Open Enrollment Is October 10-27, What s New for 2018? Enrolling in Your Benefits. Making Mid-Year Changes

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1 Y URBENEFITS EXPLORE YOUR COUNTY OF RIVERSIDE BENEFIT OPTIONS Open Enrollment Is October 10-27, 2017 What s New for 2018? Enrolling in Your Benefits Making Mid-Year Changes

2 TABLE OF CONTENTS Table of Contents YOUR COUNTY OF RIVERSIDE BENEFITS Benefits Enrollment Important Dates... 4 ENROLLING IN YOUR BENEFITS... 5 Making Your Annual Enrollment Decisions Adding or Deleting Dependents When Coverage Begins Making Mid-year Changes... 8 ELIGIBILITY FOR COVERAGE... 9 Retiree Eligibility Dependent Eligibility Required Proof of Eligibility YOUR HEALTH CARE OPTIONS Medical Plan Eligibility How Your Medicare Eligibility Affects Your Choice of Plans Important Note About Living in Your Plan s Service Area MEDICAL PLANS FOR RETIREES WHO ARE NOT ELIGIBLE FOR MEDICARE Health Maintenance Organization (HMO) Plans Exclusive Provider Organization (EPO) Plan UnitedHealthcare PPO Medical Plan Patient Protection Notice Plan Comparison Charts MEDICAL PLANS FOR MEDICARE-ELIGIBLE RETIREES Health Maintenance Organization (HMO) Plans Medicare Coordination Plans Medicare Supplement Plan Plan Comparison Charts for Plans that Coordinate with Medicare Medicare Supplement Plan Comparison Chart Plan Comparison Charts for Medicare Advantage HMO Plans Medicare Prescription Drugs Important Notice from the County of Riverside About Your Prescription Drug Coverage and Medicare DENTAL PLANS Dental Plan Eligibility DeltaCare USA HMO Dental Plan Local Advantage Plus EPO Dental Plan Delta Dental PPO Dental Plan VISION PLAN Medical Eye Services (MES) Vision MES Vision Plan Benefits COST OF COVERAGE Monthly Plan Costs for Retirees Who Are Not Eligible for Medicare Monthly County Contributions Monthly Costs for Medicare-Eligible Retirees Monthly Costs for Dental and Vision Coverage CONTACT INFORMATION COR Benefits Guide

3 YOUR COUNTY OF RIVERSIDE BENEFITS Your County of Riverside Benefits The County of Riverside is proud of the benefits package it makes available to retirees. We have an impressive array of benefits from which you can choose, and we encourage you to be well-informed so you take full advantage of the County s plans and programs. This Enrollment Guide is designed to help you research your options and provide the necessary information for you to make informed decisions. We encourage you to review it thoroughly and think carefully about your personal benefit needs before you enroll. What s New for 2018? The Delta Dental PPO Plan will now cover implants. You will pay 40% in-network and 50% after the deductible out-of-network. The cost of routine checkups, cleanings and x-rays will not count toward your calendar year maximum, leaving more benefits for major services. There will be no other changes to your County s benefits this year! The benefits and coverage we currently offer will remain the same, with only a slight increase in the benefit plan rates. Keep reading for a comparison of your medical plan options and their related cost. Remember, if you need help with your benefits decisions, call an Advocate at (888) or visit the Advocacy site at COR Benefits Guide 3

4 YOUR COUNTY OF RIVERSIDE BENEFITS 2018 BENEFITS ENROLLMENT IMPORTANT DATES Annual Enrollment for County plans: The County s annual enrollment period for retirees is October 10-27, This includes enrollment in County medical, dental and vision plans. County plan rate changes will be effective January 1, You will see rate changes for medical, dental and vision plans on your January CalPERS warrant. Contributions are collected from your retiree warrant to pay for the current month of coverage. For example, the deductions from your January retiree warrant are used to pay for January coverage. If your retiree warrant is insufficient to pay premiums for the coverage you elect, the County s Benefits Division will send an invoice directly to you for the premiums due. If your premiums exceed your CalPERS allowance, you will be responsible for paying your premiums directly to the County of Riverside. Your premiums must be received on or before the 25th day of the month preceding coverage. For example: Your premiums for January are due on or before December 25. Please make sure your premiums are paid on time to avoid a lapse or termination in your coverage. CalPERS health plan enrollment (for retirees who retired from DDAA, LEMU, or RSA Public Safety): The CalPERS annual enrollment period was September 11 - October 6, If you dropped your CalPERS plan coverage so that you could enroll in one of the County s Exclusive Care plans, now is the time to make your Exclusive Care plan election for To enroll in an Exclusive Care plan or a County-sponsored dental or vision plan, you must complete the enclosed Retiree Benefit Election Form. ELIGIBLE FOR MEDICARE? ADDITIONAL PLAN-SPECIFIC FORMS REQUIRED! If you or your dependent is eligible for Medicare, you must also complete a Medicare enrollment form for the specific medical plan you elect (Kaiser Senior Advantage High Option or Low Option, UnitedHealthcare Medicare Advantage Plan or SCAN HMO), and you must send us a copy of your Medicare ID card. Please contact the Benefits Information Line at (951) and Select Option 1 to request the correct form. If you terminate coverage for yourself or a dependent who is currently enrolled in one of these plans, Medicare rules require that you complete a disenrollment form. If you do not complete the required Medicare enrollment forms or disenrollment forms, the County will not be able to make the election changes you request COR Benefits Guide

5 ENROLLING IN YOUR BENEFITS Enrolling in Your Benefits Complete the 2018 Retiree Benefit Election Form and return it to the County of Riverside Benefits Division no later than October 27, Please consider your elections carefully, and submit your form one time only. Remember to keep a copy for your records. If you are enrolling a spouse, registered domestic partner or dependent children, you will need to enroll your dependent(s) on the form AND provide supporting documentation such as marriage or birth certificates. You must submit your documentation with the Retiree Benefit Election Form to the County of Riverside Benefits Division no later than October 27, Your enrollment form cannot be processed without the supporting documentation. See Required Proof of Eligibility on pages for requirements. DURING ANNUAL ENROLLMENT, YOU CAN... Do nothing, and your current health care coverage will continue as long as you remain eligible Choose a different plan or cancel your medical, dental or vision plan Add or delete coverage for an eligible dependent DO I NEED TO TAKE ACTION DURING OPEN ENROLLMENT? If you do not wish to change your elections for 2018, you do not need to do anything. Please DO NOT send a Retiree Benefit Election Form. You only need to take action during Annual Enrollment if you want to: Change or add medical, dental or vision coverage Add or delete dependent coverage MAKING YOUR ANNUAL ENROLLMENT DECISIONS This enrollment guide provides basic information about your County-sponsored medical, dental and vision care plans, including resources that you may need to evaluate your options. Step 1: Read all the information contained in your personalized enrollment letter. This letter shows your current coverage and the coverage options available to you in Note: If you are eligible for or enrolled in a medical plan through CalPERS, this election will not be indicated in your County of Riverside personalized enrollment letter (because your coverage is maintained by CalPERS). You will receive a confirmation statement from CalPERS about your medical plan. Step 2: Use this guide to learn more about the benefit options available to you. If you have questions, be sure to get them answered before you select benefits and complete your Retiree Benefit Election Form. Forms are available online at or from the Benefits Information Line at (951) , Select Option COR Benefits Guide 5

6 ENROLLING IN YOUR BENEFITS Step 3: Consider your health and financial needs carefully. Ask yourself these questions: Does your current benefit coverage meet your needs? Are your current prescription drugs covered under the plan? Is your CalPERS warrant sufficient to cover your premium? Are you or your dependent(s) newly eligible for Medicare, or will you become eligible this year? Do the plan s premium costs fit your budget? Have your health care needs changed? Has your marital status changed? Have your eligible dependents changed? Step 4: If you would like to change your elections, mark your County benefit choices on the Retiree Benefit Election Form that you received with this package. DO NOT submit a new election form if you are not making changes to your current coverage. Step 5: Complete any additional enrollment forms required by the plan you ve selected. These additional forms are generally required if you or your dependent is over 65 and/or eligible for Medicare and you are enrolling in or disenrolling from one of the following plans: UnitedHealthcare Medicare Advantage or Coordination of Benefits (COB) Plan, Kaiser Senior Advantage High Option or Low Option, or the SCAN HMO. We will not be able to process your medical plan enrollment without these completed forms. You must also provide a copy of the Medicare card that verifies enrollment in Parts A and B. Step 6: Once you have chosen your benefits, add up all of your costs. Your benefit costs will continue to be deducted monthly, whenever possible, from your CalPERS pension warrant for Remember, we will reduce the cost of your medical premium by applying your County contribution (see page 48) or your CalPERS warrant. Step 7: Be sure to provide your current dependent information. Step 8: Sign and date each of your completed forms. Step 9: Attach copies of documentation that verifies the eligibility of your dependents. See pages for documentation requirements. Step 10: Make a copy of your form(s) and any documentation for your records. Step 11: Submit your benefit forms to the County of Riverside Benefits Division no later than October 27, Remember: If you do not wish to change your benefit elections, you do not need to complete a Retiree Benefit Election Form for the 2018 plan year. Note: Please consider your options carefully and review the total cost of your coverage before submitting your Retiree Benefit Election Form, to make sure you are enrolling in the benefits you want and can afford COR Benefits Guide

7 ENROLLING IN YOUR BENEFITS ADDING OR DELETING DEPENDENTS You can add or delete eligible dependents from County-sponsored medical, dental and vision plans during Annual Enrollment by completing the enclosed Retiree Benefit Election Form. TO ADD DEPENDENTS AND/OR A REGISTERED DOMESTIC PARTNER 1. Complete the dependent section of your Retiree Benefit Election Form. Be sure to provide complete information for each dependent and choose a primary care physician and/or primary care dentist, if required by the plan. Note: You must list ALL of your eligible dependents (even if they are currently enrolled). Make sure you clearly indicate the coverage options (medical, dental and vision) you want for EACH dependent. Any dependents not listed will not be covered for the new plan year. 2. Provide required dependent documentation. See pages for details. Attach the required documentation with your Retiree Benefit Election Form. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY SPECIAL ENROLLMENT RIGHTS If you are waiving enrollment for yourself or your dependents (including your spouse/registered domestic partner) because of other health insurance coverage, in the future you may be able to enroll yourself and/or your dependents in a plan, provided that you request enrollment within 60 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 60 days after the event occurs. 3. Submit your completed forms to the County of Riverside Benefits Division no later than October 27, Remember to make a copy and keep it for your records. TO DELETE SPOUSE/REGISTERED DOMESTIC PARTNER AND/OR DEPENDENTS 1. Complete the enclosed Retiree Benefit Election Form. List all dependents you want enrolled, but leave off the dependent whose coverage you wish to delete. Any dependents not listed will not be covered for the new plan year. 2. Submit your completed election form to the County of Riverside Benefits Division no later than October 27, Remember to make a copy and keep it for your records. If you are electing or terminating a Medicare Advantage plan, you must complete a planspecific enrollment or disenrollment form. WHEN COVERAGE BEGINS If you are enrolling for coverage or making changes to your current benefit elections during the annual enrollment period, your new coverage will be effective January 1, 2018, and will continue through December 31, 2018, or until you cease to be eligible for coverage, if earlier. Your premiums for coverage are taken beginning with your first CalPERS retiree warrant in January for coverage beginning January 1, If you are enrolling for coverage as a new retiree or making mid-year election changes, your new coverage will generally be effective the first of the month following receipt of your completed Retiree Benefit Election Form with appropriate supporting documentation, unless another effective date is required to comply with the special enrollment rights under the Health Insurance Portability and Accountability Act (HIPAA) or to coordinate your coverage with Medicare COR Benefits Guide 7

