Regence Member Resource Guide

Transcription

1
This guide will help you find answers to commonly asked questions. If you
are viewing it electronically, you may go to any of the websites listed by
simply clicking on the address.
step 1
how to find your benefit info
Most of what you’ll need you’ll find on myRegence.com
If you’re new to myRegence.com:
1. Go to myRegence.com (have your Regence member card handy).
2. Click Register Now.
3. Enter your member number, which you’ll find on the front of your
member card.
4. Create a user name and password.
Once you’re on myRegence.com, you will be able to find answers to your
benefit questions, including details on your pharmacy benefit, finding a
doctor or hospital, how to file a claim, and much more.
To find details about your benefits on myRegence.com, follow this path:
My Navigator > My Account > View My Coverage > Benefit Booklet.
If you don’t have Internet access or need a hard copy of your benefits
booklet, give us a call at 1 (888) 367-2119.
2
Thisguidewillhelpyoufindanswerstocommonlyaskedquestions.Ifyou
areviewingitelectronically,youmaygotoanyofthewebsiteslistedby
simplyclickingontheaddress.
step 1
HOW TO FIND YOUR BENEFIT INFO
Mostofwhatyou’llneedyou’llfindonmyRegence.com
Ifyou’renewtomyRegence.com:
1.GotomyRegence.com(haveyourRegencemembercardhandy).
2.ClickRegister Now.
3.Enteryourmembernumber,whichyou’llfindonthefrontofyour
membercard.
4.Createausernameandpassword.
Onceyou’reonmyRegence.com,youwillbeabletofindanswerstoyour
benefitquestions,includingdetailsonyourpharmacybenefit,findinga
doctororhospital,howtofileaclaim,andmuchmore.
TofinddetailsaboutyourbenefitsonmyRegence.com,followthispath:
My Navigator > My Account > View My Coverage > Benefit Booklet.
Ifyoudon’thaveInternetaccessorneedahardcopyofyourbenefits
booklet,giveusacallat1(888)367-2119.
2
step 2
finding your providers
While your plan is built on a specific provider network, you have a choice of
provider (doctors, hospitals, clinics, etc.). All providers set their own fees for
their services. We negotiate lower fees (called allowed amounts) with many of
them. While most providers accept these allowed amounts, some don’t.
• Find a provider by following this path on myRegence.com: My Navigator >
Provider Search.
• Search by name and location or other available search fields.
• The search results will give you useful information about network providers,
including specialty, location, education, board certifications, subspecialties
and languages spoken.
If you are on a Regence Innova® plan
Preferred ValueCare (PVC) is your Category 1 provider network. When you
choose a provider in Category 1 (indicated by a $ symbol) or Category 2 ($$),
they accept our allowed amounts as payment in full—after your deductible
and/or coinsurance—and your out-of-pocket costs will be lower. When you
choose a provider in Category 3 (NP) ($$$), you may be billed for any balance
over the allowed amount.
If you are on a BluePoint or Regence HSA Healthplan3.0SM plan
Your plan will be based on one of the following provider networks: Preferred
Focal Point (PFP), Preferred ValueCare (PVC) or Participating (PAR). There are
two levels of benefits—in-network and out-of-network. If you visit a provider
in your network, your treatments and services will be covered at the highest
benefit level, and your out-of-pocket costs will be lowest. If you visit an out-ofnetwork (NP) provider, your out-of-pocket costs may be significantly higher. Reading your member card
In the upper right corner of your member card, you will find benefit and
network descriptors that will assist you in understanding which providers may
be seen for the best benefit.
Innova
BluePoint or HSA 3.0
PVC/PAR/NP
Network/NP
BlueCard coverage goes with you
With the BlueCard Program, you can see providers that are contracted with
their local Blue Cross and/or Blue Shield Plan anywhere in the country, as well
as contracted providers in 200 countries around the world.
For more information, call 1 (800) 810-BLUE (2583) or go to myRegence.com
and click: My Navigator > Provider Search > BlueCard Worldwide®.
3
step 3
understanding your
prescription coverage
Any covered prescription medication will fall into one of these three types:
• Generics ($)
• Brand-name formulary ($$)
• Brand-name non-formulary ($$$)
A formulary is a list of medications your plan covers. If a medication is
not on the formulary, your costs will be higher.
Your benefits for brand-name and generic medications
The amount you pay for prescription medications is determined by the
RegenceRx Maximum Allowable Cost policy. Please read this portion of
your benefit summary carefully to find out coverage details if choosing a
brand-name medication when a generic equivalent is available.
You’ll find the formulary for your plan on myRegence.com under
My Navigator > My Account > Benefit Booklet. You can find additional
information at regenceRx.com.
Postal Prescription Services (PPS) and Walgreens Mail Service offer mail
order for many prescriptions. Follow the path My Navigator > Forms >
Prescription Medication Claim Form > RegenceRx Member website.
Download or print the Prescription Medication Mail Order Forms.
4
step 4
how to file a claim
Most providers will bill us on your behalf. But if you need to request
reimbursement for services you paid for out of your pocket (such as when
you see a provider in Category 3), use the claim form you’ll find on
myRegence.com at My Navigator > Forms > Claims.
Send claim forms and original receipts to:
Regence BlueCross BlueShield of Utah
P.O. Box 30272
Salt Lake City, UT 84130-30272
5
Contact Information and Resources
Customer
Service
Hours
Services
Toll free number
Web Sites
RegenceRx
www.myRegence.com
A trusted advisor that can offer members reliable
advice, help them navigate the health care system
and help them live healthier lives.
View your claims and personal account information
• Compare hospital, procedure costs, and quality
based on your personal needs
• Use the interactive health and medical
encyclopedia
• Join the conversation: open forums allow
members to interact with health care experts
and with each other
• Online wellness programs
www.ut.regence.com
The Regence Web site provides links to the following
features for members under “Why Us”:
• Find a Provider
• Member Advantages (discounted products
and services) – including vision, hearing,
local gym memberships, weight loss programs
and child health and safety products
• Member Resources – myRegence.com,
member forms, member notices and links to
Regence Advantages discount services
www.regenceRx.com
As a member you will have access to a network of
more than 50,000 pharmacies nationwide, including
two mail-order options, tools and information to help
you and your doctor discuss medication choices, call
center support and more.
These tools include:
• Nationwide pharmacy directory
• Learn about medications
• How your Rx benefits work
• About generics
• Understanding health care costs
1 (800) 572-0316
Toll free number
BlueCard
Monday - Friday, 7:00 a.m. to 7:00 p.m. MT
Membership, eligibility, benefits, claims status,
locating providers, ordering new member cards,
questions and answers
1 (888) 367-2119
www.bluecares.com
Toll free number
Blue Cross and Blue Shield plans give you access to
doctors and hospitals almost everywhere, giving you
peace of mind that you’ll always find the care you
need.
1 (800) 810-BLUE (2583)
12/15/2011
6
3UHIHUUHG9DOXH&DUH1HWZRUN
URGENT CARE CENTERS
AFTER HOURS MEDICAL
476 N 900 W STE C
AMERICAN FORK
1126 E 12300 S
DRAPER
1550 N MAIN ST STE E
LAYTON
3451 S 5600 W STE F
SALT LAKE CITY
7998 S 1300 E
SANDY
10433 S REDWOOD RD
SOUTH JORDAN
BASIN CLINIC
379 N 500 W STE 1A
VERNAL
(801)501-0500
(801)545-0600
(801)614-9030
(801)957-0900
(801)255-2000
(801)501-0500
(435)789-1165
COPPERVIEW MEDICAL CENTER
3556 W 9800 S STE 101 (801)567-9780
SOUTH JORDAN
FIRSTMED EAST URGENT CARE
1950 E 7000 S
SALT LAKE CITY
(801)943-3300
FIRSTMED MURRAY URGENT CARE
5911 S FASHION BLVD
SALT LAKE CITY
(801)266-6483
FIRSTMED NORTH URGENT CARE
214 W 1500 S
BOUNTIFUL
(801)295-6483
FIRSTMED WEST URGENT CARE
8822 REDWOOD RD STE E122(801)256-0009
WEST JORDAN
IHC INSTACARE BOUNTIFUL
390 N MAIN ST
BOUNTIFUL
(801)292-6100
IHC INSTACARE CEDAR CITY
962 SAGE DR
CEDAR CITY
(435)865-3440
IHC INSTACARE HEREFORDSHIRE
1915 W 5950 S
ROY
(801)387-8100
IHC INSTACARE HIGHLAND
10968 N ALPINE HWY
HIGHLAND
(801)763-2900
IHC INSTACARE HOLLADAY
3934 S 2300 E
SALT LAKE CITY
(801)273-6777
IHC INSTACARE HURRICANE
75 N 2260 W
HURRICANE
(435)635-6550
IHC INSTACARE LAYTON
2075 N 1200 W
LAYTON
(801)779-6200
IHC INSTACARE LOGAN
412 N 200 E
LOGAN
(435)713-2710
IHC INSTACARE MEMORIAL
2000 S 900 E
SALT LAKE CITY
(801)464-7777
IHC INSTACARE MURRAY
196 E WINCHESTER ST (801)639-5500
SALT LAKE CITY
IHC INSTACARE NORTH OGDEN
2400 N WASHINGTON BLVD(801)387-8300
OGDEN
URGENT CARE CENTERS
Sorted by Name
IHC INSTACARE RIVER ROAD
577 S RIVER RD
ST GEORGE
(435)688-6000
IHC INSTACARE SANDY
9493 S 700 E
SANDY
(801)523-2483
IHC INSTACARE SARATOGA SPRINGS
354 W STATE ROAD 73 (801)766-4567
SARATOGA SPRINGS
IHC INSTACARE SOUTH OGDEN
975 CHAMBERS ST
OGDEN
(801)387-6200
IHC INSTACARE SOUTHRIDGE
3723 W 12600 S STE 150(801)285-4560
RIVERTON
IHC INSTACARE SPRINGVILLE
762 W 400 S
SPRINGVILLE
(801)489-3244
IHC INSTACARE SUNSET
1739 W SUNSET BLVD
ST GEORGE
(435)634-6000
IHC INSTACARE SYRACUSE
745 S 2000 W
SYRACUSE
(801)525-2400
IHC INSTACARE TAYLORSVILLE
3845 W 4700 S
SALT LAKE CITY
(801)840-2020
IHC INSTACARE TOOELE
777 N MAIN ST
TOOELE
(435)228-1200
IHC INSTACARE WEST JORDAN
2655 W 9000 S
WEST JORDAN
(801)256-6399
IHC NORTHERN UTAH KIDSCARE
390 N MAIN ST
(801)294-9933
BOUNTIFUL
2075 UNIVERSITY PARK BLVD(801)779-6200
LAYTON
4403 HARRISON BLVD STE 4633(801)387-4500
OGDEN
3723 W 12600 S STE 150(801)285-4561
RIVERTON
2000 S 900 E
(801)464-7788
SALT LAKE CITY
3845 W 4700 S STE 105 (801)840-2101
SALT LAKE CITY
9720 S 1300 E STE E100(801)501-9933
SANDY
2655 W 9000 S
(801)568-9933
WEST JORDAN
OGDEN CLINIC
1159 12TH ST
OGDEN
4650 HARRISON BLVD
OGDEN
(801)786-4000
(801)479-9870
RIVERWOODS URGENT CARE LLC
280 RIVER PARK DR STE 120(801)229-2011
PROVO
TRI CITY MEDICAL CLINIC
830 N 2000 W
PLEASANT GROVE
(801)756-3511
UUHC URGENT CARE
1525 W 2100 S
SALT LAKE CITY
(801)887-2400
WEE CARE PEDIATRICS
2084 N 1700 W STE A
LAYTON
(801)773-8644
IHC INSTACARE NORTH OREM
1975 N STATE ST
OREM
(801)714-5000
IHC INSTACARE PROVO
1134 N 500 W STE 102 (801)357-1770
PROVO
January 21, 2012
7
3
Preferred ValueCare Network
Utah Hospitals
Hospital
Alta View
American Fork
Ashley Regional Medical Center
Bear River Valley
Beaver Valley
Blue Mountain Hospital
Brigham City Community
Cache Valley Specialty
Castleview
Central Valley Medical Center
Davis Hospital and Medical Center
Delta Community Medical Center
Dixie Regional Medical: 400 East
Dixie Regional Medical: 1380 East
Fillmore Community Medical Center
Garfield Memorial
Gunnison Valley
Heber Valley Medical Center
Huntsman Cancer
Intermountain Medical
Jordan Valley Medical Center
Kane County
Lakeview
LDS
Logan Regional
McKay-Dee
Milford Valley
Moab Regional
Mountain View
Mountain West Medical Center
Ogden Regional
Orem Community
The Orthopedic Specialty (TOSH)
Park City Medical Center
Pioneer Valley
Primary Children's Medical Center
Riverton Hospital
Riverton Hospital Children's Unit
Salt Lake Regional Medical Center
San Juan County
Sanpete Valley
Sevier Valley Medical Center
St. Mark's
Timpanogos Regional
Uintah Basin Medical Center
University Medical Center
University Orthopedic Center
Utah Valley Regional Medical Center
Valley View Medical Center
8
Preferred ValueCare (PVC)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
W H AT YO U N E E D TO K N OW A B O U T
PREVENTIVE HEALTH CARE COVERAGE
What preventive services are covered?
Regence follows government guidelines to determine
which preventive services we cover1.
Wondering what preventive care services are covered
by your health plan? As you’re probably aware,
the federal health care reform law passed in 2010
requires insurers to include specific preventive care
services in their benefit plans. Regence supports that
initiative. In fact, Regence plans already provided benefits
for many preventive care services, as we have long
believed that preventive care and early detection
are key to the long-term health and well-being of our
members. This brochure explains preventive care
eligibility and shows which services are available to
you and the family members covered by your plan.
