Human Resources Division

Transcription

1 Human Resources Division Ted J. Cwiek, Director Katherine Harris, Deputy Director RETIREE OPEN ENROLLMENT MARCH 1 30, 2018 March 1, 2018 Dear San Joaquin County Retiree: Enclosed is information about the health, dental, and vision plans available to you as a San Joaquin County retiree. Your open enrollment period is your annual opportunity to change plans and to add or delete dependents. You may change your coverage, or add or delete coverage for your eligible dependents only during open enrollment or within 60 days after a qualifying life event. Federal reporting requirements for employer-sponsored group plans require the County to collect Social Security Numbers for each dependent you enroll in your health, dental, or vision coverage. Without this information, claims cannot be processed. When enrolling a dependent on your health, dental, or vision plan, you must provide each dependent's Social Security Number at the time of enrollment. If you are planning to complete and submit your enrollment forms during one of the Open Enrollment meetings on Wednesday, March 21, 2018, please be sure to have your dependent(s) Social Security Number(s) available. Completed enrollment forms must be returned to SJCERA by Friday, March 30, You only need to complete an enrollment form if you are changing plans, adding/deleting dependents, or newly enrolling in a health, dental, or vision care plan. If you are not making any changes to your existing plan enrollment or dependents, you do not need to return any documentation. Please note, that although open enrollment is a time to make changes or add members, if you or your dependents were previously enrolled and opted out, you may not re-enroll. If you are planning to cancel your County-sponsored retiree health, dental, or vision insurance, please notify SJCERA right away. It is imperative to complete cancellation documents through SJCERA in order to discontinue premium deductions from your monthly retirement allowance. 44 N. San Joaquin Street, Suite 330 Stockton, California T F humanresources@sjgov.org

2 Human Resources Division Read Carefully In Order to Understand Your Benefits: County Managed Care Plan (CMCP): Pomco - Third Party Administrator (TPA): As you are aware, the County selected a new third-party administrator (TPA) for the CMCP self-funded medical plan last year. Weeks after this transition, Pomco was purchased by UMR, a subsidiary of United Healthcare Services, Inc. Over the past year, Pomco has continued to provide services to the County, however, this purchase may require the County to make future changes. County staff will provide notification of any changes to the TPA, network, or personnel providing services as soon as we re made aware. We appreciate your understanding during this time of transition. Provider Networks: The network of providers offered for CMCP is provided through Anthem, Inc. For those living outside of California, Pomco utilizes a wrap network through the First Health Network. If you have any questions about your provider being part of the Anthem network, please contact Pomco s/umr s Customer Service number for verification, at (844) Physician Selection Members enrolled in CMCP are required to designate a Primary Care Physician (PCP) who will direct all of your care. You may change your personal physician at any time by contacting Pomco s/umr s Customer Service number, at (844) Important: Members are responsible for verifying that any primary or specialty doctor who will provide services is a network provider before care is received to assure that benefits will be paid. All Other Plans: Benefits and co-payment changes: There have been some minor changes, including benefit enhancements, on some of the Benefits Summary documents for the health, dental, and vision plans offered to County retirees. You are encouraged to review these summaries and the Evidence of Coverage and/or Certificate of Insurance (available at the Open Enrollment meetings or upon request to SJCERA) for your current plan and any other plan you are considering during this Open Enrollment period. 2 of 5

3 Human Resources Division Summary of Changes in Monthly Premiums for all Plans: Medical: Anthem Blue Cross Premium increase of 5% to 7.8% CMCP Self-Funded Premium increase of 16% HealthNet Premium increase of 1.3% to 8.1% Kaiser Enrollees without Medicare - Premium decrease of 0.5% Kaiser Northwest Premium increase of 2.9% to 14.1% Kaiser Senior Advantage High - Premium increase of 0.2% to 3.5% Kaiser Senior Advantage Low - Premium increase of 0.4% to 6.4% Dental: Delta Dental - Premium increase of less than 1% United Healthcare Dental - Premium decrease of approximately 1% Vision: Vision Service Plan (VSP) - Premium increase of less than 1% Plan and Monthly Premium Information Attached Monthly premium rates, benefit, and co-payment summaries for plans offered are attached. The information is color coded as follows: Blue Medicare Plans Rate Sheets and Benefit Summaries Green Yellow White Pink Non-Medicare Plans - Rate Sheets and Benefit Summaries Blended - Rate Sheet for Medicare and Non-Medicare Families Dental Plan Rates and Benefits Summaries VSP Signature Choice Plan Rates and Benefit Summary 3 of 5

4 Human Resources Division Open Enrollment Meetings Location and Schedule Open Enrollment meetings will be held in Assembly Room 2 at: San Joaquin County Robert J. Cabral Agricultural Center 2101 E. Earhart Ave Stockton, California This location provides a large, comfortable meeting space and free parking. A map and driving directions to this location are attached. Please note the following: Purpose for meetings: To give you an opportunity to hear from representatives from each of the health, dental, and vision plans who will be present to answer your questions and assist you with enrollment forms. Separate meetings for retirees who have Medicare: Please attend the appropriate session that corresponds to the first letter of your last name (see schedule below). One meeting only for retirees without Medicare Open Enrollment Meeting Schedule NOTE: If you cannot attend your assigned meeting, you may attend another session. Retirees With Medicare: Last Name begins with A L Wednesday, March 21-9:00 a.m. L Last Name begins with M Z Wednesday, March 21-11:00 a.m. All Retirees Without Medicare: Wednesday, March 21-1:30 p.m. 4 of 5

5 Human Resources Division How to Learn More About Your Plans Attend your Open Enrollment meeting to hear a short presentation from representatives of each of the plans available to you. This will help you make informed decisions about the different health plans, adding or deleting dependents, or enrolling in a dental or vision plan. How to Obtain Enrollment Forms Enrollment forms for health, dental, and vision plans will be available at the Open Enrollment meetings or you may obtain insurance packets and enrollment forms by contacting SJCERA, 6 S. El Dorado Street, Suite 400, Stockton, CA, or by calling (209) Questions about Open Enrollment? Call SJCERA at (209) of 5

