WELCOME

Medicare Advantage KING, PIERCE, SNOHOMISH, AND THURSTON COUNTIES

 

Dear valued Premera Blue Cross customer,

I want to welcome you to Premera Blue Cross and your new Medicare Advantage plan. This kit includes all the information you need to get the most from your coverage.

Your confirmation letter states that your eligibility with Premera Blue Cross Medicare Advantage has been confirmed by the Centers for Medicare & Medicaid Services, and your membership is fully approved.

Your Evidence of Coverage (EOC) booklet gives you details about your coverage and explains how to get the care you need. Your EOC is an important legal document, so please keep it in a safe place.

Your online customer account provides secure access to your claims history, your list of covered drugs, and much more.

Your ID card will arrive soon. Please review this card and make sure all information is accurate.

If you have any questions concerning the enclosed information, please call us toll free at 888-850-8526 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

Thank you for choosing Premera for your healthcare and prescription needs. We value your membership and look forward to serving you.

Sincerely,

Jim Havens Senior Vice President, Individual and Senior Markets

Look for the Log In button on premera.com/ma, and answer a few simple questions to create your secure customer account.

Thanks for being a Medical Advantage plan customer.

2018

4 - STAR Overall Rating*

*4 out of 5 Stars

We're happy to tell you that Premera Medicare Advantage plans received a 4-star overall rating from the Centers for Medicare & Medicaid Services (CMS) for 2018.

Star ratings measure the quality of services you receive from your Medicare Advantage plan. They assess how well we're helping you stay healthy and how satisfied you are as a Premera Medicare Advantage member.

Thanks again for choosing Premera. We look forward to providing this high quality of service to you.

Creating your customer account

Activate your online customer account as soon as you receive this kit to find useful information about your Medicare Advantage membership.

• Find a covered drug• Review medical claims• Reorder your ID card if misplaced

Your wellness

Completing your health survey

Now it’s time to begin using your new Medicare Advantage plan. To start, we’ll mail you a survey to complete within your first few weeks as a new customer.

Please take a few minutes to answer the simple questions on the Health Risk Assessment form and mail it back to us in the prepaid envelope. Questions cover your recent vaccinations, health conditions, and general health status. The assessment is a great starting point for us to help you have a smooth transition from your previous health plan to ours.

Selecting a Primary Care Provider

Chances are, when you completed your enrollment form, you told us who you want for your primary care provider (PCP). This provider gets to know you and works with you to manage your health. If you’re not sure if you selected a PCP or want to make a change, please call Customer Service at 888-850-8526 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

Checkups are important

Getting an annual check-up or going in for a preventive visit is useful for everyone, not just children. Routine exams can help spot health issues before they begin. They can also identify problems early, before they become more serious and more difficult to treat. That’s why Premera offers an annual physical exam at no cost, as part of your plan benefits. Preventive checkups are a great time to do the following:

• Review your family history, personal medical and surgical history, current illnesses, medications and allergies.

• Schedule screening labs and other tests, if you are due for them. (You may pay part of the cost for some tests your doctor recommends.)

• Review any chronic conditions and assess how well they’re being treated. (The cost for necessary changes in care is not typically covered as part of an annual checkup.)

• Ensure you’re up to date on vaccinations and boosters.

Please call us at 888-850-8526 if you’d prefer to complete the survey over the phone.

Dental and vision

Preventive dental benefits

Our Medicare Advantage Classic HMO and Classic Plus HMO plans include preventive dental coverage, offering customers access to hundreds of local dentists.

Go to premera.com/ma to see if your dentist is in our Medicare Advantage Select Dental network.

INCLUDED SERVICES IN-NETWORK COVERAGE Routine oral exams $0 copay (2/year) Cleanings/periodontal maintenance $0 copay (2/year total) Fluoride treatments $0 copay (1/year) Bitewing x-rays $0 copay (1 set/year) Periapical x-rays $0 copay Panoramic or complete x-rays $0 copay (1 set/60 months)

Medicare Advantage $0 HMO plan customers: To add dental coverage for just $26 a month, call 888-868-7767 (TTY: 711), Monday–Friday, 8 a.m. to 8 p.m. (October 1-February 14, 7 days a week, 8 a.m. to 8 p.m.)

