BENEFITS ANNUAL ENROLLMENT

Transcription

1 Current Retirees and Participants on Disability Status: Open Enrollment changes effective January 1, 2018 Application for Coverage Inside BENEFITS ANNUAL ENROLLMENT New Retirees and Participants on Disability Status: Enrollment for 2018

2 2018 Retirees Benefits Annual Enrollment Guide This guide contains the University enrollment materials and applications for the benefits available to you as an eligible University retiree. You have different medical plan options to choose from for 2018 depending on whether you are under age 65 or age 65 or over. CERTIFICATE OF COVERAGE If you are age 65 or over: Upon enrollment, a Certificate of Coverage will be mailed to your home by your medical plan along with more detailed information about your medical benefits. If there are any differences between this guide and the Certificate of Coverage, the Certificate will govern. SUMMARY OF BENEFITS If you are under age 65: The Medical Summary of Benefits and Dental Summary of Benefits that describe your medical or dental coverage are available online at humanresources.umn.edu/ employee-benefits/medical and humanresources.umn.edu/employee-benefits/dental. If you require a print copy, call Employee Benefits at or and select option 1. If there are any differences between this guide and the Summary of Benefits, the Summary will govern.

3 Benefits Enrollment OVERVIEW This guide contains benefits enrollment information for two groups of participants: Retirees and participants on disability status who can select different medical and dental plans during Open Enrollment from November 1 to November 30 that will be effective on January 1, 2018 Employees and participants on disability status who become eligible for retiree benefits coverage during the 2018 calendar year If you are a participant on disability status who has both Medicare Part A and Part B, you may choose coverage from the medical plans for retirees over age 65 or from the plans offered to retirees under age 65. PICK THE SECTIONS THAT APPLY TO YOU Pages 1-2: Pages 3-20: Pages 21-26: Pages 27-30: Pages 31-32: Pages 33-34: Enrollment guidelines Medical plans available to retirees age 65 or over and participants on disability status who have Medicare Parts A & B Medical plans available to retirees under age 65 and participants on disability status Dental plans available to all retirees and participants on disability status Important Notice from the UPlan Medical Program Application for Retiree Age 65 or Over: Complete only if you decide to make a change Pages 35-36: Application for Retiree Under Age 65: Complete only if you decide to make a change ENROLLMENT GUIDELINES Open Enrollment: If you are making a coverage change, complete the application found at the back of this guide. Return the form to Employee Benefits by November 30. No action is necessary if you are not making a change. Soon-to-Retire Employees: Plan to meet with a benefits counselor one to three months prior to your retirement or disability status to complete the paperwork needed to continue your medical and dental coverage. The benefits counselor will give you a benefits continuation form to complete. You have 30 days after you retire to decide about continuing coverage. If you do not continue coverage, you and your dependents will not have an opportunity to re-enroll in the University s medical or dental plans in the future. CHOOSE THE RIGHT PLAN FOR YOUR AGE GROUP If you and your spouse are in the same age group both under age 65 or both age 65 or over you must enroll with the same carrier, and if you are both age 65 or over, one of you may enroll in Plan 1 and the other in Plan 2. If you are in different age groups one is under age 65 and one is age 65 or over you must select plans appropriate for your age group. MEMBER ID CARDS Generally, the plans send new member ID cards if you have a made a plan change. Some of the carriers send new cards each year. Open Enrollment 1

4 Benefits Enrollment MEDICARE PART D PRESCRIPTION DRUG COVERAGE Medicare Part D is optional insurance coverage offered through Medicare for prescription drugs. As a participant in any of the University s medical plans, you are automatically enrolled in Medicare Part D prescription drug coverage, and your premium for Medicare Part D is automatically included in the monthly premium you pay for your medical plan. Please note that if you enroll in one of the Medicare Part D prescription drug plans available in the open marketplace, you will lose your coverage through the University. In this event, you will no longer be able to participate in the University s group benefits. For more information: Visit: Call: MEDICARE ( ) TTY users should call Open Enrollment

5 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Blue Cross Blue Shield of Minnesota U of M Retiree Plan Toll Free: TTY: Call the National Relay Center at 711 and ask for Group Platinum Blue Plan C with Group MedicareBlue Rx Toll Free: TTY: Call the National Relay Center at 711 and ask for Prescription Pharmacy for BCBS: Group MedicareBlue Rx Telephone: TTY: HealthPartners Freedom and HealthPartners Retiree National Choice U of M Plans 1 & 2 Telephone: Toll Free: TYY: Call the National Relay Center at 711, Then ask for UCare for Seniors U of M Plans 1 & 2 Telephone: Toll Free: TTY: TTY: Groupsales@ucare.org MEDICAL PLAN DETAILS The medical plan descriptions are on the following pages. You can find details on coverage on the comparison charts on pages How to enroll is on page 20. Employee Benefits Service Center Telephone: Toll Free: humanresources.umn.edu/benefits Medica Group Prime Solution U of M Plans 1 & 2 Telephone: Toll Free: TTY: Please call the National Relay Center at and ask for Open Enrollment 3

6 Medical Plan Descriptions - Retirees Age 65 or Over Blue Cross Blue Shield of Minnesota Toll Free: Toll Free: TTY: Call the National Relay Center at Plan Blue Cross Blue Shield Plan 1 Blue Cross Blue Shield Plan 2 Type of Network Open Access Open Access Must Designate Clinic No No Referrals Required No No Plan Manages Paperwork Can Live Outside of Plan s Service Area Yes, when using network providers Yes Yes, when using network providers Travel/Extended Absence No limitation Up to 9 months per year No University of Minnesota Retiree Plan with Group MedicareBlue Rx Blue Cross and Blue Shield of Minnesota remains committed to supporting the University of Minnesota s pledge to provide comprehensive retiree health care benefits at an affordable cost. Blue Cross has a trusted reputation nationwide. The U of M Retiree Plan works with Medicare to provide additional medical and prescription drug coverage. The following plan features are included: Easy access to providers Go to nearly any doctor, specialist, or hospital that accepts Medicare. No referrals required. Worldwide coverage Live and travel anywhere in the world and receive plan coverage Preventive care Annual physical, vision and hearing exams, plus cancer screenings Medicare alone does not cover everything. There are s, copayments, and coinsurance for Medicareeligible services and supplies that are covered under the U of M Retiree Plan. Group Platinum Blue Plan C with Group MedicareBlue Rx Group Platinum Blue Plan C works with your Medicare benefits to help you manage your out-of-pocket costs for Medicare-eligible services. The plan offers lower premiums and somewhat higher copays and coinsurance for health care services, but with the protection of an annual out-of-pocket maximum. You must be a permanent resident of Minnesota to enroll in this plan. The following plan features are included: Easy access to providers Members have access to a broad network of providers with no referrals necessary Travel coverage Travel outside the service area within the United States for up to nine months and receive plan coverage; emergency services are covered worldwide Preventive care Annual physical, vision and hearing exams, plus cancer screenings 4 Open Enrollment

7 Medical Plan Descriptions - Retirees Age 65 or Over Blue Cross Blue Shield of Minnesota Medicare Part D prescription drug benefit Both plans are paired with Group MedicareBlue Rx, which offers a simplified copay structure with no and no coverage gap. You have access to over 67,000 participating pharmacies nationwide. You can save more by purchasing 90-day supplies of covered prescriptions for two copays through the mail order program or from a Preferred Extended Supply retail pharmacy. Open Enrollment 5