These guidelines are updated periodically to reflect
new scientific and medical advances. Additionally,
current services could be revised and subject to
different limitations; thus, benefits are subject to
change. New guidelines will be implemented within
one year of the recommendation’s publication.
You can learn more details about these services at
healthcare.gov, including recommended child and
adolescent immunization schedules.
Who’s eligible for these preventive services?
To be eligible for these preventive services, you must
first be covered by a current Regence policy.
What is the coinsurance/copay for these
preventive services?
The services listed in this brochure will be paid at 100%
(no deductibles, coinsurance or copays) when you
see preferred or participating providers (Category 1 or
Category 2) or in-network providers. Deductibles and/or
coinsurance may apply when you see other providers.
Benefits for the federally required preventive services:
•
is an Independent Licensee of the Blue Cross and Blue Shield Association
•
•
•
1
Are not required in “grandfathered” policies,
which are essentially policies that were in effect
on March 23, 2010, as long as few or no benefit
changes have been made to them (please note
that Regence has chosen to retain grandfathered
status for a very limited number of policies)
May be covered by grandfathered plans that have
chosen to include the benefit
May apply to retiree-only plans
Apply to Association plans at the Association’s
plan renewal date
To find out if you’re eligible for preventive
coverage, call the Customer Service number
on the back of your member card or go to the
“Contact Us” link at regence.com.
Evidence-based preventive guidelines are developed and validated by the following government entities:
United States Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
9
Suggested guidelines
Adult abdominal aortic aneurysm
Screening is covered once per lifetime for men age 65 and over if they have
ever smoked.
ü
Alcohol misuse
Screening and behavioral counseling intervention covered for adults
age 19 and older.
ü
ü
Anemia (iron deficiency)
Screening covered up to age 21, and pregnant women.
ü
ü
Bacteriuria (urinary tract infection)
Screening for asymptomatic pregnant women.
Children (0-17)
Health screenings, counseling and
services for:
Pregnant Women
Women
Men
Covered preventive services
ü
ü
ü
ü
ü
Blood pressure
Screening covered for adults age 18 and older.
Breast cancer
Screening for women age 40 and older and those at increased risk.
Mammograms only.
ü
Breast cancer chemoprevention
Counseling for women at increased risk.
ü
Breastfeeding equipment
Manual and electric breastfeeding pumps are covered when purchased or rented
from a licensed provider. Off-the-shelf pumps from a retail outlet are not covered.
Hospital-grade pumps are not covered. See Note 1.
ü
Breastfeeding - lactation support and
counseling
Lactation support and counseling are covered when provided by a
licensed provider.
ü
Breastfeeding supplies
Initial breastfeeding supplies provided with a breastfeeding pump. See Note 1.
ü
Cervical cancer
Screening for sexually active women.
ü
Chlamydia infection
Screening for infection.
ü
Cholesterol
Screening for men age 35 and older and men ages 20-35 who are at increased
risk for coronary heart disease. Screening for women age 45 and older and those
20-45 who are at increased risk for coronary heart disease.
ü
ü
Colorectal cancer
Screening for those age 50 and older, once every 5 years for a sigmoidoscopy and
every 10 years for a colonoscopy, fecal occult blood testing annually.
ü
ü
Congenital hypothyroidism
Screening for newborns.
Contraceptive education and training
Education and training on contraceptive methods. See Notes 1 and 2.
ü
ü
Contraceptive devices - implants, cervical caps, Generic contraceptive devices are covered. When no generic exists, a brand is
intrauterine devices (IUDs), diaphragms
covered. If a generic becomes available, the brand will no longer be covered under
Preventive Care.
Insertion of a device is covered under Preventive Care. Removal is covered at
regular plan benefits if a Family Planning benefit applies. See Notes 1 and 2.
ü
ü
ü
ü
ü
Depression screening
Screening during wellness exams.
ü
ü
Diabetes (Type 2)
Screening for adults with sustained high blood pressure.
ü
ü
Diabetes (Gestational)
Screening for pregnant women between 24 and 28 weeks of gestation and the
first pre-natal visit for pregnant women at high risk for diabetes. See Note 1.
Diet behavioral counseling
Counseling for adults with hyperlipidemia and other risk factors.
Genetic risk assessment and BRCA (breast
cancer susceptibility) mutation counseling
For women with family risk of breast and ovarian cancer.
Gonorrhea medication
Preventive medication for the eyes of newborns.
Gonorrhea screening
Screening for males up to age 21 and all females.
Hearing
One screening in the first year of life for newborns.
10
ü
ü
ü
ü
ü
ü
ü
ü
ü
Children (0-17)
Pregnant Women
Women
Men
ü
Hepatitis B
Screening for pregnant women.
HIV
Screening and counseling during wellness exams for sexually active women.
Screening during wellness exams for men, women and children at increased risk.
HPV
Screening for women from age 30, every 3 years. See Note 1.
ü
Interpersonal and domestic violence
Screening and counseling during wellness exams. See Note 1.
ü
Lead screening
Screening up to age 21.
Metabolic screening
Screening up to age 2 months.
Obesity
Screening and counseling for age 6 and older.
Oral health
Risk assessment for preschool children.
Osteoporosis
Screening for women age 65 and older and all women at increased risk.
Phenylketonuria (PKU)
Newborn screening for genetic disorders.
RH(D) incompatibility
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Sexually transmitted infection (STI)
Counseling during wellness exams.
Sickle cell
Screening for children up to 12 months old.
Sterilization
Sterilization is covered. See Notes 1 and 2.
Syphilis
Screening for those at increased risk and those up to age 21;
also includes pregnant women.
ü
ü
ü
Tobacco use
Counseling and interventions. Does not include programs or classes.
See also “Tobacco use” below.
ü
ü
ü
Tuberculosis
Skin test for children.
ü
Vision
Screening for children age 3 up to age 5.
ü
ü
ü
ü
Immunization vaccines please consult your physician
for frequency
ü
Diphtheria, pertussis, tetanus (DPT)
ü
ü
ü
Haemophilus influenzae type b (Hib)
Hepatitis A
ü
ü
ü
ü
ü
ü
Herpes zoster (shingles)
Age 60 and older.
ü
ü
Human papillomavirus (HPV)
Up to age 27.
ü
ü
Hepatitis B
ü
ü
Inactivated poliovirus
Influenza
ü
ü
ü
Measles, mumps, rubella (MMR)
ü
ü
ü
Meningococcal
ü
ü
ü
Pneumococcal
ü
ü
ü
ü
Rotavirus
ü
Varicella
11
ü
ü
ü
Children (0-17)
Women
ü
Pregnant Women
Men
Prescription medications
Only the types of prescription medications listed below are covered under Preventive Care.
Medications require a prescription. Over-the-counter products are not covered.
Get the most value for your health care dollar with preferred medications. Learn more at regencerx.com/learn/covered.
Aspirin use for the prevention of
cardiovascular disease
For men age 45-79 and women age 55-79.
Contraceptive injectables
Generic contraceptive injectables. See Notes 1 and 2.
ü
ü
Contraceptive pills
Generic contraceptive pills. See Notes 1 and 2.
ü
ü
Contraceptive products-topical
Diaphragms and patches. See Notes 1, 2 and 3.
ü
ü
Emergency contraceptive products
Generic contraceptive pills. See Notes 1, 2 and 3.
ü
ü
Fluoride supplements
For children 6 months through age 6 without sufficient fluoride
Folic acid supplements
For all women planning or capable of pregnancy.
Iron supplements
For children age 6-12 months at increased risk - drops only.
Tobacco use
Generic tobacco cessation medications.
Wellness exams
Well-child exams
For children through 17 years of age.
Annual physical exams
Ages 18 and over.
ü
ü
ü
ü
Have questions? Call the Customer Service number on the back of
your member card or go to the “Contact Us” link at regence.com.
05394rep04976-ut / 09-12
©2012. Regence BlueCross BlueShield of Utah, all rights reserved.
12
ü
ü
ü
Notes:
1. This benefit is available upon renewal of your plan, on or after August 1, 2012.
2. This benefit may not be available to members of groups who have applied for a religious exemption from contraceptive coverage.
3. Generic contraceptives are covered. When no generic exists, a formulary brand is covered. If a generic becomes available,
the formulary brand will no longer be covered under Preventive Care.
ü
ü
Facing a health challenge?
YOUR PERSONAL CARE
T E A M
c a n
h e l p.
Integrated Care Management
When you’re dealing with a health challenge, a helping hand can make
all the difference. A Personal Care Team is ready to assist you with an
ongoing medical condition, or serious illness or injury. The program
provides easy access to one-on-one support at no extra cost to you.
This program is not insurance, but is offered in addition to your medical
plan to help you get information and support when you need it.
Specialized support in times of need
Imagine having a team of clinical health experts helping you manage a
complex or chronic medical condition. That’s what you’ll experience with
a Regence Personal Care Team.
Our specialists utilize a holistic approach. We’ll partner with you to develop
a customized care plan that supports your health goals and specific
challenges. You’ll communicate directly with a designated nurse, social
worker or care advocate. Behind the scenes you’ll be supported by a team
of experts. Together, we’ll work with you and your doctors to manage your
care. Teams can include certified case managers, pediatric and maternity
nurses, behavioral health clinicians, transplant specialists, and others who
understand you and what you’re facing.
The goal is to get you the right care at the right time and help you
achieve the best possible health.
Who uses Integrated Care Management services?
We provide support for a variety of medical concerns. Here are some real-life
examples of members who’ve been helped by a Personal Care Team:
• A pregnant mother who’s just found out she’s carrying triplets and feels
overwhelmed by the challenges facing her family
• An 84-year-old man whose leg wounds were infected with
antibiotic-resistant bacteria
• A 48-year-old man suffering from a lung disease who now receives
intravenous treatment in the comfort of his own home
• A 17-year-old student whose kidney transplant saved her life
13
What you can expect
A big-picture viewpoint of your
health can lead to targeted
interventions, extra support for
managing medications, custom
treatment plans and even
suggestions for lifestyle changes.
All of these can significantly
impact your overall health.
Expect your Personal Care Team to:
We know that addressing potential
health issues early on can mean
better health outcomes in the long
run. That’s why a care advocate
may reach out directly to you or
a family member if it appears you
could use some help.
Need help or want to learn more?
Call toll-free: 1 (866) 543-5765.
• Answer questions and provide
information about your condition,
illness or injury
• Be your advocate and help you
navigate the health care system
• Work with your doctors and
support your care plan
• Help you make informed
decisions based on all your
treatment options
• Make sure you’re getting the most
from your health care benefits
• Help you understand what
actions you can take to improve
your health
04615-ut / 09-11
© 2011. The Regence Group, all rights reserved.
14
Regence has
covered
Across the country and
a r o u n d t h e w o r l d.
The BlueCard® Program
With coverage from Regence, you take your health care benefits with you–
across the country and around the world. The BlueCard Program gives you
access to doctors and hospitals nearly everywhere, so you’ll have peace of
mind knowing that you can always find the health care provider you need.
Choices
Your Regence membership gives you a world of choices. Through the
BlueCard Worldwide® Program, you’re free to choose doctors and
hospitals that best suit you and your family in more than 200 countries
and territories around the world.
Designed to save money
In most cases, when you travel or live outside the Regence service
area, you can take advantage of savings the local Blue Plan has
negotiated with providers in the area where you are. For covered
services, you should not have to pay any amount above these
negotiated rates. You should also not have to pay amounts above
any applicable out-of-pocket expenses.
BlueCard Program Advantages
Provider choice
You have access to more than 85% of providers
and 96% of hospitals nationwide.
Benefit consistency
BlueCard ensures that you receive in-network
benefits when choosing participating providers of any
Blue Cross and/or Blue Shield Plan.
Billing protection
Accessing a Blue Cross and/or Blue Shield Plan
participating provider ensures that you are not
responsible for any balance billed amount.
Ease of access
It’s quick and easy to locate a participating provider
at regence.com or by calling (1-800-810-BLUE).
15
How it works
You see a provider
outside the Regence
service area
Participating provider
provides care for you
Local Blue Plan
pays provider
Local Blue Plan
prices the claim and
submits it to Regence
Processes the claim and
authorizes payment
Sends an explanation of
benefits to you
To learn more about the BlueCard
program, call your local Blue Plan
or visit regence.com.
BlueCard and BlueCard Worldwide are registered service marks of the
Blue Cross and Blue Shield Association.
03781-ut / 07-10
16
myRegence.com
Everything you’ve always wanted to know about your health. In one place.
Imagine a place where you can find answers and support for all of your health needs. myRegence.com is your
complete source of health and wellness information. And it’s simple to understand. So whether you want to get
started on an exercise program, need tips on eating healthier, or just want to know if we’ve paid your claim,
visit myRegence.com today.
Advise
Consider health care decisions, explore treatment options
and plan ahead for financial needs.
• Compare cost and quality of hospitals, clinics
and providers.
• Research treatment options and out-of-pocket
cost estimates.
• Learn about medical conditions, medications and
cost-saving generics.
• Explore and enjoy health articles, videos and podcasts.
Navigate
Discover tools that help you track your coverage
and make informed decisions about your
health care.
• Review details about your coverage.
• Manage your claims online and eliminate paper
Explanation of Benefits.
• Find a doctor or specialist and read patient
reviews—online or on your mobile device.
• Create a secure, confidential Personal Health Record.
• Discuss a variety of important health and wellness topics on My Community,
a nationwide social networking site.