Eyewear allowance

Do you wear eyeglasses or contacts? Receive up to $150 a year to purchase new frames, lenses, and contacts if you’re enrolled in our Medicare Advantage Classic HMO or Classic Plus HMO plans.

Visit any optometrist in the United States who accepts Medicare. Find what you like and send us a copy of your receipt. After we’ve received the receipt, we’ll reimburse you up to $150 for your purchase.

Free programs for your good health

Discover discounts and more in your newsletter

As a Premera Blue Cross Medicare Advantage customer, you have insider access to the Senior Healthsource newsletter. In the online newsletter, you will find general interest articles about fun activities, travel destinations, and tips about how to use your Medicare Advantage plan. Be sure to bookmark the Senior Healthsource website at seniorhealth.premera.com.

Get a good deal with Premera Senior Discounts

Enjoy real savings on medical services, fitness clubs, and wellness products with Senior Discounts, a unique program for Premera Blue Cross customers.

http:seniorhealth.premera.com

Take advantage of this fitness program today by creating a Silver&Fit account at silverandfit.com.

Get fit your way with Silver&Fit

You have access to the free Silver&Fit® fitness program if you enrolled in the Medicare Advantage Classic HMO or Classic Plus HMO plans.

• Access to thousands of local and nationwide fitness clubs

• Use of gym equipment, swimming pools, and other amenities

• Attend a fitness class, join a walking group, or take part in a fun social activity

• Silver&Fit also offers the Home Fitness Program if you can’t make it to the gym

Help is a call or click away

24/7 Nurse Line

The Premera Blue Cross 24/7 Nurse Line gives you free and confidential answers to your medical questions, day or night, seven days a week.

You may be uncertain about what to do if you have a sudden illness or unexplained pain.

• Call the 24/7 Nurse Line at 855-339-8123 to speak to a registered nurse in the event of a non-emergency or if you’re unsure what to do.

• Call 911 or go to the emergency room in the case of a life-threatening condition, such as a heart attack or stroke.

Online tools

When you go to premera.com/ma you will be able to access tools to help you find what you need.

• Drug list - look up your prescriptions

• Pharmacies - find a pharmacy near you

• Doctors - find a healthcare provider in your area

With thousands of doctors in our Medicare Advantage network, you’re sure to find a provider that’s right for you and close to home at premera.com/ma.

Questions?We’re here to make Medicare easy.Call toll free at 888-850-8526 (TTY: 711)October 1—February 14, 7 days a week, 8 a.m. to 8 p.m.February 15—September 30, Monday—Friday, 8 a.m. to 8 p.m.

031417 (10-10-2017)H7245_PBC1510_Accepted

Premera Blue Cross is an HMO plan with a Medicare contract. This information is not a complete description of benefits. Contact the plan for more information. Enrollment in Premera Blue Cross depends on contract renewal. Limitations, copayments, and restrictions may apply. Benefits, premium, and/or copayments and coinsurance may change on January 1 of each year. The formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. You must continue to pay your Medicare Part B premiums. The Silver&Fit program is a product of American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH and used with permission herein.

*Medicare evaluates plans based on a 5-star rating system. Star ratings are calculated each year and may change from one year to the next.

Discrimination is Against the Law Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

Premera: • Provides free aids and services to people with

disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio,

accessible electronic formats, other formats) • Provides free language services to people whose

primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, contact the Civil Rights Coordinator.

If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals Premera Blue Cross Medicare Advantage Plans - Complaints & Appeals PO Box 696578 San Antonio, TX 78269-6578 Phone: 888-850-8526, fax: 800-889-1076, TTY: 711 Email AppealsDepartmentInquiries@Premera.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Getting Help in Other Languages This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 888-850-8526 (TTY: 711).

አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 888-850-8526 (TTY: 711) ይደውሉ።

(Arabic): ةربيعلا .امةه

لوصحلادريتيلتا ةطيلتغا أو كلبط صصوخب ةمهمتاوملمع راشعاإل ذاهيوحيدق تماوعلم ارعشإلااهذ يويح

خرياوت كاهن نوتك دق .Premera Blue Cross لخال مناليهع ةنمعي خرياوت في اءرجإذاخالت جاحتتدقو.راشعاإل هذا فيةمهم

لكقحي.فليالتكا د ةعداسملل أوةحيصلاكيتطتغ لىعظاحفلل فع في .ةفلتك

(TTY: 711) 8526-850-888ـب لصات ةأي دتكب نودكلغتبةعداسموال تاموعلمال ههذ لىع ولصحلا

中文 (Chinese):本通知有重要的訊息。本通知可能有關於您透

過 Premera Blue Cross 提交的申請或保險的重要訊

息。本通知內可能有重要日期。您可能需要在截

止日期之前採取行動，以保留您的健康保險或者

費用補貼。您有權利免費以您的母語得到本訊息

和幫助。請撥電話 888-850-8526 (TTY: 711)。

028023 (06-01-2017)

http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfhttp:AppealsDepartmentInquiries@Premera.com

Oromoo (Cushite):Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 888-850-8526 (TTY: 711) tii bilbilaa.

Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 888-850-8526 (TTY: 711).

日本語 (Japanese): この通知には重要な情報が含まれています。この通知には、 Premera Blue Crossの申請または補償範囲に関する重要な情報が含まれている場合があります。この通知に

記載されている可能性がある重要な日付をご確

認ください。健康保険や有料サポートを維持す

るには、特定の期日までに行動を取らなければ

ならない場合があります。ご希望の言語による

情報とサポートが無料で提供されます。888-850-8526 (TTY: 711)までお電話ください。

본

한국어 (Korean): 통지서에는 중요한 정보가 들어 있습니다. 즉

이 통지서는 귀하의 신청에 관하여 그리고

정보를 포함하고 있을 수 있습니다 . 본

있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 888-850-8526 (TTY: 711) 로 전화하십시오.

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ຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ທ

ມຊ່ວຍເຫືຼອເ ລືອງຄ່າໃຊ້ຈ່າຍຂອງທ່ານໄວ້ ານມີສິດ .

ແຈ້ງການນີມີຂໍມູນສໍາຄັນ ແຈ້ງການນີອາດຈະມີຂໍ. ມູນສໍາຄັນກ່ຽວກັບຄໍາຮ້ອງສະໝັກ ຫຼື ຄວາມຄຸມ

ອາດຈະມີວັນທີສໍາຄັນໃນແຈ້ງການນີ ານອາດຈະ .ຈໍາເ ປັນຕ້ອງດໍາເນີນການຕາມກໍານົດເວລາສະເພາະ ເພືອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫືຼ ຄວາ

ທ ໄດ້ຮັບຂໍມູນນີ ແລະ ຄວາມຊ່ວຍເຫືຼອເ ປັນພາສາຂອງ ທ່ານໂດຍບໍເສຍຄ່າ. ໃຫ້ໂທຫາ 888-850-8526

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(TTY: 711).

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ਮਹੱ ਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨ� ਿਜਸ ਜਵਚ

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ਿਰੱਖਣੀ ਹਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ਇਛੱੁ ਕ ਹ ਤ�

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ਲੋੜ ਹੋ ਸਕਦੀ ਹੈ ੂੰ ਮੁਫ਼ਤ ਿਵੱਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ,ਤਹਾਨ

ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪ�ਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ 888-850-8526 (TTY: 711).

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Pусский (Russian):Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 888-850-8526 (TTY: 711).

Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 888-850-8526 (TTY: 711).

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 888-850-8526 (TTY: 711).

Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 888-850-8526 (TTY: 711).

Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 888-850-8526 (TTY: 711).

028023_06-2017.pdfLanguage and Nondiscrimination Tagline for Medicare Advantage 12pt አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 888-850-8526 (TTY: 711) ይደውሉ። (Arabic): ﺍﻟﻌﻳﺑﺭﺔ ﻫﺔﻣﺎ. ﻣﻬﻣﺔ ﺑﺧﻭﺻﺹ ﻁﺑﻠﻙ ﻭﺃ ﺍﻐﺗﻟﻳﻁﺔ ﺍﺗﻟﻲﺗﻳﺭﺩﺍﻟﺣﺻﻭﻝﻗﺩﻳﺣﻭﻱﻫﺍﺫ ﻹﺍﻌﺷﺎﺭ ﻌﻣﻠﻣﻭﺎﺕﺣﻳﻭﻱ ﺫﻫﺍﺍﻹﺷﻌﺭﺎ ﻣﻠﻌﻭﺎﻣﺕ ﻗﺩ ﻛﺗﻭﻥ ﻧﻫﺎﻙ ﺗﻭﺍﻳﺭﺦ.Premera Blue Cross ﻋﻬﻳﻠﺎﻥﻣ ﻼﺧﻝ ﻣﻬﻣﺔﻲﻓ ﺍﺫﻫ ﻹﺍﻌﺷﺎﺭ.ﻭﻗﺩﺗﺗﺣﺎﺝ ﺗﻻﺧﺎﺫﺇﺟﺭءﺍ ﻲﻓ ﺗﻭﺍﻳﺭﺦ ﻳﻌﻣﻧﺔ ﻟﻠﻔﺣﺎﻅﻋﻰﻠ ﻐﺗﻁﺗﻳﻙﺍﻟﺻﻳﺣﺔﻭﺃ ﻠﻟﻣﺳﺎﺩﻋﺓ ﺩ ﺍﻛﺗﻟﺎﻳﻟﻑ.ﻳﺣﻕﻙﻟﻲﻓ ﻊﻓﻛﺗﻠﻔﺔ. ﺗﺍﺻﻝ ﺑـ888-850-8526 (TTY: 711)ﺍﻟﺣﺻﻝﻭ ﻋﻰﻠ ﺫﻫﻩ ﻟﺍﻣﻠﻌﻭﻣﺎﺕ ﻟﺍﻭﻣﺳﺎﺩﻋﺓﺑﺗﻐﻠﻙﺩﻭﻥ ﺑﻛﺗﺩ ﻳﺃﺔ Discrimination is Against the Law Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Premera: If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can Getting Help in Other Languages This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 888-850-8526 (TTY: 711). file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals Premera Blue Cross Medicare Advantage Plans - Complaints & Appeals PO Box 696578 San Antonio, TX 78269-6578 Phone: 888-850-8526, fax: 800-889-1076, TTY: 711 Email AppealsDepartmentInquiries@Premera.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at . 中文 (Chinese):本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross提交的申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母語得到本訊息和幫助。請撥電話 888-850-8526 (TTY: 711)。028023 (06-01-2017) Oromoo (Cushite):Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakk 본한국어 (Korean): 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에 관하여 그리고 정보를 포함하고 있을 수 있습니다 . 본 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 888-850-8526 (TTY: 711) 로 전화하십시오. 통지서에는핵심이되는날짜들이있을수 Premera Blue Cross 를통한커버리지에관한 ជជជ។់ងសំ�ន�ន�៉៌ណឹងេនះ�នព័តំនដីេសចក�� អអ�័ត�ន ពងេនះ្របែហល�ននឹណំនដីេសចក�ងសំី Khmer)��ែខ�រ (: ន្របែហល�នទ ទ�ឹំនដីងេសចក��ំទស���ហររេដើរ្ីនឹងរកកទដហ់កំណ័ៃថ�លក់ច�ស��ទ ក�ររ���រ់រងសទុតនររស់អ� ក�នសិទទិនហនព័ត�នេនះទ អ�កេ�យរ់ងត�ររស�ំនិងជ�ន់អំនទ្រងបរររទទ ឬ�រ��រ់រងររស់អ�ក�ររយៈទ។ទ Premera Blue Cross េច�ន់េ�កណងេនះ។ទ ក្របែហល្័រត�ររេបេ�សរ័មតនទ កទឬ្រក់ជំន ຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ທ ມຊ່ວຍເຫຼືອເ ລືອງຄ່າໃຊ້ຈ່າຍຂອງທ່ານໄວ້ານມີສິດ . ແຈ້ງການນີມີຂໍມູນສໍາຄັນແຈ້ງການນີອາດຈະມີຂໍ. ມູນສໍາຄັນກ່ຽວກັບຄໍາຮ້ອງສະໝັກ ຫືຼ ຄວາມຄຸມ ອາດຈະມີວັນທີສໍາຄັນໃນແຈ້ງການນີານອາດຈະ .