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7 2018 San Joaquin County RETIREE OPEN ENROLLMENT MEETINGS Wednesday, March 21, 2018 LOCATION: San Joaquin County Meeting Room: Assembly Room 2 Robert J. Cabral Agricultural Center 9:00 a.m. Retirees with Medicare (A-L) 2101 E. Earhart Ave 11:00 a.m. Retirees with Medicare (M-Z) Stockton, CA :30 p.m. ALL Retirees without Medicare Driving Directions FROM LODI / NORTH STOCKTON: FROM LATHROP / MANTECA: Travel SOUTH on HIGHWAY 99 Travel NORTH on HIGHWAY 99 Take the ARCH ROAD exit Take the ARCH ROAD exit Travel WEST on ARCH ROAD Travel WEST on ARCH ROAD Turn LEFT onto POCK LANE Turn LEFT onto POCK LANE Turn RIGHT onto EARHART AVE Turn RIGHT onto EARHART AVE FROM TRACY: Travel EAST on I-205 Merge onto I-5 NORTH Merge onto HIGHWAY 120 EAST Merge onto HIGHWAY 99 NORTH Take the ARCH ROAD exit Travel WEST on ARCH ROAD Turn LEFT onto POCK LANE Turn RIGHT onto EARHART AVE PARKING: There is ample free visitor parking located directly outside of the building.

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9 Human Resources Division Ted J. Cwiek, Director Katherine Harris, Deputy Director Retiree Open Enrollment Packet Effective May 1, 2018 through April 30, 2019 Plan and Monthly Premium Information Attached Monthly premium rates, benefit, and co-payment summaries for each of the plans offered to County retirees are included in this packet. The information is color-coded as follows: Blue Medicare Plans Rates & Benefit Summaries Green Non-Medicare Plans Rates & Benefit Summaries Yellow Blended: Medicare & Non Medicare Rates & Benefit Summaries White Dental Plans Rates & Benefit Summaries Pink VSP Signature Choice Plan Rates & Benefit Summary 44 N. San Joaquin Street, Suite 330 Stockton, California T F humanresources@sjgov.org

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11 MEDICARE PLAN MONTHLY PREMIUMS Effective May 1, April 30, 2019 For individuals and dependents who all have Medicare MEDICARE HMOs Members must assign Medicare Parts A & B Kaiser Permanente SENIOR ADVANTAGE Health Net SENIORITY PLUS Enrollees Traditional High Option Plan Traditional Low Option Plan Kaiser Northwest High Option Plan Low Option Plan From To From To From To From To From To Retiree Only Retiree + 1 Dependent , , MEDICARE COORDINATED PLANS No assignment of Medicare required Enrollees CMCP or CMCP Out-of-Area Anthem Blue Cross Assurance + 1 Health Net COB Health Net Flex Out-of-Area From To From To From To From To Retiree Only , , Retiree + 1 Dependent 1, , , , , , , ,921.41

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13 County Managed Care Plan (CMCP) Benefits and Co-Payments for In-Network and Out-of-Network MEDICARE May 1, 2018 to April 30, 2019 In-Network Out-of Network (Patient pays charges above UCR) Deductible per Plan Year None $100 / person; 3 per family max Lifetime Maximum Benefits Payable Unlimited Unlimited Out-of-Pocket Maximum - excludes deductibles, costs above UCR, emergency care, prescriptions, chiropractic, and durable medical. Hospital Inpatient or ICU $1,000 per Person, $2,500 per family per year Once annual maximum is met, plan pays 100% of eligible expense for balance of plan year. $100 per admission (waived at SJGH), 90%/10%* $3,000 per Person 20% Outpatient Surgery Facility 90%/10%* 15% Emergency Room - Outpatient $30 SJGH/$40, waived if admitted $40, waived if admitted Ambulance, if pre-authorized or emergency 90%/10% 20% Skilled Nursing Facility/Home Health Care/Hospice 90% / 10% - 60 days max per year per condition 20% - 60 days max per condition; 100 days per year Doctor Visits $15 20% Urgent Care Facility $20 $20 plus 10% of remaining allowable charge Diagnostic Lab/X-Ray Outpatient 90%/10%* 20% Prescriptions (Rx) Outpatient Provided through Medicare Prescription Drug Plan Physical, Speech, or Occupational Therapy - 60 visits max per year for all $5 generic $20 preferred brand-name $35 non-preferred brand- name $5.00 plus 20% of charges in excess of $35.00 $15 per visit 20% *only if no PPO provider available Chiropractic, with valid diagnostic code - Maximum 20 visits per year Plan pays $25 per visit Plan pays $25 per visit Eye Refraction /Hearing Tests, age 18 or under $15 20% Allergy Test or Treatment $15 20% Durable Medical /Prosthetics Mental Health & Substance Abuse Outpatient 50% - least expensive of purchase, rental or repair $15 20% Mental Health & Substance Abuse Inpatient $100 per admission (waived at SJGH), 90%/10%* 20%

14 County Managed Care Plan (CMCP) Benefits and Co-Payments for In-Network and Out-of-Network MEDICARE CMCP In-Network For Medicare recipients, Medicare is primary. Benefits will be coordinated with Medicare after plan deductibles are satisfied. No assignment of Medicare is required. Prescription co-payments for a 30-day supply are $5 for generic, $20 for preferred brand name, and $35 for non-preferred brand name. New in 2018: New federal guidelines and best practices require limits on Opioid drug quantities prescribed. These limit restrictions began on March 1, Co-insurance for inpatient and outpatient services is waived for services received at SJC Health Care Services facilities. For all other providers, the Plan pays 90% of the covered expense; the member pays 10% up to the out-of-pocket maximum of $1,000 per individual and $2,500 per family per plan year. The coinsurance does not apply to physician visits, prescription drugs, chiropractic services, emergency care, and durable medical equipment. CMCP Out-of-Network For Medicare recipients, Medicare is primary. Benefits will be coordinated with Medicare after plan deductibles are satisfied. No assignment of Medicare is required. Benefits and out-of pocket limits are based on allowable rates for In-Network and UCR (Usual, Customary and Reasonable) for out-of-network. Participants using out-of-network providers will be responsible for all charges in excess of UCR. See benefit handbook for actual language, limitations, and exclusions. The benefit handbook can be obtained at the open enrollment meetings or at SJCERA. Participants Out-of-Network utilizing In-Network providers receive In-Network benefits.

