Humana Medicare Advantage Plan. Humana Medicare Advantage Plan Features. For questions. regarding the. Humana. Medicare. Advantage Plan, please call

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1 Humana Medicare Advantage Plan Features Deductible per calendar year Single $250 Out-of-pocket limit per calendar year (excluding deductible) Single $850 Lifetime Maximum Unlimited MEDICAL SERVICES Outpatient Hospice Covered by Medicare at a certified hospice agency, Mental Health Substance Abuse (including Alcohol) Office Visit EMERGENCY SERVICES Emergency Rooms $50 co-pay (waived if admitted) Urgent Care $50 co-pay PREVENTIVE Routine Physical Exam Annual PAP, Mammography, PSA Colorectal Cancer Screening (for all members age 50 and over) Bone Density Testing Flu, Pneumonia, Hepatitis B vaccines OTHER MEDICAL Diagnostic lab and x-ray Lab/pathology, X-ray Chiropractors (for manual manipulation of the spine to the extent covered by Medicare) Physical Therapy Ambulance Home Health Care Durable Medical Equipment INPATIENT Inpatient Deductible None Semi-Private Room Pre-Admission Testing Skilled Nursing Facility For questions regarding the Humana Medicare Advantage Plan, please call Humana at Humana Medicare Advantage Plan Hospice (Respite Care) Covered by Medicare at a certified hospice agency, 95% All charges subject to medical necessity. The prescription drug program will be the same as the Medical Mutual Enhanced Plan administered by Express Scripts. (See page 8) 4

2 MEDICAL MUTUAL PLAN FEATURES All limits and maximums are per covered individual OPERS Medical Plans UCR Usual and Customary Rate - UCR limits generally apply to any service provided out-of-network. text In Enhanced Out of In Intermediate Out of In Basic Out of Deductible per calendar year $500 $750 $750 $1,500 $2,000 $4,000 Out-of-Pocket limit per calendar year $1,000 $2,000 $3,000 $6,000 $5,000 $10,000 Lifetime Maximum MEDICAL SERVICES Outpatient Hospice Mental Health Substance Abuse (including alcohol) Office Visit EMERGENCY SERVICES Emergency Room Urgent Care PREVENTIVE** (must be billed as routine) $20 co-pay $100 co-pay* facility other services $35 co-pay $75 co-pay $75 $100 co-pay* facility other services $25 co-pay $45 co-pay $50 co-pay Annual routine physical Annual PAP, Mammography, PSA EKG, Cholesterol, Blood Sugar, Lipid, Colonoscopy, Sigmoid, Bone Density Testing Flu, Pneumonia and Shingles Vaccines OTHER MEDICAL Lab and Diagnostic Chiropractors (10 visit limit) Physical Therapy Ambulance Home Health Care Durable Medical Equipment Medically Necessary Wigs** 100 visits then 75% 75% All Other INPATIENT Inpatient Deductible (per admission) Semi-Private Room Pre-Admission Testing Skilled Nursing Facility Hospice $100 $200 $100 $200 $100 $200 ALL SERVICES SUBJECT TO MEDICAL NECESSITY. *Waived if admitted **Not subject to coinsurance or deductible 6

3 Medical Mutual Medical Mutual (continued) Covered families with both Medicare-eligible and non-medicare eligible members - Retirees eligible for Medicare and covering a non-medicare spouse and/or a child will be enrolled in the Medical Mutual plan as opposed to the Humana Medicare Advantage Plan. For Medicare-eligible retirees, Medicare (in most cases) pays first and Medical Mutual pays second. OPERS refers to this coverage as "After Medicare" and these retirees will be eligible for coverage listed as In- on page 6 regardless of the provider they choose with just a couple of differences. The chart below outlines these differences. All other coverage is the same as listed on page 6. Please contact Medical Mutual if you have any questions OPERS health care plan After Medicare Annual Deductible Annual Out-of-Pocket Maximum Office Visit (plan pays) Urgent Care (plan pays) $250 $ percent after Medicare 80 percent after Medicare Out-of-Area - s are not available for retirees living outside of the United States. There are also a few areas within the United States that do not have networks established. In the event that Medical Mutual does not have a network in a retiree s area, his or her coverage will be referred to as "Out-of-Area". These retirees will be eligible for coverage listed as In- on page 6 regardless of 2010 OPERS health care plan Out-of-Area Office Visit (plan pays) Urgent Care (plan pays) Frequently Asked Questions the provider they choose, with just a couple of differences. The chart below outlines these differences. All other coverage is the same as listed on page 6. Providers may still bill retirees for the difference between Medical Mutual s allowable charge and the provider s billed amount. Retirees should contact Medical Mutual with questions. 80 percent UCR* 80 percent UCR* *Usual and Customary Rate My doctor/hospital does not accept Medical Mutual. Will my claims be paid as out of network if I continue to see this provider? Medical Mutual offers a large network of providers. If your provider does not accept Medical Mutual, please contact Medical Mutual and they will help you find a local provider that accepts the plan. Use of non-emergency, out-of-network providers can cost you significantly more and providers may bill you for the difference between Medical Mutual s allowed amount and the provider s billed amount. 77 If you are currently in active treatment, Medical Mutual may provide you with a transitional care waiver that gives you a day grace period, beginning Jan. 1, 2010, allowing out-of-network claims for active treatment to be processed as in-network. Waivers will be reviewed on a case-bycase basis. Call Medical Mutual s Care Management department at to have your case reviewed. Please note: amounts paid to out-of-network providers in excess of Medical Mutual s allowed amounts do not apply to out-of-pocket maximum limits.

