Benefit Choices and Enrollment Guide For Individuals Who Retired Prior to January 1, 2012

Transcription

1 2018 Benefit Choices and Enrollment Guide For Individuals Who Retired Prior to January 1, 2012 For PreMedicare and Medicare Retirees, Surviving Spouses, Long-Term Disability (LTD) Terminees, and/or PreMedicare Dependents

2 PreMedicare + Medicare Page intentionally left blank 2 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

3 Welcome To Your New Benefits Choices and Enrollment Guide Sandia National Laboratories is pleased to provide a new and improved Benefit Choices and Enrollment Guide for Two guides are available this year, one guide for those who retired prior to 2012 and another guide for those who retired after You have received the guide that is appropriate for your situation, which will allow (if applicable) both you and your spouse to utilize one guide, even if one of you is over age 65 and the other is under age 65. We have added easy-to-use color coding to make it simpler for you to quickly turn to the sections that apply to you. Color Coding Information This guide combines information for people who retired before January 1, 2012 for both PreMedicare and Medicare. The sections are segmented by color and title: PreMedicare + Medicare = Both PreMedicare and Medicare = PreMedicare only = Medicare only Please keep this guide as a reference to use during the enrollment process and as a reference throughout the year. All guides provided to retirees will be available on SandiaRetireeBenefits.com. Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 3

4 Table Of Contents PreMedicare + Medicare 03 Welcome To Your New Benefits Choices and Enrollment Guide 04 Table of Contents Open Enrollment Meetings 08 Do You Need to Take Action 09 Changes to Medicare Benefits 11 Eligibility Guidelines for PreMedicare 13 PreMedicare Retiree Medical Premium Sharing 14 OneExchange by Towers Watson 15 Changing Your PreMedicare Benefits Elections 16 Sandia Total Health Program 18 Sandia Total Health Administered by Blue Cross Blue Shield of New Mexico (BCBSNM) 20 Sandia Total Health Administered by UnitedHealthcare (UHC) 22 BCBSNM and UHC Prescription Drug Coverage Administered by Express Scripts 24 Sandia Total Health Administered by Kaiser Permanente 26 Kaiser Permanente Prescription Drug Coverage Administered by Kaiser Pharmacy 28 Health Reimbursement Account 31 Eligibility Guidelines for Medicare 33 Retiree Medical Premium Sharing and Your Spending Arrangement (YSA) Credits 35 About OneExchange 36 Working with OneExchange 37 Changing Your Benefits Elections 38 What to Expect After You Enroll 40 Become Familiar with Medicare 42 Understanding Your Sandia National Laboratories Benefits Choices 43 Sandia-Sponsored Medicare Advantage Plans Overview 44 Humana Medicare Employer HMO Plan 48 Presbyterian Senior Care HMO-POS 53 Kaiser Senior Advantage 57 Your Spending Arrangement (YSA) 59 Evaluate Your Options 61 Examples of Plan Choices 4 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

5 62 PreMedicare & Medicare Benefits for Surviving Spouses of Employees or Retirees 66 PreMedicare & Medicare Long-Term Disability (LTD) Terminees 71 Dental Care Program & Vision Affinity Discount Program 77 Women s Health and Cancer Rights Act 78 Sandia Prescription Drug Program Creditable Coverage Notice 81 Frequently Asked Questions (FAQ) 86 PreMedicare and Medicare Interactive Voice Recognition (IVR) Shortcuts 89 Contact Information PreMedicare + Medicare Color Coding Information This guide combines information for people who retired before January 1, 2012 for both PreMedicare and Medicare. The sections are segmented by color and title: = Both PreMedicare and Medicare = PreMedicare only = Medicare only Please keep this guide as a reference to use during the enrollment process and as a reference throughout the year. All guides provided to retirees will be available on SandiaRetireeBenefits.com. Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 5

6 2018 Open Enrollment Meetings PreMedicare + Medicare 2018 Open Enrollment for Sandia National Laboratories PreMedicare retirees runs from Sunday, October 15 through Friday, November 17, The Sandia National Laboratories Medicare Retiree Open Enrollment runs from Sunday, October 15 through Thursday, December 7, ALBUQUERQUE, NEW MEXICO All presentations will be held at UNM Continuing Education Center 1634 University Blvd., Albuquerque, NM Fair Time Presentation Time Presenters PREMEDICARE: THURSDAY, OCTOBER 26 9:00-11:30 a.m. 10:00-11:00 a.m. OneExchange, Blue Cross Blue Shield of New Mexico, UnitedHealthcare Fair Time Presentation Time Presenters Fair Time Presentation Time Presenters Fair Time Presentation Time Presenters MEDICARE: THURSDAY, OCTOBER 26 1:30-3:30 p.m. 2:00-3:00 p.m. OneExchange, Presbyterian, and Humana PREMEDICARE: WEDNESDAY, NOVEMBER 15 1:30-3:30 p.m. 2:00-3:00 p.m. OneExchange, Blue Cross Blue Shield of New Mexico, UnitedHealthcare MEDICARE: WEDNESDAY, NOVEMBER 15 9:00-11:30 a.m. 10:00-11:00 a.m. OneExchange, Presbyterian, and Humana 6 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