8 Medical Plan Descriptions - Retirees Age 65 or Over HealthPartners Freedom/HealthPartners Retiree National Choice Telephone: Toll Free: TYY: Call the National Relay Center at 711, Then ask for Plan Type of Network HealthPartners Freedom Plan 1 & Plan 2 Open Access HealthPartners Retiree National Choice Plan 1 & 2 No contracted network. Members can see any Medicare provider in the U.S. Must Designate Clinic No No Referrals Required No No Plan Manages Paperwork Can Live Outside of Plan s Service Area Travel/Extended Absence Yes, when using network providers No Up to 9 consecutive months Yes Yes No need to get plan approval for travel. members can see any Medicare provider in the U.S. For more than 50 years, HealthPartners has been a local option for Medicare coverage. With more than 1.5 million members in Minnesota and western Wisconsin, HealthPartners is the largest consumer-governed, nonprofit health care organization in the nation. HealthPartners offers two options under the umbrella of its HealthPartners Freedom and HealthPartners Retiree National Choice plans: This option will cost less when you receive services, but it has a higher monthly premium. This option will cost more when you receive services, but it has a lower monthly premium. HealthPartners Freedom Plan and HealthPartners Retiree National Choice have the same benefits and monthly premiums in each of the plans. Both plan options also include the following features: Easy access to providers Access to a broad network of providers with no referrals necessary within the network Travel coverage Travel outside the service area for up to nine months with in-network coverage; emergency and urgent care covered worldwide Assist America assists members who are more than 100 miles from home for less than 90 days by providing around the clock access to immediate expert consultation and arranging appropriate transportation home or to the next level of care. Preventive care Annual physical, vision and hearing exams, plus cancer screenings HealthPartners Freedom Plan You are encouraged to use HealthPartners providers, but you do not assign your Medicare benefits to HealthPartners. Health care services are provided by more than 51,000 in-network providers that you can access without a referral. And you retain your Medicare benefits to use outside of the network at any time. 6 Open Enrollment

9 Medical Plan Descriptions - Retirees Age 65 or Over Medicare pays primary for Part A inpatient hospital, skilled nursing facility, and home health care expenses. HealthPartners pays Medicare coinsurance and s. HealthPartners pays primary for Part B medical expenses. HealthPartners Retiree National Choice You must permanently live outside of the Minnesota and western Wisconsin service area to enroll in HealthPartners Retiree National Choice. Medicare pays primary for Part A and B services. Providers will bill Medicare as the primary payer and HealthPartners as the secondary payer. Members can use any provider that is Medicare certified and accepts Medicare assignment. Medicare Part D prescription drug benefit For both HealthPartners plans, you are automatically enrolled in Medicare Part D, and the Part D premium is included with the premium for the medical plan you elect. Open Enrollment 7

10 Medical Plan Descriptions - Retirees Age 65 or Over Medica Group Prime Solution Telephone: Toll Free: TTY: Please call the National Relay Center at and ask for Plan Medica Plan 1 Medica Plan 2 Type of Network Open Access Open Access Must Designate Clinic No No Referrals Required No, when using most network providers No, when using most network providers Plan Manages Paperwork Yes Yes Can Live Outside of Plan s Service Area Travel/Extended Absence No Up to 9 consecutive months No Up to 9 consecutive months Medica is a local company that has been providing nonprofit health coverage in the Midwest for decades. Medica values its members and works hard to give them outstanding customer service and coverage. As a member, you have access to a large network of doctors, clinics, and hospitals. You can still use your Medicare benefits if you choose to go outside of the Prime Solution provider network for services while in the Medica service area. Medica Prime Solution also has nationwide coverage when you travel or spend extended time in another part of the country. Medica Group Prime Solution U of M Plans 1 and 2 This plan option is a comprehensive plan with low copay and coinsurance amounts, and it helps limit your out-of-pocket expenses. This plan option offers a lower monthly premium and has somewhat higher copay and coinsurance amounts. Both Medica plans have the same network of providers and service area and include the following features: Easy access to providers Access to a broad network of providers with no referrals necessary within the network Travel coverage Travel outside the service area within the United States for up to nine months and receive medical and prescription coverage; emergency and urgently needed care covered worldwide Preventive care Annual physical, vision and hearing exams, plus cancer screenings The current Medica service area includes all Minnesota counties; 37 counties in North Dakota, 60 counties in South Dakota, and 13 counties in Wisconsin. Medicare Part D prescription drug benefit For both Medica Group Prime Solution plans, you are automatically enrolled in Medicare Part D, and the Part D premium is included with the premium for the medical plan you elect. 8 Open Enrollment

11 Medical Plan Descriptions - Retirees Age 65 or Over UCare for Seniors Telephone: Toll Free: TTY: TTY: Groupsales@ucare.org Plan UCare Plan 1 UCare Plan 2 Type of Network Open Access Open Access Must Designate Clinic Referrals Required Yes, for Primary Care only No, when using most network providers Yes, for Primary Care only No, when using most network providers Plan Manages Paperwork Yes Yes Can Live Outside of Plan s Service Area Travel/Extended Absence No Up to 6 consecutive months No Up to 6 consecutive months UCare is an independent, nonprofit health plan providing health coverage and services to members in Minnesota and western Wisconsin. UCare was founded in 1984 by the Department of Family Practice and Community Health at the University of Minnesota Medical School. Members have access to more than 43,000 physicians at thousands of locations across Minnesota and western Wisconsin. In addition, thanks to strong collaboration with our providers and community partners, UCare delivers measurable, high-quality care to all members. Quality monitoring and program initiatives demonstrate positive outcomes. The group UCare for Seniors plans cover all parts of Medicare. UCare coordinates the assignment of your Medicare so that you do not have to deal with claims paperwork. UCare for Seniors U of M Plans 1 and 2 This plan provides comprehensive coverage for your medical needs and unlimited prescription drug coverage throughout the year after copays. This plan option is a lower-priced option that will provide coverage for your medical needs. It is for retirees who may have lower prescription drug usage. Plan 2 has some higher copays than Plan 1. Both UCare for Seniors plans include these features: Easy access to providers Go to a broad network of providers with no referrals necessary for specialty care. Worldwide emergency coverage Receive coverage for emergency services worldwide and travel outside the service area for up to six months. Preventive care Annual physical, vision and hearing exams, immunizations, and cancer screenings. Provider Network See the UCare for Seniors Provider Directory or Find a Doctor at The current UCare for Seniors service area includes all counties in Minnesota, plus 26 Wisconsin counties. Medicare Part D prescription drug benefit For both plans, you are automatically enrolled in Medicare Part D, and the Part D premium is included with the premium you pay for the medical plan you elect. Open Enrollment 9

12 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of Minnesota HealthPartners HealthPartners Program Name U of M Retiree Plan with Group MedicareBlue SM Rx Group Platinum Blue SM Plan C with Group MedicareBlue SM Rx HealthPartners Freedom Plan & HealthPartners Retiree National Choice HealthPartners Freedom Plan & HealthPartners Retiree National Choice Type of Policy Coordinates with Medicare and includes Medicare Prescription Drug Plan Medicare Cost Plan with Medicare Prescription Drug Plan Medicare Cost Plan with Medicare Prescription Drug Coverage Medicare Cost Plan with Medicare Prescription Drug Coverage Monthly Premium $ $ $ $ How Plan Works with Medicare and Medicare Assignment U of M Retiree Plan pays after applying U of M Retiree Plan inpatient and coinsurance. You pay Medicare Part B annual s. Medicare pays primary for Part A inpatient hospital, skilled nursing facility, and home health care expenses. For most in-network claims, Blue Cross pays Medicare Part B provider expenses. Medicare pays primary for Part A inpatient hospital, skilled nursing facility, and home health care expenses. HealthPartners pays Medicare Part B provider expenses. Medicare pays primary for Part A inpatient hospital, skilled nursing facility, and home health care expenses. HealthPartners pays Medicare Part B provider expenses. Medicare Assignment You are encouraged to use BCBS network providers, but you do not assign your Medicare benefits to Blue Cross. You are allowed to use your Medicare benefits outside of the BCBS network. You are encouraged to use BCBS network providers, but you do not assign your Medicare benefits to Blue Cross. You are allowed to use your Medicare benefits outside of the BCBS network. HealthPartners Freedom members are encouraged to use network providers, but are able to use Medicare benefits outside of the Freedom network. Retiree National Choice members may see any provider who accepts Medicare. HealthPartners Freedom members are encouraged to use network providers, but are able to use Medicare benefits outside of the Freedom network. Retiree National Choice members may see any provider who accepts Medicare. Outpatient Hospital Outpatient Surgery 100% after Medicare Part B annual $ for 2017/subject to change for % after $75 copay 100% 100% after $75 copay Lab/X-Ray, CT scan, MRI, other outpatient diagnostic tests 100% of remaining balance after Medicare Part B is met 100% Lab services at 100% and all other services at $15 Lab services at 100% and all other services at $30 copay Emergency Services 100% after Medicare Part B annual $ for 2017/subject to change for % after $50 copay 100% after $50 copay 100% after $100 copay Ambulance 100% after Medicare Part B annual $ for 2017/subject to change for % after $75 copay 100% 80% 10 Open Enrollment