4 Express Scripts, Inc. Retail pharmacy program - Retirees can receive up to a 30-day supply of medication, plus refills, as prescribed by their physician. In order to use the retail pharmacy network, they must present their prescription drug ID card and prescription(s) to the pharmacist. Mail pharmacy program - Retirees can receive up to a 90-day supply of medication, plus refills, as prescribed by their physician. Mail the prescription(s) and the correct copayment in the special order envelope to Express Scripts. Note: Express Scripts will always dispense a generic medication unless the written prescription is marked with Dispense as Written (DAW). If retirees choose to purchase a brand name drug when there is an equivalent lower-cost generic available, they will be charged the non-formulary brand copayment (subject to plan deductible and copayment if applicable). Express Scripts, Inc OPERS PRESCRIPTION DRUG PLAN Enhanced/ Humana Medicare Plan Intermediate Basic (after deductible is met) Deductible Does not apply Does not apply $550 per individual Generic $4 Retail $12 Mail $10 Retail $30 Mail 35% copayment Formulary Brand (Preferred) $20 Retail $60 Mail $35 Retail $105 Mail 35% copayment Non-Formulary Brand (Non-Preferred) Mail Mail copayment Enhanced/ Humana PPI Coverage Medicare Plan Intermediate Basic (after deductible is met) OTC Prilosec OTC Omeprazole Generic Omeprazole, Pantoprazole and Lansoprazole Nexium Prevacid, Aciphex, Prilosec, Protonix, Zegerid and Kapidex $5 Retail $15 Mail $25 Retail $75 Mail Mail $75 Retail $225 Mail $5 Retail $15 Mail $25 Retail $75 Mail Mail $75 Retail $225 Mail $5 Retail $15 Mail $25 Retail $75 Mail Mail $75 Retail $225 Mail Proton Pump Inhibitors (PPIs) are subject to different copayments than other }medications. Non-covered drug program For prescription drugs not covered by the OPERS health care plan, a non-covered program is available. Retirees can receive up to a 90-day supply through the mail pharmacy at a significant discount. When retirees use this program, Express Scripts will advise them of the cost prior to dispensing the prescription. The program is beneficial when obtaining drugs that are not covered by the OPERS health care plan. Please contact Express Scripts directly for more information on this program. 8

5 AultCare PPO Plan AultCare PPO Plan Retirees may enroll in the AultCare PPO plan in place of the Humana/Medical Mutual health care plans if they live in the service area. Page 3 of the Personal Health Care Open Enrollment Statement will feature this plan as a choice if retirees are eligible for this plan. The AultCare plan will provide coverage regardless of which provider is used. However, retirees will receive the highest level of coverage by using the plan's network providers. Retirees wanting to enroll in an alternate plan must obtain enrollment materials from AultCare (not OPERS). Please note: Premiums will change when retirees and/or their spouses turn age 65. AultCare is available to those residing in the following Ohio counties: Stark, Carroll, Holmes, Summit, Tuscarawas and Wayne. AultCare may also be an option for retirees living in select areas of Columbiana, Coshocton, Mahoning, and Portage Counties as well as many other neighboring counties. For more information: To receive a complete packet of information call (local) or (out of area) or visit AultCare Health Provider Deductible (per calendar year) Out-of-Pocket/Co-Insurance (per calendar year) Coverage Panel / Non-Panel Provider / Any Provider Single $250 / $500, Family $500 / $1,000 Single $1,250 / $2,500, Family $2,500 / $5,000 Physician Services Office Visit/Primary Care Routine Physical Exam / * / * to $200 / after deductible to $200 Hospital Coverage Admission Deductible Semi-private Room Pre-admission Testing Emergency Room Hearing Aid(s) Vision and Dental None / * / * / UCR (approved emergency) No coverage No coverage *After the calendar year deductible is met. All charges are subject to medical necessity. Prescription drug program will be the OPERS Enhanced Plan administered by Express Scripts, Inc. See page 8. 9

6 Kaiser Permanente Kaiser Permanente is an alternative to the OPERS health care plan for both Medicare-eligible and non-medicare-eligible retirees. Page 3 of the Personal Health Care Open Enrollment Statement will feature Kaiser as a choice if retirees are eligible for this plan. Retirees wanting to enroll in the plan must obtain enrollment materials from Kaiser (not OPERS). Please note: Premiums will change when retirees and/or their spouses turn age 65. Kaiser coverage is more comprehensive than some other group plans. They handle claim filing and vision and dental coverage is included. Kaiser requires that participants use their network doctors and facilities to receive coverage. Retirees should not sign up for Kaiser if they expect to be outside the Kaiser service area for more than 90 days. Kaiser Permanente Kaiser is available to those residing in the following Ohio counties: Cuyahoga, Geauga, Lake, Lorain, Medina, Portage, Summit For more information: Please call or (216) or TTY (216) or visit - You Pay - Health Provider Plan Provider Kaiser Permanente Deductible (per calendar year) Out-of-Pocket/Co-Insurance (per calendar year) Physician Services Office Visit/Primary Care Routine Physical Exam Hospital Coverage Admission Deductible Semi-private Room Pre-admission Testing Emergency Room Hearing - Exam Hearing Aid Vision - Exam Frames and lenses Dental $250 single / $500 family $2,000 single / $6,000 family 10% after deductible None 10% after deductible 10% after deductible $50 co-pay (co-pay waived if admitted) Not covered Up to $300 / 24 months using United Optical preventive / basic restorative / major restorative / must use Delta Dental dentist All charges are subject to medical necessity. Prescription drug program will be the OPERS Enhanced Plan administered by Express Scripts, Inc. See page 8. 10