8 ENROLLING IN YOUR BENEFITS MAKING MID-YEAR CHANGES Each year, during the annual enrollment period, you have an opportunity to change your benefit plan elections for the following plan year. Generally, the benefit elections you make during Annual Enrollment will stay in effect from January 1 through December 31, if you remain eligible for benefits. However, if you incur a qualified change of status, please notify the County s Benefits Division to make the appropriate change. Qualified status changes include: Marriage or registration of a registered domestic partnership Divorce or separation from a registered domestic partner Birth or adoption of a child Death of a spouse/registered domestic partner or a child Change in your spouse s/registered domestic partner s employment Significant changes in your spouse s/registered domestic partner s employer s medical coverage Child s loss of eligibility due to age Full-time/part-time employment status change that results in an insurance eligibility change You, your spouse or your dependent child becomes eligible for Medicare, Medicaid or Medi-Cal A judgment, decree or court order requires a coverage change Most status changes are easy to manage. Simply complete a Retiree Benefit Election Form and return it to the County of Riverside Benefits Division within 60 days of the event that caused the status change. You must include documentation of the event (such as a certified birth certificate or certified marriage certificate). Most changes are made prospectively from the date that the County of Riverside Benefits Division receives a properly completed and signed Retiree Benefit Election or Cancellation Form. Exceptions are made for birth or adoption to comply with the special enrollment rights defined under the Health Insurance Portability and Accountability Act (HIPAA), and to coordinate your Medicare eligibility. Please keep in mind that any changes to your coverage must be consistent with the qualified change of status. For example, if you get married, you can enroll your new spouse in the benefit plans but you cannot make unrelated changes, such as switching from one medical plan to another. Due to the CalPERS processing deadlines, you may experience a delay in when the deductions from your CalPERS warrant start or stop. In these cases, you will be billed for the premium difference or given a refund for any premium you overpaid. Important: You must notify the County of Riverside Benefits Division within 60 days of a change in status. Failure to notify the County of Riverside Benefits Division may result in the County s inability to correct and/or refund premium deductions COR Benefits Guide

9 ELIGIBILITY FOR COVERAGE Eligibility for Coverage RETIREE ELIGIBILITY To be eligible for enrollment, all of the following conditions must be met: You must retire within 120 days from the date you separate from employment with the County of Riverside; You must receive a retirement allowance from CalPERS; and You must have been eligible for enrollment on the date of separation from the County of Riverside. The surviving dependent of a retiree may also be eligible. MEDICAL, DENTAL AND VISION COVERAGE County medical plans. All County retirees who were previously represented by LIUNA and SEIU, elected officials, and those in Management, Confidential and Unrepresented units are eligible. CalPERS medical plans. County retirees who were represented by DDAA, LEMU and RSA Public Safety Unit are eligible. Participants eligible for CalPERS plans are also eligible to enroll in the County s Exclusive Care plans. Any election changes must be coordinated with the CalPERS enrollment period, which was September 11 - October 6, Even if you choose not to enroll in a medical plan when you retire, if you meet all of the criteria listed above, you are eligible to enroll in a medical plan at any subsequent annual enrollment period. In addition, you are eligible to enroll in a medical plan if you experience a loss of eligibility for other coverage due to a qualifying event and you request enrollment within 60 days of the event that caused the loss of coverage. County dental plans. All retirees who meet the general eligibility criteria can enroll in the dental plan. Even if you choose not to enroll in the dental plan at the time you retire, you can enroll at any subsequent annual enrollment period. Once you or your dependent reaches age 65 or becomes eligible for Medicare, your plan options and rates change. Refer to page 14 for a description of how Medicare eligibility affects your benefit choices. The County s monthly retiree contribution toward your medical coverage is the same for all medical plans COR Benefits Guide 9

10 ELIGIBILITY FOR COVERAGE County vision plan. All retirees who meet the general eligibility criteria can enroll in the vision plan. Even if you choose not to enroll in the vision plan at the time you retire, you can enroll at any subsequent annual enrollment period. Before enrolling in the vision plan, it s a good idea to see what kind of vision benefits your medical plan covers, to avoid duplication of benefits. DEPENDENT ELIGIBILITY You can enroll your eligible dependents in your medical, dental and vision coverage. Eligible dependents include your: Legal spouse Registered domestic partner, if you and your domestic partner meet all of the criteria listed below. A domestic partnership is defined as two people who both:»» Are at least 18 years of age, unmarried, and not a blood relative close enough to bar marriage in the State of California;»» Live in a mutually exclusive relationship in which they are jointly responsible for each other s welfare and financial obligations;»» Live in the same principal residence and intend to do so indefinitely; and»» Have registered with the State of California by completing a Declaration of Domestic Partnership with both partners signatures notarized, submitting the form (with the appropriate fee) to the Secretary of State, and receiving documentation from the State with proof of filing. Based on state law (AB26 and AB25), the following partners are eligible to register with the state:»» Specified same-sex domestic partnerships between persons who are both at least 18 years of age; or»» Specified opposite-sex domestic partnerships in which one or both partners are age 62 or older. Children. Your child must be under age 26. Eligible children include your or your spouse s/ registered domestic partner s:»» Natural child»» Stepchild»» Adopted child who is adopted by you or placed in your physical custody for adoption prior to age 18. Placed for adoption means that you have assumed a legal obligation for total or partial support of the child in anticipation of adopting the child. The child must be available for adoption, and the legal process must have begun.»» Child for whom you have legal custody or guardianship COR Benefits Guide

11 ELIGIBILITY FOR COVERAGE»» Disabled child over age 26 (who, except for age, meets the above eligibility requirements), if he or she is incapable of self-support because of a mental or physical disability that existed before age 26 (and continuously since age 26). The child must be dependent on you or your spouse/registered domestic partner for support and claimed as your dependent for federal income tax purposes. Coverage for a disabled child beyond age 26 can only be established when you first enroll for benefits or as a continuation of coverage in a Countysponsored plan. The following are examples of individuals who are not considered eligible dependents: Your spouse following final decree of dissolution, divorce, or legal separation Someone else s child (such as your grandchildren, nieces or nephews), unless you have been awarded legal custody or guardianship Parents or grandparents, regardless of their IRS dependent status Your child s spouse IMPORTANT NEWS ABOUT DEPENDENT ELIGIBILITY During Annual Enrollment, you MUST review your dependent elections and certify that each enrolled dependent continues to meet our eligibility rules. You also must be prepared to provide appropriate documentation to confirm your dependent s eligibility if you are selected for a dependent audit. If you re enrolling a dependent for the first time, you are required to provide documentation before the end of Annual Enrollment. Please keep the following rules in mind: 1. It is against the law to enroll ineligible people. If you do, you may have to pay for all costs incurred by the ineligible dependent from the date the coverage began. 2. If you do not add newly eligible dependents to your health plan within the 60-day period of eligibility, you will have to wait until the next annual enrollment period before you can enroll them. 3. Your former spouse/registered domestic partner, parents, parents-in-law, other relatives, and non-disabled children age 26 and over are not eligible for coverage under your health care plans. 4. You must drop coverage for your enrolled dependent when he or she loses eligibility (for example, if you and your spouse divorce or your child reaches age 26). REQUIRED PROOF OF ELIGIBILITY You will need to provide proof of eligibility the first time you request that a dependent be added to your medical, dental or vision plan (and periodically to comply with a benefits audit process). Once you have completed your Retiree Benefit Election Form, submit all of the necessary documentation to the County of Riverside Benefits Division. If you are doing so during Annual Enrollment, you must submit the documentation no later than October 27, Please remember to keep a copy of all documentation for your records COR Benefits Guide 11

12 ELIGIBILITY FOR COVERAGE LEGAL SPOUSE A copy of your certificate of marriage and your spouse s Social Security number must be submitted at the time your spouse is enrolled. DOMESTIC PARTNER You must provide a copy of the Declaration of Domestic Partnership registered with the Secretary of State and your partner s Social Security number. CHILDREN For a natural child or stepchild, provide a copy of the child s birth certificate. For an adopted child or a child for whom you have legal custody or guardianship, you must provide a copy of the child s birth certificate and a copy of the judgment or decree. You must also provide the child s Social Security number. DISABLED CHILDREN (AGE 26 OR OVER) You must submit a copy of your most recent federal income tax return indicating that the child is a qualified tax dependent, provide the child s Social Security number, and complete a Member Questionnaire for the Disabled Dependent Form and a Medical Report Form. These forms must be received within 60 days of your initial enrollment or the child s 26th birthday. The forms must be approved by the insurance carrier upon enrollment and updated upon request COR Benefits Guide

13 YOUR HEALTH CARE OPTIONS Your Health Care Options Riverside County offers a number of medical, dental and vision plan options. While the dental and vision plans are available to all bargaining and employee units, your specific medical plan options depend on your bargaining or employee unit at retirement, your age, Medicare eligibility and where you live (see the charts on the following pages). Before making your health care elections, think about how you use your health care plans, the required premiums for each plan, and what s important to you and your family. You can use the County s medical and dental comparison charts in this guide to help you evaluate each plan s features. MEDICAL PLAN ELIGIBILITY Riverside County is pleased to offer you a choice of medical plan options. MEDICAL PLAN ELIGIBILITY Eligible for County Medical Plans Elected Officials SEIU Represented Employees LIUNA Represented Employees Management Employees Confidential Employees Unrepresented Employees Eligible for CalPERS or Exclusive Care Medical Plans DDAA Represented Employees LEMU Represented Employees RSA Public Safety Employees Contact CalPERS directly for information about their plans. For CalPERS medical plan features, refer to the CalPERS Benefit Summary and Program Guide. You can obtain these materials by contacting CalPERS directly. (See Contact Information on the back cover.) These elections are not reflected on your County benefit forms COR Benefits Guide 13

14 YOUR HEALTH CARE OPTIONS HOW YOUR MEDICARE ELIGIBILITY AFFECTS YOUR CHOICE OF PLANS The County medical plans available to you depend on your age, your eligibility for Medicare and where you live. If you are enrolling dependents, you must also consider their ages, eligibility and residence to make sure that you enroll in a plan that is appropriate for you and your eligible dependents. FOR RETIREES WHO ARE NOT ELIGIBLE FOR MEDICARE IF YOU ARE UNDER AGE 65 AND ARE NOT ELIGIBLE FOR MEDICARE, YOU CAN ENROLL IN THESE PLANS: If you live in the plan s service area Exclusive Care EPO UnitedHealthcare PPO UnitedHealthcare Signature Value HMO Kaiser Permanente HMO If you live outside the plan s service area UnitedHealthcare PPO Family members who are Medicare-eligible will be enrolled in the Medicare version of the plan you elect. For example, if you are not Medicare-eligible and choose the Exclusive Care EPO plan, your spouse who is eligible for Medicare will be enrolled in the Exclusive Care Select Medicare Supplement Plan. If your dependent is over age 65 but not enrolled in Medicare Parts A and B, your premium will be higher. Please contact the Benefits Information Line for options and costs. FOR RETIREES WHO ARE ELIGIBLE FOR MEDICARE IF YOU AND/OR YOUR DEPENDENTS ARE ELIGIBLE FOR MEDICARE, YOU CAN ENROLL IN THESE PLANS: If you live in the plan s service area Exclusive Care Select Medicare Coordination Plan Exclusive Care Select Medicare Supplement Plan Kaiser Senior Advantage HMO - High Option Kaiser Senior Advantage HMO - Low Option UnitedHealthcare EPO Coordination of Benefits Plan UnitedHealthcare PPO Coordination of Benefits Plan UnitedHealthcare Medicare Advantage HMO Plan SCAN HMO If you live outside the plan s service area Exclusive Care Select Medicare Coordination Plan Exclusive Care Select Medicare Supplement Plan UnitedHealthcare Medicare Indemnity Coordination Plan available only outside California UnitedHealthcare PPO Coordination of Benefits Plan Choose one of these plans if you or one or more of your dependents are eligible for Medicare. Family members who are not Medicare-eligible will be enrolled in the non-medicare version of the plan. For example, if you are Medicare-eligible and choose a Kaiser Senior Advantage plan, your dependents who are not eligible for Medicare will be enrolled in the Kaiser Permanente HMO plan. (Keep in mind that you and your dependents may be enrolled in plans with different copayments for this reason.) The one exception is the SCAN plan, which is open to Medicare-eligible members only and has no non-medicare counterpart. If you are eligible for Medicare but your dependents are not, you cannot enroll in the SCAN plan COR Benefits Guide

