PPONANANANA1211of 11Summary of Benefits and Coverage What this PlanCovers What You Pay For Covered ServicesCoverage Period 0101202112312021Anthem Blue Cross Life and Health Insurance Compa ID: 897395
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1 CA/L/A/UniversityofCaliforniaCorePlan -
CA/L/A/UniversityofCaliforniaCorePlan - PPO - NA/NA - NA/NA/1 - 21 1 of 11 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021 â 12/31/2021 Anthem Blue Cross Life and Health Insurance Company : University of California : CORE Plan Coverage for: Individual + Family | Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the p remium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, www.ucppoplans.com . For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deducti ble , provider , or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc - glossary/ or call (844) 437 - 0486 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible ? $3,000 /individual for All Providers . Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan , each family member must meet their own individual deductible until the overall family deductible is met. Are there services covered before you meet your deductible ? Yes. Preventive care for In - Network Providers . This plan covers some átems aná serváces even áf you havenât yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost - sharing and before you meet your deductible . See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive - care - benefits/ . Are there other deductible s for specific services? No. You don't have to meet deductible s for specific services. What is the out - of - pocket limit for this plan ? $6,350 /individual or $12,700 /family for All Providers . The out - of - pocket limit is the most you could pay in a year for covered servi
2 ces. If you have other family members i
ces. If you have other family members in this plan , they have to meet their own out - of - pocket limits until the overall family out - of - pocket limit has been met. What is not included in the out - of - pocket limit ? Premiums , balance - billing charges, and health care this plan doesn't cover. Even though you pay these eá penses, they áonât count towará the out - of - pocket limit . Will you pay less if you use a network provider ? Yes, Prudent Buyer PPO. See www.ucppoplans.com or call (844) 437 - 0486 for a list of network providers . This plan uses a provider network . You will pay less if you use a provider in the planâs network . You will pay the most if you use an out - of - network provider , and you might receive a bill from a provider for the difference between the provááerâs charge and what your plan pays ( balance billing ). Be aware your network provider might use an out - of - network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist ? No. You can see the specialist you choose without a referral . * For more information about limitations and exceptions, see plan or policy document at www.ucppoplans.com . 2 of 11 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Anthem Prudent Buyer PPO Provider (You will pay the least ) Out - of - Network Provider (You will pay the most) If you visit a health care provááerâs office or clinic Primary care visit to treat an injury or illness 20% coinsurance 20% coinsurance -------- none -------- Specialist visit 20% coinsurance 20% coinsurance -------- none -------- Preventive care / screening / immunization No charge 20% coinsurance You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x - ray, blood work) 20% coinsurance 20% coinsurance Cost may vary by site of service. Imaging (CT/PET scans, MRIs)
3 20% coinsurance 20% coinsurance
20% coinsurance 20% coinsurance Coverage for Out - of - Network Provider is limited to $280 maximum/visit . If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http://www.anthe m.com/ca/pharm acyinformation/ Essential 4 - Tier T ier 1 - Typically Generic 20% c oinsurance /prescription (retail, home delivery, UC Pharmacies and Retail90) 20% c oinsurance (retail) of the prescription drug maximum allowed amount and costs in excess of the prescription drug maximum allowed amount Most home delivery is 90 - day supply. *See Prescription Drug section of the plan or policy document (e.g. evidence of coverage or certificate). Tier 2 - Typically Preferred / Brand 20% c oinsurance /prescription (retail, home delivery, UC Pharmacies and Retail90) 20% c oinsurance (retail) of the prescription drug maximum allowed amount and costs in excess of the prescription drug maximum allowed amount Tier 3 - Typically Non - Preferred / Specialty Drugs 20% c oinsurance /prescription (retail, home delivery, UC Pharmacies and Retail90) 20% c oinsurance (retail) of the prescription drug maximum allowed amount and costs in excess of the prescription drug maximum allowed amount * For more information about limitations and exceptions, see plan or policy document at www.ucppoplans.com . 