15 Anthem Assurance Plus 1 Benefits and Co-Payments - In-Network Coverage* May 1, 2018 to April 30, 2019 Assurance Plus 1 MEDICARE Deductible Hospital Stay Outpatient Surgery Emergency Room within continental US only Ambulance Skilled Nursing Facility Home Health Doctor Office Visit Lab/X-ray Outpatient Prescriptions Outpatient Physical Exam Physical, Occupational or Speech Therapy Services Chiropractic Eye Exam Hearing Tests Appliances Outpatient Mental or Nervous Disorders None (Plan does not pay Part B Deductible) No Charge; refer to Certificate of Insurance for complete limitations 100% after member pays annual Part B Deductible 100% after member pays annual Part B Deductible, Out of US see Certificate of Insurance 100% after member pays annual Part B Deductible Covered 100% of co-pay 21 st day thru 100 th day Not Covered 100% after member pays annual Part B Deductible 100% after member pays annual Part B Deductible $0 Select Generic $10 Generic $20 Preferred Brands, Non-Preferred Brands, Nonformulary $10 Diabetic Supplies Insulin Syringes & Alcohol Swabs up to 90-day supply Medicare coverage only Plan pays up to $100 per calendar year for each Not Covered, unless specified by Medicare Not Covered, unless specified by Medicare Not Covered, unless specified by Medicare 100% after member pays annual Part B Deductible 100% after member pays annual Part B Deductible * Out- of-network - See Certificate of Insurance for benefits through non-participating providers of plan or Medicare. This is only a summary of plan benefits and co-payments for medically necessary services and not inclusive of complete benefits and limitations. Refer to Evidence of Coverage or Certificate of Insurance at open enrollment meetings or at SJCERA for complete description of benefits, exclusions, and limitations. This is a Medicare supplement. No assignment of Medicare is required. You do not have to designate a Primary Care Physician. However, out-of-pocket costs are lowest when using providers in the Anthem Blue Cross Prudent Buyer network and are highest when using providers outside the network who do not accept Medicare rates.

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17 MEDICARE Health Net Seniority Plus and COB Benefits and Co-payments May 1, 2018 to April 30, 2019 HEALTH NET SENIORITY PLUS HEALTH NET SENIORITY PLUS LOW OPTION HEALTH NET COB Deductible None None None Hospital Stay No copay $250 Covered in full Medicare Must Assign Must Assign No Assignment Outpatient Surgery No copay No copay Covered in full Emergency Room $20 per visit; waived if admitted $50 per visit; waived if admitted $35; waived if admitted Ambulance No copay (does not cover nonemergency ambulance service) No copay ((does not cover nonemergency ambulance service) Covered in full Skilled Nursing Facility No copay up to 100 days per benefit period Home Health No copay No copay $20 copay per day / (3-day copay max), limited to 100 days per benefit period Covered in full; limit 100 days $10, starting 31 days after 1 st visit Doctor Visit $5 $15 $5 Urgent Care $20 out-of-area $50 $35 Lab/X-ray Outpatient No charge No copay No charge Prescriptions Outpatient Retail Up to 30-day supply: Tier 1 - $10 (Preferred Generic) Tier 2 - $15 (Preferred Brand) Tier 3 - $35 (Non-Preferred Brand) Tier 4-25% (Injectable Drugs) Tier 5-25% (Specialty Drugs) Retail Up to 30-day supply: Tier 1 - $10 (Preferred Generic) Tier 2 - $25 (Preferred Brand) Tier 3 - $50 (Non-Preferred Brand) Tier 4-25% (Injectable Drugs) Tier 5-25% (Specialty Drugs) Retail Up to 30-day supply: Tier 1 - $10 (Preferred Generic) Tier 2 - $20 (Preferred Brand) Tier 3 - $35 (Non-Preferred Brand) Tier 4-25% (Injectable Drugs) Mail Order Tier 1-3: 2x Retail co pay for up to a 90- day supply Mail Order Tier 1-3: 2x Retail co pay for up to a 90- day supply Mail Order Tier 1-3: 2x Retail co pay for up to a 90- day supply Periodic Health Evaluation Outpatient Rehab Therapy No charge No charge $5 No copay No copay Covered in full Chiropractic $5 per visit up to 20 visits per calendar year $15 co pay referred by PCP through Medical Group $15 per visit up to 20 visits Vision Services $5 for one routine vision exam per year; $100 frame allowance every 24 months $10 for one routine vision exam per year; $100 frame allowance every 24 months $5 for one routine vision exam per year; $100 frame allowance every 24 months Hearing Tests $5 $10 $5 1