15 YOUR HEALTH CARE OPTIONS IMPORTANT NOTE ABOUT LIVING IN YOUR PLAN S SERVICE AREA Some of the medical plan options offer coverage only to members who live in their service area. The guidelines for determining whether you live in a plan s service area are shown below. Remember to contact the County of Riverside Benefits Division team if you move out of your plan s service area. UnitedHealthcare Signature Value HMO, UnitedHealthcare EPO Coordination of Benefits Plan or UnitedHealthcare Medicare Advantage Plan: You must live or work within the plan s service area. You will be covered only for urgent care and emergency services when temporarily outside the service area. If you move outside the plan s service area, your coverage will be terminated, and you ll have to elect another plan. Exclusive Care EPO Plan: You must have a permanent address within 30 miles of the border of Riverside County and reside at that address 12 months out of the year. Out-ofarea/out-of-network care is covered only in the case of an emergency during travel. If you live somewhere else part of the year, you should enroll in the UnitedHealthcare PPO Plan for greater flexibility in choosing cost-effective care. Kaiser Senior Advantage HMO (High Option and Low Option): You must have a permanent home address in the plan s service area; a post office box or rental mailbox cannot be used to determine whether you meet the residence eligibility. If you permanently move outside the Kaiser service area, or you are temporarily absent from the service area for a period of more than six months in a row, you must notify Kaiser. You will not be able to continue your Senior Advantage membership under this plan. SCAN HMO: You must live within the plan s service area for more than six months of the year to be eligible. Your membership will end if you move out of the service area or stay out of the service area for more than six consecutive months. Coverage for services provided outside the network is limited to emergency care only. If you or your dependents are age 65 or older and are NOT eligible for Medicare, the UnitedHealthcare Signature Value HMO, Kaiser HMO, Exclusive Care EPO and UnitedHealthcare PPO remain available to you. Please contact the Benefits Information Line for assistance with your eligibility, enrollment and premiums. Following are brief descriptions of the types of plans offered to pre-medicare-eligible retirees in Key features and benefits of these plans are shown in the comparison charts on pages (early retirees) and pages (Medicare-eligible retirees) COR Benefits Guide 15

16 NOT ELIGIBLE FOR MEDICARE MEDICAL PLANS FOR RETIREES WHO ARE Not Eligible for Medicare HEALTH MAINTENANCE ORGANIZATION (HMO) PLANS The County offers two HMO plans for early retirees under age 65 who do not have Medicare: UnitedHealthcare Signature Value HMO Kaiser Permanente HMO UnitedHealthcare Signature Value HMO. If you enroll in the UnitedHealthcare HMO plan, you (and each enrolled member of your family) will choose a primary care physician (PCP) who is part of the HMO provider network. Your PCP will coordinate all of your health care. If you need specialty care, your PCP will refer you to a network specialist or hospital within the same participating group. You have no annual deductibles or claim forms to complete, and you pay only an affordable copayment each time you go to the doctor. If you need a provider directory, visit UnitedHealthcare online at or contact the UnitedHealthcare Member Services Department toll-free at (800) Kaiser Permanente HMO. This plan is available to you if you are under age 65 and not eligible for Medicare. If you enroll in the Kaiser Permanente HMO, you must go to Kaiser Permanente doctors, hospitals and other Kaiser health care facilities whenever you need medical care. You pay no annual deductible under this plan and will generally receive 100% coverage after a copayment for office visits. In a life-threatening emergency, you are covered wherever you seek services. If you need a listing of Kaiser Permanente facilities, visit or contact the plan s Member Services at (800) Please note that the Kaiser Permanente plan is available only to retirees who live within the plan s Southern California service area. IMPORTANT INFORMATION ABOUT HMO PROVIDERS If you enroll in an HMO plan (other than the Kaiser HMO Plan), you ll be asked to designate a primary care physician (PCP). To locate a PCP in your area, visit the plan s website or call Member Services. If you do not select a PCP, one will be assigned to you. (See page 51 for contact information.) COR Benefits Guide

17 NOT ELIGIBLE FOR MEDICARE EXCLUSIVE PROVIDER ORGANIZATION (EPO) PLAN Exclusive Care is the County of Riverside s self-administered EPO plan. Both County and CalPERS eligible retirees can enroll in the Exclusive Care EPO. The Exclusive Care EPO is available to all early retirees and eligible dependents who live or work in the plan s local service area. Exclusive Care s local service area includes all of Riverside County, as well as areas immediately adjacent to Riverside County whose ZIP codes are within 30 miles of the Riverside County border. Eligible dependents who do not reside with you and live outside of the Exclusive Care service area can receive benefits under Exclusive Care s out-of-area indemnity plan feature. Exclusive Care provides coverage through contracted health care providers. Unlike other managed health care plans, Exclusive Care s primary care providers are not paid a fixed amount per month. All providers are paid for each treatment, no matter how frequently the patient is seen. Exclusive Care was created by the County of Riverside as a high-value health plan option whose members pay substantially less than other health plans in premiums and copayments. The savings in premiums alone often enables the retiree to purchase two-party or family coverage versus individual coverage. How the EPO Plan Works. If you enroll in this plan, you (and each enrolled family member) will choose a primary care physician (PCP) from the Exclusive Care network. Your chosen PCP will coordinate all of your non-emergency health care needs. This PCP can be a family practitioner, internist, pediatrician or general practitioner. If you need specialty care, your PCP will refer you to a network specialist or hospital. Through your PCP, you will have access to full-service medical care within the network and in some circumstances outside the network. Initial visits to OB/GYNs and chiropractors can be made without a referral from your PCP. You pay no annual deductible under this plan and will generally receive 100% coverage with a small copayment for office visits, prescription drugs and other services. There is a maximum out-of-pocket limit of $3,000 per member each calendar year. In a life-threatening emergency, you are covered wherever you seek services, even if outside the network. If an enrolled dependent lives outside of the plan s service area, please contact Exclusive Care for more information about their out-of-area benefits. For additional information or a provider directory, visit Exclusive Care at or contact Exclusive Care Member Services at (800) You can also learn more about Exclusive Care by contacting the Benefits Information Line at (951) COR Benefits Guide 17

18 NOT ELIGIBLE FOR MEDICARE UNITEDHEALTHCARE SELECT PLUS PPO MEDICAL PLAN A Preferred Provider Organization (PPO) gives you the freedom to receive medical services from any licensed provider you choose, with lower copayments when you use UnitedHealthcare Select Plus PPO network providers. The County offers a PPO plan through UnitedHealthcare. How the PPO Plan Works. A PPO is a network of doctors and health care facilities that provide services to plan members at special discounted rates. The PPO plan gives you the freedom to go to any provider you choose but it pays higher benefits when you go to a doctor or health care facility in the UnitedHealthcare PPO Select Plus network. You must pay a portion of most covered medical expenses each year before the plan will pay benefits. This amount is called your deductible. After the deductible is paid, you will pay a percentage of your covered medical expenses; this percentage is called your coinsurance. If your share of the medical expenses reaches an amount called the out-of-pocket maximum, you will not have to pay any more coinsurance for the rest of the calendar year (as long as you continue to use network providers). In the PPO Network. When you go to a PPO provider, your coinsurance will be lower and you can take advantage of the PPO provider s discounted rates. Also, there are no claim forms to complete when you go to an in-network provider. Outside the PPO Network. If you go to a doctor or health care facility that does not belong to the UnitedHealthcare PPO network, your out-of-pocket costs will be higher. Also, the plan will pay benefits only up to the allowed amount, which is based on a limited fee schedule. You will have to pay any charges above the allowed amount (in addition to your regular coinsurance). If you need a provider directory, visit UnitedHealthcare online at or contact UnitedHealthcare Member Services at (866) COR Benefits Guide

19 NOT ELIGIBLE FOR MEDICARE PATIENT PROTECTION NOTICE The UnitedHealthcare Signature Value HMO and Exclusive Care EPO plans generally require the designation of a primary care provider. You have the right to designate any primary care provider who participates in the plan s network and who is available to accept you or your family members. For children, you can designate a pediatrician as the primary care provider. You do not need prior authorization from UnitedHealthcare, Kaiser or Exclusive Care, or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the plan s network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a preapproved treatment plan, or following procedures for making referrals. For information about how to select a primary care provider, and for a list of the participating primary care providers including a list of participating health care professionals who specialize in obstetrics and gynecology contact your health plan. Contact information for each plan is listed on the back cover of this guide. Please refer to the individual medical plan booklets for a summary of plan benefits. If there are any discrepancies between these booklets and the official plan documents, the official plan documents will prevail. Medical plan booklets are available on the benefits website at or by contacting the Benefits Information Line at (951) For information about CalPERS medical plans, refer to your CalPERS enrollment materials. PLEASE USE THE FOLLOWING FOOTNOTE REFERENCES WITH COUNTY MEDICAL PLANS COMPARISON CHARTS ON PAGES 20 THROUGH You will pay any amount charged by an out-ofnetwork provider that is in excess of the plan s fee schedules. 2. Benefits are not subject to a deductible. 3. Deductibles and copayments do not count toward the out-of-pocket maximum. 4. Women s preventive care services include: screening for gestational diabetes; human papillomavirus (HPV) DNA testing for women 30 years and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV screening and counseling; family planning; FDAapproved contraception methods and contraceptive counseling; breastfeeding support, supplies, and counseling; domestic violence screening and counseling; and preventive sterilizations. The applicable cost sharing for preventive care will apply to these services. 5. Infertility services, supplies, injections, and medications are limited to a lifetime maximum benefit of $2,000 (combined PPO network and outof-network). 6. Infertility benefit is limited to physician services and diagnostic testing only COR Benefits Guide 19

