Member FAQ

Understanding your health plan

Health insurance can be a little overwhelming. We’re here to help you make sense of it with answers to many of the common questions we hear from our members. If you don’t see your question below, sign in to your account and select My benefits to view your Benefit Booklet. Or you can call the Customer Service number on the back of your member ID card. We’re always here to help.

Loading...
Shopping

Shopping for plans

 How do I enroll?

Choosing a health plan is a big decision. That’s why we’re here to help you find the coverage that fits you best. Visit our Explore plans page to get started or call us directly at 1-888-REGENCE (734-3623) (TTY:711).

 When do I qualify for special enrollment?

In general, when open enrollment ends, you can't apply for health insurance until the next year. However, special enrollment lets you apply for health insurance during other times of the year if you have a qualifying life event, for example getting married, having a baby or moving to a new ZIP code.

 What are metallic plans?

Each plan type is offered at one or more metal levels. All insurance companies use these levels to help you compare plans. Your out-of-pocket costs (what you’re responsible to pay in deductible, coinsurance and copays before your insurance kicks in) are lower in Gold plans and higher in Bronze plans. Silver falls in the middle. They all have an out-of-pocket maximum. That is the limit to how much you’ll pay out of pocket in a calendar year. Once you hit that maximum, your covered care is paid at 100% for the rest of the year.

 How do I know if I qualify for a subsidy?

Whether you qualify for a health care subsidy depends on your household income. When you apply for coverage at HealthCare.gov or your state’s Marketplace, you’ll know right away if you qualify for a subsidy.

 What is the “exchange” or “Marketplace”?

The “exchange” and “Marketplace” are terms for the Health Insurance Marketplace®, which is where individuals and families can shop for and enroll in affordable health care insurance. You’ll find our Regence plans on your state’s health insurance Marketplace. Whether you purchase a health plan from Regence or on the Marketplace, the plans are the same. However, shopping on the Marketplace makes the most sense if you’re using a subsidy to offset the cost of your premium, or if you’ve used the Marketplace to buy your own plan in the past. To find your state’s Marketplace, visit HeathCare.gov.

 What are important terms to know?

Here are some of the most common terms you’ll need to know. For a more complete list, visit our Definitions page.

  • Premium: The amount that you pay for your health plan every month.

  • Deductible: The amount you pay for covered health care services before your health plan starts to pay. With an annual $2,000 deductible, for example, you pay the first $2,000 of most covered services yourself.

  • Copay: A fixed amount ($15, for example) you pay for a covered health care service, usually when you receive the service.

  • Coinsurance: Your share of the costs of a covered health care service. For most care, you pay any deductibles before coinsurance kicks in. For example, if a doctor’s visit is $100 and you’ve already met your deductible, your coinsurance of 20% would be $20. Regence pays the rest.

  • Out-of-pocket maximum: The limit to how much you’ll pay out of pocket for covered in-network services in a year. Once you hit that maximum, your covered in-network care is paid by Regence at 100% for the rest of the year.
Know your plan

Getting to know your health plan

 When will my member ID card arrive?

Your member ID card will be sent to the address in your account 10 business days from the effective date or renewal date of your coverage. If you need it sooner or want a replacement, you can pull up a virtual member ID card on the Regence app or download and print a copy at regence.com > My account > Member ID cards.

 How do I use my member ID card?

You may need to share your member ID card information at your provider’s office, when you have a telehealth appointment or when you go to the pharmacy if you have prescription drug coverage. It identifies you as a Regence member, and it simplifies billing and reimbursement. It also has contact information to reach us.

 Do I need my member ID card to seek care?

To ensure Regence covers your care and that you’re billed correctly, the information on your member ID is needed to process a claim. So, it’s important to always carry your card with you—either the paper version or the virtual one on the Regence app. You’ll also want to make sure you have it with you when you’re traveling or have an emergency.

 How do I set up my paperless preferences?

Save trees and sign up to receive electronic disclosures, including your explanation of benefits (EOB). Sign in to your account on regence.com and make your selections at My account > Communication preferences.

 How do I sign up for communications?

Sign in to your account on regence.com and sign up for news and updates under My account > Communication preferences.

 How can my health plan help me save money?

As a Regence member, you have access to tools and resources to save money on high-quality care. Here are a few ways you can save:

  • Procedures: With our Cost Estimator, you can compare prices of hospital stays, MRIs, surgeries, X-rays and more. The Cost Estimator gives you estimates based on your deductible and out-of-pocket maximum.