3 of 11 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Anthem Prudent Buyer PPO Provider (You will pay the least ) Out - of - Network Provider (You will pay the most) Tier 4 - Typically Specialty (brand and generic) 20% c oinsurance /prescription ( retail , home deli very and Select UC Pharmacies ) Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 20% coinsurance Coverage for Out - of - Network Provider is limited to $280 maximum/visit . Physician/surgeon fees 20% coinsurance 20% coinsurance -------- none -------- If you need immediate medical attention Emergency room care 20% coinsurance Covered as In - Network 20% coinsurance for Emergency Room Physician Fee. Emergency medical transportation 20%
4 coinsurance deductible does not ap
coinsurance deductible does not apply Covered as In - Network -------- none -------- Urgent care 20% coinsurance Covered as In - Network -------- none -------- If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 20% coinsurance Coverage for Out - of - Network Provider is limited to $480 maximum/day. If no pre - authorization is obtained for out of network providers, there will be an additional $250 copay. Physician/surgeon fees 20% coinsurance 20% coinsurance -------- none -------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit -------- none -------- Other Outpatient -------- none -------- Inpatient services 20% coinsurance 20% coinsurance Coverage for Out - of - Network Provider is limited to $480 maximum/day . If no pre - authorization is obtained for out of network providers, there will be an additional $250 copay. 20% coinsurance for Inpatient Physician Fee In - Network Providers . 20% coinsurance for Inpatient Physician Fee Out - of - Network Providers . If you are pregnant Office visits 20% coinsurance 20% coinsurance Coverage for Out - of - Network Provider is limited to $480 maximum/day. Maternity care may include tests and Childbirth/delivery professional services 20% coinsurance 20% coinsurance * For more information about limitations and exceptions, see plan or policy document at www.ucppoplans.com . 4 of 11 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Anthem Prudent Buyer PPO Provider (You will pay the least ) Out - of - Network Provider (You will pay the most) Childbirth/delivery facility services 20% coinsurance 20% coinsurance services described elsewhere in the SBC (i.e. ultrasound.) If no pre - authorization is obtained for out of network providers, there will be an additional $250 copay. If you need help recovering or have other special health needs Home health care 20% coinsurance Not covered 100 visits/benefit period . Rehabilitation services 20% coinsurance 20% c
5 oinsurance *See Therapy Services secti
oinsurance *See Therapy Services section Habilitation services 20% coinsurance 20% coinsurance Skilled nursing care 20% coinsurance 20% coinsurance 100 days limit/benefit period. Durable medical equipment 20% coinsurance 20% coinsurance -------- none -------- Hospice services 20% coinsurance Not covered -------- none -------- If your child needs dental or eye care Chálárenâs eye eá am Not covered Not covered *See Vision Services section Chálárenâs glasses Not covered Not covered Chálárenâs áental check - up Not covered Not covered *See Dental Services section Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services . ) ï· Cosmetic surgery ï· Dental care (adult) ï· Dental Check - up ï· Eye exams for a child ï· Glasses for a child ï· Hearing aids ï· Infertility treatment ï· Long - term care ï· Private - duty nursing ï· Routine eye care (adult) ï· Routine foot care unless you have been diagnosed with diabetes. ï· Weight loss programs Other Covereá Serváces áLámátatáons may apply to these serváces. Thás ásnât a complete lást. á°lease see your plan document.) ï· Acupuncture 24 visits/benefit period combined with chiropractic services. ï· Bariatric surgery ï· Chiropractic care 24 visits/benefit period combined with acupuncture. ï· Most coverage provided outside the United States. See www.bcbsglobalcore.com * For more information about limitations and exceptions, see plan or policy document at www.ucppoplans.com . 5 of 11 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor, Employee Benefits Security Administration, (866) 444 - EBSA (3272), www.dol.gov/ebsa/healthreform . Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insuran
6 ce Marketplace . For more information a