ຈໍາເ ປັນຕ້ອງດໍາເນີນການຕາມກໍານົດເວລາສະເພາະ ເພືອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບຫຼືຄວາ ທ ໄດ້ຮັບຂໍມູນນີແລະ ຄວາມຊ່ວຍເຫຼືອເ ປັນພາສາຂອງ ທ່ານໂດຍບໍເສຍຄ່າ. ໃຫ້ໂທຫາ 888-850-8526 ລາວ (Lao): (TTY: 711). Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie knnten bis zu bestimmten Stichtagen handeln msen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unte日本語 (Japanese): この通知には重要な情報が含まれています。この通知には、 Premera Blue Crossの申請または補償範囲に関する重要な情報が含まれている場合があります。この通知に記載されている可能性がある重要な日付をご確認ください。健康保険や有料サポートを維持するには、特定の期日までに行動を取らなければならない場合があります。ご希望の言語による情報とサポートが無料で提供されます。888-850-8526 (TTY: 711)までお電話ください。 ਪੰਜਾਬੀ (Punjabi): ਇਸ ਨ�ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹ.ਇਸ ਨ�ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ� ਤੁਹਾਡੀ ਕਵਰੇੇਜ ਅਤੇ ਅਰਜੀ ਬਾਰਮਹੱ ਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨ�ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇੁੇਜਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਿਰੱਖਣੀ ਹਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ਇਛੁੱ ਕ ਹ ਤ� ਤੁਹਾਨ ਅੰਤਮ ਤਾਰੀਖ਼ ਤ� ਪਿਹਲ� ਕੁੱਝ ਖਾਸ ਕਦਮ ਚੁੱਕਣ ਦੀ ਲੋੜ ਹੋ ਸਕਦੀ ਹੈੂੰਮੁਫ਼ਤ ਿਵੱਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ,ਤਹਾਨਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪ�ਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ 888-850-8526 (TTY: 711). Pусский (Russian):Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 888-850-8526 (TTY: 711). Espal (Spanish): Este Aviso contiene informaci importante. Es posible que este aviso contenga informaci importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta informaci y ayuda en su idioma sin costo alguno. Llame al 888-850-8526 (TTY: 711). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng wУкраїнський (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на ВTiếng Việt (Vietnamese): Thng báo này cung cấp thng tin quan trọng. Thng báo này cthng tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quvị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thng báo này. Quvị cthể phải thực hiện theo thng báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ gi thêm về chi phí. Quvị cquyền được biết thng tin này và được trợ gi bằng ngn ngữ của mình miễn phí. Xin gọi số 888-850-8526 (TTY: 711).