18 MEDICARE Health Net Seniority Plus and COB Benefits and Co-payments May 1, 2018 to April 30, 2019 HEALTH NET SENIORITY PLUS HEALTH NET SENIORITY PLUS LOW OPTION HEALTH NET COB Allergy Testing and Injection No charge No charge Covered in full Immunizations No charge for preventative (20% for foreign travel) No charge for preventative (20% for foreign travel) No charge for preventative (20% for foreign travel) Durable Medical No copay No copay Covered in full Prosthetics No copay No copay Covered in full Mental Health Outpatient Mental Health Inpatient $5 $15 $5 No copay $250 Covered in full These are only summaries of plan benefits. Refer to plan documents at open enrollment meetings or at SJCERA for specific coverage provisions. Co-payments are based on using plan providers. Use of outside providers may result in reduced coverage or no coverage. Health Net Seniority Plus: Enrollment in Health Net Seniority Plus requires assignment of Medicare to Health Net. This plan is offered in the following counties in California. You must live in one of these places to join the plan. Alameda Sacramento Santa Clara Contra Costa San Bernardino Santa Cruz Kern* San Diego Solano Los Angeles San Francisco Sonoma Orange San Joaquin Stanislaus Placer* San Mateo* Tulare Riverside Santa Barbara* Yolo *Indicates only specified zip codes are covered in this county. You must live in one of the specified zip codes to join the plan. (Refer to plan documents for zip codes for these counties.) Health Net Coordination of Benefits (COB): This is a Medicare HMO. Medicare assignment is not required. However, you must designate a Primary Care Physician, and you must obtain referrals and authorizations within your PCP s medical group in order to receive coverage supplemental to Medicare. 2

19 MEDICARE Kaiser Permanente Medicare HMOS Senior Advantage Traditional Plan and Lower Premium Plan Benefits and Co-Payments May 1, 2018 to April 30, 2019 KAISER PERMANENTE SENIOR ADVANTAGE TRADITIONAL PLAN KAISER PERMANENTE SENIOR ADVANTAGE LOWER PREMIUM PLAN Deductible or Lifetime Maximum Annual Out-of-Pocket Maximum Hospital Stay None $1,500 per member; $3,000 per family (Co-payments and co insurance for most services count toward this maximum) $100 per admission None $1,500 per member; $3,000 per family (Co-payments and co insurance for most services count toward this maximum) $100 per day (up to out-of-pocket maximum) Medicare Must Assign Must Assign Outpatient Surgery $20 per procedure $150 per procedure Emergency Room $50 per visit; waived if admitted $50 per visit; waived if admitted Ambulance $100 per trip $150 per trip Skilled Nursing Facility No charge up to 100 days per benefit period No charge up to 100 days per benefit period Home Health No charge No charge Doctor Visit $20 per visit $25 per visit Urgent Care $20 per visit $25 per visit Lab/X-ray outpatient No charge No charge Prescriptions Outpatient $10 Generic; $20 Brand up to 100-day supply for most drugs $10 Generic (30-day supply); $25 Brand/Specialty (30-day supply) Physical exam $20 $25 Outpatient Rehab Therapy $20 per individual therapy visit; $5 per group therapy visit Chiropractic Not covered Not covered $25 per individual therapy visit; $5 per group therapy visit Vision Care $20 for one exam per year; $150 materials allowance once every 2 years $25 for one exam per year; $150 materials allowance once every 2 years Hearing Tests $20 $25 Allergy Exam/Visit $3 injection; $20 visit No charge for injections; $25/testing visit Immunizations No charge No charge Durable Medical Equip No charge (inside service area only) 20% Prosthetics No charge No charge 1

20 MEDICARE Kaiser Permanente Medicare HMOS Senior Advantage Traditional Plan and Lower Premium Plan Benefits and Co-Payments May 1, 2018 to April 30, 2019 Mental Health Outpatient Mental Health Inpatient KAISER PERMANENTE SENIOR ADVANTAGE TRADITIONAL PLAN $20 per visit - individual $10 per visit - group therapy $100 per admit; 190 days per lifetime as covered by Medicare; then up to 45 days per calendar year KAISER PERMANENTE SENIOR ADVANTAGE LOWER PREMIUM PLAN $25 per visit - individual $12 per visit - group therapy $100 per day; 190 days per lifetime as covered by Medicare; then up to 45 days per calendar year These are only summaries of plan benefits, co-payments, and co-insurance for medically necessary services. See plan documents at open enrollment meetings or at SJCERA for specific coverage provisions. Kaiser Permanente Senior Advantage is for members entitled to Medicare. Enrollment in a Senior Advantage with Part D Plan means that you are automatically enrolled in Medicare Part D. Kaiser Permanente Senior Advantage requires assignment of your Medicare benefits to Kaiser. 2

21 Kaiser Northwest Traditional Senior Advantage (Over 65) Benefits and Co-Payments MEDICARE OUT-OF-AREA May 1, 2018 to April 30, 2019 Kaiser Northwest Deductible per Plan Year Lifetime Maximum Benefits Payable Annual Limit to Co-payments Hospital Inpatient or ICU Hospital Rehab Outpatient Surgery Emergency Room In Plan/Out of Plan Emergency room / Urgent care Non Plan Urgent Care Kaiser Facility Ambulance, if pre-authorized or emergency Skilled Nursing Facility Home Health Care/Hospice care Doctor Visits Diagnostic Lab/X-Ray Outpatient Prescriptions (Rx) Outpatient up to a 30-day supply. Home delivery of maintenance drugs up to a 90-day supply for 2 co-payments. Preventive care / Physical Exam Outpatient Physical, Speech, or Occupational Therapy Vision Services None None $1000 per member; $2,000 per family $200 per admit $200 per admit $100 per procedure $50 per visit; waived if admitted $50 per visit; waived if admitted $20 per visit $75 per trip No charge up to 100 days per year No charge within service area $15 Primary Care / $20 Specialty Care No charge / $25 per visit for CT, MRI, PET scans $10 for Generic $20 for Brand Name $40 for Approved Non-formulary 15% Coinsurance for administered medications, including injections (all outpatient settings) No charge $20 per visit $15 for eye exam; $100 credit for lenses and frames once every 2 years Hearing Test $15 Allergy Test or Treatment $10 Immunizations Durable Medical Equipment and Prosthetics & Orthotics Mental Health Outpatient Mental Health Inpatient No charge; $10 office visit Plan pays 80%; Co-insurance 20% $15 per visit $200 per admit This is only a summary of plan benefits and co-payments for medically necessary services. See Certificate of Insurance at open enrollment meetings or at SJCERA for specific coverage provisions.

