Regence Disease Management is a support and education program for people with chronic conditions such as diabetes,
heart disease, asthma and/or depression. The Claims Administrator's nurses and behavioral health care coordinators
provide tailored educational materials, tools and other services to help you get on track with your care and stay there. They
can help you understand the care plan you've developed with your physician, and make smarter choices for better health.
To learn more, please call 1 (866) 543-5765.

Special Beginnings Program
Pregnancy is a time of planning and excitement, but it can also be a time of confusion and questions. Special Beginnings
can provide answers and assistance so that you can relax and enjoy those nine life-changing months.
This program offers expectant mothers access to a nurse 24 hours a day, 7 days a week, an informative maternity book or
DVD and educational materials tailored to their needs. To learn more call 1 (888) JOY-BABY (569-2229).

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Regence Health CoachSM
With the Regence Health Coach program, you can work one-on-one with a certified health coach who will help you set and
reach goals for a healthier life. The Claims Administrator's health coaches can help you set goals focusing on weight
management and nutrition, tobacco cessation, exercise and fitness, stress management, and improved sleep.
The Regence Health Coach program provides free health coaching by phone or e-mail and program materials to help you set
and track your goals. Participation is completely confidential. What do you have to lose? Call a Regence Health Coach
today at 1 (800) 856-8543.

Quit for Life(R) Tobacco Cessation Program
A separate tobacco cessation program offered through CIS for all eligible members. For details please go to
www.cisbenefits.org. (From there, select "Healthy Benefits & Wellness," then "Tobacco Free Program.")

(R)
BlueCard Program (Out of Area Services)
The BlueCard Program is a unique program that enables you to access hospitals and physicians when outside the four-state
area Regence serves (Idaho, Oregon, Utah and Washington), as well as receive care in 200 countries around the world.
Find a provider near you at www.bcbs.com or call 1 (800) 810-BLUE (2583).

General Exclusions
The Plan will not provide benefits for any of the following conditions, treatments, services, supplies or accommodations,
including any direct complications or consequences that arise from them. However, these exclusions will not apply with
regard to an otherwise covered service for: 1) an injury, if the injury results from an act of domestic violence or a medical
condition (including physical and mental) and regardless of whether such condition was diagnosed before the injury, as
required by federal law; 2) a preventive service as specified under the preventive care benefit; or 3) services and supplies
furnished in an emergency room for stabilization of a patient.