Reward
Healthy living has its own rewards, but Regence Rewards
points can help.
• Earn points for browsing our health news, podcasts
and videos.
• Receive points for healthy everyday activities—such as
eating fruits and veggies and walking the dog, or joining
an online wellness program.
• Redeem points for an Amazon.com gift card.
®
®
17
myRegence.com
Want more value for your health care dollars? Log on to myRegence.com and discover
online resources and interactive experiences focused on your health. It’s easy to join and
you’ll earn 5,000 points with Regence Rewards just for registering.
Become an informed health care consumer.
Log on today and earn 5,000 points.
Simply use the information on your member card and follow these steps.
1. Go to myRegence.com.
2.Click New Member Registration.
3. Complete the required My Member Account Information fields. The name,
member and group numbers you enter must match your member card.
4. Create a user name and secure password.
5. Click Register and Login.
Take a confidential General Health Assessment. Earn up to 10,000 points.
Learn how you’ve been managing your health to date, and get practical tips on how to
improve your health and well-being.
Manage stress and get into shape. Earn 5,000 points at completion.
Reach for a healthy lifestyle with wellness programs on Weight Loss, Healthier Diet, Stress
Relief, Healthy Aging, going Smoke-Free and more.
Keep your health history at your fingertips. Earn up to 6,000 points.
Create a secure, confidential record of your medical history with the Personal
Health Record tool. Input your own information about allergies, immunizations, emergency
contacts and more.
Get social in My Community. Earn up to 2,400 points.
Join the conversation and earn points for posting in My Community—an online health and
wellness social networking site where members nationwide are talking, asking questions of
our experts, following bloggers and receiving support in achieving their goals.
What are you waiting for? Register now at myRegence.com!
®
®
05476rep05212-ut / 06-12
18
© 2012. Regence BlueCross BlueShield of Utah, all
rights reserved.
01363-or
/ 6-08
Quick Search
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19
Feeling good
d o e s n ’ t h a v e t o c o s t a l o t.
Regence Advantages
As a Regence member, you can enjoy savings on the following
health-related products and services. This discount program is offered
to all Regence members at no additional cost (although some
discounted programs offered by vendors may carry separate fees).
Regence Advantages is not insurance but is offered in addition to your
medical and/or dental plan(s) to help you stay healthy and live better.
• TruVision™: Significant discounts are offered on laser vision
correction procedures such as LASIK and PRK. Also, save 10% to 15%
on mail-order contact lenses.
• TruHearingTM: TruHearing™ offers deep discounts on state-of-the-art
digital hearing aids, and contracts with a national network of audiologists
and hearing instrument specialists to provide lower costs on expert
advice and service. It offers two programs to choose from—TruHearing
ValueAdd™ and TruHearing MemberPlus. Both include special health
plan-contracted pricing on hearing aids, one-time loss or damage
replacement for three years, a 45-day money back guarantee and
48 batteries per hearing aid purchased. Similar to warehouse
memberships, TruHearing MemberPlus saves you an additional $300 to
$1,100 on hearing aids for an annual membership fee of $108.
• QualSight®: Save 40% to 50% on traditional or custom LASIK through
the QualSight network. IntraLase bladeless LASIK is also available for
an additional $450 per eye.
• Epic® Dental: Purchase smile-protecting supplies at 25% off,
including mouthwash, gums, mints and toothpaste. All items contain
xylitol, a natural ingredient that fights cavities.
• CHP CAMaffinity Program: As a Regence member, you’re eligible
for the CHP CAMaffinity Program, which provides a 20% discount
on complementary and alternative medicine (CAM) services offered
through The CHP Group’s growing network of chiropractors,
acupuncturists, naturopathic physicians and massage therapists.
Regence is completely independent from the companies that provide these products and services.
Regence does not endorse or guarantee the products and services offered or their effectiveness.
Regence reserves the right to change the program at any time without prior notice.
20
• CHP Active and Healthy: CHP
Active and Healthy is the discount
program that gets you up,
moving, and saving money! With
discounts offered by thousands
of participating vendors (e.g.
health clubs, ski resorts, sporting
events, museums, etc.) for a small
annual fee, it’s your source for
great deals on healthy and
fun activities.
• Banfield® Pet Hospital: As a
Regence member, you receive
a waived enrollment fee for
Banfield Pet Hospital’s Optimum
Wellness Plans®, packages of
preventive care that include
annual blood work, vaccinations,
de-worming, unlimited office
visits, plus much more. Banfield is
the largest veterinary hospital in
the world with 800 hospitals
in 43 states; most located inside
PetSmartTM. Learn more
at banfield.com/regence.
• Take Shape for Life®: This
safe weight management
and health program uses
clinically proven Medifast®
products and a personal health
coach to provide one-on-one
guidance and encouragement.
The program helps you lose
weight and manage disease
and health through nutritional
intervention, free access to
health care professionals,
educational materials, and
healthy habits that last a lifetime.
There are no hidden costs or
start-up fees. Learn more at
stayhealthy4ever.com. Special
savings for Regence members:
––$25 special credit on your
first order
––Additional $25 to $50 off
first month’s order for the
progressive “BeSlim” savings
plan: 5% to 10% off monthly
order and free shipping
(minimum order required)
––Free “The Secret is Out” book
––Redeemable rewards points
• CorCell® Saving Baby’s Cord
Blood®: Cord blood stem cells
are now being used to treat more
than 70 diseases, and research
is ongoing to find treatments
for even more. Regence has
partnered with CorCell to offer
a $350 discount when you bank
your baby’s umbilical cord blood.
Protect your child or give the gift
of cord blood preservation to
your grandchild, niece, nephew,
friend or other loved one. Visit
corcell.com for more information.
• HearPO®: Receive a 40%
discount on diagnostic services,
including hearing exams, and
significant savings on hearing
aids. You’ll enjoy a 60-day no-risk
trial period; one-year followup care; a three-year warranty,
including coverage for loss and
damage; and free batteries
(160 cells per hearing aid)—all
with a lowest-price guarantee.
• Everest, The First Nationwide
Funeral Planning and Concierge
Service: Save $50 off the
enrollment fee for Everest’s suite
of funeral-planning services. With
advisors available 24 hours a
day, you’ll get the information you
need to make informed decisions
about all funeral-related issues,
within your budget, and with a
funeral home of your choice.
* Plus the cost of food. Plus the cost of shipping, if applicable. Offer applies to initial membership
fee only and is valid at participating centres in the United States, Canada and Puerto Rico and
through Jenny Craig At Home. Each offer is a separate offer and can be used only once per
person. Restrictions apply.
**Discounts through HearPO (also includes extended family), TruHearing and Beltone are
available to members and their parents and grandparents.
05270 rep 04957-ut / 05-12
© 2012. Regence BlueCross BlueShield of Utah, all rights reserved.
21
• EyeMed Vision Care®: Save 35%
on a complete pair of glasses
(frames and lenses). Save 15%
on non-disposable contacts
and $10 on contact lens fittings.
These discounts are available at
leading retailers and many private
practice locations.
• Jenny®: Jenny Craig plans are
personalized and offer one-on-one
support from trained weight-loss
consultants. With every Jenny Craig
Program you’ll receive weekly
scheduled consultations, planned
or personalized menus, and free
online support at jennycraig.com.
Choose from two special offers:
––A Free 30-day Program*
––25% off a Premium Program*
• Beltone™**: Receive a free
screening, a 25% discount
on Beltone hearing aids, a
one-year supply of hearing-aid
batteries and free follow-up
visits and testing.
• Safe Beginnings®: Save 15% on
Safe Beginnings products, including
safety gates, cabinet locks, outlet
covers, window guards, and many
other baby-proofing products.
Want to learn more?
Go to myRegence.com/advantages
or regence.com/advantages
Get round-the-clock
answers from a
registered nurse.
CareEnhance®
Get the right care at the right time
If you have a question, don’t know how to treat a health condition or
are unsure about what kind of care you need, a free call to a registered
nurse can get you on the right track. CareEnhance is not insurance but
is offered in addition to your medical plan to help you get information
when you need it.
A CareEnhance nurse will:
• Ask about your symptoms
• Direct you to an emergency room when necessary
• Help you decide if you should see a doctor
• Provide helpful self-care suggestions
• Even call back to see how you’re feeling
When should you call?
Call anytime day or night when:
• You or a family member is sick, hurt or needs health care advice
• You’re not sure whether to go to the emergency room, make a doctor’s
appointment or treat your problem at home
CareEnhance nurses:
• Have an average of 15 years of hands-on clinical experience
• Are supported by doctors and the most advanced information systems
• Are able to assess your symptoms and help you decide on the best
level of care
94% of CareEnhance callers are satisfied
with their experience.
22
Some examples of health problems we can help with:
• Vomiting, nausea or upset stomach
• Cuts, minor burns, scrapes
• Colds, viruses, coughing
• Dizziness and headaches
• Sore throats or flu
• Back pain
• Crying or hot baby
• Just feeling bad, but you don’t know why
Also try our Audio Health Library®
CareEnhance also gives you access to general health information. When
you call, you can visit the Audio Health Library directory and listen to
recorded messages on a variety of health topics. If you have questions
about information provided through this service, contact your physician.
If you believe your condition is life- or limb-threatening, call 911.
If you’re not sure whether you should take care of a problem at home,
contact your doctor or go to the ER, then call a CareEnhance nurse at
1 (800) 267-6729. Registered nurses are there 24 hours a day to help
you make informed decisions about your health.
04004-ut / 06-11
23
Find your way
around your Rx plan
i n a f l a s h.
A quick guide to your RegenceRx® prescription program
Here’s a quick reference sheet to help you better understand your
prescription benefits and find the Rx information you need. It’s one more
tool you can use to navigate the health care system and make informed
decisions about your care. Check it out!
With more than 65,000 pharmacies in our network, it’s easy to find
one near you.
Using your Rx benefits
Simply present your Regence member card at the pharmacy, and the
pharmacist will submit your claim online. The system will calculate the claim
cost based on your pharmacy benefit, then the pharmacist will tell you how
much you owe.
Your member card
Take a minute to look at your member card. It verifies that you have
prescription coverage and gives our participating pharmacies everything
they need in order to submit your claim online. If you have questions, just
call us at the phone number on the back of your card.
Your deductible and copay
If you have a plan with a pharmacy deductible, then you’ll pay for
each covered prescription in full until you’ve met your deductible.
(The pharmacist will still submit your claim as usual so that your purchase
counts toward your deductible.) After you meet your deductible, then you’ll
simply pay your portion of the cost (copay/coinsurance).
If you have a plan with a copay only (no deductible), then you’ll just pay that
amount for each covered prescription medication when you pick it up.
You’ll find your prescription deductible and copay amounts summarized in
your benefits booklet on myRegence.com.
24
Generics: another way to save
You’ll save money by using generic medications
whenever possible. If the medication you need is not
available in generic form, ask your doctor if another
generic can be used to treat the same condition, or if
there is a less expensive brand-name medication. Your
doctor is the best person to determine the medication
that’s right for you.
Filing claims and getting reimbursed
The pharmacist will file your claim for you, and we’ll
pay the pharmacy directly, so you won’t have to worry
about paperwork or getting reimbursed. In the rare
event that you do need to file a claim, we make it
painless. Just go to regenceRx.com to download the
proper claim form, or give us a call at the number on
the back of your member card.
Prior authorization and our Generics First policy
Some brand-name medications require prior
authorization to ensure they’re covered, such as
antidepressant, diabetes, pain, heartburn and
cholesterol medications. Go to regenceRx.com and
click on “Prior Auth/Medication Quantities” in the
“Learn About Medications” section for a list of
medications needing prior authorization.
If you misplace your member card, we’ll replace
it. Just call us toll-free at 1 (888) 367-2119 or
visit myRegence.com.
Explore regenceRx.com: a site devoted to
your Rx benefits
Visit regenceRx.com for information specifically
related to your RegenceRx prescription benefit.
Use it to:
• Find a participating pharmacy
• Access our formulary
• Learn about your medication choices
• Preview medications to learn if they require
prior authorization, or if they have any limitations
or restrictions
• Print out a prescription claim form
If you take one of these medications or keep one on
hand to use as needed, then you’ll need to do one
of two things in order to be sure your medication will
continue to be covered:
1.Try a generic first! Switch to a generic version of
the brand-name medication you are taking. Just
ask your pharmacist to fill your prescription with
the generic rather than the brand-name.
Go to myRegence.com to make the most
of all your benefits
To discover all the advantages of your Regence
membership beyond prescriptions, go to
myRegence.com. There you can view and manage
details related to your medical and prescription
coverage, explore events and rewards for healthy
living, and plan ahead using our Health Cost Estimators.
or
2.Get prior authorization for that brand-name
medication. The brand-name medication might be
denied if it hasn’t been approved ahead of time.
Ask your doctor or pharmacist to send a prior
authorization request with your medical or
medication history before your next refill. Your
pharmacist may fax your prescription profile
to 1 (888) 437-1510 or call 1 (800) 572-0316.
Maximize your benefit: Always
show your member card to the
pharmacy where you purchase
your prescriptions.
05219rep03460-ut / 04-12
25
Non-Preferred/Non-Formulary Brands:
Generic and Preferred Brand Alternatives
Effective April 1, 2012
This list can be used to assist you and your doctor in choosing a generic or preferred/formulary alternative.
• Generic medications are listed in lower case bold. Example: fluconazole.
• Non-preferred/non-formulary brands are listed in parenthesis only as a reference for generically available medications.
• This is a partial list. New or rarely used medications may not be listed. • Other, less-expensive options may be available over the counter (OTC) without a prescription. OTC products generally are not a covered prescription benefit.