13 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Medica Medica UCare UCare Program Name Medica Group Prime Solution Medica Group Prime Solution UCare for Seniors UCare for Seniors Type of Policy Medicare Cost Plan with Medicare Prescription Drug Coverage Medicare Cost Plan with Medicare Prescription Drug Coverage Medicare Advantage Plan including Prescription Drug Coverage Medicare Advantage Plan including Prescription Drug Coverage Monthly Premium $ $ $ $ How Plan Works with Medicare and Medicare Assignment Medicare pays primary for Part A inpatient hospital, skilled nursing facility, and home health care expenses. Medica pays Medicare Part B provider expenses. Medicare pays primary for Part A inpatient hospital, skilled nursing facility, and home health care expenses. Medica pays Medicare Part B provider expenses. UCare administers benefits and claims payment of Medicare Parts A and B, as well as additional benefits included in plan, such as Prescription Drug coverage (Part D) and preventive care. Bills for health care services are sent directly to UCare by providers (not to Medicare) and are processed in UCare Claims department. UCare administers benefits and claims payment of Medicare Parts A and B, as well as additional benefits included in plan, such as Prescription Drug coverage (Part D) and preventive care. Bills for health care services are sent directly to UCare by providers (not to Medicare) and are processed in UCare Claims department. Medicare Assignment You are encouraged to use Medica network providers, but you do not assign your Medicare benefits to Medica. You are allowed to use your Medicare benefits outside of the Medica network. You are encouraged to use Medica network providers, but you do not assign your Medicare benefits to Medica. You are allowed to use your Medicare benefits outside of the Medica network. You cannot use your Medicare benefits outside of UCare network unless an emergency occurs. You cannot use your Medicare benefits outside of UCare network unless an emergency occurs. Outpatient Hospital Outpatient Surgery 100% 100% after $50 copay 100% 100% after $100 copay Lab/X-Ray, CT scan, MRI, other outpatient diagnostic tests Lab Services 100%. All other services $15 copay Lab Services 100% All other services $20 copay Primary or Specialty - 100% OP Hospital / Surg. Ctr. $25 copay Primary or Specialty - 100% OP Hospital / Surg. Ctr. $25 copay Emergency Services 100% after $50 copay 100% after $65 copay (20% coinsurance outside the U.S. Expenses do not apply to Out-of-Pocket Maximum) 100% after $50 copay 100% after $75 copay Ambulance 100% 80% coinsurance 100% 100% after $100 copay Open Enrollment 11

14 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of Minnesota HealthPartners HealthPartners Urgent Care Visit Inpatient 100% after Medicare Part B annual $183 for 2017/subject to change for % after $20 copay 100% after $15 copay 100% after $30 copay Hospital Plan pays 80% of first $2,900 of total allowed amount following $100 annual inpatient ; then 100% through end of calendar year. Out-of-pocket expense limited to $680 per year including $ % after $200 copay for each Medicare-covered stay. No limit on number of days covered by plan 100% 100% after $200 copay per visit Skilled Nursing Plan pays 80% of first $2,900 of total allowed amount following $100 annual inpatient ; then 100% through end of calendar year. Out-of-pocket expense limited to $680 per year including $100. No 3-day hospital stay requirement 100% after 3-day hospitalization for up to 100 days per benefit period 100% after 3-day hospitalization for up to 100 days per benefit period 100% after 3-day hospitalization for up to 100 days per benefit period Mental Health Plan pays 80% of first $2,900 of total allowed amount following $100 annual inpatient ; then 100% through end of calendar year. Out-of-pocket expense limited to $680 per year including $ % after $200 copay up to 190 days of inpatient psychiatric hospital care in a lifetime. This limitation does not apply to inpatient psychiatric services furnished in a general hospital 100% 100% after $200 copay per visit Chemical Dependency Plan pays 80% of first $2,900 of total allowed amount following $100 annual inpatient ; then 100% through end of calendar year. Out-of-pocket expense limited to $680 per year including $ % after $200 copay 100% 100% after $200 copay per visit Outpatient Medical Preventive 100% 100% 100% 100% Physician Office Visit 100% after Medicare Part B annual $183 for 2017/subject to change for % after $20 copay 100% after $15 copay 100% after: Primary Care $20 copay/ Specialist $30 copay 12 Open Enrollment

15 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Medica Medica UCare UCare Urgent Care Visit 100% after $15 copay 100% after $30 copay 100% after $20 copay 100% after $35 copay Inpatient Hospital 100% 100% after $200 copay 100% 100% after $200 copay Skilled Nursing 100% after 3-day hospitalization for up to 100 days per benefit period 100% after 3-day hospitalization for up to 100 days per benefit period 100% coverage for up to 100 days per benefit period; no 3-day hospital stay requirement 100% coverage for up to 100 days per benefit period; no 3-day hospital stay requirement Mental Health 100% 100% after $200 copay 100% 100% after $200 copay Chemical Dependency 100% 100% after $200 copay 100% 100% after $200 copay Outpatient Medical Preventive 100% 100% 100% 100% Physician Office Visit 100% after $15 copay 100% after: Primary Care $20 copay/ Specialist $30 copay 100% after $15 copay 100% after: Primary Care $20 copay/ Specialist $30 copay Open Enrollment 13

16 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of Minnesota HealthPartners HealthPartners Medications Delivered in Physician Office Setting and Paid under Medicare Part B 100% after Medicare Part B annual $ for 2017/subject to change for % after $20 copay 100% after $15 copay (If Part B drugs are billed separately, coverage is 80%) 100% after Primary Care $20 copay/specialist $30 copay (If Part B drugs are billed separately, coverage is 80%) Routine Eye and Hearing Exams 100% 100% 100% 100% Outpatient Mental Health 100% after Medicare Part B annual $ for 2017/subject to change for % after $20 copay 100% after $15 individual/ $7.50 group 100% after $30 individual/ $15 group Outpatient Chemical Dependency Chiropractic Care Podiatry Physical & Occupational Therapy Speech & Language Therapy Home Health Care Medical Equipment DME Prosthetics 100% after Medicare Part B annual $ for 2017/subject to change for % after Medicare Part B annual $ for 2017/subject to change for % after Medicare Part B annual $ for 2017/subject to change for % after Medicare Part B annual $ for 2017/subject to change for % after Medicare Part B annual $ for 2017/subject to change for % after Medicare Part B annual $ for 2017/subject to change for % after Medicare Part B annual $ for 2017/subject to change for % after $20 copay 100% after $15 copay 100% after $30 copay 100% after $20 copay 100% 100% after $30 copay 100% after $20 copay 100% after $15 copay 100% after $30 copay 100% after $20 copay 100% after $15 copay 100% after $30 copay 100% after $20 copay 100% after $15 copay 100% after $30 copay 100% 100% 100% 80% 90% 80% Hearing Aids 80% for hearing aids every 3 years $450 plan coverage limit for hearing aids every year 80% coverage for 1 selected hearing aid for each ear every 3 years. No implantable devices No coverage. Discounts available 14 Open Enrollment