20 NOT ELIGIBLE FOR MEDICARE FOR RETIREES AND DEPENDENTS UNDER AGE 65 AND/OR WHO ARE NOT MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. UHC SELECT PLUS PPO PPO NETWORK OUT-OF-NETWORK 1 Choice of physician Any network provider Any licensed provider Deductible Calendar year out-of-pocket maximum 3 Lifetime maximum benefit $500/person; $1,000/family $3,000/person; $6,000/family Unlimited OFFICE VISIT BENEFITS Physician office visits 100% after $20 copay 2 40% after deductible Diagnostic X-ray and lab 100% 2 40% after deductible Adult preventive care (includes mammography, Pap smear, sigmoidoscopy and prostate exam) 100% 2 100% 2 Well-baby care 100% 2 100% after deductible Well-woman care 100% 2 100% after deductible Vision exams (preventive) 100% 100% after deductible Vision exams (refractive) 100% after $20 copay 40% after deductible PRESCRIPTION DRUGS Network retail pharmacies (up to a 30-day supply) Network mail order (up to a 90-day supply) Generic: $5 copay 2 Preferred brand: $15 copay 2 Nonpreferred brand: $45 copay 2 Generic: $10 copay 2 Preferred brand: $30 copay 2 Nonpreferred brand: $90 copay 2 Generic: $5 copay Preferred brand: $15 copay Nonpreferred brand: $45 copay Plus 50% of average wholesale price Not covered HOSPITAL AND EMERGENCY ROOM SERVICES Inpatient hospital services 20% after deductible 40% after deductible Physician hospital visits 20% after deductible 40% after deductible Ambulatory surgical center 20% after deductible 40% after deductible Ambulance (medically necessary) 20% after deductible 20% after deductible Hospital emergency room $50 deductible applies if not admitted $50 copay applies if not admitted Urgent care facility $20 deductible applies if not admitted 40% after deductible MENTAL HEALTH Inpatient services 20% after deductible 40% after deductible Outpatient services 100% after $20 copay 2 40% after deductible SUBSTANCE ABUSE TREATMENT Inpatient program 20% after deductible 40% after deductible Outpatient office visits 100% after $20 copay 2 40% after deductible Refer to footnotes on page COR Benefits Guide

21 NOT ELIGIBLE FOR MEDICARE FOR RETIREES AND DEPENDENTS UNDER AGE 65 AND/OR WHO ARE NOT MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. UHC SELECT PLUS PPO PPO NETWORK OUT-OF-NETWORK 1 OTHER BENEFITS Chiropractic $20copay/visit 40% after deductible Benefits limited to 24 visits/calendar year (combined PPO network and out-of-network) Durable medical equipment 20% after deductible 40% after deductible Home health care 20% after deductible 40% after deductible Benefits limited to 100 visits/calendar year (combined PPO network and out-of-network) Hospice services 20% after deductible 40% after deductible (15-visit maximum) Rehabilitation therapy (includes outpatient physical, speech, occupational, respiratory, and cardiac therapy) 100% after $20 copay/visit 40% after deductible Skilled nursing facility 20% after deductible 40% after deductible FAMILY PLANNING SERVICES (PROFESSIONAL SERVICES ONLY) Benefits limited to 60 days/calendar year Contraceptive methods (includes intrauterine device (IUD) and injectable or implantable contraceptives) 20% after deductible 40% after deductible Infertility services (includes professional services, inpatient and outpatient care, treatment by injection, and prescription drugs). 20% after deductible up to a lifetime maximum of $2, % after deductible Sterilization of females 20% after deductible 40% after deductible Sterilization of males 20% after deductible 40% after deductible Reversal of sterilization Not covered Not covered Refer to footnotes on page COR Benefits Guide 21

22 NOT ELIGIBLE FOR MEDICARE FOR RETIREES AND DEPENDENTS UNDER AGE 65 AND/OR WHO ARE NOT MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. Choice of physician EXCLUSIVE CARE EPO KAISER HMO UHC SIGNATURE VALUE HMO NETWORK ONLY NETWORK ONLY NETWORK ONLY Any Exclusive Care network physician Any Kaiser physician and/or facility Calendar year deductible None None None Calendar year out-of-pocket maximum $1,500/person $3,000/family $1,500/person $3,000/family All care must be coordinated by your PCP $1,500/person $3,000/family Lifetime maximum benefit Unlimited Unlimited Unlimited Pre-existing condition limitation Fully covered Fully covered Fully covered OFFICE VISIT BENEFITS W H A T T H E P L A N P A Y S Diagnostic X-ray and lab 100% 100% 100% Immunizations 100% 100% 100% (you pay 20% coinsurance for foreign travel immunizations) Periodic health evaluations/ physicals 100% 100% 100% Physician office visits 100% after $15 copay 100% after $15 copay 100% after $15 copay Vision exams 100% for screening and refraction 100% after $15 copay 100% for screening; $15 copay for refraction Well-baby care 100% 100% 100% Well-woman care 100% 100% 100% PRESCRIPTION DRUGS W H A T T H E P L A N P A Y S Network retail pharmacies (30- to 34-day supply) Network mail order (90-day supply) Generic: 100% after $10 copay Brand formulary: 100% after $25 copay Brand nonformulary: 100% after $50 copay Generic: 100% after $20 copay Brand formulary: 100% after $50 copay Brand nonformulary: 100% after $100 copay Mail order is MANDATORY for maintenance medications after a 30-day trial Generic: 100% after $10 copay (31-day supply) Brand formulary: 100% after $25 copay (31-day supply) Generic: 100% after $20 copay (100-day supply) Brand formulary: 100% after $50 copay (100-day supply) Generic: 100% after $10 copay Brand* formulary: 100% after $25 copay Brand* nonformulary: 100% after $50 copay Generic: 100% after $20 copay Brand formulary: 100% after $50 copay Brand nonformulary: 100% after $100 copay * If you have a prescription filled with a brand-name drug when a generic equivalent is available, you will pay the copayment PLUS the cost difference between that drug and the generic (unless your physician indicates that the brand-name drug must be dispensed as written). Some medications require prior authorization from UnitedHealthcare. Refer to footnotes on page COR Benefits Guide

23 NOT ELIGIBLE FOR MEDICARE FOR RETIREES AND DEPENDENTS UNDER AGE 65 AND/OR WHO ARE NOT MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. EXCLUSIVE CARE EPO KAISER HMO UHC SIGNATURE VALUE HMO NETWORK ONLY NETWORK ONLY NETWORK ONLY HOSPITAL AND EMERGENCY ROOM SERVICE W H A T T H E P L A N P A Y S Ambulance (medically necessary) 100% 100% 100% Ambulatory surgical center 100% 100% after $15 copay 100% Physician hospital visits 100% 100% after $100 copay/ admission Inpatient hospital 100% after $100 copay/ admission 100% after $100 copay/ admission Outpatient hospital 100% 100%; $15 copay/procedure for outpatient surgery Hospital emergency room 100% after $100 copay (waived if admitted) 100% after $100 copay (waived if admitted) Urgent care 100% after $20 copay 100% after $15 copay $35 copay MENTAL HEALTH W H A T T H E P L A N P A Y S 100% 100% after $100 copay/ admission 100% 100% after $100 copay; waived if admitted Inpatient benefit $100 copay/admission 100% after $100 copay/admission Outpatient benefit $15 copay/visit $15 copay/private visit; $7 copay/group visit $100 copay/admission $15 copay/visit Refer to footnotes on page COR Benefits Guide 23

24 NOT ELIGIBLE FOR MEDICARE FOR RETIREES AND DEPENDENTS UNDER AGE 65 AND/OR WHO ARE NOT MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. EXCLUSIVE CARE EPO KAISER HMO UHC SIGNATURE VALUE HMO NETWORK ONLY NETWORK ONLY NETWORK ONLY SUBSTANCE ABUSE TREATMENT W H A T T H E P L A N P A Y S Inpatient detoxification 100%; $100 copay/admission $100 copay/admission No charge Outpatient detoxification $15 copay/visit $15 copay/private visit; $5 copay/group visit $15 copay/visit OTHER BENEFITS W H A T T H E P L A N P A Y S Allergy testing and treatment 100% after $15 copay 100% after $15 copay/visit for testing; 100% after $3 copay/ visit for injections 100% after $15 copay Chiropractic 100% after $15 copay; up to 12 visits/calendar year 100% after $15 copay/visit; up to 20 visits/calendar year 100% after $15 copay for chiropractic and acupuncture; up to 20 visits combined annual maximum Durable medical equipment 50% 100% 100% Family planning - Elective pregnancy termination 100% after $50 copay for 1st trimester; $100 for 2nd trimester; 3rd trimester not covered unless life-threatening - Infertility services 50% of costs up to a lifetime maximum benefit of $10, % after $15 copay 100% after $125 copay 50% of costs 6 50% of cost copay (see plan rider for additional information) - Tubal ligation 100% 100% after $15 copay 100% - Vasectomy 100% 100% after $15 copay $50 copay Home health care 100% 100% /100 visit max 100% after $15 copay, up to 100 visits/calendar year Hospice (routine home and inpatient respite care) Hospice (24-hour continuous home care and general inpatient care) 100% 100% 100% 100% 100% 100% (prognosis of life expectancy of one year or less); after a $100 copay/admission Physical therapy $15 copay/visit; up to 30 visits/ disability (within 90-day period) 100% after $15 copay 100% Skilled nursing facility 100%, up to 100 days/disability 100% up to 100 days/calendar year 100% after $100 copay/ admission, up to 100 days/ benefit period Refer to footnotes on page COR Benefits Guide

25 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR Medicare-Eligible Retirees HEALTH MAINTENANCE ORGANIZATION (HMO) PLANS The County offers four HMO plans for retirees and their eligible family members who have Medicare: UnitedHealthcare Medicare Advantage Plan Kaiser Senior Advantage High Option and Low Option SCAN HMO These plans are Medicare Advantage plans under Medicare Part C. If you enroll in one of these plans, you must be enrolled in and maintain enrollment in Medicare Parts A and B. You will then assign your Medicare benefits to the plan and receive all of your medical care within the plan s HMO network. You will receive benefits at least as good as, and often better than, what you would have received with Medicare alone. Because of your Medicare assignment, Medicare will pay a portion of your medical plan premium in lieu of paying your medical benefit. Therefore, your monthly premium will be lower with one of these plans. The premium you pay will be the amount required over and above what Medicare will pay on your behalf. Also, because your Medicare benefits will be assigned to the HMO plan, you will not be allowed to go outside of the HMO network for care (except in the case of an emergency). SCAN Independent Living Power. SCAN offers unique in-home services, known as Independent Living Power, to help keep people on Medicare healthy and independent. These services can help you during recovery from a hospital stay or provide support during an acute episode of longterm illness. Many seniors find that these services provide the extra assistance necessary to stay out of a nursing home. IMPORTANT REMINDERS If you do not enroll in Medicare when you first become eligible, you may not be eligible for some plans or your costs may be higher. Here are a few important things to keep in mind as you consider your enrollment decisions: In order to avoid penalties, you should elect Medicare when you first become eligible. Check with Medicare to learn more about these penalties and how to avoid them. There are some reasons you may delay Medicare enrollment without a penalty. One example is if you are covered by your spouse s employer-based coverage. You should NOT enroll in a separate Medicare Part D plan. You will get your prescription drug coverage through your County of Riverside medical plan, so you do not need other Medicare Part D coverage. If you enroll in another Medicare Part D plan, you and your dependents will not be eligible to receive all of your health and prescription drug benefits and will be disenrolled from the plan. If you enroll in the Kaiser Senior Advantage High Option or Low Option, the UnitedHealthcare Medicare Advantage Plan or the SCAN medical plan, you will automatically be enrolled in Medicare Part D and assign your benefits to the plan. This enrollment will be done for you when you join one of these plans, and you will NOT be required to pay any additional monthly premium. Do not sign up for a Medicare Part D plan on your own. Please note that if you decide to switch from the Kaiser, UnitedHealthcare Medicare Advantage Plan or SCAN plan to one of the other plans, it will take up to 30 days for Medicare to disenroll you from Medicare Part D coverage or change your assignment of Medicare benefits COR Benefits Guide 25