Additional Information:
- Preferred/formulary medications are limited to the dosage form and strength listed; if no strength is listed,
all strengths for the listed dosage form are preferred/formulary. - Sustained action/release (SA/SR), extended release (ER/XR), long-acting (LA), and enteric coated (EC)
medications are only preferred/formulary if listed. - Occasionally, preferred/formulary medications may be contract exclusions and, therefore, are not covered. - Some medications may require prior authorization or have quantity limits. Please note that the PML/formulary list may change. To view the most current list, visit our Web site at www.
regencerx.com. For more detailed prescription benefit information, please refer to your benefits booklet. Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Generic and Preferred Brand
Alternatives
A
Acanya®
clindamycin gel + benzoyl peroxide gel
Accu-Chek® Bayer Breeze® 2 test strips, Bayer
Contour® test strips
Aceon®
benazepril (Lotensin®), enalapril
(Vasotec®), fosinopril, lisinopril (Zestril®,
Prinivil®), losartan (Cozaar®), moexipril
(Univasc®), quinapril (Accupril®),
trandolapril (Mavik®), Benicar®, Micardis®
Aciphex®
omeprazole (Prilosec®), pantoprazole
(Protonix®), Dexilant™
Activella®
estradiol (Estrace®) +
medroxyprogesterone (Provera®),
estradiol (Estrace®) + norethindrone
(Aygestin®), FemHRT®, Prempro®,
Premphase®
Adderall
amphetamine salt combo tablet
Adoxa
doxycycline (Vibramycin®)
Advicor®
simvastatin (Zocor®), pravastatin
(Pravachol®), lovastatin (Mevacor®),
Crestor® + Niaspan®
Aerobid® / M
Alvesco , Asmanex , Flovent Diskus ,
Flovent® HFA, Pulmicort®, QVAR®
®
®
®
®
®
Aggrenox
®
cilostazol (Pletal®), dipyridamole
(Persantine®) + aspirin (OTC),
ticlopidine, Plavix®
cromolyn ophthalmic solution,
ketorolac 0.5% ophthalmic solution
(Acular®), ketotifen fumarate
ophthalmic solution (Zaditor®), Alocril®,
Patanol®
Alamast®
Allegra-D
OTC loratadine, OTC Claritin-D®, OTC
Alavert-D™, fexofenadine (Allegra®) +
decongestant
Alomide®
ketotifen fumarate ophthalmic
solution (Zaditor®), Alocril®, Patanol®
Altabax®
mupirocin (Bactroban®)
Altace®
benazepril (Lotensin®), captopril,
enalapril (Vasotec®), fosinopril,
lisinopril (Zestril®, Prinivil®), moexipril
(Univasc®), quinapril (Accupril®),
trandolapril (Mavik®)
Ambien CR™
flurazepam, temazepam (Restoril®),
triazolam (Halcion®), zolpidem tartrate
(Ambien®)
®
®
Alternatives
©2012. RegenceRx. All Rights Reserved.
26
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
lactulose, polyethylene glycol/
electrolyte solution
cyclobenzaprine (Flexeril®)
Amitiza®
Amrix®
Avinza®
fentanyl transdermal (Duragesic®),
hydromorphone (Dilaudid®), morphine
SR (MS Contin®), morphine sulfate,
oxycodone, codeine sulfate
Axert®
sumatriptan (Imitrex®), Maxalt®,
Maxalt-MLT®, Relpax®
lisinopril (Zestril®, Prinivil®), losartan
(Cozaar®), moexipril (Univasc®),
quinapril (Accupril®), trandolapril
(Mavik®), Benicar™, Micardis®
Androderm®
testosterone cypionate (DepoTestosterone®), testosterone enanthate
(Delatestryl®)
Angeliq®
FemHrt®, Premphase®, Prempro®
Anzemet®
granisetron HCL (Kytril ),
metoclopramide (Reglan®),
ondansetron/ODT (Zofran®, Zofran
ODT®), prochlorperazine, promethazine
Azor®
Humalog®, Novolog®
Crixivan®, Invirase®, Lexiva®, Norvir®,
Reyataz®, Viracept®
B
®
Apidra®
Aptivus®
choline magnesium trisalicylate,
diclofenac, etodolac, meloxicam
(Mobic®), naproxen (Naprosyn®), salsalate
Arthrotec®
azelastine (Astelin®)
(Cozaar®), moexipril (Univasc ®),
(Mavik®), Benicar®, Micardis®
Astepro®
Atacand® Atacand HCT® benazepril/HCTZ (Lotensin HCT®),
captopril/HCTZ, enalapril/HCTZ
(Vaseretic®), fosinopril/HCTZ, lisinopril/
HCTZ (Zestoretic®), losartan/HCTZ
(Hyzaar®), moexipril/HCTZ (Uniretic®),
Benicar HCT™, Micardis HCT®
Augmentin XR
amoxicillin/clavulanate (Augmentin )
Avalide®
benazepril/HCTZ (Lotensin HCT®),
(Vasoretic®), fosinopril/HCTZ, lisinopril/
Benicar HCT™, Micardis HCT®
®
Avandamet
®
Avandia®
Avapro®
Bacitracin®
ophthalmic
neomycin/polymyxin/bacitracin,
neomycin/polymyxin/gramacidin
(Neosporin®)
Beconase AQ®
flunisolide, fluticasone propionate
(Flonase®), triamcinolone acetonide
(Nasacort® AQ)
Bepreve™
(Acular®), Alocril®, Pataday®, Patanol®
Betaseron®
Avonex®, Copaxone®, Rebif ®
B-D® test strips Bayer® test strips
Boniva
alendronate sodium (Fosamax®),
editronate disodium (Didronel®),
Actonel®, Evista®
®
Brevoxyl® benzoyl peroxide (Benzac®, Triaz®)
Brovana
C
Foradil®, Serevent Diskus®
®
®
glimepiride (Amaryl®), glipizide
(Glucotrol®), glyburide (Diabeta®),
metformin (Glucophage®)
glimepiride (Amaryl®), glipizide
(Glucotrol®), glyburide (Diabeta®),
benazapril (Lotensin®), captopril,
(Cozaar®), moexipril (Univasc ®),
Alternatives
Caduet®
diltiazem SR (Cardizem SR®),
verapamil SR (Calan SR®), nifedipine SA
(Adalat CC®), felodipine + simvastatin
(Zocor®), pravastatin (Pravachol®),
lovastatin (Mevacor®),
Crestor®
Campral®
disulfiram (Antabuse®), naltrexone
(ReVia®)
Celebrex®
diclofenac, etodolac, naproxen
(Naprosyn®), salsalate
Cenestin®
estradiol, estropipate, Enjuvia®
Cipro XR®
ciprofloxacin (Cipro®)
Clarinex®
OTC loratadine, OTC Claritin®, OTC
Alavert™
Climara Pro®
FemHRT®, Prempro®, Premphase®
27
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
clobetasol propionate (Temovate®),
betamethasone dipropionate
(Diprolene®)
Elidel®
Colazal®
sulfasalazine (Azulfidine Entabs®),
Asacol®, Dipentum®, Pentasa®
Enablex®
Entocort EC®
Combigan®
brimonidine tartrate (Alphagan P®) +
timolol maleate, dorzolamide/timolol
(Cosopt®)
Clobex
®
Alternatives
(Diprolene®), fluocinolone acetonide,
triamcinolone acetonide
oxybutynin (Ditropan®), oxybutynin
chloride ER (Ditropan XL®), Detrol LA®
prednisone, methylprednisolone
Epiduo®
clindamycin/benzoyl peroxide
(BenzaClin®), erythromycin base/
benzoyl peroxide (Benzamycin®), Detrol
LA®
Combipatch
FemHRT , Prempro , Premphase
Concerta®
methylphenidate ER (Ritalin SR®),
Metadate CD®, Adderall XR®
Estrace®
vaginal cream
estradiol, Premarin® vaginal cream,
Vagifem®
Cortef ®
prednisone, dexamethasone,
methylprednisolone (Medrol®)
Estring®
estradiol, Premarin® vaginal cream,
Vagifem®
Cymbalta®
bupropion SR (Wellbutrin SR®),
citalopram (Celexa®), fluoxetine
(Prozac®), paroxetine (Paxil®), sertraline
(Zoloft®)
Exalgo®
morphine SR (MS Contin®)
Exelderm®
clotrimazole, econazole, ketoconazole,
nystatin, OTC terbinafine
Exforge®
Exforge HCT®
quinapril/HCTZ (Accuretic®), Benicar
HCT®, Micardis HCT®
®
®
®
®
D
Daytrana®
Denavir®
Adderall XR®, Metadate CD®
acyclovir capsule (Zovirax®)
Detrol LA®, oxybutynin (Ditropan®),
oxybutynin chloride ER (Ditropan® XL)
Detrol
®
Diovan
®
Diovan HCT®
Doryx®
HCT™, Micardis HCT®
doxycycline hyclate (Vibramycin®)
F
Femring®
estradiol (Estrace®), Premarin® vaginal
cream
Fentora®
codeine sulfate, fentanyl citrate,
hydromorphone (Dilaudid®), morphine
sulfate, oxycodone
Finacea®
Azelex®
fluorometholone (Fluor-Op®),
prednisolone sodium acetate (Pred
Forte®), Alrex®
Duac CS®
benzoyl peroxide (Benzamycin®)
DynaCirc CR®
diltiazem SR (Cardizem SR ),
felodipine, isradipine (DynaCirc®),
nifedipine SA (Adalat CC®), verapamil
SR (Calan SR®)
Flarex®
Focalin®
Metadate CD®
estradiol, estradiol transdermal
(Estraderm®, Vivelle DOT®), estropipate,
Premarin® vaginal cream, Vagifem®
Focalin XR®
Adderall XR®, Metadate CD®
Foltx®
folic acid + Vitamin B12 + Vitamin B6
®
E
Elestrin®
Obtain from a designated Specialty Pharmacy.