17 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Medica Medica UCare UCare Medications Delivered in Physician Office Setting and Paid under Medicare Part B Routine Eye and Hearing Exams Outpatient Mental Health Coverage is 80% Coverage is 80% 80% covered 80% covered 100% 100% 100% 100% 100% after $15 copay 100% after $30 copay 100% after $15 copay 100% after $30 copay Outpatient Chemical Dependency 100% after $15 copay 100% after $30 copay 100% after $15 copay 100% after $30 copay Chiropractic Care 100% after $15 copay 100% after $20 copay 100% 100% Podiatry 100% after $15 copay 100% after $30 copay 100% after $15 copay 100% after $30 copay Physical & Occupational Therapy 100% after $15 copay 100% after $30 copay 100% after $15 copay 100% after $30 copay Speech & Language Therapy 100% after $15 copay 100% after $30 copay 100% after $15 copay 100% after $30 copay Home Health Care 100% 100% 100% 100% Medical Equipment DME Prosthetics 100% 80% coinsurance 80% DME/ 100% Prosthetics 80% DME/ 100% Prosthetics Hearing Aids $500 allowance per year No coverage $500 allowance every 36 months $500 allowance every 36 months Open Enrollment 15

18 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of Minnesota HealthPartners HealthPartners Prescription Drugs Generic Drugs Retail Formulary Brand Drugs Retail Non-preferred Formulary Brand Retail $10 copay $10 copay $10 copay $10 copay $30 copay $25 copay $30 copay $35 copay $50 copay $60 copay $30 copay $70 copay Specialty Drugs $50 copay Participants will pay 25% coinsurance $50 copay 75% coverage Supplemental Drugs Participants will pay 25% coinsurance Participants will pay 25% coinsurance Covered at generic and brand copays shown above Covered at generic and brand copays shown above Mail Order 3-month supply for 2 copays through mail order or if using Preferred Extended Network (PXT) within Group MedicareBlue Rx pharmacy network 3-month supply for 2 copays through mail order or if using Preferred Extended Network (PXT) within Group Medicare- Blue Rx pharmacy network 3-month supply for 2 copays 3-month supply for 2 copays Benefits in the Medicare Coverage Gap (Between $3,750 total prescription costs and $5,000 total outof-pocket expenses) 100% coverage after $10 generic copay, $30 brand copay or $50 non-preferred brand and specialty copays. 25% coinsurance for supplemental drugs 100% coverage after $10 generic copay, $25 brand copay or $60 non-preferred brand copay. 25% coinsurance for specialty and supplemental drugs 100% coverage after $10 generic, $30 brand, or $50 specialty copay 100% coverage after $10 generic copay. Participants will pay 35% coinsurance for their brand or specialty medications Catastrophic Level (after $5,000 in total out-of-pocket expenses) Member cost will be the greater of $3.35 for covered generic or multisource preferred brand drugs and $8.35 for all other covered drugs, or 5% of the cost of the drug Member cost will be the greater of $3.35 for covered generic or multi-source preferred brand drugs and $8.35 for all other covered drugs, or 5% of the cost of covered drugs The lesser of 5% or the above copays Member cost will be the greater of 5% of drug cost or $3.35 copay for generic drugs, and $8.35 copay for brand/ formulary drugs Wellness Benefits Fitness Club Membership Fitness discount that credits your fitness center account $20 a month for membership fees when you work out 12 times a month Silver & Fit Exercise and Healthy Aging Program provides a fitness club membership at participating facilities or home exercise kits Fitness club membership provided at no cost for participating facilities. You may also request a home exercise kit. Nurseline 24-hour Nurse Line 24-hour Nurse Line Free access to registered nurses 24/7 through the CareLine SM nurse line Other Wellness Benefits Stop Smoking Program Wellness Discount Marketplace blue365deals.com/bcbsmn Stop Smoking support Up to $125 limit for non-medicare covered eyewear every year Wellness Discount Marketplace blue365deals.com/bcbsmn Free, unlimited number of virtuwell visits for Freedom Plan members Healthy discounts on hearing aids, eating services, delivery services, fitness equipment and much more Up to 35% discount off eyewear 16 Open Enrollment

19 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Medica Medica UCare UCare Prescription Drugs Generic Drugs Retail Preferred Generic - $10 Copay Non-Preferred Generic - $30 Copay Preferred Generic - $10 Copay Non-Preferred Generic - $20 Copay $10 copay $10 copay Formulary Brand Drugs Retail Non-preferred Formulary Retail $30 copay $30 copay $30 copay $30 copay $30 copay $70 copay $50 copay $60 copay Specialty Drugs $30 copay 75% coverage $50 copay 75% coverage Supplemental Drugs Not covered Not covered Mail Order 90-day supply for 2 copays 90-day supply for 2 copays Covered at generic and brand copays shown above 90-day supply for 2 copays through mail order or Preferred Pharmacy network (retail) Not covered 90-day supply for 2 copays through mail order or Preferred Pharmacy network (retail) Benefits in the Medicare Coverage Gap (Between $3,750 total prescription costs and $5,000 total out-of-pocket expenses) 100% coverage after $10 or $30 generic copay or $30 brand copay 100% coverage after $10 or $20 copay for generic medications. 65% coverage for brand name medications. 50% reimbursement from brand drug manufacturer at pharmacy counts toward the $5,000 OOP expenses. 100% coverage after $10 generic copay, $30 preferred brand copay, $50 non-preferred drug or specialty drug copay (counts toward the OOP max.) 100% coverage after $10 generic copay. No coverage for brand drugs but 60% manufacturer discount assessed at the pharmacy (counts toward the OOP max.) Catastrophic Level (after $5,000 in total out-of-pocket expenses) 100% coverage after $10 generic copay or $30 brand copay Member cost will be the greater of 5% of drug cost or $3.35 copay for generic drugs and $8.35 copay for brand/ formulary drugs 100% coverage after $10 generic copay, $30 preferred brand copay, $50 nonpreferred drug or specialty drug copay Member cost will be the greater of 5% of drug cost or $3.35 copay for generic drugs and $8.35 copay for brand/ formulary drugs Wellness Benefits Fitness Club Membership Nurseline Other Wellness Benefits Silver Sneakers Fitness Program Personal Health Advocate can help navigate the healthcare system as well as provide access to registered nurses for guidance and support 24 hours a day/7 days a week Hearing Aid Discount program A survey for senior members that is reviewed by nurses in Medica s Care Management area to assess additional needs Medication Therapy Management (MTM) program provides information and resources to improve medication use and patient care Silver Sneakers Fitness Program UCare Health Club Savings Program Health Connections 24-Hour Nurse Line, Community Education Class reimbursement, My Health Decisions Online Tool Hearing Aid Discount program $150 Annual Eyewear allowance Quit Smoking, plus Disease and Case Management Programs Weight Loss Mammogram Incentive Programs Open Enrollment 17

20 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan Features Blue Cross Blue Shield of Minnesota Blue Cross Blue Shield of Minnesota HealthPartners HealthPartners Travel and Out-of-Area Benefits Travel benefits No limitations May travel out of the service area and within the United States for 9 months, no activation of benefit required May be out of the service area for up to 9 consecutive months annually; benefits are activated by calling Member Services May be out of the service area for up to 9 consecutive months annually; benefits are activated by calling Member Services Option to live outside of service area Yes No Yes, through HealthPartners Retiree National Choice Yes, through HealthPartners Retiree National Choice Maximums Annual Out-of-Pocket $863 that includes $680 plus $183 (for 2017) Part B (Pharmacy copays do not apply). Part B subject to change in 2018 $3,000. This amount does not include Medicare Part D copays/coinsurance $3,000 (Pharmacy copays do not apply) $3,000 (Pharmacy copays do not apply) Lifetime Unlimited Unlimited Unlimited Unlimited 18 Open Enrollment