26 MEDICARE-ELIGIBLE RETIREES Members who qualify for Independent Living Power are eligible for up to $500 per month in additional benefits, such as free home-delivered meals and a range of home health care and homemaking services for only a $15 copayment. Independent Living Power is available only to members who live in approved ZIP codes within Los Angeles, Orange, Riverside and San Bernardino counties. For more information, please contact SCAN at (877) or the Benefits Information Line at (951) Plans for Family Members Who Are Not Eligible for Medicare. One of the advantages of the County s group plans is that Exclusive Care Select Medicare Supplement, Exclusive Care Medicare Coordination, UnitedHealthcare Medicare Advantage, UnitedHealthcare EPO Coordination Plan, UnitedHealthcare PPO Coordination Plan, UnitedHealthcare Indemnity Coordination Plan, and the Kaiser Senior Advantage High Option and Low Option plans will allow you to enroll you and your dependents in the appropriate type of coverage if someone in your family is under 65 and not eligible for Medicare. For example, if you are Medicare-eligible but your spouse is not, you would be enrolled in the Kaiser Senior Advantage High Option or Low Option plan, and your spouse would be enrolled in the Kaiser HMO plan offered to non-medicare-eligible retirees. You will pay one premium rate for your entire family, but each family member will have access to a health plan based on his or her age and eligibility for Medicare. Please note the SCAN plan does not offer coverage to dependents who are not eligible for Medicare. If your dependent is not eligible for Medicare, you must select another plan for both yourself and your dependents. WARNING! DO NOT RISK LOSING YOUR COUNTY COVERAGE BY JOINING A PRIVATE MEDICARE ADVANTAGE PLAN! You may receive offers or advertisements for free private Medicare Advantage plans. If you enroll in one of these plans, your Medicare benefits or other Medicare plan will be assigned to the new plan, and you will lose your County medical coverage. Please do not enroll in one of these plans without studying the benefits closely. These plans typically have higher out-of-pocket costs when you receive care and may have no coverage or minimal coverage for prescription drugs. If you have any questions about how your County medical benefits compare with plans on the private market, please call the Benefits Information Line at (951) and Select Option COR Benefits Guide

27 MEDICARE-ELIGIBLE RETIREES MEDICARE COORDINATION PLANS The County offers several medical plans that coordinate your benefits with your Medicare coverage. Medicare-eligible retirees and family members can choose from the following coordination of benefits (COB) plans: Exclusive Care Select Medicare Coordination Plan UnitedHealthcare EPO COB Plan UnitedHealthcare PPO COB Plan UnitedHealthcare Indemnity Medicare COB Plan members outside California only Exclusive Care Select Medicare Coordination Plan. Under this plan, you can seek care from any provider who accepts Medicare assignment. Medicare will pay benefits first, with the Exclusive Care Select Medicare Coordination Plan providing secondary coverage up to the plan limits. The plan will pay Tier 1 benefits for Exclusive Care providers and Tier 2 benefits for other providers who accept Medicare assignment (subject to the plan s benefit limits and reasonable and customary amounts). You must be enrolled in and maintain enrollment in Medicare Part A and/or Part B to sign up for the Exclusive Care Select Medicare Coordination Plan. Exclusive Care Centers of Excellence Members must obtain prior authorization from Exclusive Care for services in cardiac care, complex and rare cancer treatments, transplant services, joint replacement surgery, mental health care and other highly specialized complex care programs. Exclusive Care s Medical Director has designated and approved access to medical facilities across the nation that have demonstrated expertise in delivering quality health care for these treatments. The Center of Excellence designation is based on rigorous, evidence-based, objective selection criteria established in collaboration with expert physicians and medical organizations recommendations. Exclusive Care members with these special treatment needs will be evaluated through prior authorization and other medical management programs to improve the overall quality and delivery of health care and to support better overall health outcomes for members. The Exclusive Care Select Plan will pay benefits at the Tier 1 level for all allowable charges approved under this program. If you do not get prior authorization and go to the designated Center of Excellence, benefits will be paid at the out-of-network level. UnitedHealthcare EPO Coordination of Benefits (COB) Plans. UnitedHealthcare s Medicare COB plans work just like traditional EPO or PPO plans, but they coordinate the cost of care with Medicare as the primary payer. You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare COB plan. You must show your Medicare card in addition to your UnitedHealthcare identification card when obtaining services. If you choose the EPO COB plan, you also must live within the UnitedHealthcare EPO service area COR Benefits Guide 27

28 MEDICARE-ELIGIBLE RETIREES PPO COB Plan. Medicare PPO coverage is designed to give you a greater level of choice. Every time you seek care, you have the option of using in-network or out-of-network care. When you use this plan, your Medicare deductibles and coinsurance are 100% covered. For in-network care, simply make an appointment with any contracted PPO doctor. There s no referral or authorization required. UnitedHealthcare s PPO network has more than 72,000 physicians. For out-of-network care, make an appointment with any licensed physician you wish to see. You will generally have higher copayments and coinsurance if you seek care or treatment from an out-of-network PPO provider. Certain services may require claim forms to be submitted to UnitedHealthcare for reimbursement. Under the Medicare COB plans, Medicare is the primary plan and UnitedHealthcare is the secondary plan. Claims are first submitted by your provider to the Medicare intermediary for determination and payment of allowable amounts. The Medicare intermediary then sends a Medicare Summary Notice to the provider of service, who will then submit the claim to UnitedHealthcare. The Medicare Summary Notice is a summary of benefits paid on your behalf by Medicare. You will also receive a copy of the Medicare Summary Notice. Please note: Some secondary claims are sent electronically to UnitedHealthcare by Medicare and do not require that the provider of service submit the claim. UnitedHealthcare and/or your medical provider is responsible for paying the difference between the amount Medicare paid and the amount of the covered service. MEDICARE SUPPLEMENT PLAN The Exclusive Care Select Medicare Supplement Plan works with your Medicare benefits to pay 100% of all Medicare-approved amounts when you receive services from a provider who accepts Medicare assignment. The plan pays your Medicare Part A deductible; it also includes prescription drug coverage. You must pay the Medicare Part B deductible each year before the plan pays its share. Under the Medicare Supplement Plan, you can go to any licensed provider you choose but your out-of-pocket expenses will be lower if you go to a provider who accepts Medicare. When you receive covered medical services, Medicare is billed first for the total cost of the services. After Medicare pays, this plan will pay the applicable amount of allowable charges, subject to any limitations, copayments or deductibles. If you go to a provider who does not accept Medicare, you will be responsible for the difference between the Medicare-approved amount and the billed charges COR Benefits Guide

29 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. EXCLUSIVE CARE SELECT MEDICARE COORDINATION PLAN TIER 1: EXCLUSIVE CARE NETWORK TIER 2: ANY PROVIDER WHO ACCEPTS MEDICARE ASSIGNMENT BENEFIT PROVISIONS Coordination with Medicare Medicare will pay benefits first; the plan will then pay the benefits shown below when you go to a Tier 1 provider who accepts Medicare assignment Medicare will pay benefits first; the plan will then pay the benefits shown below when you go to a provider who accepts Medicare assignment (based on Medicare reimbursement fees) Choice of physician Any Exclusive Care contracted provider Any provider who accepts Medicare assignment Deductible $250/person; $750/family $500/person; $1,500/family Out-of-pocket maximum 3 $1,500/person; $4,500/family $2,500/person; $7,500/family Lifetime maximum benefit Pre-existing condition limitation Unlimited Fully covered (provided it is a covered benefit) Fully covered (provided it is a covered benefit) OFFICE VISIT BENEFITS W H A T T H E P L A N P A Y S Physician office visits 100% after $10 copay 2 100% after $25 copay 2 Diagnostic X-ray and lab 90% after deductible 80% after deductible Immunizations 100% 2 100% 2 Periodic health evaluations/ physicals 100% 2 100% 2 Vision exams 100% 2 100% 2 Well-woman care 100% 2 100% 2 PRESCRIPTION DRUGS W H A T T H E P L A N P A Y S Network retail pharmacies (30- to 34-day supply) Network mail order (90-day supply) HOSPITAL AND EMERGENCY ROOM SERVICES Ambulance (medically necessary) Generic drugs: 100% after $15 copay; brand formulary: 100% after $25 copay; brand nonformulary: 100% after $40 copay; significant or new therapeutic class drugs: 50% Generic drugs: 100% after $30 copay; brand formulary: 100% after $50 copay; brand nonformulary: 100% after $80 copay; Mail order is MANDATORY for maintenance medications after a 30-day trial. No copays required for diabetic, cholesterol and hypertension medications W H A T T H E P L A N P A Y S 90% after deductible 80% after deductible Ambulatory surgical center 90% after deductible 80% after deductible Physician hospital visits 100% after $10 copay 2 100% after $25 copay 2 Inpatient hospital care 90% after deductible 80% after deductible Outpatient hospital care 90% after deductible 80% after deductible Hospital emergency room 90% after a $50 copay 2 80% after $100 copay 2 Urgent care 100% after $20 copay 2 100% after $50 copay COR Benefits Guide 29

30 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. EXCLUSIVE CARE SELECT MEDICARE COORDINATION PLAN TIER 1: EXCLUSIVE CARE NETWORK TIER 2: ANY PROVIDER WHO ACCEPTS MEDICARE ASSIGNMENT MENTAL HEALTH W H A T T H E P L A N P A Y S Inpatient care 90% after deductible 80% after deductible Outpatient care $20 copay 2, up to 30 visits/calendar year Not covered SUBSTANCE ABUSE TREATMENT W H A T T H E P L A N P A Y S Inpatient program 90% after deductible 80% after deductible Inpatient detoxification 90% after deductible 80% after deductible Outpatient hospital services Outpatient office visits 100% after $20 copay/visit 2, up to 30 visits/calendar year 100% after $20 copay/visit 2, up to 30 visits/calendar year OTHER BENEFITS W H A T T H E P L A N P A Y S Allergy testing and treatment 90% after deductible 80% after deductible Chiropractic Not covered Not covered Durable medical equipment 90% after deductible 80% after deductible Home health care 90% after deductible, up to combined max of 26 days/calendar year 80% after deductible, up to combined max of 26 days/calendar year Hospice (routine home and inpatient respite care) Hospice (24-hour continuous home care and general inpatient care) 90% after deductible 80% after deductible 90% after deductible 80% after deductible Physical therapy 90% after deductible. Subject to prior authorization and any therapy cap or threshold limits established by Medicare. 80% after deductible. Subject to prior authorization and any therapy cap or threshold limits established by Medicare. Skilled nursing facility 90% after deductible, up to combined max of 100 days/calendar year 80% after deductible, up to combined max of 100 days/calendar year Refer to footnotes on page COR Benefits Guide