+
2
28
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
Fortamet®
metformin (Glucophage®), metformin
ER (Glucophage® XR)
Lexapro
Fosamax Plus D™
alendronate sodium (Fosamax ) +
vitamin D (OTC)
citalopram (Celexa®), fluoxetine
(Prozac®), paroxetine (Paxil®), sertraline
(Zoloft®)
Lialda®
Freestyle® test
strips
sulfasalazine (Azulfidine® EN-tabs®),
Asacol®, Dipentum®, Pentasa®
Bayer® test strips
Frova®
G
Genotropin®+
®
®
Lidoderm®
Livalo®
Nutropin®+, Nutropin AQ®+, Omnitrope®+
Glyset®
glyburide (Diabeta®), glipizide
(Glucotrol®), metformin (Glucophage®)
Glumetza®
metformin (Glucophage®), metformin
ER (Glucophage® XR)
Gralise™
Lovaza®
amitriptyline, gabapentin (Neurontin®),
nortriptyline (Pamelor®)
Crestor®
fenofibrate, gemfibrozil (Lopid®),
lofibra, lovastatin (Mevacor®),
pravastatin (Pravachol®), simvastatin
(Zocor®)
gabapentin (Neurontin )
Lunesta®
(Ambien®)
polyethylene glycol/electrolyte
solution
calcitriol (Rocaltrol®)
Lybrel®
aviane*, enpresse*, lessina*, levora28*, lutera*, portia*, sronyx*, trivora-28*
M
Malarone®
hydroxychloroquine (Plaquenil®),
mefloquine, chloroquine (Aralen®)
Pegasys®, Peg-Intron®
Maxair®
ProAir® HFA, Ventolin® HFA
Innohep®
enoxaparin (Lovenox®), heparin sodium
pramipexole (Mirapex® )
Intuniv®
methylphenidate ER (Ritalin® SR),
Adderall XR™, Metadate® CD, Vyvanse®
Mirapex® ER
N
Invega™
clozapine (Clozaril ), haloperidol,
risperidone (Risperdal®), Seroquel®,
olanzapine (Zyprexa®), olanzapine ODT
(Zyprexa® Zydis®)
®
H
Half-Lytely®
Hectorol®
Humatrope®+
I
Infergen®
Namenda
®
®
Nasonex®
K
Natelle®
Kadian®
Ketek
®
Kineret®
Lescol®
Lescol XL®
Levaquin®
donepezil HCL (Aricept® ), galantamine
HBR (Razadyne™), rivastigmine tartrate
(Exelon®)
(Nasacort® AQ)
generic prenatal vitamins with
folic acid
codeine sulfate, fentanyl transdermal
(Duragesic®), hydromorphone
(Dilaudid®), morphine SR (MS Contin®),
morphine sulfate, oxycodone
Nexium®
Niravam®
amoxicillin/clavulanate (Augmentin®),
clarithromycin (Biaxin®), doxycycline
(Vibramycin®), azithromycin (Zithromax®)
alprazolam, clonazepam, diazepam,
lorazepam
Norditropin®+
Norditropin
Nordiflex®+
NuvaRing®
apri*, junel*, levora-28*, low-Ogestrel*,
mononessa*, necon*, portia*, sprintec*
methotrexate (Rheumatrex ),
leflunomide (Arava®), Enbrel®
®
L
+
Alternatives
O
Crestor®
Crestor®
ofloxacin, ciprofloxacin (Cipro®), Avelox®
2
29
O-Cal FA
folic acid
One-Touch® test
strips
Bayer Breeze® 2 test strips, Bayer
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
One-Touch® Ultra® Bayer Breeze® 2 test strips, Bayer
test strips
trospium (Sanctura®)
Sarafem®
fluoxetine (Prozac®)
methylphenidate ER, Metadate CD®,
Adderall XR®
Advair Diskus®, Advair® HFA
fluoxetine (Prozac)® + olanzapine
(Zyprexa®)
oxymorphone (Opana )
Serostim+
Oracea®
doxycycline (Periostat®, Vibramycin®),
minocycline (Minocin®), tetracycline
Strattera®
Ovcon-50®
aviane*, junel*, levora-28*, lessina*,
microgestin*, necon*, nortrel*, portia*,
sprintec*
Symbyax®
Oxistat®
clotrimazole, econazole, ketoconazole,
Oxycontin®
morphine SR (MS Contin®)
Oxytrol®
Detrol LA®, oxybutynin (Ditropan®),
oxybutynin chloride ER (Ditropan® XL)
®
Symbicort®
T
Tekturna®
lisinopril (Prinivil®, Zestril®), losartan
Tekturna HCT®
Teveten®
Helidac®, PrevPac®
Teveten HCT®
alfuzosin (Uroxatral®), doxazosin
(Cardura®), finasteride (Proscar®),
prazosin (Minipress®), terazosin
Eliphos™
Tev-Tropin+
Rhinocort Aqua
(Nasacort®AQ)
Treximet®
Ritalin LA
methylphenidate ER, Metadate CD
Tribenzor®
Tricor®
fenofibrate, gemfibrozil (Lopid®), lofibra
Tyzeka®
Baraclude™, Epivir® HBV, Hepsera®,
Intron A®, Pegasys®
P
Perforomist®
Precision QID®
Precision Xtra®
teststrips
Foradil®, Serevent®Diskus®
Bayer® test strips
Bayer® test strips
Prenate Elite®
generic prenatal vitamins
with folic acid
Prometrium
medroxyprogesterone (Provera )
Protopic®
(Diprolene®), fluocinolone acetonide,
Provigil®
amphetamine salt combo tablet,
dextroamphetamine (Dexedrine®),
®
®
Pylera®
R
Rapaflo®
Renagel®
®
®
Rosac®
Rozerem™
S
Saizen®
+
Sanctura® XR
Opana ER
®
Alternatives
®
Trans-Derm Scop® meclizine (Antivert®)
®
sulfacetamide sodium/sulfur (Plexion®),
benzoyl peroxide
(Ambien®)
Nutropin , Nutropin AQ , Omnitrope
®+
®+
®+
2
30
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
V
Alternatives
Valturna®
Ziana®
adapalene (Differin®), clindamycin
(Cleocin®), sulfacetamide sodium
(Klaron®), clindamycin/benzoyl
peroxide (BenzaClin®), erythromycin
base/benzoyl peroxide (Benzamycin®),
erythromycin gel, sulfacetamide
sodium (Klaron®), tretinoin (Retin A®),
Tazorac®
Veramyst®
(Nasacort® AQ)
Zomig®
sumatriptan (Imitrex®), Maxalt®, MaxaltMLT®, Relpax®
Verdeso®
desonide (DesOwen®), fluocinolone
acetonide, triamcinolone acetonide
Zomig-ZMT®
sumatriptan (Imitrex®), Maxalt®, MaxaltMLT®, Relpax®
Vesicare®
chloride ER (Ditropan® XL), Detrol LA®
Zorbtive®▼
Nutropin®▼, Nutropin AQ®▼, Omnitrope®▼
Vigamox®
ciprofloxacin (Ciloxan ), ofloxacin
(Ocuflox®)
Zovirax® ointment
acyclovir (Zovirax) tablet, capsule or
suspension, valacyclovir HCL (Valtrex®)
tablet
Zyflo®
Accolate®, Singulair®
Vimovo™
Zylet®
tobramycin/dexamethasone
ophthalmic suspension (TobraDex®)
Zyrtec®
Alavert™, fexofenadine (Allegra®)
®
Vusion
OTC miconazole nitrate cream
Vytorin®
Crestor®
®
W
Zyrtec-D
®
Welchol
®
X
Xalatan®
cholestyramine (Questran®),
colestipol HCL (Colestid®)
Travatan Z®, Lumigan®
Xibrom®
flurbiprofen (Ocufen®), ketorolac 0.4%
(Acular LS®), ketorolac 0.5% (Acular®)
Xifaxan
azithromycin (Zithromax®),
ciprofloxacin (Cipro®), metronidazole,
neomycin, ofloxacin
Xopenex®
concentrate,
solution
albuterol, levalbuterol (Xopenex®)
Xopenex HFA®
ProAir® HFA, Ventolin® HFA
®
OTC loratadine + decongestant
OTC Claritin-D®, OTC Alavert-D™,
fexodenadine (Allegra®) +
decongestant
Y
Z
Zetia
®
Crestor®
31
32
33
rev. 12/2009
34
35
36
37
38
39
step 2
FINDING YOUR PROVIDERS
Whileyourplanisbuiltonaspecificprovidernetwork,youhaveachoiceof
provider(doctors,hospitals,clinics,etc.).Allproviderssettheirownfeesfor
theirservices.Wenegotiatelowerfees(calledallowedamounts)withmanyof
them.Whilemostprovidersaccepttheseallowedamounts,somedon’t.
• FindaproviderbyfollowingthispathonmyRegence.com:My Navigator >
Provider Search.
• Searchbynameandlocationorotheravailablesearchfields.
• Thesearchresultswillgiveyouusefulinformationaboutnetworkproviders,
includingspecialty,location,education,boardcertifications,subspecialties
andlanguagesspoken.
If you are on a Regence Innova® plan
PreferredValueCare(PVC)isyourCategory1providernetwork.Whenyou
chooseaproviderinCategory1(indicatedbya$symbol)orCategory2($$),
theyacceptourallowedamountsaspaymentinfull—afteryourdeductible
and/orcoinsurance—andyourout-of-pocketcostswillbelower.Whenyou
chooseaproviderinCategory3(NP)($$$),youmaybebilledforanybalance
overtheallowedamount.
If you are on a BluePoint or Regence HSA Healthplan3.0SM plan
Yourplanwillbebasedononeofthefollowingprovidernetworks:Preferred
FocalPoint(PFP),PreferredValueCare(PVC)orParticipating(PAR).Thereare
twolevelsofbenefits—in-networkandout-of-network.Ifyouvisitaprovider
inyournetwork,yourtreatmentsandserviceswillbecoveredatthehighest
benefitlevel,andyourout-of-pocketcostswillbelowest.Ifyouvisitanout-ofnetwork(NP)provider,yourout-of-pocketcostsmaybesignificantlyhigher.
Reading your member card
Intheupperrightcornerofyourmembercard,youwillfindbenefitand
networkdescriptorsthatwillassistyouinunderstandingwhichprovidersmay
beseenforthebestbenefit.
Innova
BluePoint or HSA 3.0
PVC/PAR/NP
Network/NP
BlueCard coverage goes with you
WiththeBlueCardProgram,youcanseeprovidersthatarecontractedwith
theirlocalBlueCrossand/orBlueShieldPlananywhereinthecountry,aswell
ascontractedprovidersin200countriesaroundtheworld.
Formoreinformation,call1(800)810-BLUE(2583)orgotomyRegence.com
andclick:My Navigator > Provider Search > BlueCard Worldwide®.
3
step 3
UNDERSTANDING YOUR
PRESCRIPTION COVERAGE
Anycoveredprescriptionmedicationwillfallintooneofthesethreetypes:
• Generics($)
• Brand-nameformulary($$)
• Brand-namenon-formulary($$$)
Aformularyisalistofmedicationsyourplancovers.Ifamedicationis
notontheformulary,yourcostswillbehigher.
Your benefits for brand-name and generic medications
Theamountyoupayforprescriptionmedicationsisdeterminedbythe
RegenceRxMaximumAllowableCostpolicy.Pleasereadthisportionof
yourbenefitsummarycarefullytofindoutcoveragedetailsifchoosinga
brand-namemedicationwhenagenericequivalentisavailable.
You’llfindtheformularyforyourplanonmyRegence.comunder
My Navigator > My Account > Benefit Booklet.Youcanfindadditional
informationatregenceRx.com.
PostalPrescriptionServices(PPS)andWalgreensMailServiceoffermail
orderformanyprescriptions.FollowthepathMy Navigator > Forms >
Prescription Medication Claim Form > RegenceRx Member website.
DownloadorprintthePrescriptionMedicationMailOrderForms.
4
step 4
HOW TO FILE A CLAIM
Mostproviderswillbillusonyourbehalf.Butifyouneedtorequest
reimbursementforservicesyoupaidforoutofyourpocket(suchaswhen
youseeaproviderinCategory3),usetheclaimformyou’llfindon
myRegence.comatMy Navigator > Forms > Claims.
Sendclaimformsandoriginalreceiptsto:
RegenceBlueCrossBlueShieldofUtah
P.O.Box30272
SaltLakeCity,UT84130-30272
5
W H AT YO U N E E D TO K N OW A B O U T
PREVENTIVE HEALTH CARE COVERAGE
What preventive services are covered?
Regence follows government guidelines to determine
which preventive services we cover1.
Wondering what preventive care services are covered
by your health plan? As you’re probably aware,
the federal health care reform law passed in 2010
requires insurers to include specific preventive care
services in their benefit plans. Regence supports that
initiative. In fact, Regence plans already provided benefits
for many preventive care services, as we have long
believed that preventive care and early detection
are key to the long-term health and well-being of our
members. This brochure explains preventive care
eligibility and shows which services are available to
you and the family members covered by your plan.
These guidelines are updated periodically to reflect
new scientific and medical advances. Additionally,
current services could be revised and subject to
different limitations; thus, benefits are subject to
change. New guidelines will be implemented within
one year of the recommendation’s publication.
You can learn more details about these services at
healthcare.gov, including recommended child and
adolescent immunization schedules.
Who’s eligible for these preventive services?
To be eligible for these preventive services, you must
first be covered by a current Regence policy.
What is the coinsurance/copay for these
preventive services?
The services listed in this brochure will be paid at 100%
(no deductibles, coinsurance or copays) when you
see preferred or participating providers (Category 1 or
Category 2) or in-network providers. Deductibles and/or
coinsurance may apply when you see other providers.
Benefits for the federally required preventive services:
•
•
•
•
1
Arenotrequiredin“grandfathered”policies,
which are essentially policies that were in effect
on March 23, 2010, as long as few or no benefit
changes have been made to them (please note
that Regence has chosen to retain grandfathered
status for a very limited number of policies)
Maybecoveredbygrandfatheredplansthathave
chosen to include the benefit
Mayapplytoretiree-onlyplans
ApplytoAssociationplansattheAssociation’s
plan renewal date
To find out if you’re eligible for preventive
coverage, call the Customer Service number
on the back of your member card or go to the
“Contact Us” link at regence.com.
Evidence-based preventive guidelines are developed and validated by the following government entities:
United States Preventive Services Task Force (USPSTF), Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA).
9
Adult abdominal aortic aneurysm
Screening is covered once per lifetime for men age 65 and over if they have
ever smoked.
ü
Alcohol misuse
Screening and behavioral counseling intervention covered for adults
age 19 and older.
ü
ü
Anemia (iron deficiency)
Screening covered up to age 21, and pregnant women.
ü
ü
Bacteriuria (urinary tract infection)
Screening for asymptomatic pregnant women.
Children (0-17)
Health screenings, counseling and
services for:
Pregnant Women
Women
Men
ü
ü
ü
ü
ü
Blood pressure
Screening covered for adults age 18 and older.
Breast cancer
Screening for women age 40 and older and those at increased risk.
Mammograms only.
ü
Breast cancer chemoprevention
Counseling for women at increased risk.
ü
Breastfeeding equipment
Manual and electric breastfeeding pumps are covered when purchased or rented
from a licensed provider. Off-the-shelf pumps from a retail outlet are not covered.
Hospital-grade pumps are not covered. See Note 1.
ü
Breastfeeding - lactation support and
counseling
Lactation support and counseling are covered when provided by a
licensed provider.
ü
Breastfeeding supplies
Initial breastfeeding supplies provided with a breastfeeding pump. See Note 1.
ü
Cervical cancer
Screening for sexually active women.
ü
Chlamydia infection
Screening for infection.
ü
Cholesterol
Screening for men age 35 and older and men ages 20-35 who are at increased
risk for coronary heart disease. Screening for women age 45 and older and those
20-45 who are at increased risk for coronary heart disease.
ü
ü
Colorectal cancer
Screening for those age 50 and older, once every 5 years for a sigmoidoscopy and
every 10 years for a colonoscopy, fecal occult blood testing annually.
ü
ü
Congenital hypothyroidism
Screening for newborns.
Contraceptive education and training
Education and training on contraceptive methods. See Notes 1 and 2.
ü
ü
Contraceptive devices - implants, cervical caps, Generic contraceptive devices are covered. When no generic exists, a brand is
intrauterine devices (IUDs), diaphragms
covered. If a generic becomes available, the brand will no longer be covered under
Preventive Care.
Insertion of a device is covered under Preventive Care. Removal is covered at
regular plan benefits if a Family Planning benefit applies. See Notes 1 and 2.
ü
ü
ü
ü
ü
Depression screening
Screening during wellness exams.
ü
ü
Diabetes (Type 2)
Screening for adults with sustained high blood pressure.
ü
ü
Diabetes (Gestational)
Screening for pregnant women between 24 and 28 weeks of gestation and the
first pre-natal visit for pregnant women at high risk for diabetes. See Note 1.
Diet behavioral counseling
Counseling for adults with hyperlipidemia and other risk factors.
Genetic risk assessment and BRCA (breast
cancer susceptibility) mutation counseling
For women with family risk of breast and ovarian cancer.
Gonorrhea medication
Preventive medication for the eyes of newborns.
Gonorrhea screening
Screening for males up to age 21 and all females.