  • Getting care: Planning ahead can save you money. For example, seeing a provider who’s in your network costs you less. That’s because we’ve negotiated discounted prices with our in-network providers, so they charge less when they treat our members. Learn more.

  • Health and wellness products: Get discounts on leading health-related products and services that you may already be using, including gym membership, LASIK, massage and more.
Networks & providers

Networks and providers

 How do I get information about the providers in my network?

You can get information about providers in your network, including contact information, professional qualifications, specialty, education and board certification status in Find a Doctor.

 Am I required to have a primary care provider (PCP) to receive primary care services? If so, how do I find one?

Only some plans require a primary care provider (PCP). If your plan does require a PCP, you can choose one in Find a Doctor. You will need to see your PCP to receive primary care services.

If your plan does not require a PCP, you may access primary care services from any doctor you choose within our network. Even if it's not required, we still recommend that you choose a PCP to help coordinate your care and provide preventive services. A PCP may also help you to find the best medical and behavioral health care specialists and to get hospital services.

For more information, sign in and go to the Benefits page to view your Medical Benefit Booklet, or call the Customer Service number on the back of your member ID card.

 How do I find and get care from specialists, behavioral health providers and hospitals?

Your primary care provider (PCP) is the best person to help you find and get care from specialists, behavioral health care providers and hospitals. For this reason, we suggest that you establish a relationship with a PCP of your choice, even if it is not required by your plan.

If your plan requires a PCP, you must get these services through your PCP.

If your plan does not require a PCP, you can get services directly, without referral. Use Find a Doctor to look up in-network specialists and behavioral care providers.

For more information about benefits, restrictions or your provider network sign into your account and go to your Member Dashboard, or call the Customer Service number on the back of your member ID card.

 How do I get care outside of normal business hours?

If you have an emergency, call 911 or go to the nearest emergency room.

If you need care outside of regular business hours and it isn't an emergency situation, first call your doctor's office to see if your doctor or provider has extended office hours. If not, you may ask the answering service to have your doctor or the on-call doctor call you back.

You can also look up virtual care options, urgent care, and walk-in and retail clinics and the hours they are open in Find a Doctor.

 What is an emergency? When should I call 911?

A medical emergency is when you believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The symptoms may be an illness, injury, severe pain or a medical condition that is quickly getting worse. If you experience an emergency situation, call 911 or go to the nearest emergency room. If the situation is not a true medical emergency, you may use Find a Doctor to discover the location and hours of urgent care, walk-in and retail clinics near you.

 How do I get care in an emergency?

In an emergency situation, call 911 or go to the nearest emergency room. Hospital care outside of your service area is a covered benefit. In- or out-of-network benefits will apply depending on your insurance plan.

In an emergency situation, prompt care comes first. But if you wish to confirm that your acute care center is a covered health care facility, you may use Find a Doctor.

Coverage & benefits

Coverage and benefits

 Which services are covered or not covered?

To see what treatments or services are covered and not covered, sign in and go to the Benefits page to view your Medical Benefit Booklet, or call the Customer Service number on the back of your member ID card.

 I have a dependent who is turning 26 soon. What should they do?

If you have a dependent on your plan who is turning 26, they will be taken off your plan and lose their health coverage. To prevent loss of coverage, they need to apply for their own policy within 60 days of their 26th birthday.

 How do I get care and services when I am traveling outside my service area? Are there any benefit restrictions?

You may get care and services outside of your service area through the BlueCard® program, which allows you to take your health care benefits with you when you travel anywhere in the United States. Blue Cross Blue Shield Global® Core gives you access to doctors, hospitals and medical assistance in most countries around the world. To learn more and to find out about your benefits and restrictions, visit the Travel coverage page or call the Customer Service number on the back of your member ID card.

Your plan may also cover telehealth—a doctor visit by phone or video chat. It's convenient, on-demand care that lets you get a diagnosis, treatment instructions and even a prescription sent to a local pharmacy. Contact us to see if your plan includes telehealth.

 How do I appeal a decision about my coverage, benefits or services?

You have the right to appeal or request an independent review of any action we take or decision we make about your coverage, benefits or services. You can make either a written or verbal request. You may learn more about the process to request an independent external review in your Medical Benefit Booklet. Visit our Appeals page to get information on time limits, understand how to make appeals and download the appeals form.