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23 Health Net Flex Net Out-of-Area Coverage Benefits and Co-Payments MEDICARE OUT-OF-AREA May 1, 2018 to April 30, 2019 Health Net Flex Net Plan Doctor Visit 100% Specialist Consultation 100% Chiropractic 100% Lab/X-Ray 100% Pharmacy Benefit Immunizations Physical, Speech, Occupational and Inhalation Therapy Hospital Care Hospital Inpatient days Hospital Inpatient days Hospital Inpatient - Beyond 90 days Hospital Inpatient - Beyond Lifetime Reserve Days Urgent Care Center Services Emergency Services Emergency Services Non-U.S. Hospital Care $75 Deductible; 20% Co-insurance Not Covered, Unless Under Preventative Services 100% No Charge Pays Medicare Deductible Pays Medicare Co-insurance Pays Medicare Co-insurance for lifetime reserve days Pays 90% of Maximum Allowable Amount up to a lifetime maximum of 365 days 100% Within the United States 100% Within the United States Hospital Care 100% Professional Medical Care 20% Co-insurance Ambulance Air / Ground 100% Durable Medical Equipment 100% Hearing Aids Not Covered Prosthesis 100% Chemical Dependency Rehab Outpatient Mental Health Outpatient Severe Mental Illnesses Chemical Dependency Detox Inpatient Mental Health Inpatient Severe Mental Illnesses 100% 100% Days 1-60 Pays Medicare deductible days Pays Medicare Co-insurance Beyond 90 days Pays Medicare Co-insurance for lifetime reserve days Beyond lifetime reserve days- pays 90% of Maximum allowable amount up to maximum of 365 days 1

24 MEDICARE OUT-OF-AREA Health Net Flex Net Out-of-Area Coverage Benefits and Co-Payments All services or treatments deemed to be medically necessary by Medicare will also be considered medically necessary by Health Net. Members must utilize participating pharmacies. There are no benefits for prescription drugs that are dispensed by non-participating pharmacies. It is very important to understand the benefits you are entitled to under Medicare Parts A and B. Flex Net covers only those charges approved by Medicare. In some cases, the patient may be responsible for the difference between approved costs and billed costs. If you have any questions regarding your Medicare coverage or would like a copy of the Medicare handbook, please call the Social Security Administration at (800) For questions regarding Flex Net, please call (800)

25 For individuals and dependents who are all under age 65 and do not have Medicare. From To From To From To From To Retiree Only , , , Retiree + Spouse 1, , , , , , , , Retiree with Family 2, , , , , , , , ATTENTION MEMBERS OVER AGE 65 WHO DO NOT HAVE MEDICARE PARTS A AND B: Coverage is not available through Anthem Blue Cross, Health Net or Kaiser for members age 65 and over who do not have both Medicare Parts A & B. You must select either the CMCP or CMCP Out-of-Area plan. CMCP and CMCP Out-of-Area plans will cover members age 65 or over who do not have both Medicare Parts A & B at an individual rate of $ 2, per month. NON-MEDICARE PLAN MONTHLY PREMIUMS Effective May 1, April 30, 2019 Enrollees CMCP or CMCP Out-of-Area Anthem California Care HMO Kaiser Permanente California Kaiser Northwest

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27 NON-MEDICARE County Managed Care Plan (CMCP) Benefits and Co-Payments In-Network and Out-of-Network May 1, 2018 to April 30, 2019 In-Network Out-of-Network (Patient pays above customary charge) Deductible per Plan Year None $100 / person; 3 per family max Lifetime Maximum Benefits Payable Unlimited Unlimited Out-of-Pocket Maximum - excludes deductibles, costs above UCR, emergency care, prescriptions, chiropractic, durable medical. Hospital Inpatient or ICU $1,000 per Person, $2,500 per family per year Once annual maximum is met, plan pays 100% of eligible expense for balance of plan year. $100 per admission (waived at SJGH), 90%/10%* $3,000 per Person 20% Outpatient Surgery Facility 90%/10%* 15% Emergency Room - Outpatient $30 SJGH/$40, waived if admitted $40, waived if admitted Ambulance, if pre-authorized or emergency 90%/10% 20% Skilled Nursing Facility/Home Health Care/Hospice 90%/10% - 60 days max per year per condition 20% - 60 days max per condition; 100 days per year Doctor Visits $15 20% Urgent Care Facility $20 $20 plus 10% of remaining allowable charge Diagnostic Lab/X-Ray Outpatient 90%/10%* 20% Prescriptions (Rx) Outpatient - 1 course of treatment or 30-day supply $10 generic $20 brand-name $35 non-formulary. Mail order available. $7 plus 20% of charges in excess of $35.00 Physical, Speech, or Occupational Therapy - 60 visits max per year for all $15 per visit 20% *only if no PPO provider available Chiropractic, with valid diagnostic code - Maximum 20 visits per year Plan pays $25 per visit Plan pays $25 per visit *only if no PPO provider available Eye Refraction /Hearing Tests (age 18 or under) $15 20% *only if no PPO provider available Allergy Test or Treatment $15 20% Durable Medical /Prosthetics Mental Health & Substance Abuse Outpatient 50% - least expensive of purchase, rental or repair $15 20% Mental Health & Substance Abuse Inpatient $100 per admission (waived SJGH), 90%/10%* *The 10% coinsurance is waived when services are received at SJC Health Care Services facilities. This plan is a grandfathered plan under the provisions of the Patient Protection and Affordable Care Act. 20%