Hearing
One screening in the first year of life for newborns.
10
ü
ü
ü
ü
ü
ü
ü
ü
ü
Children (0-17)
Pregnant Women
Women
Men
ü
Hepatitis B
HIV
Screening and counseling during wellness exams for sexually active women.
Screening during wellness exams for men, women and children at increased risk.
HPV
Screening for women from age 30, every 3 years. See Note 1.
ü
Interpersonal and domestic violence
Screening and counseling during wellness exams. See Note 1.
ü
Lead screening
Screening up to age 21.
Metabolic screening
Screening up to age 2 months.
Obesity
Screening and counseling for age 6 and older.
Oral health
Risk assessment for preschool children.
Osteoporosis
Screening for women age 65 and older and all women at increased risk.
Phenylketonuria (PKU)
Newborn screening for genetic disorders.
RH(D) incompatibility
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
ü
Sexually transmitted infection (STI)
Counseling during wellness exams.
Sickle cell
Screening for children up to 12 months old.
Sterilization
Sterilization is covered. See Notes 1 and 2.
Syphilis
Screening for those at increased risk and those up to age 21;
also includes pregnant women.
ü
ü
ü
Tobacco use
Counseling and interventions. Does not include programs or classes.
See also “Tobacco use” below.
ü
ü
ü
Tuberculosis
Skin test for children.
ü
Vision
Screening for children age 3 up to age 5.
ü
ü
ü
ü
Immunization vaccines please consult your physician
for frequency
ü
Diphtheria, pertussis, tetanus (DPT)
ü
ü
ü
Haemophilus influenzae type b (Hib)
Hepatitis A
ü
ü
ü
ü
ü
ü
Herpes zoster (shingles)
Age 60 and older.
ü
ü
Human papillomavirus (HPV)
Up to age 27.
ü
ü
Hepatitis B
ü
ü
Inactivated poliovirus
Influenza
ü
ü
ü
Measles, mumps, rubella (MMR)
ü
ü
ü
Meningococcal
ü
ü
ü
Pneumococcal
ü
ü
ü
ü
Rotavirus
ü
Varicella
11
ü
ü
ü
Children (0-17)
Women
ü
Pregnant Women
Men
Prescription medications
Only the types of prescription medications listed below are covered under Preventive Care.
Medications require a prescription. Over-the-counter products are not covered.
Get the most value for your health care dollar with preferred medications. Learn more at regencerx.com/learn/covered.
Aspirin use for the prevention of
cardiovascular disease
For men age 45-79 and women age 55-79.
Contraceptive injectables
Generic contraceptive injectables. See Notes 1 and 2.
ü
ü
Contraceptive pills
Generic contraceptive pills. See Notes 1 and 2.
ü
ü
Contraceptive products-topical
Diaphragms and patches. See Notes 1, 2 and 3.
ü
ü
Emergency contraceptive products
Generic contraceptive pills. See Notes 1, 2 and 3.
ü
ü
Fluoride supplements
For children 6 months through age 6 without sufficient fluoride
Folic acid supplements
For all women planning or capable of pregnancy.
Iron supplements
For children age 6-12 months at increased risk - drops only.
Tobacco use
Generic tobacco cessation medications.
Wellness exams
Well-child exams
For children through 17 years of age.
Annual physical exams
Ages 18 and over.
ü
ü
ü
ü
Have questions? Call the Customer Service number on the back of
your member card or go to the “Contact Us” link at regence.com.
05394rep04976-ut / 09-12
©2012. Regence BlueCross BlueShield of Utah, all rights reserved.
12
ü
ü
ü
Notes:
1. This benefit is available upon renewal of your plan, on or after August 1, 2012.
2. This benefit may not be available to members of groups who have applied for a religious exemption from contraceptive coverage.
3. Generic contraceptives are covered. When no generic exists, a formulary brand is covered. If a generic becomes available,
the formulary brand will no longer be covered under Preventive Care.
ü
ü
Facing a health challenge?
YOUR PERSONAL CARE
T E A M
C A N
H E L P.
Integrated Care Management
When you’re dealing with a health challenge, a helping hand can make
all the difference. A Personal Care Team is ready to assist you with an
ongoing medical condition, or serious illness or injury. The program
provides easy access to one-on-one support at no extra cost to you.
This program is not insurance, but is offered in addition to your medical
plan to help you get information and support when you need it.
Specialized support in times of need
Imagine having a team of clinical health experts helping you manage a
complex or chronic medical condition. That’s what you’ll experience with
a Regence Personal Care Team.
Our specialists utilize a holistic approach. We’ll partner with you to develop
a customized care plan that supports your health goals and specific
challenges. You’ll communicate directly with a designated nurse, social
worker or care advocate. Behind the scenes you’ll be supported by a team
of experts. Together, we’ll work with you and your doctors to manage your
care. Teams can include certified case managers, pediatric and maternity
nurses, behavioral health clinicians, transplant specialists, and others who
understand you and what you’re facing.
The goal is to get you the right care at the right time and help you
achieve the best possible health.
Who uses Integrated Care Management services?
We provide support for a variety of medical concerns. Here are some real-life
examples of members who’ve been helped by a Personal Care Team:
• A pregnant mother who’s just found out she’s carrying triplets and feels
overwhelmed by the challenges facing her family
• An 84-year-old man whose leg wounds were infected with
antibiotic-resistant bacteria
• A 48-year-old man suffering from a lung disease who now receives
intravenous treatment in the comfort of his own home
• A 17-year-old student whose kidney transplant saved her life
13
What you can expect
A big-picture viewpoint of your
health can lead to targeted
interventions, extra support for
managing medications, custom
treatment plans and even
suggestions for lifestyle changes.
All of these can significantly
impact your overall health.
Expect your Personal Care Team to:
We know that addressing potential
health issues early on can mean
better health outcomes in the long
run. That’s why a care advocate
may reach out directly to you or
a family member if it appears you
could use some help.
Need help or want to learn more?
Call toll-free: 1 (866) 543-5765.
• Answer questions and provide
information about your condition,
illness or injury
• Be your advocate and help you
navigate the health care system
• Work with your doctors and
support your care plan
• Help you make informed
decisions based on all your
treatment options
• Make sure you’re getting the most
from your health care benefits
• Help you understand what
actions you can take to improve
your health
04615-ut / 09-11
14
Regence has
covered
ACROSS THE COUNTRY AND
A R O U N D T H E W O R L D.
The BlueCard® Program
With coverage from Regence, you take your health care benefits with you–
across the country and around the world. The BlueCard Program gives you
access to doctors and hospitals nearly everywhere, so you’ll have peace of
mind knowing that you can always find the health care provider you need.
Choices
Your Regence membership gives you a world of choices. Through the
BlueCard Worldwide® Program, you’re free to choose doctors and
hospitals that best suit you and your family in more than 200 countries
and territories around the world.
Designed to save money
In most cases, when you travel or live outside the Regence service
area, you can take advantage of savings the local Blue Plan has
negotiated with providers in the area where you are. For covered
services, you should not have to pay any amount above these
negotiated rates. You should also not have to pay amounts above
any applicable out-of-pocket expenses.
BlueCard Program Advantages
PROVIDER CHOICE
You have access to more than 85% of providers
and 96% of hospitals nationwide.
BENEFIT CONSISTENCY
BlueCard ensures that you receive in-network
benefits when choosing participating providers of any
Blue Cross and/or Blue Shield Plan.
BILLING PROTECTION
Accessing a Blue Cross and/or Blue Shield Plan
participating provider ensures that you are not
responsible for any balance billed amount.
EASE OF ACCESS
It’s quick and easy to locate a participating provider
at regence.com or by calling (1-800-810-BLUE).
15
How it works
You see a provider
outside the Regence
service area
Participating provider
provides care for you
Local Blue Plan
pays provider
Local Blue Plan
prices the claim and
submits it to Regence
Processes the claim and
authorizes payment
Sends an explanation of
benefits to you
To learn more about the BlueCard
program, call your local Blue Plan
or visit regence.com.
BlueCard and BlueCard Worldwide are registered service marks of the
Blue Cross and Blue Shield Association.
03781-ut / 07-10
16
myRegence.com
Everything you’ve always wanted to know about your health. In one place.
Imagine a place where you can find answers and support for all of your health needs. myRegence.com is your
complete source of health and wellness information. And it’s simple to understand. So whether you want to get
started on an exercise program, need tips on eating healthier, or just want to know if we’ve paid your claim,
visit myRegence.com today.
Advise
Consider health care decisions, explore treatment options
and plan ahead for financial needs.
• Compare cost and quality of hospitals, clinics
and providers.
• Research treatment options and out-of-pocket
cost estimates.
• Learn about medical conditions, medications and
cost-saving generics.
• Explore and enjoy health articles, videos and podcasts.
Navigate
Discover tools that help you track your coverage
and make informed decisions about your
health care.
• Review details about your coverage.
• Manage your claims online and eliminate paper
Explanation of Benefits.
• Find a doctor or specialist and read patient
reviews—online or on your mobile device.
• Create a secure, confidential Personal Health Record.
• Discuss a variety of important health and wellness topics on My Community,
a nationwide social networking site.
Reward
Healthy living has its own rewards, but Regence Rewards
points can help.
•Earn points for browsing our health news, podcasts
and videos.
•Receive points for healthy everyday activities—such as
eating fruits and veggies and walking the dog, or joining
an online wellness program.
•Redeem points for an Amazon.com gift card.
®
®
17
myRegence.com
Want more value for your health care dollars? Log on to myRegence.com and discover
online resources and interactive experiences focused on your health. It’s easy to join and
you’ll earn 5,000 points with Regence Rewards just for registering.
Become an informed health care consumer.
Log on today and earn 5,000 points.
Simply use the information on your member card and follow these steps.
1. Go to myRegence.com.
2. Click New Member Registration.
3. Complete the required My Member Account Information fields. The name,
member and group numbers you enter must match your member card.
4. Create a user name and secure password.
5. Click Register and Login.
Take a confidential General Health Assessment. Earn up to 10,000 points.
Learn how you’ve been managing your health to date, and get practical tips on how to
improve your health and well-being.
Manage stress and get into shape. Earn 5,000 points at completion.
Reach for a healthy lifestyle with wellness programs on Weight Loss, Healthier Diet, Stress
Relief, Healthy Aging, going Smoke-Free and more.
Keep your health history at your fingertips. Earn up to 6,000 points.
Create a secure, confidential record of your medical history with the Personal
Health Record tool. Input your own information about allergies, immunizations, emergency
contacts and more.
Get social in My Community. Earn up to 2,400 points.
Join the conversation and earn points for posting in My Community—an online health and
wellness social networking site where members nationwide are talking, asking questions of
our experts, following bloggers and receiving support in achieving their goals.
What are you waiting for? Register now at myRegence.com!
®
®
05476rep05212-ut / 06-12
18
© 2012. Regence BlueCross BlueShield of Utah, all
rights reserved.
01363-or
/ 6-08
Feeling good
D O E S N ’ T H A V E T O C O S T A L O T.
Regence Advantages
As a Regence member, you can enjoy savings on the following
health-related products and services. This discount program is offered
to all Regence members at no additional cost (although some
discounted programs offered by vendors may carry separate fees).
Regence Advantages is not insurance but is offered in addition to your
medical and/or dental plan(s) to help you stay healthy and live better.
• TruVision™: Significant discounts are offered on laser vision
correction procedures such as LASIK and PRK. Also, save 10% to 15%
on mail-order contact lenses.
• TruHearingTM: TruHearing™ offers deep discounts on state-of-the-art
digital hearing aids, and contracts with a national network of audiologists
and hearing instrument specialists to provide lower costs on expert
advice and service. It offers two programs to choose from—TruHearing
ValueAdd™ and TruHearing MemberPlus. Both include special health
plan-contracted pricing on hearing aids, one-time loss or damage
replacement for three years, a 45-day money back guarantee and
48 batteries per hearing aid purchased. Similar to warehouse
memberships, TruHearing MemberPlus saves you an additional $300 to
$1,100 on hearing aids for an annual membership fee of $108.
• QualSight®: Save 40% to 50% on traditional or custom LASIK through
the QualSight network. IntraLase bladeless LASIK is also available for
an additional $450 per eye.
• Epic® Dental: Purchase smile-protecting supplies at 25% off,
including mouthwash, gums, mints and toothpaste. All items contain
xylitol, a natural ingredient that fights cavities.
• CHP CAMaffinity Program: As a Regence member, you’re eligible
for the CHP CAMaffinity Program, which provides a 20% discount
on complementary and alternative medicine (CAM) services offered
through The CHP Group’s growing network of chiropractors,
acupuncturists, naturopathic physicians and massage therapists.
Regence is completely independent from the companies that provide these products and services.
Regence does not endorse or guarantee the products and services offered or their effectiveness.
Regence reserves the right to change the program at any time without prior notice.
20
• CHP Active and Healthy: CHP
Active and Healthy is the discount
program that gets you up,
moving, and saving money! With
discounts offered by thousands
of participating vendors (e.g.
health clubs, ski resorts, sporting
events, museums, etc.) for a small
annual fee, it’s your source for
great deals on healthy and
fun activities.
• Banfield® Pet Hospital: As a
Regence member, you receive
a waived enrollment fee for
Banfield Pet Hospital’s Optimum
Wellness Plans®, packages of
preventive care that include
annual blood work, vaccinations,
de-worming, unlimited office
visits, plus much more. Banfield is
the largest veterinary hospital in
the world with 800 hospitals
in 43 states; most located inside
PetSmartTM. Learn more
at banfield.com/regence.