 How are decisions made about benefits coverage for new technology and advances in health care?

New technology may include but is not limited to behavioral health and medical treatments and procedures, medical devices and pharmaceuticals. Reviews of new technologies are initiated through referrals from our staff, the physician and provider community, and members. A review of published peer-reviewed literature for the evaluation of effectiveness and safety is conducted on all new technologies selected for review. Once approved, the policies are updated every year. This process ensures that new advancements can be included in the benefits that members receive, that members have fair access to safe and effective care, and that we are aware of changes in the industry. If you have questions about the rules or restrictions, please call Customer Service at the phone number on the back of your member ID card.

 When is pre-authorization (also called prior authorization) required?

Some medical procedures require pre-authorization before you receive treatment in order to get coverage from your health plan.

Pre-authorization allows us to review your treatment within the context of any other health issues you may have and to consider the latest scientific research available to manage your condition. Some conditions have a wide range of treatment choices, and some treatments work better than others. Checking in on your progress after a series of treatments helps us make sure your treatment is effective, medically necessary and right for you.

These treatments, services and equipment may require pre-authorization:

  • Some surgeries and reconstructive surgery
  • Planned admission into hospitals or skilled nursing facilities
  • Transplant and donor services
  • Specialized imaging such as MRIs, CT scans and cardiac imaging
  • Non-emergency air ambulance transport
  • Prosthetics and some orthotics
  • Home medical equipment
  • Interventional pain procedures
  • Physical medicine services such as physical therapy and chiropractic care
  • Sleep studies

These prescription medications may require pre-authorization:

  • Some high-cost injectable medications
  • Specialty drugs

If a doctor does not get pre-authorization before treating you, your health plan will not cover those costs and the doctor may bill you for that treatment.

If you use an in-network doctor, you don't need to do anything. The doctor's office will handle the pre-authorization process. Our clinical partner evaluates your treatment plan to make sure it is the most effective treatment based on published research. Our partner also ensures that it is medically necessary and covered by your health plan.

If you use an out-of-network doctor, call the number on the back of your member ID card and we can talk with you about your options. Using an out-of-network doctor may mean higher out-of-pocket costs for you.

 I'm facing a health crisis or a chronic medical condition. How do I get care management support?

If you or a family member who is on your plan faces a serious medical situation, you'll have easy access to one-on-one support at no extra cost.

Our Care Management staff, including registered nurses and clinical behavioral health specialists, are available to help guide you through the health care system and work closely with you and your doctor on a personal treatment plan. They will also work with disease and behavioral specialists to help with other chronic conditions, including chemical dependency and depression. Care Management is not insurance, but is included with your plan to help you get information and support when you need it.

For more information, or to refer yourself, visit the Care Management page or call toll-free: 1 (866) 543-5765.

 Does my health plan cover complementary and alternative medicine like massage, chiropractic care and naturopathic care?

There are some alternative treatments that your health plan may cover. Acupuncture and spinal manipulation care may be covered if they're medically necessary. Many plans include physical therapy, and if massage therapy is determined a part of your therapy, it could be covered, too. The best way to find out what's covered is to look at your plan details. Sign in to your account at regence.com and select My benefits for more information. Your Medical Benefit Booklet outlines what kind of treatments are covered under your plan.

If you have further questions—like if you'll need a prescription or if you're limited to a number of visits—reach out to Customer Service at 1 (844) REGENCE (734-3623).

Claims & payments

Claims and payments

 What charges are my responsibility?

You are responsible for copayments, your annual deductible and any required coinsurance up to your annual out-of-pocket maximum.

 How do I submit a claim for reimbursement of covered services?

Sign in to your Member Dashboard and go to the Claims center. From there, you can submit a claim for reimbursement.

 How do I pay my premium?

From paying online or over the phone by credit or debit card to mailing a check, there are several ways to pay your monthly premium. Learn about the ways to pay.

 How do I access member-only discounts?

Sign in to your Member Dashboard and go to Resources > Discounts.

Pharmacy

Pharmacy

 How do I get information on my pharmacy and medication coverage?

For information about your pharmacy benefits, such as copays, deductibles and what benefits and services are covered and not covered, sign in and view your Medical Benefit Booklet on the Benefits page or call the Customer Service number on the back of your member ID card.

To learn about the covered medications in your pharmacy plan, locate a pharmacy and more, visit the Pharmacy benefits page.

 How do I know if my prescribed medication requires pre-authorization?