21 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage Plan features Medica Medica UCare UCare Travel and Out-of-Area Benefits Travel benefits Extended Absence Option allows members to use medical and prescription drug coverage when traveling away from the Medica service area for up to 9 consecutive months Extended Absence Option allows members to use medical and prescription drug coverage when traveling away from the Medica service area for up to 9 consecutive months Members may be out of UCare service area for up to 6 consecutive months. Members do not need to notify UCare when they leave or return. Emergency benefits are worldwide: $50 copay for ER visits; waived if admitted to the hospital. 80% coverage for nonemergency services anywhere in the US. $100,000 plan benefit maximum; $10,000 OOP maximum Members may be out of UCare service area for up to 6 consecutive months. Members do not need to notify UCare when they leave or return. Emergency benefits are worldwide: $75 copay for ER visits; waived if admitted to the hospital. 80% coverage for non-emergency services anywhere in the US. $100,000 plan benefit maximum; $10,000 OOP maximum Option to live outside of service area No No No No Maximums Annual Out-of-Pocket $1,000 on Medical (Pharmacy copays do not apply) $3,000 on Medical (Pharmacy copays do not apply) $3,400 Medical Out-of- Pocket Maximum (Pharmacy copays do not apply) $3,400 Medical Out-of-Pocket Maximum (Pharmacy copays do not apply) Lifetime Unlimited Unlimited Unlimited Unlimited 2018 Monthly Premium (includes premium for Medicare Part D) Medical Plan Blue Cross Blue Shield U of M Retiree Plan Group Platinum Blue SM Plan C Cost per person* Plan 1: $ Plan 2: $ HealthPartners Freedom Plan and HealthPartners Retiree National Choice Plan 1: $ Plan 2: $ Medica Group Prime Solution UCare for Seniors Plan 1: $ Plan 2: $ Plan 1: $ Plan 2: $ * Retiree, spouse, surviving spouse, and participant on disability status with Medicare Part A and Part B Open Enrollment 19

22 Medical Plan Options - Retirees Age 65 or Over/ Disabled Participants with Medicare Coverage HOW TO ENROLL You will receive enrollments materials from the University of Minnesota each year prior to open enrollment or at the time you decide to retire. This guide contains the University enrollment materials you need for Open Enrollment If you decide to remain with your current Retiree Medical plan carrier and plan option, you do not need to do anything at this time; your coverage with your current plan will continue into If you want to change Retiree Medical carriers or switch plan options within your current carrier, you need to complete the application from the back of this guide and return it to Employee Benefits by 4:30 p.m., Thursday, November 30, 2017, or if mailed, postmarked no later than November 30. Employee Benefits will register your enrollment at the University and forward the application to your Retiree Medical carrier. The Retiree Medical carrier will mail an enrollment kit to you, including an enrollment form required by Medicare for their plan. With Blue Cross Blue Shield, you will receive a separate enrollment form for the Group MedicareBlue Rx pharmacy program. To make a plan change, you must complete both the University of Minnesota and Retiree Plan applications. You need to complete and return your Retiree Medical carrier s enrollment form to them before December 31, 2017, for your new coverage to become effective on January 1, Once the carrier has your enrollment forms, you will receive a confirmation letter, ID card, and other member materials. If you will have a new clinic under your new plan, remember to have your current clinic send a copy of your records to your new clinic prior to that time. New Retiree If you wish to select a Retiree Medical Plan option, you should complete the University s enrollment form and return it to Employee Benefits, preferably before you retire but within 30 days of your retirement. Employee Benefits will register your enrollment at the University and forward the form to your Retiree Medical carrier. The Retiree Medical carrier will mail an enrollment kit to you, including an enrollment form required by Medicare for their plan. With Blue Cross Blue Shield, you will receive a separate enrollment form for the Group MedicareBlue Rx pharmacy program. You need to complete and return the carrier s enrollment form to them as soon as possible. Supplemental plans cannot backdate coverage. If the carrier s enrollment form is not received in their office by the last day of the month before your effective date, your coverage will not take effect until the next month. In this event, you will have to stay on your current plan and pay the full cost. Once the carrier has your enrollment forms, you will receive a confirmation letter, ID card, and other member materials. 20 Open Enrollment

23 Medical Plan Options - Retirees Under Age 65/ Participants on Disability Status MEDICAL PLAN OPTIONS Medical plan options for retirees under age 65 and participants on disability status are the same Medica options that are available to active employees. You can select any medical plan that is available in the area where you live or worked. You pay the full cost of the coverage you select. Statements will be mailed to you directly from your medical plan administrator. There are five medical plan options: Medica Accountable Care Organization (ACO) Plan In an Accountable Care Organization (ACO), Medica and the provider network work together to deliver coordinated health care and more member support. The ACO networks are: Crookston area: Altru & You with Medica Duluth area and parts of northeastern Minnesota: Essentia Choice Care with Medica Rochester area: Medica CompleteHealth (featuring care at Mayo Clinic) Twin Cities metro area: VantagePlus with Medica (Fairview, HealthEast, and North Memorial networks and Boynton and U of M Physicians); Park Nicollet First with Medica; and Ridgeview Community Network powered by Medica An ACO is a good option when all family members already use the same provider network. You can see any primary care provider or specialist in your network without a referral. The ACOs have low rates, low copays, and high member satisfaction. Medica Choice Regional This plan uses the statewide Medica Choice network in the Greater Minnesota area, including the Crookston, Morris, and Rochester campuses. You can see any primary care provider or specialist in the network without a referral. Choice Regional has moderate rates and copays. Medica Choice National This is an open access plan with the statewide Medica Choice network and the national United Healthcare Options PPO network for use when traveling or working outside the service area. You can see any primary care provider or specialist in the broad network without a referral. Choice National has the highest rates and copays. Medica Elect/Essential This plan combines two networks that include 20 major health care systems in the Twin Cities and Duluth areas. Family members choose their primary care clinic (PCC) in either the Elect or Essential care system when they enroll. Your PCC helps you with referrals to specialists if your care system requires that step. Elect/Essential has moderate rates and copays. Medica Health Savings Account (HSA) This is a high plan with open access to the statewide Medica Choice network and the national United Healthcare Options PPO network for use when traveling or working outside the service area. You can see any primary care provider or specialist in the network without a referral. The University does not contribute to your HSA; instead, the rates are reduced to account for that. You can make your own contributions to the HSA. You will receive a debit card to spend HSA dollars for pharmacy or medical expenses. The HSA plan has moderate rates but high s. You pay for expenses out of your pocket to meet the before the plan pays. Important Notice: Due to federal law, if you have any other medical coverage, including any part of Medicare, or you are on a spouse s plan that is not a high health plan, you are not eligible to enroll in Medica HSA. However, if you are age 65 or older and delay taking Social Security benefits and Medicare Part A, you remain eligible for Medica HSA. Open Enrollment 21

24 Medical Plan Comparison - Retirees under Age 65/Participants on Disability Status IN-NETWORK SERVICES Health Care Services Base Plan Medica Elect/Essential Medica Choice Regional Medica ACO Plan Medica Choice National Medica HSA Preventive Care* 100% coverage 100% coverage 100% coverage 100% coverage** Eye and Hearing Exam (routine) 100% coverage 100% coverage 100% coverage 100% coverage Physician*** $25 Primary/ $35 Specialty copay $20 Primary/ $30 Specialty copay $40 Primary/ $50 Specialty copay 90% coverage after All Walk-in/ Convenience Clinics and Virtual Care**** $15 copay $15 copay $20 copay 90% coverage after Outpatient MRI and CT Scan Urgent Care: In-Network and Out-of-Network $50 copay $40 copay $50 copay $25 copay $20 copay $40 copay 90% coverage after 90% coverage after Emergency Care: In-Network and Out-of-Network $100 copay, waived if admitted $100 copay, waived if admitted $100 copay, waived if admitted 90% coverage after Outpatient Mental Health/ Substance Abuse $25 copay $20 copay $40 copay 90% coverage after Chiropractic Care $25 copay $20 copay $40 copay 90% coverage after Physical, Speech, and Occupational Therapy $25 copay $20 copay $40 copay 90% coverage after Home Health Care $25 copay $20 copay $40 copay 90% coverage after * Preventive care includes routine physical, hearing and eye exams; well child care; prenatal care; immunizations; and allergy injections. **HSA guidelines do not view allergy injections as preventive; therefore, the and coinsurance apply to this service. *** Primary Care includes Family Medicine, Internal Medicine, Obstetrics/Gynecology, and Pediatrics. **** Gopher Quick Clinic in the Twin Cities, WellCare in Duluth, and other walk-in/convenience care clinics; also applies to virtual care. 22 Open Enrollment