28 NON-MEDICARE County Managed Care Plan (CMCP) Benefits and Co-Payments In-Network and Out-of-Network CMCP In-Network Prescription co-payments for a 30-day supply are $10 for generic, $20 for brandname, and $35 for non-formulary medicines. Mail order is available for a 90-day supply of maintenance medications for co-payments of $20 for generic, $40 for brand name and $70 for non-formulary. Co-insurance for inpatient and outpatient services is waived for services received at SJC Health Care Services facilities. For all other providers, the Plan pays 90% of the covered expense; the member pays 10% up to the out- of-pocket maximum of $1,000 per individual and $2,500 per family per plan year. The coinsurance does not apply to physician visits, prescription drugs, chiropractic services, emergency care, and durable medical equipment. New in 2018: New federal guidelines and best practices require limits on Opioid drug quantities prescribed. These limit restrictions began on March 1, CMCP Out-of-Network Benefits and out-of-pocket limits are based on allowable rates for In-Network and UCR (Usual, Customary and Reasonable) for out-of-network. Participants using out-of-network providers will be responsible for all charges in excess of UCR. See benefit handbook for actual language, limitations, and exclusions. The benefit handbook can be obtained at the open enrollment meetings or at SJCERA.

29 Anthem California Care HMO Benefits and Co-Payment NON-MEDICARE May 1, 2018 to April 30, 2019 Anthem California Care Plan with PPO Rider HMO In Network HMO Out of Network PPO Rider ($2,500 maximum) Deductible None Not Applicable $100 / calendar year Max of 3 per family Out-of-Pocket Maximum $1500 per Member $3,000 per Family Not Applicable Not Applicable Hospital Stay $150/admit Not Covered Not Covered Outpatient Surgery No Copayment Not Covered 20% Emergency Room $100 (waived if admitted) $100 (waived if admitted) Not Covered Ambulance $100/trip Not Covered Not Covered Skilled Nursing Facility No Copayment Not Covered Not Covered Home Health Care $15 per visit/100 visits per year Not Covered Not Covered Doctor Office Visit $15 per visit Not Covered 20% office and home visits, including specialists and consultants. Urgent Care In Area $15 per visit Not Covered Not Covered Lab/X-Ray Outpatient No Copayment Not Covered 20% Prescriptions Outpatient $10 Tier 1 drugs (includes diabetic supplies) $20 Tier 2 drugs a,b $20 Tier 3 drugs a,b (includes compound drugs) $20 Tier 4 drugs c 1 Member pays the retail pharmacy copay (as shown in the HMO In Network column) plus 50% of the remaining prescription drug maximum allowed amount and costs in excess of the prescription drug maximum allowed amount d Not Covered Preventative Exam $15 per visit Not Covered Not Covered Outpatient Rehabilitation Services $15 per visit; Up to 60 days per illness or injury Not Covered 20% a Preferred Generic Program. If a member requests a brand name drug when a generic drug version exists, the member pays the generic drug copay plus the difference in cost between the prescription drug maximum allowed amount for the generic drug and the brand name drug dispensed, but not more than 50% of our average cost of that type of prescription drug. The Preferred Generic Program does not apply when the physician has specified dispense as written (DAW) or when it has been determined that the brand name drug is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply. b Drugs indicated as non-preferred on the Preferred Drug Program list may be dispensed when the physician has specified dispense as written (DAW) or when determined that the brand name drug is medically necessary for the member. c Classified specialty drugs terms of the program. d Compound drugs and certain specialty pharmacy drugs not covered at Non-Participating Pharmacies.

30 Anthem California Care HMO Benefits and Co-Payment NON-MEDICARE May 1, 2018 to April 30, 2019 Anthem California Care Plan with PPO Rider HMO In Network HMO Out of Network PPO Rider ($2,500 maximum) Preventive Hearing / Vision Screening No Charge Not Covered 20% Allergy Exam/Visit $15 per visit Not Covered 20% Immunizations Preventive immunizations administered by a retail pharmacy No Charge Not Covered Not Covered Durable Medical 20 % Not Covered Not Covered Prosthetics No Charge Not Covered Not Covered Mental Health & Substance Abuse Outpatient $15 per visit Not Covered Not Covered Mental Health & Substance Abuse Inpatient $150 co-payment Not Covered Not Covered This is only a summary of plan benefits and co-payments for medically necessary services. See Evidence of Coverage or Certificate of Insurance at open enrollment meetings or at SJCERA for specific coverage provisions. This is an HMO plan for members under age 65 who do not have Medicare. You must select a Primary Care Physician (PCP). Referrals are required for consultation or treatment by a specialist. 2

31 NON-MEDICARE Kaiser Permanente California Benefits and Co-Payments May 1, 2018 to April 30, 2019 Kaiser Permanente California Deductible per Plan Year Co-insurance Annual Out-of-Pocket Maximum Hospital Stay Outpatient Surgery Emergency Room Ambulance Skilled Nursing Facility Home Health Care None None $1,500 per person; $3,000 per family $100 per admission $20 per procedure $50 per visit; waived if admitted $50 per trip No charge to 100 days per year No charge Doctor Office visit $20 Urgent Care Lab/X-Ray Outpatient $20 per visit No charge Prescriptions Outpatient $10 Generic $20 Brand up to 100 days most drugs Physical exam $20 Outpatient Rehabilitation Services Chiropractic $20 per individual therapy visit Not covered Vision screening $20 Hearing Tests $20 Allergy Exam/Visit $20 Immunizations Durable Medical and Prosthetics Mental Health Outpatient No charge No charge $20 per visit Mental Health Inpatient $100 per admit