31 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. UNITEDHEALTHCARE EPO COORDINATION OF BENEFITS PLAN UNITEDHEALTHCARE PPO COORDINATION OF BENEFITS PLAN NETWORK ONLY PPO NETWORK OUT-OF-NETWORK 1 UNITEDHEALTHCARE INDEMNITY COORDINATION OF BENEFITS PLAN BENEFIT PROVISIONS Coordination with Medicare The plan pays all Medicare deductibles. Providers first submit claims to Medicare and then submit claims to the plan for the remainder of the Medicare allowed amount. The provider can charge you the office visit copayment. You must use providers in the UnitedHealthcare HMO network who accept Medicare assignment. The plan pays all Medicare deductibles. Providers first submit claims to Medicare and then submit claims to the plan for the remainder of the Medicare allowed amount. As long as you use providers in the UnitedHealthcare PPO network who accept Medicare assignment, you will have no out-ofpocket costs for benefits covered by Medicare. If you use providers outside the UnitedHealthcare PPO network, you may have out-of-pocket costs. Medicare will pay benefits first. The plan will then pay the benefits shown below when you go to a provider who accepts Medicare assignment (based on Medicare reimbursement fees). Choice of physician All care must be coordinated by your PCP Any PPO network provider Any provider who accepts Medicare assignment Any licensed physician who accepts Medicare Deductible None $500/person $1,000/family Out-of-pocket $1,500/person; $3,000/family $1,000/person maximum 3 $2,000/family None $6,350/person $12,700/family Lifetime maximum benefit Unlimited Unlimited Unlimited OFFICE VISIT BENEFITS W H A T T H E P L A N P A Y S Physician office visits 100% after $15 copay 100% after $20 copay 2 40% after deductible Covered in full Diagnostic X-ray and lab 100% 20% after deductible 40% after deductible Covered in full Immunizations 100% 100% 40% after deductible Covered in full (immunizations for foreign travel or occupational purpose not covered) Periodic health evaluations/physicals Vision exams (preventive) 100% 100% 100% Covered in full 100% 100% 100% Covered in full Vision exams (refractive) - Children - Adults 100% after $15 copay 100% after $15 copay 100% after $20 copay 100% after $20 copay 40% after deductible 40% after deductible Covered in full Well-woman care 100% 100% 100% Covered in full Refer to footnotes on page COR Benefits Guide 31

32 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. UNITEDHEALTHCARE EPO COORDINATION OF BENEFITS PLAN UNITEDHEALTHCARE PPO COORDINATION OF BENEFITS PLAN NETWORK ONLY PPO NETWORK OUT-OF-NETWORK 1 UNITEDHEALTHCARE INDEMNITY COORDINATION OF BENEFITS PLAN PRESCRIPTION DRUGS5 W H A T T H E P L A N P A Y S Network retail pharmacies (31- to 34-day supply) Network mail order (90-day supply) Generic: 100% after $10 copay. Brand 6 formulary: 100% after $25 copay. Brand 6 nonformulary: 100% after $50 copay. Injectables: $50 copay 2. Specialty drugs: $50 copay 2. Generic: 100% after $20 copay. Brand formulary: 100% after $50 copay. Brand nonformulary: 100% after $100 copay. Injectables: $100 copay 2. Specialty drugs: $100 copay 2. Generic: $5 copay 2. Preferred brand: $15 copay 2. Nonpreferred brand: $45 copay 2. Injectables: $45 copay 2. Specialty drugs: $45 copay 2. Generic: $10 copay 2. Preferred brand: $30 copay 2. Nonpreferred brand: $90 copay 2. Injectables: $90 copay 2. Specialty drugs: $90 copay 2. Generic: $5 copay. Preferred brand: $15 copay. Nonpreferred brand: $45 copay. plus 50% of average wholesale price. Injectables: $45 copay. Specialty drugs: $45 copay. Generic: $5 copay 2. Preferred brand: $15 copay 2. Nonpreferred brand: $45 copay 2. Injectables: $45 copay 2. Specialty drugs: $45 copay 2. Not covered Generic: $10 copay 2 Preferred brand: $30 copay 2. Nonpreferred brand: $90 copay 2. Injectables: $90 copay 2. Specialty drugs: $90 copay 2. HOSPITAL AND EMERGENCY ROOM SERVICES W H A T T H E P L A N P A Y S Ambulance (medically necessary) Physician hospital visits 100% 20% after deductible 20% after deductible Covered in full 100% 20% after deductible 40% after deductible Covered in full Inpatient hospital care 100% after $100 copay/ admission 20% after deductible 40% after deductible Covered in full Outpatient surgery 100% 20% after deductible 40% after deductible Covered in full Hospital emergency room 100% after $100 copay; waived if admitted 100% after $50 copay; applies if not admitted 100% after $50 copay; applies if not admitted Covered in full Urgent care $35 copay 100% after $20 copay; applies if not admitted 40% after deductible Covered in full Refer to footnotes on page COR Benefits Guide

33 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. UNITEDHEALTHCARE EPO COORDINATION OF BENEFITS PLAN UNITEDHEALTHCARE PPO COORDINATION OF BENEFITS PLAN NETWORK ONLY PPO NETWORK OUT-OF-NETWORK 1 MENTAL HEALTH W H A T T H E P L A N P A Y S Inpatient benefit Outpatient benefit $100 copay/admission (unlimited admissions) $15 copay/visit (unlimited visits) 20% after deductible 40% after deductible Covered in full 100% after $20 copay 2 40% after deductible Covered in full SUBSTANCE ABUSE TREATMENT W H A T T H E P L A N P A Y S Inpatient detoxification Outpatient detoxification $100 copay/admission (unlimited admissions) $15 copay/visit (unlimited visits) 20% after deductible 40% after deductible Covered in full 100% after $20 copay 2 40% after deductible Covered in full OTHER BENEFITS W H A T T H E P L A N P A Y S Allergy testing and treatment 100% after $15 copay 100% after $20 copay 2 40% after deductible Covered in full Chiropractic Not covered $20 copay 40% after deductible Covered in full Durable medical equipment Home health care Refer to footnotes on page visits/calendar year 100% 20% after deductible 40% after deductible Covered in full 100%, up to 100 visits/ calendar year UNITEDHEALTHCARE INDEMNITY COORDINATION OF BENEFITS PLAN 20% after deductible 40% after deductible 100 visits per calendar year. 100 visits/calendar year Intermittent care is Skilled Nursing Care provided or needed either fewer than 7 days each week or fewer than 8 hours each day for periods of 21 days or less 2018 COR Benefits Guide 33

34 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. UNITEDHEALTHCARE EPO COORDINATION OF BENEFITS PLAN UNITEDHEALTHCARE PPO COORDINATION OF BENEFITS PLAN NETWORK ONLY PPO NETWORK OUT-OF-NETWORK 1 UNITEDHEALTHCARE INDEMNITY COORDINATION OF BENEFITS PLAN OTHER BENEFITS W H A T T H E P L A N P A Y S Hospice (routine home and inpatient respite care) Hospice (24-hour continuous home care and general inpatient care) Rehabilitative therapy services (includes outpatient physical, speech, occupational, respiratory and cardiac therapy) Skilled nursing facility 100% 20% after deductible 40% after deductible Covered in full Inpatient respite care is limited to a maximum of 5 consecutive days 100% 20% after deductible 40% after deductible Covered in full 100% after $15 copay 100% after $20 copay 40% after deductible Covered in full 100% after $100 copay, up to 60 days/calendar year 20% after deductible 40% after deductible Covered in full Limited to 60 days per year combined Network and Non-Network Refer to footnotes below. PLEASE USE THE FOLLOWING FOOTNOTE REFERENCES FOR THE COUNTY MEDICAL PLANS COMPARISON CHARTS ON THE PREVIOUS PAGES. 1. You will pay any amount charged by an out-of-network provider that is in excess of the plan s fee schedules. 2. Benefits are not subject to deductible. 3. Copayments do not count toward the out-of-pocket maximum. 4. Infertility benefit is limited to physician services and diagnostic testing only. 6. If you have a prescription filled with a brand-name drug when a generic equivalent is available, you will pay the copayment PLUS the cost difference between that drug and the generic (unless your physician indicates that the brand-name drug must be dispensed as written). Some medications require prior authorization from UnitedHealthcare COR Benefits Guide

35 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. EXCLUSIVE CARE SELECT MEDICARE SUPPLEMENT PLAN BENEFIT PROVISIONS Coordination with Medicare This plan supplements your Medicare coverage. After Medicare pays benefits, the plan is billed. Between this plan and Medicare, you will be covered for 100% of all Medicare-approved amounts when you receive services from a provider who accepts Medicare assignment. If you go to a provider who does not accept Medicare assignment, the plan will pay only up to 20% of the Medicare-approved amount, and you will have to pay the balance (in addition to plan copayments, deductibles and coinsurance). Choices of physician You can go to any provider you choose, but your out-of-pocket expenses will be lower when you go to a provider who accepts Medicare assignment. Deductible Plan pays your Medicare Part A deductible. You are responsible for your Part B deductible before the plan pays for covered services. Out-of-pocket maximum N/A Lifetime maximum benefit Unlimited OFFICE VISIT BENEFITS W H A T T H E P L A N P A Y S Physician office visits Plan pays 20% coinsurance (Medicare pays 80%), after member fulfills annual Medicare Part B deductible. Annual health evaluations/physicals Plan pays any Medicare coinsurance amounts up to the Medicare-approved amount after any applicable Part B deductible. Diagnostic X-ray and lab Plan pays 20% coinsurance (Medicare pays 80%), after member fulfills annual Medicare Part B deductible. PRESCRIPTION DRUGS5 W H A T T H E P L A N P A Y S Participating retail pharmacies, including Exclusive Care s Rubidoux Pharmacy (30- to 34-day supply) Exclusive Care Rubidoux mail order (up to 90-day supply) Generic drugs: 100% after $15 copay Brand formulary: 100% after $25 copay Brand nonformulary: 100% after $40 copay Significant or new therapeutic class drugs: 50% Generic drugs: 100% after $30 copay Brand formulary: 100% after $50 copay Brand nonformulary: 100% after $80 copay No copays required for diabetic, cholesterol and hypertension medications Mail order is MANDATORY for maintenance medications after a 30-day trial. No copays required for diabetic, cholesterol and hypertension medications HOSPITAL AND EMERGENCY ROOM SERVICES W H A T T H E P L A N P A Y S Inpatient hospital care Days 1 60: Plan pays initial Part A annual Medicare deductible Days 61 90: Plan pays additional Medicare daily copay amount Day 91 and after: While using 60 lifetime reserve days, plan pays additional day deductible After 60 Medicare lifetime reserve days are used, plan pays 100% of Medicare-eligible expenses for 365 lifetime additional days Benefits limited to 365 days/lifetime maximum Hospital emergency room Plan pays Medicare-required copay amount, after member fulfills annual Medicare Part B deductible. Skilled nursing facility Days 1 20: Plan pays initial Part A annual Medicare deductible Days : Plan pays Medicare daily copay Day 101 and beyond: Not covered OTHER SERVICES W H A T T H E P L A N P A Y S Physical therapy Plan pays 20% coinsurance (Medicare pays 80%), after member fulfills annual Medicare Part B deductible. Hearing exams and aids Plan pays the amounts listed below, up to a combined benefit of $3,000 every 36 months. Hearing exams: Plan pays the difference (if any) between the amount charged by your provider and the Medicare-approved amount Hearing aids: Plan pays up to $3,000 Durable medical equipment Plan pays 20% coinsurance (Medicare pays 80%), after member fulfills annual Medicare Part B deductible. Refer to footnotes on page COR Benefits Guide 35