7 2018 Open Enrollment Meetings, continued LIVERMORE, CALIFORNIA The California presentation will be held at Sandia National Laboratories 7011 East Ave. Building 904, Auditorium, Livermore, CA Fair Time Presentation Time Presenters PREMEDICARE: THURSDAY, NOVEMBER 2 8:30-11:30 a.m. 9:00-10:00 a.m. OneExchange, Blue Cross Blue Shield of New Mexico, Kaiser Permanente, and UnitedHealthcare PreMedicare + Medicare Fair Time Presentation Time Presenters MEDICARE: THURSDAY, NOVEMBER 2 8:30-11:30 a.m. 10:00-11:00 a.m. OneExchange and Kaiser Permanente Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 7

8 Do You Need to Take Action? PreMedicare + Medicare If you don't want to make any changes, you do not need to take action, your plan will automatically renew. However, you must call OneExchange if you wish to do any of the following: COVERAGE: MEDICAL FOR PREMEDICARE RETIREES TAKE ACTION: To enroll or disenroll in a medical plan To change your current medical plan To waive coverage Become Medicare-eligible due to disability PREMEDICARE HEALTH REIMBURSEMENT ACCOUNT (HRA) FUNDING MEDICAL FOR MEDICARE RETIREES DENTAL (RETIREES ONLY) DEPENDENT COVERAGE ADDRESS INFORMATION UPDATE YOUR LIFE INSURANCE BENEFICIARY(IES) Complete an annual Health Assessment with your medical insurance carrier to earn $250. See page 28 for details and instructions. To enroll or disenroll in a medical plan or the Sandia Your Spending Arrangement (YSA) To change your current medical plan To waive coverage Important: If you are eligible for the YSA you must enroll in a Medicare plan through OneExchange. If you enroll directly through the carrier, you will not be eligible for the Sandia YSA. To enroll or disenroll in the dental plan To waive coverage If you wish to add a dependent, you must do so during open enrollment. Mid-year additions require a qualifying event. You may drop a dependent at any time. Please make sure your address is current with OneExchange by December 1 to ensure that your tax information is sent to your current address on file. Open Enrollment is a great time to make sure your life insurance beneficiary information is up to date. You may do this through prudential.com/mybenefits or by calling to request a paper form. 8 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

9 Changes to Medical Benefits The following changes to medical benefits are effective January 1, 2018: CHANGES TO MEDICAL BENEFITS FOR PREMEDICARE INDIVIDUALS Albuquerque Health Partners has changed their name to DaVita Medical Group. $ per person out-of-pocket increase, and various increases to Rx copays. Effectively in July 1, 2017, Express Scripts will have mandatory mail order for maintenance medications. See page 6 for details. PreMedicare + Medicare CHANGES TO MEDICAL BENEFITS FOR MEDICARE INDIVIDUALS In 2018 there will be an increase in YSA allowance. BCBS HMO members will move to Humana January 1, See page 44 for more details. New YSA forms New personalized Reimbursement Request Forms will be sent to you to use with your YSA Health Reimbursement Account. The new forms are unique to you, prefilled with your name and address and a personalized barcode. The barcode eliminates the necessity of using your Social Security number to identify you. These forms increase accuracy and efficiency when processing your Reimbursement Requests. CHANGES TO MEDICAL BENEFITS BOTH PREMEDICARE & MEDICARE INDIVIDUALS Interactive Voice Recognition (IVR): -- Reimbursement Request Form can be requested. (2018) -- Direct Deposit updates can be made on the IVR. (2018) Website: -- Claim denial reason definition updates. (2018) -- Improving Online Enrollment for Medicare Retirees. (2018) -- Expand the number of MA/MAPD, PDP, and Medicare Supplement plans that allow us to take enrollment applications online. Customer Service Tools: -- Improving the accuracy of Prescription Profiler. (2018) -- Customers Rx cabinets will be fully consistent with Medicare.gov. -- Legacy participants who want to discuss medical plans will be transferred directly to the Special Situation Team (SST) without having to talk to a regular BA first. (August) Funding Department: -- Updated forms and communications that include bar codes to assist with imaging and processing. (August and September) Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 9

10 For PreMedicare Retirees, and/or Surviving Spouse, Long-Term Disability (LTD) Terminees, and/or PreMedicare Dependents PreMedicare 10 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