25 Medical Plan Comparison - Retirees under Age 65/Participants on Disability Status IN-NETWORK AND OUT-OF-NETWORK Deductibles and Services Base Plan Medica Elect/Essential Medica Choice Regional Medica ACO Plan Medica Choice National Medica HSA In-Network Deductible* Out-of-Network Deductible $100 per person/ $200 per family $600 per person/ $1,200 per family $100 per person/ $200 per family $600 per person/ $1,200 per family $200 per person/ $400 per family $600 per person/ $1,200 per family Total in-network and out-of-network: Employee only: $1,500 Family: $3,000 Lab/X-Ray 100% coverage after 100% coverage after 100% coverage after 90% coverage after Outpatient Surgery 100% coverage after 100% coverage after 100% coverage after 90% coverage after In-Network Hospital (General and Mental Health/ Substance Abuse Care) 100% coverage after 100% coverage after 100% coverage after 90% coverage after Ground and Air Ambulance to Nearest Facility 80% coverage 80% coverage 80% coverage 90% coverage after Prosthetics, Durable Medical Equipment 80% coverage, including hearing aids 80% coverage, including hearing aids 80% coverage, including hearing aids 90% coverage after, including hearing aids Out-of-Network Care 70% coinsurance after is met, up to the annual out-ofpocket maximum 70% coinsurance after is met, up to the annual out-of-pocket maximum 70% coinsurance after is met, up to the annual out-of-pocket maximum 70% coinsurance after is met, up to the annual out-of-pocket maximum *In-network applies to expenses without a copay, primarily in- and out-patient hospital, and lab/x-ray. Open Enrollment 23

26 Medical Plan Comparison - Retirees under Age 65/Participants on Disability Status PRESCRIPTION DRUGS The UPlan Pharmacy program is provided through Prime Therapeutics and Fairview Specialty Pharmacy. It is automatically provided to members in all UPlan medical options. A prescription is dispensed as a 30-day supply (including insulin) in network pharmacies only. Prescription Drug Categories Base Plan Medica Elect/ Essential Medica Choice Regional Medica ACO Plan Medica Choice National Medica HSA Certain Preventive Medications Specified in the Affordable Care Act and Contraceptives in the Generic Plus Category $0 copay $0 copay $0 copay 100% Generic Plus (Tier 1) Drugs (includes all generic drugs and some low-cost brand drugs if there is no generic drug in a given therapeutic class) Formulary Brand Name (Tier 2) Drugs (includes all other formulary brand drugs) Non-formulary (Tier 3) Drugs (includes covered brand drugs not listed on formulary) $10 copay $10 copay $10 copay $30 copay $30 copay $30 copay $75 copay $75 copay $75 copay Prescriptions are covered in the HSA and at 90% in medical plan after Prescriptions are covered in the HSA and at 90% in medical plan after Prescriptions are covered in the HSA and at 90% in medical plan after Purchase of Brand Drug When Chemically Equivalent Generic is Available Pay the generic copay and difference in cost* between the brand drug and the generic drug Pay the generic copay and difference in cost* between the brand drug and the generic drug Pay the generic copay and difference in cost* between the brand drug and the generic drug Prescriptions are covered in the HSA and at 90% in medical plan after ** Drugs Purchased by Mail Order 3-month supply available for two copays 3-month supply available for two copays 3-month supply available for two copays 90-day supply available at discount Annual Out-of-Pocket Maximum (Rx only) $750 per person/ $1,500 per family $750 per person/ $1,500 per family $750 per person/ $1,500 per family No separate out-ofpocket maximum for prescriptions * The difference in cost does not apply toward the annual out-of-pocket maximum. ** When in the coinsurance level, pay 10 percent coinsurance based on generic price in addition to difference in cost between the brand drug and the generic drug. 24 Open Enrollment

27 Medical Plan Comparison - Retirees under Age 65/Participants on Disability Status OTHER COVERAGE AND MAXIMUMS Other Coverage and Maximums Base Plan Medica Elect/Essential Medica Choice Regional Medica ACO Plan Medica Choice National Medica HSA Travel Benefit: In-Network Coverage For students and other travelers if services are provided by United Healthcare Options PPO providers For students and other travelers if services are provided by United Healthcare Options PPO providers For out-of-area residents, students and other travelers if services are provided by United Healthcare Options PPO providers For out-of-area residents, students and other travelers if services are provided by United Healthcare Options PPO providers National Coverage Available through emergency or out-of-network benefit only Available through emergency or out-ofnetwork benefit only Available in-network through United Healthcare Options PPO network Available in-network through United Healthcare Options PPO network Annual Out-of-Pocket Maximum Total annual in-network and out-of-network $2,500 per person/ $4,000 per family $2,500 per person/ $4,000 per family $2,500 per person/ $4,000 per family $3,000 per person/ $6,000 per family (Note: Out-of-pocket maximums include the ) Lifetime Maximum Unlimited Unlimited Unlimited Unlimited HSA* Employee Contributions Employee-only amount $3,450 Catch-up amount Age 55 or over $1,000 Family coverage amount (either tier) $6,850 Catch-up amount Age 55 or over $1,000 * Maximum contribution you can make under an HSA. Medica: TTY users, please call 711 Web: Open Enrollment 25

28 Medical Plan: 2018 Monthly Rates Retirees under Age 65/ Participants on Disability Status If you earned the required number of wellness points for a $400 or $600 reduction, your cost is shown in Your Wellness Program Achievement Rates column. If you did not participate in or earn the required number of wellness points, your cost is shown in Your Standard Rates column. Retiree only; Spouse under age 65 only; Surviving Spouse only; or One Dependent Child only Plan Medica Elect/Essential: Twin Cities & Duluth Base Plan Medica Choice Regional: Greater Minnesota Base Plan Medica ACO Plan: Crookston area, Duluth area & parts of northeastern Minnesota, Rochester area, Twin Cities metro area Your Wellness Program Achievement Rates Your Standard Rates $ $ $ $ Medica Choice National $ $ Medica HSA $ $ Retiree and Children; Spouse under age 65 and Children; Surviving Spouse and Children; or Two or more Dependent Children only Plan Medica Elect/Essential: Twin Cities & Duluth Base Plan Medica Choice Regional: Greater Minnesota Base Plan Medica ACO Plan: Crookston area, Duluth area & parts of northeastern Minnesota, Rochester area, Twin Cities metro area Your Wellness Program Achievement Rates Your Standard Rates $1, $1, $1, $1, Medica Choice National $1, $1, Medica HSA $ $ Retiree and Spouse with or without Children Plan Medica Elect/Essential: Twin Cities & Duluth Base Plan Medica Choice Regional: Greater Minnesota Base Plan Medica ACO Plan: Crookston area, Duluth area & parts of northeastern Minnesota, Rochester area, Twin Cities metro area Your Wellness Program Achievement Rates Your Standard Rates $1, $1, $1, $1, Medica Choice National $1, $1, Medica HSA $1, $1, Open Enrollment