ce Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 1 - 800 - 318 - 2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim . This complaint is called a grievance or appeal . For more information about your rights, look at the explanation of benefits you will receive for that medical claim . Your plan documents also provide complete information to submit a claim , appeal , or a grievance for any reason to your plan . For more infor mation about your rights, this notice, or assistance, contact: ATTN: Grievances and Appeals , P.O. Box 4310, Woodland Hills, CA 91365 - 4310 Department of Labor, Employee Benefits Security Administration, (866) 444 - EBSA (3272), www.dol.gov/ebsa/healthreform California Department of Insurance, Consumer Services Division, 300 South Spring Street, South Tower, Los Angeles, CA 90013, (800) 927 - HELP (4357) California Department of Insurance, Consumer Communications Bureau, 300 South Spring Street, South Tower, Los Angeles, CA 90013, 1 - 800 - 927 - HELP (4357), 1 - 213 - 897 - 8921, 1 - 800 - 482 - 4TDD (4633), www.insurance.ca.gov/ Does this plan prov ide Minimum Essential Coverage? Yes Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are elig ible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit. Does this plan meet the Minimum Value Standards? Yes If your plan áoesnât meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace . ââââââââââââââââââââââ To see examples of how this plan might cover costs for a sample medical situation, see the next section. âââââââââââ âââââââââââ The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 11 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
7 dependin g on the actual care you recei
dependin g on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts ( deductible s , copayment s and coinsurance ) and excluded services under the plan . Use this information to compare the portion of costs you might pay under different health plan s . Please note these coverage examples are based on self - only coverage. Peg is Having a Baby (9 months of in - network pre - natal care and a hospital delivery) áanagáng Joeâs type 2 Dáabetes (a year of routine in - network care of a well - controlled condition) ááaâs Sámple Fracture (in - network emergency room visit and follow up care) ï® The plan âs overall deductible $3,000 ï® The plan âs overall deductible $3,000 ï® The plan âs overall ded uctible $3,000 ï® Specialist coinsurance 20% ï® Specialist coinsurance 20% ï® Specialist coinsurance 20% ï® Hospital (facility) coinsurance 20% ï® Hospital (facility) coinsurance 20% ï® Hospital (facility) coinsurance 20% ï® Other coinsurance 20% ï® Other coinsurance 20% ï® Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits ( prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests ( ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits ( including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x - ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $2,010 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductible s $3,000 Deductible s $959 Deductible s $936 Copay ment s $0 Copayment s $0 Copayment s $0 Coinsurance $2,52
8 0 Coinsurance $240 Coinsurance
0 Coinsurance $240 Coinsurance $385 What ásnât covereá What ásnât covereá What ásnât covereá Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0 The total Peg would pay is $5,580 The total Joe would pay is $1,254 The total Mia would pay is $1,321 Language Access Services: 7 of 11 (TTY/TDD: 711) Albanian (Shqip): Nëse keni pyetje në lidhje me këtë dokument, keni të drejtë të merrni falas ndihmë dhe informacion në gjuhën tuaj. Për të kontaktuar me një përkthyes, telefononi (844) 437 - 0486 Amharic ( á ááá ) ᦠáµááá á°ááµ ááááá á¥á«á á«áááµ á á«áµá ááá á¥áá³á³ á¥á áá á áá¨á á áá» á¨ááááµ áá¥áµ á áááµá¢ á áµá°ááá ááááá (844) 437 - 0486 áá°ááᢠ. (844) 437 - 0486 Armenian ( Õ°Õ¡Õµê°Öê°Õ¶ ). ÔµÕ©ê° Õ¡ÕµÕ½ ÖÕ¡Õ½Õ¿Õ¡Õ©Õ²Õ©Õ« Õ°ê°Õ¿ Õ¯Õ¡ÕºÕ¾Õ¡Õ® Õ°Õ¡ÖÖê°Ö Õ¸ÖÕ¶ê°Ö , Õ¤Õ¸ÖÖ Õ«ÖÕ¡Õ¾Õ¸ÖÕ¶Ö Õ¸ÖÕ¶ê°Ö Õ¡Õ¶Õ¾Õ³Õ¡Ö Õ½Õ¿Õ¡Õ¶Õ¡Õ¬ Ö Õ£Õ¶Õ¸ÖÕ©ÕµÕ¸ÖÕ¶ Ö Õ¿ê°Õ²ê°Õ¯Õ¡Õ¿Õ¾Õ¸ÖÕ©ÕµÕ¸ÖÕ¶ Õ±ê°Ö Õ¬ê°Õ¦Õ¾Õ¸Õ¾ : Ô¹Õ¡ÖÕ£Õ´Õ¡Õ¶Õ¹Õ« Õ°ê°Õ¿ ÕÕ¸Õ½ê°Õ¬Õ¸Ö Õ°Õ¡Õ´Õ¡Ö Õ¦Õ¡Õ¶Õ£Õ¡Õ°Õ¡Öê°Ö Õ°ê°Õ¿ÖÕµÕ¡Õ¬ Õ°ê°Õ¼Õ¡ÕÕ¸Õ½Õ¡Õ°Õ¡Õ´Õ¡ÖÕ¸Õ¾Õ (844) 437 - 0486 : (844) 437 - 0486 . (844) 437 - 0486 (844) 437 - 0486 Chinese ( ä¸æ ) ï¼ å¦ææ¨å°æ¬æ件æä»»ä½çåï¼æ¨ææ¬ä½¿ç¨æ¨çèªè¨å è²»ç²å¾åå©åè³è¨ãå¦éèè¯å¡é話ï¼è«è´é» (844) 437 - 0486 ã (844) 437 - 0486 . Dutch (Nederlands): Bij vragen over dit document hebt u recht op hulp en informatie in uw taal zonder bijkomende kosten. Als u een tolk wilt spre ken, belt u (844) 437 - 0486 . (844) 437 - 0486 French (Français) : Sá vous avez áes questáons sur ce áocument, vous avez la possábálátáµ áâaccáµáer gratuátement à ces ánformatáons et à une aááe dans votre langue. Pour parler à un interprète, appelez le (844) 437 - 0486 . Language Access Services: 8 of 11 German (Deutsch): Wenn Sie Fragen zu diesem Dokument haben, haben Sie Anspruch auf kostenfreie Hilfe und Information in Ihrer Sprache. Um mit einem Dolmetscher zu sprechen,
9 bitte wählen Sie (844) 437 - 0486 .