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33 OUT-OF-AREA Kaiser Health Plan Northwest (Under 65) Benefits and Co-Payments May 1, 2018 to April 30, 2019 Kaiser Northwest Deductible per Plan Year Lifetime Maximum Benefits Payable Annual Limit to Co-payments Hospital Inpatient or ICU Hospital Rehab Outpatient Surgery Emergency Room In Plan/Out of Plan Urgent Care Kaiser Facility Ambulance, if pre-authorized or emergency Skilled Nursing Facility Home Health Care/Hospice care Doctor Visits Diagnostic Lab/X-Ray Outpatient Prescriptions (Rx) Outpatient up to a 30-day supply. Home delivery of maintenance drugs up to a 90-day supply for 2 co-payments. Preventive care / Physical Exam Outpatient Physical, Speech, or Occupational Therapy Vision Services None None $1000 per member; $2,000 per family $100 a day up to $500 per admit No charge $50 per procedure $200 per visit; waived if admitted $40 per visit $75 per trip No charge up to 100 days per year No charge within service area $20 Primary Care / $30 Specialty Care $20 per visit / $50 per visit for CT, MRI, PET scans $10 for Generic $20 for Brand Name $40 for non-preferred brand/specialty 20% Coinsurance for administered medications, including injections (all outpatient settings) No charge $30 per visit; Up to 20 visits per therapy per Calendar Year $20 for eye exam; Vision hardware not covered Hearing Test $20 Allergy Test or Treatment $10 Immunizations Durable Medical Equipment and Prosthetics & Orthotics Mental Health Outpatient Mental Health Inpatient No charge; $10 office visit Plan pays 80%; Co-insurance 20% $20 per visit $100 a day up to $500 per admission This is only a summary of plan benefits and co-payments for medically necessary services. See Certificate of Insurance at open enrollment meetings or at SJCERA for specific coverage provisions.

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35 Any blank rates below indicate that there are currently no retirees enrolled in this specific plan/tier. If interested, we will contact the vendor for a quote. 1, , BLENDED FAMILY MONTHLY PREMIUMS Medicare & Non-Medicare Plan Premiums Effective May 1, April 30, 2019 For Families with Medicare and Non-Medicare Enrollees *Blended low option only available if the retiree/subscriber have Medicare. Rates below assume that over 65 members are enrolled in Medicare. Please note that if an over 65 retiree has no Medicare, rates are higher. ENROLLEES: CMCP ANTHEM BLUE CROSS KAISER PERMANENTE With & Without Medicare (blended) CMCP Over 65 Assurance + 1 Senior Advantage & & & CMCP Under 65 Kaiser Permanente California California Care HMO High Option Plan Low Option Plan* Kaiser Northwest Premiums for: From To From To From To From To From To 1 with and 1 without Medicare 1 with and 2 without Medicare 1, , , , , , , , , , , ,431.76

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37 Comparison of Voluntary Dental Plans DENTAL May 1, 2018 to April 30, 2019 United Healthcare Dental Delta Dental (Patient out-of-pocket costs may be lower at a Preferred Provider Dentist) D125H-Santa Cruz 150 Plan MONTHLY PREMIUM One-party $19.32 A2011 Plan $42.20 $79.59 Two-party $28.39 Family $44.42 $ Max per person None $1,000 $50/150 family max; waived Calendar Year None for diagnostic and preventive Deductible YOU PAY TOTAL COST YOU PAY: LESS THE FOLLOWING AMOUNTS THE PLAN PAYS: PREVENTIVE X-rays, full mouth No charge $64 Cleaning No charge $48 Topical fluoride No charge $64 includes cleaning $16 w/o cleaning FILLINGS One surface No Charge $81 ORAL SURGERY Extraction (uncomplicated) No Charge $75 Complete bony impaction $75 $222 ENDODONTICS Root canal - Anterior $45 $331 CROWNS & PONTICS Cost of gold extra* Full metal crown $125* $472 3/4 metal crown $125* $509 Porcelain w/metal (non-precious; for molar) $125 $470 PROSTHODONTICS Partial upper or lower (conventional clasps, rests, and teeth) $115 Complete upper or lower $150 ORTHODONTICS $532 - Upper $548 - Lower $706 - Upper $700 - Lower 24-month treatment $1,895 Not covered IMPLANTS Surgical Placement of Implant $1,035 Not covered These are only summaries of plan benefits. Not all procedures are represented. See respective plan documents at open enrollment meetings for specific coverage provisions.

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39 County of San Joaquin Vision Service Plan (VSP) This is only a summary of benefits. Consult the plan document at SJCERA for more specific coverage details. May 1, 2018 to April 30, 2019 VSP Choice Plan Network Well Vision Exam MONTHLY PREMIUM One-party Two-party Family $ 6.37 $12.47 $ ,000 doctors, 15,500 participating retail chains $10 co-pay Thorough eye exam covered in full 1 once every 12 months for each enrollee Retinal Screening: No more than a $39 co-payment on routine retinal screening as part of WellVision Exam. Lenses $25 co-pay for materials (frame and/or lenses) Once every 12 months for each enrollee Single vision, lined bifocal or lined trifocal prescription lenses are covered in full 1 Polycarbonate lenses for dependent children Frame Allowance (See increased benefit for frame allowance) Once every 24 months for each enrollee Frames are covered in full 1 up to the retail allowance of $150 (increased from $130) 20% off any amount exceeding allowance Contact Lens Allowance (instead of glasses) Up to $60.00 co-pay $150 toward any type of prescription contact lenses; copay does not apply. Once every 12 months for each enrollee Contact lens exam (fitting and evaluation) services and materials are covered in full up to $60 Laser Vision Care Program Discounts average 15% off or 5% off if the laser center is offering a promotional price 2 Diabetic EyeCare Plus Program $20 co-pay Services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD). Retinal screening for eligible members with diabetes. Limitations and coordination with medical coverage may apply. 1