Some medications require pre-authorization (also called prior authorization) to be covered by your insurance plan. See the Pharmacy benefits page to look up your medication.

 How do I fill a prescription?

To fill a prescription, bring your prescription to a network pharmacy near you and show your member ID card. For information on how to find a network pharmacy, fill prescriptions by mail order or fill specialty medications, see the Pharmacy benefits page. You’ll also find information there about how often you can refill a prescription and how much medication you can pick up each time you fill your prescription.

 How can I find out the cost of my prescribed medication before I pick it up? How do I know if a generic version of the medication is available?

See the Pharmacy benefits page for information about how Prime, our pharmacy benefit manager, offers a price guide for the average price of common medications and a list of generic medications.

General information

General information

 What are my rights as a member?

You have the right to:

  • Receive information about our company and services, as well as the doctors and other providers in our network.
  • Receive information about your member rights and responsibilities.
  • Make recommendations regarding our company's rights and responsibilities policy.
  • Be treated with respect and dignity.
  • Privacy of your personal information.
  • Participate in decisions about your care with your doctor and other health care professionals.
  • Openly discuss with your doctor the appropriate or medically necessary treatment options for your condition, regardless of cost or benefit coverage.
  • Submit complaints or appeal decisions made by your health plan or about the care provided to you.
 What are my responsibilities as a member?

You have the responsibility to:

  • Give as much information as possible to your plan, doctors and other providers so they can give you the right care.
  • Follow plans and instructions for care that you and your doctor have agreed to.
  • Understand the condition of your health and participate in developing mutually agreed-upon treatment goals, as much as possible.
  • Know and confirm your benefits and eligibility before receiving services.
 How is my personal health information protected?

At Regence, we know you value your privacy. We do too. That’s why we are committed to the confidentiality and security of your personal information. We maintain physical, administrative and technical safeguards to protect against unauthorized access, use, or disclosure of your personal information, including information we share internally either orally, electronically or in writing. The Terms & Privacy page informs you of your rights and how we protect and use your personal information.

We take our obligation to protect your information seriously. Regence has put in place many safeguards to protect the privacy and security of your information. Our employees are required to complete privacy and security training when they are hired and to complete additional training every year. Employees are required to sign a privacy and security acknowledgement statement.

Only those employees with a business need to know have access to health information. We have a number of technical safeguards in place to protect your data including badge access areas and network security systems. We monitor our systems to make sure your information is accessed appropriately.

 I don’t speak English and am a TTY user. How do I get language help?

To get help in languages other than English, call our Customer Service department at the phone number on the back of your member ID card. TTY users call 711.

Para asistencia en español, por favor llame al teléfono de Servicio al Cliente en la parte de atrás de su tarjeta de miembro.

Para humingi ng tulong sa Tagalog, pakitawagan ang numero ng telepono ng Serbisyo sa Kostumer (Customer Service) na nakasulat sa likod ng inyong kard bilang miyembro.

如需中文幫助,請撥打客戶服務電話, 號碼位於您會員卡背面。

Diné kʼehjí áká'eʼyeedgo, t'áá shǫǫdí áká anídaalwoʼí bi béésh bee haneʼé ninaaltsoos bee atah nílínígíí bineʼdę̀ę̀ bikááʼ.

 How do I submit a complaint?

If you have a concern or are unhappy about the service or care provided to you by your health plan, a clinic, doctor, or any health care provider, you may submit a complaint (also called a grievance). There are several ways to submit a complaint.

  • Health plan grievances You may submit a complaint about your health plan by contacting Customer Service at the phone number on the back of your member ID card. A Customer Service representative can help you try to resolve your concern or, if you prefer, provide you with instruction on how to submit your grievance in writing.

  • Provider grievances If you want to submit a complaint about your service or care by a clinic, doctor, or any health care provider there are two options:

    • Submit your complaint verbally or get instruction on how to submit a complaint in writing, by contacting Customer Service.
    • Submit your grievance online via secure email to your health plan by completing the correct Health Care Quality Concerns Form for your state:

For more information about submitting a complaint or grievance call the Customer Service number on the back of your member ID card or follow the grievance process in your Benefit Booklet (available on the Benefits page after signing in).

 What do I need to know if I am affected by disaster declaration, evacuation, or a state of emergency?

In the event of a disaster declaration or displacement, call or Live Chat with customer service to get help with replacing medications, accessing care, and more. Learn more >>