29 Dental Plan Options - Retirees of all Ages/Participants on Disability Status YOUR DENTAL COVERAGE Dental plan options for retirees under age 65 and participants on disability status are the same options that are available to active employees. As you consider your options, you may want to check which of the UPlan dental plans your dentist participates in and enroll accordingly. You can select any dental plan that is available in the area where you live or worked. You pay the full cost of the coverage you select. Statements will be mailed to you directly from your dental plan administrator. For all of the dental plans, the annual maximum benefit is $1,800 per person per contract year. There are five dental plan options: Delta Dental PPO Network-only plan offers the greatest cost savings when receiving care from a dentist in the PPO network, except for out-of-area emergencies. Network includes nearly 1,700 participating dentists and specialists in 75 Minnesota counties and border communities. National Delta Dental PPO network offers 89,500 participating dentists across the country. Delta Dental PPO has the lowest rates for the Twin Cities and Duluth areas. Delta Dental Premier Flexible plan offers access to the broad Delta Dental Premier network and the PPO network, and offers out-of-network benefits. Largest dental network in Minnesota with more than 3,100 participating dentists and specialists in Minnesota and border communities Largest dental network in the country with over 145,000 participating providers Seeing a dentist in a Delta Dental network will help you make the most of your benefits and can result in lower out-of-pocket costs. Delta Dental Premier has the lowest rates for the Greater Minnesota area but higher rates for the Twin Cities and Duluth areas. University Choice Open plan, administered by Delta Dental, offers freedom to see any provider of your choice. Seeing a dentist in either the Delta Dental PPO or Delta Dental Premier network may result in lower out-of-pocket costs, in addition to waiving the $50 under this program. University Choice has the highest rates and most flexibility in choosing a provider. UPlan HealthPartners Dental Network-only plan offers the greatest cost savings when receiving care from a dentist in the PPO network, except for out-of-area emergencies. Network includes more than 1,700 dentists and specialists at over 1,350 dental clinics in Minnesota and border communities. HealthPartners Dental has a large nationwide network of participating dentist and specialists. HealthPartners Dental has low rates. UPlan HealthPartners Dental Choice Flexible plan offers access to the broad HealthPartners Dental Choice network and the HealthPartners Dental PPO network, and offers out-of-network benefits. Network has more than 2,700 dentists and specialists at over 2,000 dental clinics in Minnesota and border communities. HealthPartners Dental Choice has a large nationwide network of participating dentists and specialists. HealthPartners Dental Choice has higher rates. Open Enrollment 27

30 Dental: Plan Comparison Plan Diagnostic and Preventive Care Basic Restorative Care Major Restorative Care Emergency Services Orthodontics DELTA DENTAL PREMIER In-network 100% coverage 80% coverage 50% coverage Emergency dental services provided same as eligible dental services 80% coverage DELTA DENTAL PREMIER Out-of-network 50% coverage After $125 annual, 50% coverage No coverage After $125 annual, emergency dental services provided same as eligible out-of-network services 50% coverage DELTA DENTAL PPO In-network coverage only 100% coverage 80% coverage 50% coverage In-network services provided same as any service; out-of-network services apply $50 then same as any in-network service 80% coverage UNIVERSITY CHOICE Open access 100% coverage After $50 annual, 80% coverage After $50 annual, 50% coverage Emergency dental services provided same as eligible dental services 80% coverage UPLAN HEALTHPARTNERS DENTAL CHOICE In-network 100% coverage 80% coverage 50% coverage Emergency dental services provided same as eligible dental services 80% coverage UPLAN HEALTHPARTNERS DENTAL CHOICE Out-of network 50% coverage After $125 annual, 50% coverage No coverage After $125 annual, emergency dental services provided same as eligible out-of-network services 50% coverage UPLAN HEALTHPARTNERS DENTAL In-network coverage only 100% coverage 80% coverage 50% coverage In-network services provided same as any service; out-of-network services apply $50 then same as any in-network service 80% coverage Covered Services under Each Type of Dental Care The Dental Plan Comparison shows the coverage levels for each category of dental care. You ll want to review what dental services are covered in each category. All of the dental plans provide comprehensive coverage, but coverage may not be the same for all services. Specifically, review the benefit for different types of fillings under each plan that is available in your area. 28 Open Enrollment

31 Dental: Plan Comparison Diagnostic and Preventive Care Oral examinations and dental cleanings X-rays Special periodontics care Topical fluoride to age 19 Space maintainers Basic Restorative Care Fillings (customary restorative materials) Benefit for back teeth is based on cost of amalgam (silver) fillings: Delta Dental PPO and HealthPartners Dental Benefit for back teeth is based on cost of composite (white) fillings: Delta Dental Premier, University Choice, and HealthPartners Dental Choice Benefit for front teeth is based on cost of composite (white) fillings: All Plans Sealants to age 19 Extractions and other oral surgery Periodontics (gum disease therapy) Endodontics (root canal therapy) Restorative crowns Inlays and onlays Repair of a crown Major Restorative Care Fixed or removable bridgework Implants as alternative treatment Full or partial dentures Denture relines or rebases Orthodontics Coverage Limited to dependents up to age 19 Separate $2,800 lifetime maximum per covered dependent that does not start over if you change plans For more information on Delta Dental Premier, Delta Dental PPO, and University Choice: Customer Service: Toll free: TTY: For information on UPlan HealthPartners Dental and UPlan HealthPartners Dental Choice: Customer Service: Toll free: TTY: Open Enrollment 29

32 Dental Plan: 2018 Monthly Rates Retirees of All Ages/ Participants on Disability Status You pay the total cost. Retiree only; Spouse under age 65 only; Surviving Spouse only; or One Dependent Child only Plan Total Cost Delta Dental PPO: Twin Cities & Duluth Base Plan $36.49 Delta Dental Premier: Greater Minnesota Base Plan $44.72 University Choice $51.50 Delta Dental Premier: Twin Cities & Duluth $44.72 HealthPartners Dental $40.50 HealthPartners Dental Choice $44.07 Retiree and Children; Spouse under age 65 and Children; Surviving Spouse and Children; or Two or more Dependent Children only Plan Total Cost Delta Dental PPO: Twin Cities & Duluth Base Plan $87.36 Delta Dental Premier: Greater Minnesota Base Plan $ University Choice $ Delta Dental Premier: Twin Cities & Duluth $ HealthPartners Dental $99.73 HealthPartners Dental Choice $ Retiree and Spouse with or without Children Plan Total Cost Delta Dental PPO: Twin Cities & Duluth Base Plan $ Delta Dental Premier: Greater Minnesota Base Plan $ University Choice $ Delta Dental Premier: Twin Cities & Duluth $ HealthPartners Dental $ HealthPartners Dental Choice $ Open Enrollment

33 Important Notice from the UPlan Medical Program Important Notice from the UPlan Medical Program for Employees, Early Retirees, Disabled, and COBRA Participants and Dependents Concerning Your Prescription Drug Coverage and Medicare If you or a covered dependent has Medicare Part A and/ or B (or will be eligible within the next 12 months) you ll want to read this notice about your current Prescription Drug Coverage and Medicare. If not, you can disregard this notice. NOTE: The Centers for Medicare and Medicaid Services (CMS) regulations require us to send this notification to all individuals with prescription drug coverage who are eligible for Medicare. We re including this information in our Guide for UPlan Benefits Enrollment because we don t know if you are entitled to Medicare or not. Medicare entitlement includes individuals who qualify for Medicare because of a disability or end-stage renal disease (ESRD), as well as individuals who are over age 65. READ THIS ENTIRE NOTICE CAREFULLY and keep it where you can find it. This notice has information about your current prescription drug coverage with the University of Minnesota s UPlan Medical Program for employees, early retirees, disabled, and COBRA participants (and dependents) and the prescription drug coverage available for people with Medicare. It also explains the options you have under Medicare prescription drug coverage and can help you decide whether or not you want to enroll. At the end of this notice is information about where you can get help to make decisions about your prescription drug coverage. 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug coverage. All Medicare prescription 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. The eight plans in the University of Minnesota Retiree Medical Program for Over 65 Retirees will automatically enroll you in the Medicare prescription drug benefit and will include coverage that is at least as good as the Medicare prescription drug benefit. 2. The University of Minnesota has determined that the prescription drug coverage offered by the UPlan Employee Medical Program is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage. If you have a spouse or dependent on a Medicare plan, separate communications will be sent to them regarding their coverage. Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show that you are not required to pay a higher premium amount. Date: October 2017 Sender: University of Minnesota Office of Human Resources Employee Benefits Contact: Employee Benefits Address: th Avenue SE, Minneapolis, MN Phone: or Open Enrollment 31