40 VISION May 1, 2018 to April 30, 2019 Exclusions / Plan Limitations VSP Choice Plan The following items are excluded under this plan: Two pairs of glasses instead of bifocals Replacement of lenses, frames or contacts Medical or surgical treatment Orthoptics, vision training or supplemental testing Items not covered under the contact lens coverage: Insurance policies or service agreements Artistically painted or non-prescription lenses Additional office visits for contact lens pathology Contact lens modification, polishing or cleaning 1 Less any applicable copay. 2 LaserVision Care discounts are only available from VSP-contracted facilities. VSP Choice Plan All County retirees are eligible to participate in this plan during the Open Enrollment period. Once you enroll yourself and/or your dependents, you will remain enrolled unless and until you notify SJCERA in writing to terminate enrollment for you and/or your dependents. Once coverage is terminated, you will not be allowed to re-enroll in the group vision care plan sponsored by San Joaquin County, unless evidence of continuous coverage in an employer-sponsored group vision care plan is provided. 2

41 Human Resources Division Ted J. Cwiek, Director Katherine Harris, Deputy Director March 1, 2018 TO: FROM: Retirees Enrolled in a Medicare Health Plan Offered by San Joaquin County San Joaquin County RE: MEDICARE PRESCRIPTION DRUG COVERAGE (PART D) Medicare Prescription Drug Coverage, also called Medicare Part D, became available in 2006 to all people with Medicare. Each of the health plans offered by San Joaquin County to retirees has implemented a prescription drug program for enrollees with Medicare that meets the requirements of a Medicare prescription drug plan. In summary, your enrollment in one of the Countysponsored health plans offered to retirees with Medicare includes enrollment in a Medicare prescription drug plan. If you or your dependents have Medicare, it is important for you to know that the prescription drug coverage you currently have as an enrollee in a health plan offered by San Joaquin County to retirees is expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage. This is important because it means: You do NOT need to enroll in a Medicare Part D drug plan separate from the prescription drug coverage included as part of the health plans offered by San Joaquin County to retirees. You will NOT be penalized later for not enrolling in a separate Medicare Part D drug plan as long as you maintain Creditable Coverage. Typically, persons who are eligible but do not enroll in a Medicare drug plan as soon as they are eligible will pay a financial penalty to enroll at a later date. This provision does not apply to you for as long as you keep your current prescription drug coverage through the Countysponsored health plan offered by the County to retirees. You must retain the enclosed Important Notice from San Joaquin County About Your Prescription Drug Coverage and Medicare to show proof of your current prescription drug coverage if you decide to enroll in a Medicare drug plan in the future. 44 N. San Joaquin Street, Suite 330 Stockton, California T F humanresources@sjgov.org

42 Human Resources Division COMMON QUESTIONS ABOUT THE MEDICARE PRESCRIPTION DRUG PLAN (Part D) Q1. I've seen many advertisements and applications to join a Medicare prescription drug plan. Should I sign up? You do not need to sign up for a Medicare prescription drug plan separate from the prescription drug coverage included with your health plan offered by San Joaquin County to retirees. The prescription drug coverage provided by all plans offered to retirees is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay and is considered Creditable Coverage. Q2. I've heard that if I don't sign up for a Medicare prescription drug plan as soon as I am eligible, I will have to pay a premium penalty later. Is this true? Do I need to sign up now? A late enrollment penalty only applies if you do not maintain prescription drug coverage that is considered Creditable Coverage. Each of the health plans offered by San Joaquin County to retirees has implemented a prescription drug program for enrollees with Medicare that meets the requirements of a Medicare prescription drug plan. In summary, your enrollment in one of the County-sponsored health plans offered to retirees with Medicare includes enrollment in a Medicare prescription drug plan. There will be no penalty as long as you maintain this coverage. If you later choose to drop your current coverage and enroll in a Medicare drug plan, you will not be subject to the late enrollment premium penalty. However, you must retain the enclosed Important Notice from San Joaquin County About Your Prescription Drug Coverage and Medicare to show proof of your current prescription drug coverage if you choose to enroll in a Medicare drug plan at a later date. Q3. Can I drop my current prescription drug coverage to enroll in a Medicare prescription drug plan but retain my current health coverage through my County-sponsored health plan? No, the plan design and monthly premiums for each of the health plans offered by the County to retirees (County Managed Care, Anthem, Health Net, and Kaiser) includes prescription drug coverage. You cannot drop your retiree prescription drug coverage to join a Medicare drug plan without also dropping your retiree health coverage. If you drop your health coverage in a health plan offered by the County to retirees, you will not be allowed to re-enroll in the future. Q4. If I elect to drop my current health plan coverage, can I choose to re-enroll sometime in the future? No. Once you drop your health coverage with any of the health plans offered by the County to retirees, you will not be allowed to re-enroll in the future. 2 of 3

43 Human Resources Division Q5. What do San Joaquin County retirees really need to know about the coverage provided by the health plans offered by San Joaquin County to retirees? If you are a retired member of SJCERA and are enrolled in a health plan offered by the County (County Managed Care, Anthem, Health Net, or Kaiser), your current prescription drug coverage is Creditable Coverage. Therefore, you will not be penalized for not enrolling in a Medicare drug plan at this time as long as you maintain your enrollment in a health plan offered by the County to retirees. However, you must retain the enclosed Important Notice from San Joaquin County About Your Prescription Drug Coverage and Medicare to show proof of your current prescription drug coverage if you decide to enroll in a Medicare drug plan in the future. Q6. Where should retirees go to obtain more information about Medicare prescription drug plans? You can get more information about Medicare prescription drug plans from these places: Visit Call your State Health Insurance Assistance Program for personalized help Within California, call For other states, see the inside back cover of your copy of the Medicare & You handbook for their telephone number Call MEDICARE ( ), available 24 hours a day, 7 days a week. TTY users should call of 3

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45 Human Resources Division Ted J. Cwiek, Director Katherine Harris, Deputy Director March 1, 2018 IMPORTANT NOTICE 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 a health plan offered by San Joaquin County to retirees (County Managed Care Plan, Anthem, Health Net and Kaiser) 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. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 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 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. 2. San Joaquin County has determined that the prescription drug coverage provided by the health plans offered by the County to retirees is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. 44 N. San Joaquin Street, Suite 330 Stockton, California T F humanresources@sjgov.org