bitte wählen Sie (844) 437 - 0486 . Greek áÎλληνικάá Îν ÎÏεÏε ÏÏ ÏÏν αÏοÏίε Ï ÏÏεÏικά με Ïο ÏαÏÏν ÎγγÏαÏο, ÎÏεÏε Ïο δικαίÏμα να λάβεÏε βοήθεια και ÏληÏοÏοÏÎ¯ÎµÏ ÏÏη γλÏÏÏα ÏÎ±Ï Î´ÏÏεάν. Îια να μιλήÏεÏε με κάÏοιον διεÏμηνÎα, ÏηλεÏÏνήÏÏε ÏÏο (844) 437 - 0486 . Gujarati ( àªà«àªàª°àª¾àª¤à« ): àªà« ઠદતાવà«àª ઠàªàªà« àªÚÚà« àªà«àªÚણ Úૠહà«àª¯ તૠ, àªà«àªÚણ àªàª વàªàª° àªÚÚà« àªàª¾àª·àª¾àª®àª¾àª મદદ ઠÚૠમાહહતૠમà«àª³àªµàªµàª¾ÚૠતમÚૠઠહÚàªàª¾àª° àªà« . દà«àªàª¾àª¹àª·àª¯àª¾ સાથૠવાત àªàª°àªµàª¾ માàªà« , àªà«àª² àªàª°à« ( 844 ) 437 - 0486 . Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele (844) 437 - 0486 . (844) 437 - 0486 Hmong (White Hmong): Yog tias koj muaj lus nug dab tsi ntsig txog daim ntawv no, koj muaj cai tau txais kev pab thiab lus qhia hais ua koj hom lus yam tsim xam tus nqi. Txhawm rau tham nrog tus neeg txhais lus, hu xov tooj rau (844) 437 - 0486 . Igbo (Igbo): á» b ụ r ụ na á» nwere aj ụ j ụ á» b ụ la gbasara akw ụ kw á» a, á» nwere ikike á» nweta enyemaka na ozi n'as ụ s ụ g á» na akw ụ gh Ỡụ gw á» á» b ụ la. Ka g á» na á» k á» wa okwu kwuo okwu, kp á»á» (844) 437 - 0486 . Ilokano ( Ilokano): Nu addaan ka iti aniaman a saludsod panggep iti daytoy a dokumento, adda karbengam a makaala ti tulong ken impormasyon babaen ti lenguahem nga awan ti bayad na. Tapno makatungtong ti maysa nga tagipatarus, awagan ti (844) 437 - 0486 . Indonesian (B ahasa Indonesia): Jika Anda memiliki pertanyaan mengenai dokumen ini, Anda memiliki hak untuk mendapatkan bantuan dan informasi dalam bahasa Anda tanpa biaya. Untuk berbicara dengan interpreter kami, hubungi (844) 437 - 0486 . Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun co sto aggiunt
10 ivo. Per parlare con un interprete, chia
ivo. Per parlare con un interprete, chiami il numero (844) 437 - 0486 (844) 437 - 0486 Language Access Services: 9 of 11 (844) 437 - 0486 Kirundi (Kirundi): Ugize ikibazo ico arico cose kuri iyi nyandiko, ufise uburenganzira bwo kuronka ubufasha mu rurimi rwawe ata giciro. Kugira u vugishe umusemuzi, akura (844) 437 - 0486 . Korean ( íêµì´ ): 본 문ìì ëí´ ì´ë í 문ìì¬íì´ë¼ë ìì ê²½ì° , ê·íìê²ë ê·íê° ì¬ì©íë ì¸ì´ë¡ ë¬´ë£ ëì ë° ì 보를 ì»ì ê¶ë¦¬ê° ììµëë¤ . íµìì¬ì ì´ì¼ê¸°íë ¤ë©´ (844) 437 - 0486 ë¡ ë¬¸ìíììì¤ . (844) 437 - 0486 . (844) 437 - 0486 . (844) 437 - 0486 Oromo (Oromifaa): Sanadi kanaa wajiin walqabaate gaffi kamiyuu yoo qabduu tanaan, Gargaarsa argachuu fi odeeffanoo afaan ketiin kaffaltii alla argachuuf mirgaa qabdaa. Turjumaana dubaachuuf, (844) 437 - 0486 bilbilla. Pennsylvania Dutch (Deitsch): Wann du Frooge iwwer selle Document hoscht, du hoscht die Recht um Helfe un Information zu griege in dei Schprooch mitaus Koscht. Um mit en Iwwersetze zu