• Take Shape for Life®: This
safe weight management
and health program uses
clinically proven Medifast®
products and a personal health
coach to provide one-on-one
guidance and encouragement.
The program helps you lose
weight and manage disease
and health through nutritional
intervention, free access to
health care professionals,
educational materials, and
healthy habits that last a lifetime.
There are no hidden costs or
start-up fees. Learn more at
stayhealthy4ever.com. Special
savings for Regence members:
– $25 special credit on your
first order
– Additional $25 to $50 off
first month’s order for the
progressive “BeSlim” savings
plan: 5% to 10% off monthly
order and free shipping
(minimum order required)
– Free “The Secret is Out” book
– Redeemable rewards points
• CorCell® Saving Baby’s Cord
Blood®: Cord blood stem cells
are now being used to treat more
than 70 diseases, and research
is ongoing to find treatments
for even more. Regence has
partnered with CorCell to offer
a $350 discount when you bank
your baby’s umbilical cord blood.
Protect your child or give the gift
of cord blood preservation to
your grandchild, niece, nephew,
friend or other loved one. Visit
corcell.com for more information.
• HearPO®: Receive a 40%
discount on diagnostic services,
including hearing exams, and
significant savings on hearing
aids. You’ll enjoy a 60-day no-risk
trial period; one-year followup care; a three-year warranty,
including coverage for loss and
damage; and free batteries
(160 cells per hearing aid)—all
with a lowest-price guarantee.
• Everest, The First Nationwide
Funeral Planning and Concierge
Service: Save $50 off the
enrollment fee for Everest’s suite
of funeral-planning services. With
advisors available 24 hours a
day, you’ll get the information you
need to make informed decisions
about all funeral-related issues,
within your budget, and with a
funeral home of your choice.
* Plus the cost of food. Plus the cost of shipping, if applicable. Offer applies to initial membership
fee only and is valid at participating centres in the United States, Canada and Puerto Rico and
through Jenny Craig At Home. Each offer is a separate offer and can be used only once per
person. Restrictions apply.
** Discounts through HearPO (also includes extended family), TruHearing and Beltone are
available to members and their parents and grandparents.
05270 rep 04957-ut / 05-12
21
• EyeMed Vision Care®: Save 35%
on a complete pair of glasses
(frames and lenses). Save 15%
on non-disposable contacts
and $10 on contact lens fittings.
These discounts are available at
leading retailers and many private
practice locations.
• Jenny®: Jenny Craig plans are
personalized and offer one-on-one
support from trained weight-loss
consultants. With every Jenny Craig
Program you’ll receive weekly
scheduled consultations, planned
or personalized menus, and free
online support at jennycraig.com.
Choose from two special offers:
– A Free 30-day Program*
– 25% off a Premium Program*
• Beltone™**: Receive a free
screening, a 25% discount
on Beltone hearing aids, a
one-year supply of hearing-aid
batteries and free follow-up
visits and testing.
• Safe Beginnings®: Save 15% on
Safe Beginnings products, including
safety gates, cabinet locks, outlet
covers, window guards, and many
other baby-proofing products.
Want to learn more?
Go to myRegence.com/advantages
or regence.com/advantages
Get round-the-clock
ANSWERS FROM A
registered nurse.
CareEnhance®
Get the right care at the right time
If you have a question, don’t know how to treat a health condition or
are unsure about what kind of care you need, a free call to a registered
nurse can get you on the right track. CareEnhance is not insurance but
is offered in addition to your medical plan to help you get information
when you need it.
A CareEnhance nurse will:
• Ask about your symptoms
• Direct you to an emergency room when necessary
• Help you decide if you should see a doctor
• Provide helpful self-care suggestions
• Even call back to see how you’re feeling
When should you call?
Call anytime day or night when:
• You or a family member is sick, hurt or needs health care advice
• You’re not sure whether to go to the emergency room, make a doctor’s
appointment or treat your problem at home
CareEnhance nurses:
• Have an average of 15 years of hands-on clinical experience
• Are supported by doctors and the most advanced information systems
• Are able to assess your symptoms and help you decide on the best
level of care
94% of CareEnhance callers are satisfied
with their experience.
22
Some examples of health problems we can help with:
• Vomiting, nausea or upset stomach
• Cuts, minor burns, scrapes
• Colds, viruses, coughing
• Dizziness and headaches
• Sore throats or flu
• Back pain
• Crying or hot baby
• Just feeling bad, but you don’t know why
Also try our Audio Health Library®
CareEnhance also gives you access to general health information. When
you call, you can visit the Audio Health Library directory and listen to
recorded messages on a variety of health topics. If you have questions
about information provided through this service, contact your physician.
If you believe your condition is life- or limb-threatening, call 911.
If you’re not sure whether you should take care of a problem at home,
contact your doctor or go to the ER, then call a CareEnhance nurse at
1 (800) 267-6729. Registered nurses are there 24 hours a day to help
you make informed decisions about your health.
04004-ut / 06-11
23
Find your way
around your Rx plan
I N A F L A S H.
A quick guide to your RegenceRx® prescription program
Here’s a quick reference sheet to help you better understand your
prescription benefits and find the Rx information you need. It’s one more
tool you can use to navigate the health care system and make informed
decisions about your care. Check it out!
With more than 65,000 pharmacies in our network, it’s easy to find
one near you.
Using your Rx benefits
Simply present your Regence member card at the pharmacy, and the
pharmacist will submit your claim online. The system will calculate the claim
cost based on your pharmacy benefit, then the pharmacist will tell you how
much you owe.
Your member card
Take a minute to look at your member card. It verifies that you have
prescription coverage and gives our participating pharmacies everything
they need in order to submit your claim online. If you have questions, just
call us at the phone number on the back of your card.
Your deductible and copay
If you have a plan with a pharmacy deductible, then you’ll pay for
each covered prescription in full until you’ve met your deductible.
(The pharmacist will still submit your claim as usual so that your purchase
counts toward your deductible.) After you meet your deductible, then you’ll
simply pay your portion of the cost (copay/coinsurance).
If you have a plan with a copay only (no deductible), then you’ll just pay that
amount for each covered prescription medication when you pick it up.
You’ll find your prescription deductible and copay amounts summarized in
your benefits booklet on myRegence.com.
24
Generics: another way to save
You’ll save money by using generic medications
whenever possible. If the medication you need is not
available in generic form, ask your doctor if another
generic can be used to treat the same condition, or if
there is a less expensive brand-name medication. Your
doctor is the best person to determine the medication
that’s right for you.
Filing claims and getting reimbursed
The pharmacist will file your claim for you, and we’ll
pay the pharmacy directly, so you won’t have to worry
about paperwork or getting reimbursed. In the rare
event that you do need to file a claim, we make it
painless. Just go to regenceRx.com to download the
proper claim form, or give us a call at the number on
the back of your member card.
Prior authorization and our Generics First policy
Some brand-name medications require prior
authorization to ensure they’re covered, such as
antidepressant, diabetes, pain, heartburn and
cholesterol medications. Go to regenceRx.com and
click on “Prior Auth/Medication Quantities” in the
“Learn About Medications” section for a list of
medications needing prior authorization.
If you misplace your member card, we’ll replace
it. Just call us toll-free at 1 (888) 367-2119 or
visit myRegence.com.
Explore regenceRx.com: a site devoted to
your Rx benefits
Visit regenceRx.com for information specifically
related to your RegenceRx prescription benefit.
Use it to:
• Find a participating pharmacy
• Access our formulary
• Learn about your medication choices
• Preview medications to learn if they require
prior authorization, or if they have any limitations
or restrictions
• Print out a prescription claim form
If you take one of these medications or keep one on
hand to use as needed, then you’ll need to do one
of two things in order to be sure your medication will
continue to be covered:
1. Try a generic first! Switch to a generic version of
the brand-name medication you are taking. Just
ask your pharmacist to fill your prescription with
the generic rather than the brand-name.
Go to myRegence.com to make the most
of all your benefits
To discover all the advantages of your Regence
membership beyond prescriptions, go to
myRegence.com. There you can view and manage
details related to your medical and prescription
coverage, explore events and rewards for healthy
living, and plan ahead using our Health Cost Estimators.
or
2. Get prior authorization for that brand-name
medication. The brand-name medication might be
denied if it hasn’t been approved ahead of time.
Ask your doctor or pharmacist to send a prior
authorization request with your medical or
medication history before your next refill. Your
pharmacist may fax your prescription profile
to 1 (888) 437-1510 or call 1 (800) 572-0316.
Maximize your benefit: Always
show your member card to the
pharmacy where you purchase
your prescriptions.
05219rep03460-ut / 04-12
25
Non-Preferred/Non-Formulary Brands:
Generic and Preferred Brand Alternatives
This list can be used to assist you and your doctor in choosing a generic or preferred/formulary alternative.
• Genericmedicationsarelistedinlowercasebold.Example:fluconazole.
• Non-preferred/non-formularybrandsarelistedinparenthesisonlyasareferenceforgenericallyavailablemedications.
• Thisisapartiallist.Neworrarelyusedmedicationsmaynotbelisted.
• Other,less-expensiveoptionsmaybeavailableoverthecounter(OTC)withoutaprescription.
OTCproductsgenerallyarenotacoveredprescriptionbenefit.
AdditionalInformation:
- Preferred/formularymedicationsarelimitedtothedosageformandstrengthlisted;ifnostrengthislisted,
allstrengthsforthelisteddosageformarepreferred/formulary.
- Sustainedaction/release(SA/SR),extendedrelease(ER/XR),long-acting(LA),andentericcoated(EC)
medicationsareonlypreferred/formularyiflisted.
- Occasionally,preferred/formularymedicationsmaybecontractexclusionsand,therefore,arenotcovered.
- Somemedicationsmayrequirepriorauthorizationorhavequantitylimits.
PleasenotethatthePML/formularylistmaychange.Toviewthemostcurrentlist,visitourWebsiteatwww.
regencerx.com.Formoredetailedprescriptionbenefitinformation,pleaserefertoyourbenefitsbooklet.