028023_06-2017.pdfLanguage and Nondiscrimination Tagline for Medicare Advantage 12pt አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 888-850-8526 (TTY: 711) ይደውሉ። (Arabic): ﺍﻟﻌﻳﺑﺭﺔ ﻫﺔﻣﺎ. ﻣﻬﻣﺔ ﺑﺧﻭﺻﺹ ﻁﺑﻠﻙ ﻭﺃ ﺍﻐﺗﻟﻳﻁﺔ ﺍﺗﻟﻲﺗﻳﺭﺩﺍﻟﺣﺻﻭﻝﻗﺩﻳﺣﻭﻱﻫﺍﺫ ﻹﺍﻌﺷﺎﺭ ﻌﻣﻠﻣﻭﺎﺕﺣﻳﻭﻱ ﺫﻫﺍﺍﻹﺷﻌﺭﺎ ﻣﻠﻌﻭﺎﻣﺕ ﻗﺩ ﻛﺗﻭﻥ ﻧﻫﺎﻙ ﺗﻭﺍﻳﺭﺦ.Premera Blue Cross ﻋﻬﻳﻠﺎﻥﻣ ﻼﺧﻝ ﻣﻬﻣﺔﻲﻓ ﺍﺫﻫ ﻹﺍﻌﺷﺎﺭ.ﻭﻗﺩﺗﺗﺣﺎﺝ ﺗﻻﺧﺎﺫﺇﺟﺭءﺍ ﻲﻓ ﺗﻭﺍﻳﺭﺦ ﻳﻌﻣﻧﺔ ﻟﻠﻔﺣﺎﻅﻋﻰﻠ ﻐﺗﻁﺗﻳﻙﺍﻟﺻﻳﺣﺔﻭﺃ ﻠﻟﻣﺳﺎﺩﻋﺓ ﺩ ﺍﻛﺗﻟﺎﻳﻟﻑ.ﻳﺣﻕﻙﻟﻲﻓ ﻊﻓﻛﺗﻠﻔﺔ. ﺗﺍﺻﻝ ﺑـ888-850-8526 (TTY: 711)ﺍﻟﺣﺻﻝﻭ ﻋﻰﻠ ﺫﻫﻩ ﻟﺍﻣﻠﻌﻭﻣﺎﺕ ﻟﺍﻭﻣﺳﺎﺩﻋﺓﺑﺗﻐﻠﻙﺩﻭﻥ ﺑﻛﺗﺩ ﻳﺃﺔ Discrimination is Against the Law Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Premera: If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can Getting Help in Other Languages This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 888-850-8526 (TTY: 711). file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals Premera Blue Cross Medicare Advantage Plans - Complaints & Appeals PO Box 696578 San Antonio, TX 78269-6578 Phone: 888-850-8526, fax: 800-889-1076, TTY: 711 Email AppealsDepartmentInquiries@Premera.com You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at . 中文 (Chinese):本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross提交的申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母語得到本訊息和幫助。請撥電話 888-850-8526 (TTY: 711)。028023 (06-01-2017) Oromoo (Cushite):Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakk 본한국어 (Korean): 통지서에는 중요한 정보가 들어 있습니다. 즉 이 통지서는 귀하의 신청에 관하여 그리고 정보를 포함하고 있을 수 있습니다 . 본 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 888-850-8526 (TTY: 711) 로 전화하십시오. 통지서에는핵심이되는날짜들이있을수 Premera Blue Cross 를통한커버리지에관한 ជជជ។់ងសំ�ន�ន�៉៌ណឹងេនះ�នព័តំនដីេសចក�� អអ�័ត�ន ពងេនះ្របែហល�ននឹណំនដីេសចក�ងសំី Khmer)��ែខ�រ (: ន្របែហល�នទ ទ�ឹំនដីងេសចក��ំទស���ហររេដើរ្ីនឹងរកកទដហ់កំណ័ៃថ�លក់ច�ស��ទ ក�ររ���រ់រងសទុតនររស់អ� ក�នសិទទិនហនព័ត�នេនះទ អ�កេ�យរ់ងត�ររស�ំនិងជ�ន់អំនទ្រងបរររទទ ឬ�រ��រ់រងររស់អ�ក�ររយៈទ។ទ Premera Blue Cross េច�ន់េ�កណងេនះ។ទ ក្របែហល្័រត�ររេបេ�សរ័មតនទ កទឬ្រក់ជំន ຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ທ ມຊ່ວຍເຫຼືອເ ລືອງຄ່າໃຊ້ຈ່າຍຂອງທ່ານໄວ້ານມີສິດ . ແຈ້ງການນີມີຂໍມູນສໍາຄັນແຈ້ງການນີອາດຈະມີຂໍ. ມູນສໍາຄັນກ່ຽວກັບຄໍາຮ້ອງສະໝັກ ຫືຼ ຄວາມຄຸມ ອາດຈະມີວັນທີສໍາຄັນໃນແຈ້ງການນີານອາດຈະ .ຈໍາເ ປັນຕ້ອງດໍາເນີນການຕາມກໍານົດເວລາສະເພາະ ເພືອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບຫຼືຄວາ ທ ໄດ້ຮັບຂໍມູນນີແລະ ຄວາມຊ່ວຍເຫຼືອເ ປັນພາສາຂອງ ທ່ານໂດຍບໍເສຍຄ່າ. ໃຫ້ໂທຫາ 888-850-8526 ລາວ (Lao): (TTY: 711). Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie knnten bis zu bestimmten Stichtagen handeln msen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unte日本語 (Japanese): この通知には重要な情報が含まれています。この通知には、 Premera Blue Crossの申請または補償範囲に関する重要な情報が含まれている場合があります。この通知に記載されている可能性がある重要な日付をご確認ください。健康保険や有料サポートを維持するには、特定の期日までに行動を取らなければならない場合があります。ご希望の言語による情報とサポートが無料で提供されます。888-850-8526 (TTY: 711)までお電話ください。 ਪੰਜਾਬੀ (Punjabi): ਇਸ ਨ�ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹ.ਇਸ ਨ�ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ� ਤੁਹਾਡੀ ਕਵਰੇੇਜ ਅਤੇ ਅਰਜੀ ਬਾਰਮਹੱ ਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨ�ਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਸਕਦੀਆਂ ਹਨ. ਜੇੁੇਜਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਿਰੱਖਣੀ ਹਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ਇਛੁੱ ਕ ਹ ਤ� ਤੁਹਾਨ ਅੰਤਮ ਤਾਰੀਖ਼ ਤ� ਪਿਹਲ� ਕੁੱਝ ਖਾਸ ਕਦਮ ਚੁੱਕਣ ਦੀ ਲੋੜ ਹੋ ਸਕਦੀ ਹੈੂੰਮੁਫ਼ਤ ਿਵੱਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ,ਤਹਾਨਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪ�ਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ 888-850-8526 (TTY: 711). Pусский (Russian):Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 888-850-8526 (TTY: 711). Espal (Spanish): Este Aviso contiene informaci importante. Es posible que este aviso contenga informaci importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta informaci y ayuda en su idioma sin costo alguno. Llame al 888-850-8526 (TTY: 711). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng wУкраїнський (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на ВTiếng Việt (Vietnamese): Thng báo này cung cấp thng tin quan trọng. Thng báo này cthng tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quvị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thng báo này. Quvị cthể phải thực hiện theo thng báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ gi thêm về chi phí. Quvị cquyền được biết thng tin này và được trợ gi bằng ngn ngữ của mình miễn phí. Xin gọi số 888-850-8526 (TTY: 711).

031417_10-10-2017_R.pdf028023_use this copy of 2018 plan year remediated taglines.pdfLanguage and Nondiscrimination Tagline for Medicare Advantage 12pt Discrimination is Against the Law Getting Help in Other Languages አማሪኛ (Amharic): ﺔﻳﺑﺭﻌﻟﺍ (Arabic): 中文 (Chinese): CushiteDeutsche (German): JapaneseKoreanKhmerLaoPunjabiRussianEspañol (Spanish): TagalogUkrainianVietnamese