Medical Exclusions
Alternative Care including acupuncture, massage or massage therapy and the services of an acupuncturist, a massage
therapist and a naturopath.
Condition Caused By Active Participation in a War or Insurrection: The treatment of any condition caused by or arising
out of a Claimant's active participation in a war or insurrection.
Condition Incurred in or Aggravated During Performances in the Uniformed Services: The treatment of any Claimant's
condition that the Secretary of Veterans Affairs determines to have been incurred in, or aggravated during, performance of
service in the uniformed services of the United States.
Cosmetic/Reconstructive Services and Supplies except to treat a congenital anomaly for Claimants up to age 18, to
restore a physical bodily function lost as result of injury or illness or related to breast reconstruction following a medically
necessary mastectomy, to the extent required by law.
Counseling in the Absence of Illness
Custodial Care: Non-skilled care and helping with activities of daily living.
Dental Services except as specifically provided under the repair of teeth benefit, the Plan does not cover dental services
provided to prevent, diagnose or treat diseases or conditions of the teeth and adjacent supporting soft tissues, including
treatment that restores the function of teeth.
Expenses Before Coverage Begins or After Coverage Ends: Services and supplies incurred before your effective date
under the Plan or after your termination under the Plan, except as may be provided under the other continuation options of
the Plan.
Fees, Taxes, Interest: Charges for shipping and handling, postage, interest or finance charges that a provider might bill.
Foot Care (Routine): Routine foot care including treatment of corns and calluses and trimming of nails, except when
indicated for diabetic patients.
Government Programs: Benefits that are covered, or would be covered in the absence of this Plan, by any federal, state or
governmental program.
Growth Hormone Therapy except as provided under the prescription medication benefits.
Hearing Care except as specifically provided under the hearing aids benefit, the Plan does not cover hearing care, routine
hearing examinations, programs or treatment for hearing loss, including, but not limited to, hearing aids (externally worn or
surgically implanted) and the surgery and services necessary to implant them. This exclusion does not apply to cochlear
implants.
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Medical Exclusions
Infertility: Treatment of infertility, except to the extent covered services are required to diagnose such condition. Non-
covered treatment includes, but is not limited to, all assisted reproductive technologies (for example, in vitro fertilization,
artificial insemination, embryo transfer or other artificial means of conception) and fertility drugs and medications.
Investigational Services: Investigational treatment or procedures (health interventions) and services, supplies and
accommodations provided in connection with investigational treatments or procedures.
Mental Health Treatment For Certain Conditions including diagnostic codes 302 through 302.9 found in the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders for all ages. Additionally, the Plan will not cover any "V
code" diagnoses except the following when medically necessary: parent-child relational problems for children five years of
age or younger, neglect or abuse of a child for children five years of age or younger and bereavement for children five years
of age or younger.
Motor Vehicle Coverage and Other Insurance Liability
Non-Direct Patient Care including appointments scheduled and not kept, charges for preparing or duplicating medical
reports and chart notes, itemized bills or claim forms and visits or consultations that are not in person, including telephone
consultations and email exchanges.
Non-Duplication of Medicare: When, by law, this coverage would not be primary to Medicare had you properly enrolled in
Medicare when first eligible, benefits will be reduced to the extent that those benefits are or would have been provided by any
part of Medicare, regardless of whether or not you choose to accept those benefits.
Obesity or Weight Reduction/Control: Except as may be specifically provided in the Plan benefits under the Turning Point
program, the Plan does not cover medical treatment, medication, surgical treatment (including reversals), programs or
supplies that are intended to result in or relate to weight reduction, regardless of diagnosis or psychological conditions.
Orthognathic Surgery: Orthognathic surgery means surgery to manipulate facial bones, including the jaw, in patients with
facial bone abnormalities resulting from abnormal development to restore the proper anatomic and functional relationship of
the facial bones. This exclusion does not apply to orthognathic surgery due to a temporomandibular joint disorder, injury,
sleep apnea or congenital anomaly.
Over the Counter Contraceptives including supplies and oral contraceptives (coverage for these services may be provided
under the prescription medication benefit).
Personal Comfort Items: Items that are primarily for comfort, convenience, cosmetics, environmental control or education.
Physical Exercise Programs and Equipment including hot tubs or membership fees at spas, health clubs or other such
facilities; applies even if the program, equipment or membership is recommended by the Claimant's provider.
Private Duty Nursing including ongoing shift care in the home.
Reversals of Sterilizations including services and supplies related to reversals of sterilization.
Riot, Rebellion and Illegal Acts: Services and supplies for treatment of an illness, injury or condition caused by a
Claimant's voluntary participation in a riot, armed invasion or aggression, insurrection or rebellion or sustained by a Claimant
arising directly from an act deemed illegal by an officer or a court of law.
Self-Help, Self-Care, Training or Instructional Programs including diet and weight monitoring services, childbirth-related
classes including infant care and breast feeding classes, instruction programs including those to learn how to stop smoking
and programs that teach a person how to use durable medical equipment or how to care for a family member, except as
specifically provided under the Plan.
Services and Supplies Provided by a Member of Your Family
Services and Supplies That Are Not Medically Necessary
Sexual Dysfunction: Services and supplies including medications for or in connection with sexual dysfunction regardless of
cause, except for counseling services provided by covered, licensed mental health practitioners when mental health services
are covered benefits under the Plan.
Sexual Reassignment Treatment and Surgery: Treatment, surgery or counseling services for sexual reassignment.
Third-Party Liability: Services and supplies for treatment of illness or injury for which a third party is or may be responsible.
Tobacco Addiction Treatment: The Plan does not cover treatment of tobacco addiction and supportive items for addiction
to tobacco, tobacco products or nicotine substitutes. However, a separate tobacco cessation program is offered through CIS
for all eligible members. Details at www.cisbenefits.org. (From there, select "Healthy Benefits & Wellness," then "Tobacco
Free Program.")
Travel and Transportation Expenses other than covered ambulance services.
Vision Care: Routine eye exam and vision hardware. Visual therapy, training and eye exercises, vision orthoptics, surgical
procedures to correct refractive errors/astigmatism, reversal or revisions of surgical procedures which alter the refractive
character of the eye. Your employer may provide vision care through VSP. Please check with your benefits department.
Work-Related Conditions: Expenses for services and supplies incurred as a result of any work-related injury or illness,
including any claims that are resolved related to a disputed claim settlement. The only exception is if a Participant is exempt
from state or federal workers' compensation law.