34 Important Notice from the UPlan Medical Program Because your existing UPlan Employee Medical coverage is on average at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in the Medicare prescription drug program. If you decide to enroll in a Medicare prescription drug plan and drop your UPlan Employee Medical Program prescription drug coverage, be aware that you cannot get this coverage back. You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare and each year from October 15 through December 7. When you leave employer coverage you may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan. You should also know that if you drop or lose your coverage with your UPlan Employee Medical Program and don t enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. For more information about this notice or your current prescription drug coverage If you go 63 days or longer without prescription drug coverage that s at least as good as Medicare s prescription drug coverage, your monthly premium will go up at least one percent per month for every month that you did not have that coverage. For example, if you go 19 months without coverage, your premium will always be at least 19 percent higher than what many other people pay. You ll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to enroll. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two month Special Enrollment Period to join a Medicare drug plan. For more information about your options under the Medicare prescription drug coverage Contact the University of Minnesota Employee Benefits Service Center by calling or NOTE: You will receive this notice annually and at other times in the future such as before the next period you can enroll in Medicare prescription drug coverage, and if this coverage through the UPlan Employee Medical Program changes. You also may request a copy. More detailed information about Medicare plans that offer prescription drug coverage is available in the Medicare & You handbook, which you receive in the mail from Medicare. You may also be contacted directly by Medicare prescription drug plans. When you are approaching age 65, you will also receive information about the University of Minnesota Retiree Medical Program for Over 65 Retirees. For more information about Medicare prescription drug plans: Visit Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at or call them at (TTY ). 32 Open Enrollment

35 Return this application ONLY if you are making a coverage change. If not, please DO NOT return this form Your current coverage will continue. Application for Coverage 2018 Plan Year: Retiree Age 65 or Over APPLICANT INFORMATION (please print) Last name First Name MI Social Security # Home Address City State Zip Code Date of Birth (M/D/Y) Daytime Phone Employee ID (if known) Check status: o Uof M Retiree age 65 or over o Spouse or Surviving Spouse Age 65 or Over Provide Retiree s Name & Social Security # PLAN OPTIONS Medical You must be currently enrolled in a medical plan to select a different medical plan. A Retiree and Spouse must elect the same medical plan carrier, but each can decide which option, either Plan 1 or Plan 2, to select within the plan. Check the boxes to show who is enrolling for medical benefits and the plan option. o Retiree o Spouse o Surviving Spouse BCBS Plan 1 o o o BCBS Plan 2 o o o HealthPartners Plan 1 o o o HealthPartners Plan 2 o o o Medica Plan 1 o o o Medica Plan 2 o o o UCare Plan 1 o o o UCare Plan 2 o o o Dental You must be currently enrolled in a dental plan to choose a different dental plan. Check the appropriate box to show who is enrolling for dental benefits and the plan option. Delta Dental Premier Delta Dental PPO University Choice HealthPartners Dental HealthPartners Dental Choice o Retiree o Spouse o Surviving Spouse o o o o o PERSONS TO BE ENROLLED Last Name First Name Social Security # Gender DOB (M/D/Y) Enrolled in Medicare Part A? Enrolled in Medicare Part B? Self Spouse Effective date of Medicare Part A: Retiree Spouse Effective date of Medicare Part B: Retiree Spouse COORDINATION OF BENEFITS o Yes o No o Yes o No o Yes o No o Yes o No Do you or your spouse have other health insurance? o Yes o No If yes, who is covered? o Self o Spouse Company where coverage is obtained: Policy# Name & address of carrier: AUTHORIZATION (Please read before signing) I am applying for coverage in the University of Minnesota UPlan for retirees, subject to approval of my eligibility. I authorize the University to disclose the above information to the insurance carriers that I elected for use in processing my application. Applicant Signature Date Spouse Signature Date Effective Date of Change: January 1, 2018 Retiree Age 65 or Over For office use only: U of M Date Please return this form to Employee Benefits: 200 Donhowe Bldg., th Avenue SE, Minneapolis, MN

36 Information and Privacy There are laws to protect your rights Several state and federal laws aid in protecting your rights to privacy and make it easier for you to review information in your insurance file. Under one of these laws the Minnesota Government Data Practices Act (Minnesota Statutes ) you have the right to know the following. A. Why the Information is needed The information we request about you, your employment, and family members is needed for one or more of the following reasons: To determine whether you are eligible for University of Minnesota UPlan Health Program coverage To establish the amount of insurance coverage for which you are eligible To determine the amount of deductions from your paycheck to pay your rate contributions B. Supplying Information Your Rights Minnesota Statute You may refuse to provide the information we request; however, without certain minimal information, we may be unable to process your application for coverage under the group plan. Federal Privacy Act of 1974; Public Law Disclosure of your Social Security number is voluntary. The information is requested to identify your records in the Employee Benefits system and the records of the Plan Administrators. While you are not legally required to furnish this information, processing of your application for group benefits will be delayed without it. C. Who Uses the Information and How It is used The information we collect will be used by University employees operating the group benefits program, the payroll system, federal and state tax authorities, and shared with the Plan Administrators involved in your benefits coverage. Depending on the coverage you request (and are eligible for), the information may be used to: Provide enrollment and/or change information to your Plan Administrators so they can provide benefits and pay claims Conduct quality improvement initiatives Prepare statistical reports and evaluative studies When you are no longer an active participant in the group benefits program, your file is kept until state retention requirements are met. D. What Information You can Access You may request in writing to be shown information about yourself that is maintained by our department. There is no charge for this service, but there is a small copy charge should you need copies.

37 Return this application ONLY if you are making a coverage change. If not, please DO NOT return this form Your current coverage will continue. Application for Coverage 2018 Plan Year: Retiree under Age 65 APPLICANT INFORMATION (please print) Last name First Name MI Social Security # Home Address City State Zip Code Daytime Phone Date of Birth (M/D/Y) o Single o Married Marriage Date Employee ID (if known) Check status: o Participant on Disability o Uof M Retiree under age 65 o Spouse under age 65 Provide Retiree s name and Social Security # MEDICAL PLAN Twin Cities and Duluth Areas o Medica Elect/Essential* (Primary Care Clinic Number required) o Medica Choice National o Medica HSA Greater Minnesota o Medica Choice Regional o Medica Choice National o Medica HSA MEDICA ACO PLAN (Refer to the Benefits website for the areas that have an ACO choice) o ACO-VantagePlus with Medica o ACO-Park Nicollet First o ACO-Ridgeview Community Network o ACO-Altru & You (Crookston Area) o ACO-Essentia Choice Care (Duluth and northern Minnesota) o ACO-Medica ChoiceHealth-Mayo (Rochester Area) o Retiree, Spouse, or Disabled Participant only COVERAGE LEVEL: o Retiree, Spouse, or Disabled Participant & Children o Retiree or Disabled Participant & Spouse with or without children DENTAL PLAN Twin Cities and Duluth Areas o Delta Dental PPO o Delta Dental Premier o University Choice o HealthPartners Dental o HealthPartners Dental Choice Greater Minnesota o Delta Dental Premier o Delta Dental PPO o University Choice o HealthPartners Dental o HealthPartners Dental Choice o Retiree, Spouse, or Disabled Participant only COVERAGE LEVEL: o Retiree, Spouse, or Disabled Participant & Children o Retiree or Disabled Participant & Spouse with or without children PERSONS TO BE ENROLLED (Complete requested information for Self and Eligible Dependents) Relationship Last Name First Name Social Security # Gender Self DOB (M/D/Y) Primary Care Clinic Number* Spouse Child (birth to age 26) Child (birth to age 26) Child (birth to age 26) *A Primary Care Clinic Number is required for enrollment in Medica Elect/Essential. Failure to add a correct number will result in an enrollment error.