schwetze, ruff (844) 437 - 0486 aa. Polish (polski): W przypaáku jakáchkolwáek pytaÅ zwáÄ zanych z nánáejszym áokumentem masz prawo áo bezpÅatnego uzyskanáa pomocy oraz ánformacjá w swoám jÄzyku. Aby porozmawáaá z tÅumaczem, zaázwoÅ p od numer (844) 437 - 0486 . Portuguese (Português): Se tiver quaisquer dúvidas acerca deste documento, tem o direito de solicitar ajuda e informações no seu idioma, sem qualquer custo. Para falar com um intérprete, ligue para (844) 437 - 0486 . (844) 437 - 0486 Language Access Services: 10 of 11 (844) 437 - 0486 . (844) 437 - 0486 . Samoan (Samoa): Afaá e áaá ná ou fesálá e uága á leneá tusá, e áaá lou âaáa e maua se fesoasoaná ma faamatalaga á lou lava gagana e aunoa ma se totogi. Ina ia talanoa i se tagata faaliliu, vili (844) 437 - 0486 . Serbian (Srpski): áµkoláko ámate bálo kakváh pátanja u vezá sa ovám áokumentom, ámate pravo áa áobájete pomoá á ánformacáje na vaÅ¡em jezáku bez ikakvih troÅ¡kova. Za razgovor sa prevoááocem, pozováte (844) 437 - 0486 . Spanish (Español):
11 Si t iene preguntas acerca de este docum
Si t iene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar co n un intérprete, llame al (844) 437 - 0486 . Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Makipag - usap sa isang tagapagpaliwanag, tawagan ang (844) 437 - 0486 . Thai ( à¹à¸à¸¢ ): (844) 437 - 0486 à¹à¸à¸·à¹à¸à¸à¸¹à¸à¸à¸¸à¸¢à¸à¸±à¸à¸¥à¹à¸²à¸¡ (844) 437 - 0486 . (844) 437 - 0486 Vietnamese (Ti ế ng Vi á» t): N ế u quý v á» có b ấ t k ỳ th ắ c m ắ c nào v á» tài li á» u này, quý v á» có quy á» n nh Ạn s á»± tr ợ giúp và thông tin b ằ ng ngôn ng ữ c ủ a quý v á» hoàn toàn mi á» n phÃ. Ä á» trao Ä á» i v á» i m á» t thông d á» ch viên, hãy g á» i (844) 437 - 0486 . . (844) 437 - 0486 (844) 437 - 0486 . Language Access Services: 11 of 11 Itâs ámportant we treat you faárly Thatâs why we follow feáeral cávál rághts laws án our health programs aná actávátáes. We áonât ááscrámánate, eá cluáe people, or trea t them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer fr ee aáás aná serváces. For people whose prámary language ásnât English, we offer free language assistance services through interpreters and other written languages. Interested in these ser vices? Call the Member Services number on your ID card for help (TTY/ TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordin ator in writ ing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002 - N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; W ashington, D.C. 20201 or by calling 1 - 800 - 368 - 1019 (TDD: 1 - 800 - 537 - 7697) or online at https://ocrportal.hhs.gov/ocr/portal/ lobby.jsf . Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html