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Prescription Medication Exclusions
Acne Medication for the treatment of acne in Claimants over age 39.
Biological Sera, Blood or Blood Plasma
Cosmetic Purposes: Prescription medications used for cosmetic purposes including, removal, inhibition or stimulation of
hair growth, retardation of aging or repair of sun-damaged skin.
Devices or Appliances (coverage for devices and appliances may otherwise be provided under the medical benefit).
However, glucometers, needles, syringes, testing supplies, lancets and serum used for treatment of diabetes are covered.
Foreign Prescription Medications except those associated with an emergency medical condition while you are traveling
outside the United States, or those you purchase while residing outside the United States.
Growth Hormones unless they are preauthorized under the Plan.
Inhibition and/or Suppression of Sleepiness: Prescription medications used to inhibit and/or suppress drowsiness,
sleepiness, tiredness or exhaustion, unless they are preauthorized under the Plan.
Insulin Pumps and Pump Administration Supplies (coverage for insulin pumps and supplies is provided under the
medical benefit).
Medications That Are Not Considered Self-Administrable (coverage for these medications may otherwise be provided
under the medical benefit).
Nonprescription Medications: Medications that by law do not require a prescription order.
Onychomycosis: Prescription medications for the treatment of onychomycosis (nail fungus), unless they are preauthorized
under the Plan.
Prescription Medications Dispensed in a Facility: Prescription medications dispensed to you while you are a patient in a
hospital, skilled nursing facility, nursing home or other health care institution.
Prescription Medications Dispensed in Connection with Participation in a Clinical Trial
Prescription Medications For Treatment of Infertility
Prescription Medications for Treatment of Tobacco Addiction: A separate tobacco cessation program is offered through
CIS for all eligible members. Details at www.cisbenefits.org. (From there, select "Healthy Benefits & Wellness," then
"Tobacco Free Program.")
Prescription Medications Not Dispensed by a Pharmacy Pursuant to a Prescription Order
Prescription Medications Not within a Provider's License: Prescription medications prescribed by providers who are not
licensed to prescribe medications (or that particular medication) or who have a restricted professional practice license.
Prescription Medications With No FDA Proven Therapeutic Indication
Prescription Medications Without Examination: Prescriptions made by a provider without recent and relevant in-person
examination of the patient, whether the prescription order is provided by mail, telephone, internet or some other means.
Professional Charges for Administration of Any Medication

Please Note: Your health coverage is insured by CIS, but administered by Regence BlueCross BlueShield of Oregon. This
means that CIS, not Regence BlueCross BlueShield of Oregon, pays for your covered medical services and supplies.
This benefit summary provides a brief description of your health care plan benefits and is not a guarantee of payment.
Please refer to your plan booklet for a complete list of benefits and the limitations and exclusions that apply. Your plan
booklet can be viewed online at the Regence Website, www.myRegence.com. (From there, select "My Navigator", then
"Benefits", then "Benefit Booklet.")




Regence BlueCross BlueShield of Oregon is an Independent
Licensee of the Blue Cross and Blue Shield Association
Contact Customer Service at 1 (866) 240-9580
Or write to us at
100 SW Market Street, Portland, OR 97207
www.regence.com www.myRegence.com
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