36 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. BENEFIT PROVISIONS Coordination with Medicare Choice of physician PLAN COMPARISON FOR MEDICARE ADVANTAGE HMO PLANS KAISER SENIOR ADVANTAGE HMO (HIGH OPTION) KAISER SENIOR ADVANTAGE HMO (LOW OPTION) UHC MEDICARE ADVANTAGE HMO SCAN HMO NETWORK ONLY NETWORK ONLY NETWORK ONLY NETWORK ONLY This plan requires you to assign your Medicare benefits to Kaiser Permanente. This means that you can only receive benefits within the Kaiser network of providers. Any Kaiser provider and/ or facility This plan requires you to assign your Medicare benefits to Kaiser Permanente. This means that you can only receive benefits within the Kaiser network of providers. Any Kaiser provider and/ or facility This plan requires you to assign your Medicare benefits to UnitedHealthcare. This means that you can only receive benefits within the UnitedHealthcare network of providers. All care must be coordinated by your PCP Deductible None None None None Out-of-pocket maximum 3 Lifetime maximum benefit Pre-existing condition limitation $1,500/person $3,000/family $1,500/person $3,000/family $3,400/person $3,400 This plan requires you to assign your Medicare benefits to SCAN. This means that you can only receive benefits within the SCAN network of providers. Any SCAN provider Unlimited Unlimited Unlimited Unlimited Fully covered Fully covered Fully covered Fully covered (provided it is a covered benefit) OFFICE VISIT BENEFITS W H A T T H E P L A N P A Y S Physician office visits 100% after $10 copay 100% after $20 copay 100% after $10 copay 100% after $15 copay Diagnostic X-ray and lab 100% 100% 100% 100% Immunizations 100% 100% 100% 100% Maternity care 100% after $10 copay 100% after $20 copay N/A N/A Periodic health evaluations/physicals 100% after $10 copay 100% after $20 copay 100% 100% after $15 copay Vision exams 100% after $10 copay 100% after $20 copay 100% 100% after $15 copay for exams to diagnose and treat diseases and conditions of the eye Well-baby care 100% after $10 copay 100% after $20 copay N/A N/A Well-woman care 100% after $10 copay 100% after $20 copay 100% 100% after $15 copay Refer to footnotes on page COR Benefits Guide

37 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. KAISER SENIOR ADVANTAGE HMO (HIGH OPTION) KAISER SENIOR ADVANTAGE HMO (LOW OPTION) UHC MEDICARE ADVANTAGE HMO SCAN HMO NETWORK ONLY NETWORK ONLY NETWORK ONLY NETWORK ONLY PRESCRIPTION DRUGS 5 W H A T T H E P L A N P A Y S Network retail pharmacies (30- to 34-day supply) Network mail order (90-day supply) 90-day supplies are also available at preferred pharmacies Generic: 100% after $5 copay Brand formulary: 100% after $15 copay 100 day supply Generic: 100% after $5 copay Brand formulary: 100% after $15 copay 100 day supply Generic: 100% after $10 copay Brand formulary: 100% after $20 copay 100 day supply Generic: 100% after $10 copay Brand formulary: 100% after $20 copay 100 day supply Generic: 100% after $10 copay Brand formulary: 100% after $20 copay 6 Brand nonformulary: 100% after $40 copay 6 Injectables: $40 copay 2 Specialty drugs: $40 copay 2 Generic: 100% after $20 copay Brand formulary: 6 100% after $40 copay Brand nonformulary: 100% after $80 copay 6 Injectables: $80 copay 2 Specialty drugs: $80 copay 2 HOSPITAL AND EMERGENCY ROOM SERVICES W H A T T H E P L A N P A Y S Ambulance (medically necessary) Ambulatory surgical center 100% 100% 100% 100% 100% after $10 copay/ procedure $50 copay/procedure 100% 100% Physician hospital visits 100% 100% 100% 100% Inpatient hospital care 100% 100%; after $500/ admission Generic: 100% after $10 copay or $5 copay at a preferred pharmacy* Brand: 100% after $20 copay Additional brand: 100% after $20 copay Specialty drugs: 100% after 25% coinsurance Generic: 100% after $20 copay or $10 copay at a preferred pharmacy* Brand: 100% after $40 copay Additional brand: 100% after $40 copay 100% 100% after $100 copay Outpatient hospital care 100% 100% 100% 100% Hospital emergency room Urgent care 100% after $10 copay; waived if admitted 100% after $10 copay; waived if admitted 100% after $50 copay; waived if admitted 100% after $20 copay; waived if admitted 100% after $50 copay; waived if admitted 100% after $50 copay; waived if admitted 100% after $50 copay; waived if admitted 100% after $25 copay; waived if admitted MENTAL HEALTH W H A T T H E P L A N P A Y S Inpatient benefit 100%; unlimited admissions 100%; $500/admission (unlimited admissions) 100% 100% after $100 copay/ admission Outpatient benefit Refer to footnotes on page 34. Individual visits: 100% after $10 copay Group visits: 100% after $5 copay Individual visits: 100% after $20 copay Group visits: 100% after $10 copay 100% after $10 copay 100% after $15 copay Please refer to the individual medical plan booklets for detailed lists of covered expenses and for exclusions and limitations. If there are any discrepancies between these booklets and the official plan documents, the official plan documents will prevail. Medical plan booklets are available by contacting the Benefits Information Line at (951) For information about CalPERS medical plans, refer to your CalPERS enrollment materials COR Benefits Guide 37

38 MEDICARE-ELIGIBLE RETIREES MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE MEDICARE-ELIGIBLE These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. KAISER SENIOR ADVANTAGE HMO KAISER SENIOR ADVANTAGE HMO (LOW OPTION) UHC MEDICARE ADVANTAGE HMO SCAN HMO NETWORK ONLY NETWORK ONLY NETWORK ONLY NETWORK ONLY SUBSTANCE ABUSE TREATMENT W H A T T H E P L A N P A Y S Inpatient detoxification 100% 100%; $500/admission 100% 100% after $100 copay/ admission Outpatient detoxification Individual visits: 100% after $10 copay Group visits: 100% after $5 copay Individual visits: 100% after $20 copay Group visits: 100% after $5 copay 100% after $10 copay 100% after $15 copay OTHER BENEFITS W H A T T H E P L A N P A Y S Allergy testing and treatment Chiropractic 100% after $10 copay/ visit for testing; 100% after $3 copay/visit for injections 100% after $15 copay/ visit; up to 20 visits/ calendar year 100% after $20 copay/ visit for testing; 100% after $3 copay/visit for injections 100% after $15 copay/ visit; up to 20 visits/ calendar year 100% 100% $10 copay for services provided by Optum Physical Health providers; up to 30 visits/calendar year Durable medical 100% 80% 100% 100% equipment Home health care 100% 100% 100% 100% Hospice (routine home and inpatient respite care) Hospice (24-hour continuous home care and general inpatient care) 100% 100% You pay nothing for hospice care from a Medicare-certified hospice care. You may have to pay part of the cost for drugs and respite care. Physical therapy 100% after $10 copay 100% after $20 copay 100% after $10 copay; limited to treatment for conditions that should significantly improve through relatively reasonable therapy Skilled nursing facility 100%; up to 100 days/calendar year Refer to footnotes on page %; up to 100 days/calendar year 100%; up to 100 days/ calender year 100% after $15 copay; up to 20 self-referred visits 100% 100% 100% after $15 copay 100%; up to 100 days for each benefit period COR Benefits Guide

39 MEDICARE PRESCRIPTION DRUGS IMPORTANT NOTICE FROM THE COUNTY OF RIVERSIDE ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the County-sponsored medical plans and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. The County of Riverside has determined that the prescription drug coverage offered by the County-sponsored health plans is, on average for all plan participants, expected to pay out as much as or more than standard Medicare prescription drug coverage pays and is considered Creditable Coverage. Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty), if you later decide to join a Medicare drug plan. You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 through December 7. This may mean that you may have to wait to join a Medicare drug plan and that you may pay a higher premium (a penalty) if you join later. You may pay that higher premium (a penalty) as long as you have Medicare prescription drug coverage if you did not enroll in coverage when you first became eligible. However, if you lose creditable prescription drug coverage through no fault of your own, you will be eligible for a 60-day Special Enrollment Period (SEP) to join a Part D plan. If you are enrolled in a County-sponsored medical plan, you should NOT enroll in a Medicare Part D plan. You will get your prescription drug coverage through your County-sponsored medical plan, so you do not need other Medicare Part D coverage. If you enroll in Medicare Part D, you and your dependents will not be eligible to receive all of your County-sponsored health and prescription drug benefits and will be dropped from the plan. If you enroll in a Kaiser Senior Advantage plan, Secure Horizons or the SCAN medical plan, you will automatically be enrolled in Medicare Part D and assign your benefits to the plan. This enrollment will be done for you when you join the plan, and you will NOT be required to pay the monthly premium. Do not sign up for a Medicare Part D plan on your own. Please note that if you decide to switch plans, it will take up to 30 days for Medicare to disenroll you from Medicare Part D coverage or reassign your Medicare benefits COR Benefits Guide 39

40 MEDICARE PRESCRIPTION DRUGS In addition, if you lose or decide to leave employer-/ union-sponsored coverage, you will be eligible to join a Part D plan at that time using an Employer Group Special Enrollment Period. You should compare your current coverage, including which drugs are covered and at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. You should also know that if you drop or lose your coverage with a County-sponsored plan and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without prescription drug coverage that is at least as good as Medicare s prescription drug coverage, your monthly premium may go up by at least 1% of the base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without coverage, your premium may consistently be at least 19% higher than the base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join a Medicare prescription drug plan. FOR MORE INFORMATION ABOUT YOUR OPTIONS UNDER MEDICARE PRESCRIPTION DRUG COVERAGE: More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. FOR MORE INFORMATION ABOUT MEDICARE PRESCRIPTION DRUG COVERAGE: Visit Call your State Health Insurance Assistance Program for personalized help (see your copy of the Medicare & You handbook for telephone numbers in your state; in California, call (800) ). Call (800) MEDICARE ( ). TTY users should call (877) If you have limited income and resources, assistance paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the Web at or call (800) (TTY: ). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained Creditable Coverage and whether or not you are required to pay a higher premium (a penalty). Date: October 1, 2017 Name of Entity/Sender: The County of Riverside Contact -- Position/Office: Human Resources, Benefits Division Address: 4080 Lemon Street, Riverside, CA Phone Number: (951) COR Benefits Guide

41 DENTAL PLANS Dental Plans Dental coverage is an important part of your County of Riverside benefits package and is key to your overall health. The County is pleased to offer you a choice of plans, providers and coverage options. Key features and benefits of the plans are listed on the comparison chart on page 43. DENTAL PLAN ELIGIBILITY Retirees who meet the general eligibility requirements described on page 9 can change plans during the annual enrollment period or elect to enroll for the 2018 plan year. DELTACARE USA HMO DENTAL PLAN The dental HMO plan operates similarly to a medical HMO plan. Dental care is provided through a network of private-practice dental offices. DeltaCare USA HMO coverage is available in California, Arizona, Florida, Nevada, New Mexico, Oregon, Texas, Utah and Wyoming. If you live in one of the states outside California, please see the out-of-state benefits brochure you received with your enrollment package for more information about this plan. When you enroll in this plan, you will select a primary care dentist for yourself and each of your dependents. Your dental office will coordinate all of your dental services. To receive benefits, services must be obtained through your chosen dental provider unless the plan has authorized services elsewhere. Once enrolled, you can change your primary dental provider by contacting the plan s Member Services department. LOCAL ADVANTAGE PLUS EPO DENTAL PLAN The Local Advantage Plus plan pays a percentage of benefits based on the type of service provided. Your dental care is provided through a network of private-practice dentists and dental groups. When you enroll in Local Advantage Plus, you and your dependents are free to choose any of the Local Advantage network providers each time you seek dental care. To receive benefits, your dental services must be obtained through your chosen dental provider unless the plan has authorized services elsewhere. DELTA DENTAL PPO DENTAL PLAN Under the PPO plan, you are free to go to any licensed dentist you choose but if you go to a dentist who is a member of Delta Dental s PPO network, you will receive a higher level of benefits and reduce your out-of-pocket costs. Also, there are no claim forms to fill out when you go to a Delta Dental dentist. The Delta Dental PPO Plan benefits are being enhanced for The plan will now cover implants. You will pay 40% in-network and 50% after the deductible out-of-network. The cost of routine checkups, cleanings and x-rays will not count toward your calendar year maximum, leaving more benefits for major services COR Benefits Guide 41