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
A
Acanya®
clindamycin gel + benzoyl peroxide gel
Accu-Chek®
BayerBreeze®2teststrips,Bayer
Contour®teststrips
Aceon®
benazepril (Lotensin®),enalapril
(Vasotec®),fosinopril,lisinopril(Zestril®,
Prinivil®),losartan(Cozaar®),moexipril
(Univasc®),quinapril (Accupril®),
trandolapril(Mavik®),Benicar®,Micardis®
Aciphex®
omeprazole(Prilosec®), pantoprazole
Activella®
estradiol(Estrace®)+
medroxyprogesterone (Provera®),
estradiol(Estrace®)+norethindrone
(Aygestin®),FemHRT®,Prempro®,
Premphase®
Adderall
amphetamine salt combo tablet
Adoxa
doxycycline(Vibramycin®)
Advicor®
simvastatin(Zocor®),pravastatin
(Pravachol®),lovastatin (Mevacor®),
Crestor®+Niaspan®
Aerobid®/M
Alvesco ,Asmanex ,Flovent Diskus ,
Flovent®HFA,Pulmicort®,QVAR®
®
®
®
®
®
Aggrenox
®
cilostazol (Pletal®), dipyridamole
(Persantine®)+aspirin(OTC),
ticlopidine,Plavix®
(Acular®), ketotifen fumarate
ophthalmic solution(Zaditor®),Alocril®,
Patanol®
Alamast®
Allegra-D
OTC loratadine, OTCClaritin-D®,OTC
Alavert-D™,fexofenadine(Allegra®)+
decongestant
Alomide®
cromolyn ophthalmicsolution,
ketotifen fumarate ophthalmic
solution(Zaditor®),Alocril®,Patanol®
Altabax®
mupirocin (Bactroban®)
Altace®
benazepril (Lotensin®),captopril,
enalapril (Vasotec®),fosinopril,
lisinopril(Zestril®,Prinivil®), moexipril
(Univasc®),quinapril (Accupril®),
trandolapril(Mavik®)
AmbienCR™
flurazepam,temazepam(Restoril®),
triazolam(Halcion®),zolpidem tartrate
(Ambien®)
®
®
Alternatives
26
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
lactulose, polyethylene glycol/
electrolyte solution
cyclobenzaprine (Flexeril®)
Amitiza®
Amrix®
Avinza®
hydromorphone(Dilaudid®),morphine
SR(MSContin®),morphine sulfate,
oxycodone,codeine sulfate
Axert®
sumatriptan (Imitrex®),Maxalt®,
Maxalt-MLT®,Relpax®
benazepril(Lotensin®),captopril,
enalapril(Vasotec®),fosinopril,
lisinopril(Zestril®,Prinivil®),losartan
(Cozaar®),moexipril(Univasc®),
quinapril(Accupril®),trandolapril
(Mavik®),Benicar™,Micardis®
Androderm®
testosterone cypionate(DepoTestosterone®),testosterone enanthate
(Delatestryl®)
Angeliq®
FemHrt®,Premphase®,Prempro®
Anzemet®
granisetron HCL(Kytril ),
metoclopramide(Reglan®),
ondansetron/ODT(Zofran®,Zofran
ODT®),prochlorperazine,promethazine
Azor®
Humalog®,Novolog®
Crixivan®,Invirase®,Lexiva®,Norvir®,
Reyataz®,Viracept®
B
®
Apidra®
Aptivus®
diclofenac, etodolac, meloxicam
(Mobic®),naproxen(Naprosyn®), salsalate
Arthrotec®
azelastine(Astelin®)
(Mavik®),Benicar®,Micardis®
Astepro®
Atacand®
AtacandHCT®
captopril/HCTZ,enalapril/HCTZ
(Vaseretic®),fosinopril/HCTZ,lisinopril/
HCTZ(Zestoretic®),losartan/HCTZ
(Hyzaar®),moexipril/HCTZ(Uniretic®),
BenicarHCT™,MicardisHCT®
Augmentin XR
amoxicillin/clavulanate (Augmentin )
Avalide®
benazepril/HCTZ(LotensinHCT®),
(Vasoretic®),fosinopril/HCTZ,lisinopril/
BenicarHCT™,MicardisHCT®
®
Avandamet
®
Avandia®
Avapro®
Bacitracin®
ophthalmic
neomycin/polymyxin/bacitracin,
neomycin/polymyxin/gramacidin
(Neosporin®)
BeconaseAQ®
flunisolide,fluticasone propionate
(Flonase®),triamcinolone acetonide
(Nasacort®AQ)
Bepreve™
(Acular®), Alocril®,Pataday®,Patanol®
Betaseron®
Avonex®,Copaxone®,Rebif ®
B-D®teststrips
Bayer®teststrips
Boniva
alendronate sodium(Fosamax®),
editronate disodium(Didronel®),
Actonel®,Evista®
®
Brevoxyl®
benzoyl peroxide(Benzac®,Triaz®)
Brovana
C
Foradil®,SereventDiskus®
®
®
glimepiride(Amaryl®),glipizide
(Glucotrol®), glyburide(Diabeta®),
glimepiride(Amaryl®),glipizide
(Glucotrol®), glyburide(Diabeta®),
benazapril(Lotensin®),captopril,
Alternatives
Caduet®
diltiazem SR (CardizemSR®),
verapamil SR (CalanSR®),nifedipine SA
(AdalatCC®),felodipine+simvastatin
(Zocor®),pravastatin(Pravachol®),
lovastatin(Mevacor®),
Crestor®
Campral®
disulfiram(Antabuse®), naltrexone
(ReVia®)
Celebrex®
diclofenac, etodolac, naproxen
(Naprosyn®), salsalate
Cenestin®
estradiol, estropipate, Enjuvia®
CiproXR®
ciprofloxacin (Cipro®)
Clarinex®
Alavert™
ClimaraPro®
FemHRT®,Prempro®,Premphase®
27
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
clobetasol propionate (Temovate®),
(Diprolene®)
Elidel®
Colazal®
sulfasalazine(AzulfidineEntabs®),
Asacol®,Dipentum®,Pentasa®
Enablex®
EntocortEC®
Combigan®
brimonidine tartrate (AlphaganP®)+
timolol maleate,dorzolamide/timolol
(Cosopt®)
Clobex
®
Alternatives
(Diprolene®), fluocinoloneacetonide,
chloride ER (DitropanXL®),DetrolLA®
prednisone, methylprednisolone
Epiduo®
benzoyl peroxide (Benzamycin®),Detrol
LA®
Combipatch
FemHRT ,Prempro ,Premphase
Concerta®
methylphenidate ER (RitalinSR®),
MetadateCD®,AdderallXR®
Estrace®
vaginalcream
estradiol,Premarin®vaginalcream,
Vagifem®
Cortef ®
prednisone,dexamethasone,
methylprednisolone(Medrol®)
Estring®
estradiol, Premarin® vaginalcream,
Vagifem®
Cymbalta®
bupropion SR(WellbutrinSR®),
citalopram (Celexa®),fluoxetine
(Prozac®),paroxetine (Paxil®), sertraline
(Zoloft®)
Exalgo®
morphineSR(MSContin®)
Exelderm®
clotrimazole,econazole,ketoconazole,
nystatin,OTCterbinafine
Exforge®
ExforgeHCT®
quinapril/HCTZ(Accuretic®),Benicar
HCT®,MicardisHCT®
®
®
®
®
D
Daytrana®
Denavir®
AdderallXR®,MetadateCD®
acyclovir capsule (Zovirax®)
DetrolLA®,oxybutynin(Ditropan®),
oxybutynin chloride ER(Ditropan®XL)
Detrol
®
Diovan ®
DiovanHCT®
Doryx®
HCT™,MicardisHCT®
doxycycline hyclate (Vibramycin®)
F
Femring®
estradiol (Estrace®), Premarin® vaginal
cream
Fentora®
codeine sulfate,fentanyl citrate,
hydromorphone(Dilaudid®),morphine
sulfate,oxycodone
Finacea®
Azelex®
fluorometholone (Fluor-Op®),
prednisolone sodium acetate(Pred
Forte®),Alrex®
DuacCS®
(BenzaClin®),erythromycin base/
benzoyl peroxide (Benzamycin®)
DynaCircCR®
diltiazem SR (CardizemSR ),
felodipine, isradipine (DynaCirc®),
nifedipine SA(AdalatCC®),verapamil
SR (CalanSR®)
Flarex®
Focalin®
MetadateCD®
estradiol,estradiol transdermal
(Estraderm®,VivelleDOT®),estropipate,
Premarin®vaginalcream,Vagifem®
FocalinXR®
AdderallXR®,MetadateCD®
Foltx®
folic acid + Vitamin B12 + Vitamin B6
®
E
Elestrin®
+
2
28
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
Fortamet®
metformin(Glucophage®),metformin
ER (Glucophage®XR)
Lexapro
FosamaxPlusD™
alendronate sodium(Fosamax ) +
vitaminD(OTC)
citalopram (Celexa®),fluoxetine
(Prozac®),paroxetine(Paxil®),sertraline
(Zoloft®)
Lialda®
Freestyle®test
strips
sulfasalazine(Azulfidine®EN-tabs®),
Asacol®,Dipentum®,Pentasa®
Bayer®teststrips
Frova®
G
Genotropin®+
®
®
Lidoderm®
Livalo®
Nutropin®+,NutropinAQ®+,Omnitrope®+
Glyset®
glyburide(Diabeta®), glipizide
(Glucotrol®), metformin (Glucophage®)
Glumetza®
metformin (Glucophage®),metformin
ER (Glucophage®XR)
Gralise™
Lovaza®
amitriptyline,gabapentin(Neurontin®),
nortriptyline(Pamelor®)
Crestor®
fenofibrate, gemfibrozil (Lopid®),
lofibra,lovastatin(Mevacor®),
pravastatin(Pravachol®),simvastatin
(Zocor®)
gabapentin(Neurontin )
Lunesta®
(Ambien®)
polyethylene glycol/electrolyte
solution
calcitriol(Rocaltrol®)
Lybrel®
aviane*, enpresse*, lessina*, levora28*, lutera*, portia*, sronyx*, trivora-28*
M
Malarone®
hydroxychloroquine (Plaquenil®),
mefloquine, chloroquine (Aralen®)
Pegasys®,Peg-Intron®
Maxair®
ProAir®HFA,Ventolin®HFA
Innohep®
enoxaparin(Lovenox®),heparin sodium
pramipexole (Mirapex®)
Intuniv®
methylphenidate ER(Ritalin®SR),
AdderallXR™,Metadate®CD,Vyvanse®
Mirapex®ER
N
Invega™
clozapine(Clozaril ),haloperidol,
risperidone(Risperdal®),Seroquel®,
olanzapine(Zyprexa®),olanzapine ODT
(Zyprexa®Zydis®)
®
H
Half-Lytely®
Hectorol®
Humatrope®+
I
Infergen®
Namenda
®
®
Nasonex®
K
Natelle®
Kadian®
Ketek
®
Kineret®
Lescol®
LescolXL®
Levaquin®
donepezil HCL (Aricept®), galantamine
HBR (Razadyne™),rivastigmine tartrate
(Exelon®)
(Nasacort®AQ)
folic acid
codeine sulfate, fentanyl transdermal
(Duragesic®),hydromorphone
(Dilaudid®),morphineSR(MSContin®),
morphine sulfate,oxycodone
Nexium®
Niravam®
amoxicillin/clavulanate (Augmentin®),
clarithromycin (Biaxin®), doxycycline
(Vibramycin®),azithromycin(Zithromax®)
alprazolam, clonazepam, diazepam,
lorazepam
Norditropin®+
Norditropin
Nordiflex®+
NuvaRing®
apri*, junel*, levora-28*, low-Ogestrel*,
mononessa*, necon*, portia*, sprintec*
methotrexate (Rheumatrex ),
leflunomide (Arava®),Enbrel®
®
L
+
Alternatives
O
Crestor®
Crestor®
ofloxacin, ciprofloxacin (Cipro®),Avelox®
2
29
O-CalFA
folic acid
One-Touch®test
strips
BayerBreeze®2teststrips,Bayer
Contour®teststrips
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
One-Touch®Ultra® BayerBreeze®2teststrips,Bayer
teststrips
Contour®teststrips
trospium(Sanctura®)
Sarafem®
fluoxetine (Prozac®)
methylphenidate ER, MetadateCD®,
AdderallXR®
AdvairDiskus®,Advair®HFA
fluoxetine (Prozac)®+olanzapine
(Zyprexa®)
oxymorphone(Opana )
Serostim+
Oracea®
doxycycline(Periostat®,Vibramycin®),
minocycline(Minocin®),tetracycline
Strattera®
Ovcon-50®
aviane*, junel*, levora-28*, lessina*,
microgestin*, necon*, nortrel*, portia*,
sprintec*
Symbyax®
Oxistat®
clotrimazole,econazole,ketoconazole,
Oxycontin®
morphineSR(MSContin®)
Oxytrol®
DetrolLA®,oxybutynin(Ditropan®),
oxybutynin chloride ER(Ditropan®XL)
®
Symbicort®
T
Tekturna®
lisinopril(Prinivil®,Zestril®),losartan
TekturnaHCT®
HCT®,MicardisHCT®
Teveten®
Helidac®,PrevPac®
TevetenHCT®
alfuzosin(Uroxatral®),doxazosin
(Cardura®), finasteride (Proscar®),
prazosin(Minipress®),terazosin
Eliphos™
HCT®,MicardisHCT®
Tev-Tropin+
Rhinocort Aqua
(Nasacort®AQ)
Treximet®
RitalinLA
methylphenidate ER, MetadateCD
Tribenzor®
HCT®,MicardisHCT®
Tricor®
fenofibrate,gemfibrozil (Lopid®),lofibra
Tyzeka®
Baraclude™,Epivir®HBV,Hepsera®,
IntronA®,Pegasys®
P
Perforomist®
PrecisionQID®
PrecisionXtra®
teststrips
Foradil®,Serevent®Diskus®
Bayer®teststrips
Bayer®teststrips
PrenateElite®
generic prenatal vitamins
with folic acid
Prometrium
medroxyprogesterone (Provera )
Protopic®
(Diprolene®), fluocinoloneacetonide,
triamcinoloneacetonide
Provigil®
amphetamine salt combo tablet,
dextroamphetamine (Dexedrine®),
®
®
Pylera®
R
Rapaflo®
Renagel®
®
®
Rosac®
Rozerem™
S
Saizen®
+
Sanctura®XR
Opana ER
®
Alternatives
®
Trans-DermScop® meclizine (Antivert®)
®
sulfacetamide sodium/sulfur (Plexion®),
benzoyl peroxide
(Ambien®)
Nutropin ,NutropinAQ ,Omnitrope
®+
®+
®+
2
30
Non-Preferred/
Non-Formulary
Brand Name
Non-Preferred/
Non-Formulary
Brand Name
Alternatives
V
Alternatives
Valturna®
Ziana®
adapalene(Differin®),clindamycin
(Cleocin®),sulfacetamide sodium
(Klaron®),clindamycin/benzoyl
peroxide (BenzaClin®),erythromycin
base/benzoyl peroxide (Benzamycin®),
erythromycin gel, sulfacetamide
sodium(Klaron®),tretinoin(RetinA®),
Tazorac®
Veramyst®
(Nasacort®AQ)
Zomig®
sumatriptan (Imitrex®),Maxalt®,MaxaltMLT®,Relpax®
Verdeso®
desonide(DesOwen®),fluocinolone
acetonide,triamcinolone acetonide
Zomig-ZMT®
sumatriptan (Imitrex®),Maxalt®,MaxaltMLT®,Relpax®
Vesicare®
oxybutynin(Ditropan®),oxybutynin
chloride ER(Ditropan®XL),DetrolLA®
Zorbtive®▼
Nutropin®▼,NutropinAQ®▼,Omnitrope®▼
Vigamox®
ciprofloxacin(Ciloxan ),ofloxacin
(Ocuflox®)
Zovirax®ointment
acyclovir(Zovirax)tablet,capsuleor
suspension,valacyclovir HCL(Valtrex®)
tablet
Zyflo®
Accolate®,Singulair®
Vimovo™
Zylet®
tobramycin/dexamethasone
ophthalmic suspension (TobraDex®)
Zyrtec®
OTCloratadine,OTCClaritin®,OTC
Alavert™,fexofenadine (Allegra®)
®
Vusion
OTC miconazole nitrate cream
Vytorin®
Crestor®
®
W
Zyrtec-D
®
Welchol
®
X
Xalatan®
cholestyramine (Questran®),
colestipolHCL(Colestid®)
TravatanZ®,Lumigan®
Xibrom®
flurbiprofen (Ocufen®),ketorolac 0.4%
(AcularLS®),ketorolac0.5%(Acular®)
Xifaxan
azithromycin (Zithromax®),
ciprofloxacin (Cipro®), metronidazole,
neomycin, ofloxacin
Xopenex®
concentrate,
solution
albuterol, levalbuterol (Xopenex®)
XopenexHFA®
ProAir®HFA,Ventolin®HFA
®
OTCloratadine+decongestant
OTCClaritin-D®,OTCAlavert-D™,
fexodenadine(Allegra®)+
decongestant
Y
Z
Zetia
®
Crestor®
31

Regence Member Resource Guide

Transcription

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