42 DENTAL PLANS Whenever you need dental care, you have three options: Delta Dental PPO Dentists. This option provides the best value for dental care. PPO dentists are a select group of dentists within the Delta Dental network, and they have agreed to charge PPO plan members significantly reduced rates. Delta Premier Dentists. If you go out of network but see a Delta Premier dentist, your out-of-pocket costs will be higher than if you see a PPO dentist. Delta Premier dentists have reduced their fees and will not bill you above their contracted fees with Delta Dental. If you see a Premier dentist, you will have to pay the difference between the PPO fee and the Premier fee. But Premier dentists cannot charge you more than Delta Dental s contracted fees, so you will receive cost protection. Out-of-Network Dentists. These dentists do not offer discounted rates to Delta Dental plan members. If you go to a non-delta Dental dentist, the plan will pay benefits only up to Delta Dental s approved fee. If your non-delta Dental dentist charges you more than the approved fee, you will have to pay the difference between that cost and the approved fee. You may also have to pay the full cost of the services at the time you receive them, and then submit a claim to Delta Dental to be reimbursed for the covered portion of your bill. Note: Always request a pretreatment estimate or predetermination of benefits before having major dental work done. Don t be afraid to ask questions! Do not agree to any treatment unless you fully understand what condition is being treated, why it is being treated, and the costs of that treatment. When in doubt, contact your dental plan; you ll find the phone numbers for each plan on the back cover of this guide. To obtain a list of participating dentists and dental offices, call the plan s Member Services. Please refer to the individual dental summary plan booklets for detailed lists of covered expenses, exclusions and limitations. If there are any discrepancies between these booklets and the official plan documents, the official plan documents will prevail. Dental summary plan booklets are available by contacting the Benefits Information Line at (951) or visiting PLEASE USE THE FOLLOWING FOOTNOTE REFERENCES WITH THE DENTAL PLANS COMPARISON CHART ON THE NEXT PAGE 1. You will pay any amount charged by your provider that is in excess of Delta Dental s approved fee. 2. You pay the applicable deductible for amalgam (silver) fillings, and the plan pays the remainder up to the allowance for amalgam fillings. 3. Applies to standard cases only. Other discounts apply for nonstandard cases. 4. The Delta PPO program will pay for an amalgam filling on a molar tooth after you pay the applicable deductible. You will be responsible for the additional costs for precious metals. Under the Delta Dental PPO plan, you ll notice that the Delta Premier dentists are shown in the same category as out-of-network dentists. That s because the plan reserves the highest level of benefits for services received from Delta Dental PPO providers COR Benefits Guide

43 DENTAL PLANS COUNTY DENTAL PLANS COMPARISON CHART These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. DELTACARE USA LOCAL ADVANTAGE EPO PLUS DELTA DENTAL PPO HIGH OPTION PLAN (10A) IN-NETWORK DELTA DENTAL PPO DENTISTS PREMIER DENTISTS OUT-OF-NETWORK DENTISTS Annual deductible None None None $50/individual $150/family Calendar year maximum benefit None $1,500/person $1,500/person $1,200/person DIAGNOSTIC AND PREVENTIVE Exams No charge No charge No charge No charge 1 Cleaning No charge No charge No charge No charge 1 Full-mouth X-rays No charge No charge No charge No charge 1 Topical fluoride child No charge No charge No charge No charge 1 Sealants (per tooth) $5 No charge (under age 14) RESTORATIVE No charge No charge 1 Fillings amalgam (silver) No charge You pay 10% You pay 20% of the PPO fee You pay 50% of the PPO fee after the deductible 1 Fillings composite resin (tooth-colored) for anterior (front) teeth Fillings composite resin (tooth-colored) for posterior (back) teeth No charge You pay 10% You pay 20% of the PPO fee $45 $75 When decay is present, you pay the cost difference between amalgam and resin. For cosmetic purposes to replace an alloy/ amalgam filling, you pay 50% 2 You pay 50% of the PPO fee after the deductible 1 Not covered 4 Not covered 4 ENDODONTICS Single root canal $45 You pay 10% You pay 20% of the PPO fee Bicuspid root canal $90 You pay 10% You pay 20% of the PPO fee Molar root canal $205 You pay 10% You pay 20% of the PPO fee You pay 50% of the PPO fee after the deductible 1 You pay 50% of the PPO fee after the deductible 1 You pay 50% of the PPO fee after the deductible 1 PERIODONTICS Periodontal scaling and root planing four or more teeth/quadrant No charge You pay 10% You pay 20% of the PPO fee You pay 50% of the PPO fee after the deductible 1 1, 2, 3, 4 Refer to the box on page 42 for footnote references COR Benefits Guide 43

44 DENTAL PLANS COUNTY DENTAL PLANS COMPARISON CHART These benefit summaries only highlight your benefits. They are not Summary Plan Descriptions (SPDs). If any discrepancy exists between these benefit summaries and the official plan documents, the official plan documents will prevail. DELTACARE USA LOCAL ADVANTAGE EPO PLUS DELTA DENTAL PPO HIGH OPTION PLAN (10A) IN-NETWORK DELTA DENTAL PPO DENTISTS PREMIER DENTISTS OUT-OF-NETWORK DENTISTS CROWNS, BRIDGES AND IMPLANTS Crowns $35 $195 You pay 35% You pay 40% of the PPO fee Bridges $55 $195 You pay 35% You pay 40% of the PPO fee Implants Not covered Not covered You pay 40% of the PPO fee You pay 50% of the PPO fee after the deductible 1 You pay 50% of the PPO fee after the deductible 1 You pay 50% of the PPO fee after the deductible 1 PROSTHODONTICS Complete upper denture $100 You pay 35% You pay 40% of the PPO fee Complete lower denture $100 You pay 35% You pay 40% of the PPO fee You pay 50% of the PPO fee after the deductible 1 You pay 50% of the PPO fee after the deductible 1 ORAL SURGERY Simple extraction No charge You pay 10% You pay 20% of the PPO fee Impaction $25 $90 You pay 10% You pay 20% of the PPO fee You pay 50% of the PPO fee after the deductible 1 You pay 50% of the PPO fee after the deductible 1 COSMETIC Veneers No benefit You pay 50% Not covered Not covered Teeth whitening $125 You pay 50% Not covered Not covered Replacement of existing amalgam filling with composite Not covered You pay 50% Not covered Not covered ORTHODONTICS Child $1,700 You pay $120 down, $120/month for 24 months 3 You pay 50% of the PPO fee You pay 50% of the PPO fee after the deductible 1 Adult (19 and up) $1,900 You pay 50% of the PPO fee You pay 50% of the PPO fee after the deductible 1 Lifetime maximum benefit None None $1,500/person $1,200/person 1, 2, 3, 4 Refer to the box on page 42 for footnote references COR Benefits Guide

45 VISION PLAN Vision Plan To help you maintain good vision, the County of Riverside offers a voluntary vision plan through MES Vision. A voluntary plan is one in which you are responsible for the full cost of the premiums. Because the County is able to leverage its size and negotiate on your behalf, the premiums are lower than what you would pay if you purchased vision coverage on your own. MEDICAL EYE SERVICES (MES) VISION HOW THE PLAN WORKS Under this vision plan, you can choose between network and non-network providers but you will receive a higher level of benefits if you go to a provider in the MES Vision network. MES Vision has the largest network in California and includes the major retail chains like LensCrafters, Walmart, Target and Pearle Vision. To find a provider in your area, you can visit MES Vision online at or call (800) When you go to a network provider, the plan pays the total cost of eye exams, as well as lenses and selected frames. Discounts are also available on lens options (such as ultraviolet protection) and laser eye surgery. If you decide to go to a nonnetwork vision care provider, you will have to pay your entire bill at the time you receive services, and then file a claim with MES Vision. You will be reimbursed for your non-network expenses up to the allowances listed in the chart on the next page. Note: This plan does not require or provide an ID card. WHAT S COVERED? The plan covers eye exams, frames, lenses and contact lenses (if you choose contacts instead of eyeglasses) once every 12 months. The plan does not cover sunglasses (prescription or cosmetic), replacements for lost lenses or frames, or postcataract lenses. For more information, contact MES Vision (see page 51 for contact information). To avoid duplication of coverage, please check to see if your medical plan provides vision benefits. The MES Vision plan does not require or provide an ID card. Using network providers will save money and be more convenient COR Benefits Guide 45

46 VISION PLAN MES VISION PLAN BENEFITS Frequency of Services Exams 12 months Lenses 12 months Frames 12 months Contacts - Necessary - Elective 12 months 12 months Benefit Network Provider Non-Network Provider Eye examinations 100% Plan reimburses up to $40 Eyeglass lenses and frames or contact lenses - Single vision lenses - Bifocal lenses - Trifocal lenses - Lenticular lenses 100% 100% 100% 100% Plan reimburses up to $40 Plan reimburses up to $60 Plan reimburses up to $80 Plan reimburses up to $125 Frames 100% up to $120 Plan reimburses up to $72 Contacts (in lieu of frames and lenses) - Necessary - Elective 100% 100% up to $105 Plan reimburses up to $210 Plan reimburses up to $ COR Benefits Guide

47 COST OF COVERAGE Cost of Coverage MONTHLY PLAN COSTS FOR EARLY RETIREES The following costs are the total costs for premiums prior to the County contribution. Refer to the County contributions chart on page 48 to determine how much the County will contribute toward your medical coverage, and deduct it from the monthly cost listed below. MEDICAL PLANS FOR RETIREES AND DEPENDENTS WHO ARE UNDER AGE 65 AND NOT ELIGIBLE FOR MEDICARE* 2017 Rate 2018 Rate Variance Exclusive Care EPO Retiree only $ $ $73.29 Retiree plus one dependent $1, $1, $ Retiree plus family $2, $2, $ UnitedHealthcare HMO Retiree only $1, $1, $ Retiree plus one dependent $2, $2, $ Retiree plus family $2, $3, $ Kaiser Permanente HMO Retiree only $ $ $ Retiree plus one dependent $1, $1, $ Retiree plus family $2, $2, $ UnitedHealthcare PPO Retiree only $1, $2, $ Retiree plus one dependent $3, $3, $ Retiree plus family $4, $5, $ * If you or your dependents are OVER age 65 and you are NOT eligible for Medicare, please contact the Benefits Information Line for assistance calculating your rate COR Benefits Guide 47

48 COST OF COVERAGE MONTHLY COUNTY CONTRIBUTIONS When you enroll in a County-sponsored medical plan, either when you retire or during a subsequent Annual Enrollment, the County will make a monthly contribution toward your medical plan premiums. The amount of the contribution is based on the bargaining unit you were in at the time of your retirement. The contributions are as follows: Bargaining Unit at Retirement County Contribution if You Retired Before 11/1/05 County Contribution if You Retired On or After 11/1/05 Confidential $128 $256 DDAA (Prosecution) $256 $256 Elected Officials $128 $256 $ $ LEMU LIUNA $25 $25 Management $128 $256 $ $ SEIU $25 $25 Unrepresented $128 $256 RSA Public Safety COR Benefits Guide