11 Eligibility Guidelines for PreMedicare If you are a PreMedicare retiree, you must maintain coverage in a Sandia National Laboratories' plan in order for your spouse and/or dependents to have coverage. If you are the primary member under the plan, your Class I dependents eligible for membership include: Spouse, not legally separated or divorced from you Child under age 26 Child who is recognized as an alternate recipient in a Qualified Medical Child Support Order Child of any age who is incapacitated as determined by the claims administrator Note 1: The claims administrator determines if the applicant is considered an incapacitated dependent. Please contact OneExchange for more information. Note 2: For survivors: no new dependents can be added, except for children born or adopted (including a pregnancy or placement for adoption that occurred) before the employee s or retiree s death. PREMEDICARE SPOUSES Eligible PreMedicare Spouses include spouses of: Non-represented employees who were hired (or rehired) on or after January 1, 2009, or OPEIU-represented employees who were hired (or rehired) on or after July 1, 2009, or MTC- and SPA-represented employees who were hired (or rehired) on or after July 1, 2010 CHILDREN Eligible children include: Primary covered member s own children, step-children, and legally-adopted children Children for whom the primary covered member has legal guardianship Natural children, legally adopted children, or children for whom the primary covered member has legal guardianship if a court decree requires coverage PreMedicare CLASS II DEPENDENTS No additional Class II Dependents can be enrolled in any of the Sandia National Laboratories medical plans. To continue to qualify for medical coverage, a Class II dependent must: Be financially dependent on you, which means that a person receives greater than 50% of their financial support for the calendar year from the primary member, Have a total income from all sources of less than $15,000/year other than the support you provide, and Have lived in your home, or one provided by you in the United States, for the most recent 6 months. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 11

12 PreMedicare Eligibility Guidelines, continued SURVIVING SPOUSES Your surviving spouse is eligible to enroll in the Surviving Spouse Medical Plan as long as he/ she is your covered dependent at the time of your death. The surviving spouse (and any dependents enrolled at the time of death) may continue coverage by paying the premiums. If your surviving spouse remarries, he or she is no longer eligible for survivor benefits with a Sandia National Laboratories-sponsored medical plan. Surviving spouses are not eligible for the Sandia Dental Care Program and the Davis Vision Affinity Discount Program. If the surviving spouse coverage terminates for any reason, the surviving spouse and any dependents (if applicable) may not return to the plan at any time. PreMedicare LTD TERMINEES LTD Terminees are not eligible for the Davis Vision Affinity Discount Program. Note: If you and/or your covered dependents become Medicare-eligible, you and/or your covered dependents will lose medical coverage through Sandia National Laboratories at the end of the month prior to the month in which you and/or your covered dependents became Medicare-eligible. If you and/or your covered dependents become Medicare-eligible, notify OneExchange. INELIGIBLE DEPENDENTS You must disenroll your ineligible dependents within 31 calendar days. Your dependents would become ineligible through: Divorce or annulment Legal separation Child reaches age 26 Incapacitated child no longer meets incapacitation criteria Child, step-child, grandchild, brother, sister, parent, step-parent or grandparent no longer meets Class II eligibility requirements criteria Class II dependent becomes Medicare-eligible For more detailed information, refer to the Sandia Health Benefits Plan for Retirees Summary Plan Description (SPD) found at hbe.sandia.gov. 12 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

13 PreMedicare Retiree Medical Premium Sharing YEARS OF SERVICE PRE Contribution % 0% 10% 15% 25% 35% 45% Member - only coverage $0 $74 $111 $185 $259 $333 Member + 1 coverage $0 $148 $222 $370 $518 $666 Member + 2 coverage $0 $222 $333 $555 $777 $999 Note: Family contributions are capped at three times the applicable rate. Employees who retired prior to January 1, 1995 will not be required to pay a premium share for themselves or any eligible Class I dependents at this time. (Exception: retirees who retired prior to January 1, 1995, but who currently pay a portion of their medical coverage will continue to do so.) PreMedicare Employees who retired after December 31, 1994, and before January 1, 2003 pay 10% of the full premium. Employees who retired on or after January 1, 2003, and before January 1, 2012 pay a percentage of the full premium based on years of service. CLASS II DEPENDENTS The monthly premium for a PreMedicare Class II dependent is $518 for Sandia Total Health program. Class II dependents for whom you currently pay a Class II premium will not be counted as dependents in calculating the premiums stated above. Any Class II dependents for whom you do not pay the full Class II premium will be counted as dependents for premium sharing in the calculation. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 13

14 OneExchange by Towers Watson OneExchange, a Towers Watson company, is your retiree health benefit administration service. OneExchange offers personalized assistance to help you navigate, evaluate, and select the healthcare option that is best for you. This service is provided at no cost to you and your dependents. When you call, you will reach a benefit advisor from OneExchange who will assist you in enrolling, changing, or disenrolling in/from your medical and dental plans. OneExchange will also help you with the following additional administrative services: PreMedicare Enrollment status/coverage elections Address/phone number changes Billing statement/payments/signing up for electronic payment Plan eligibility information Notifications of death and/or termination of coverage for yourself or dependents Power of attorney designation/authorized representative Become Medicare-eligible due to disability TOOLS & RESOURCES In addition to working with licensed benefit advisors over the phone, you may access online tools at SandiaRetireeBenefits.com that will provide additional information regarding your Sandia National Laboratories benefits. PAYMENT INFORMATION Sandia Retiree Benefits Plan PO Box Des Moines, IA PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

15 Changing Your PreMedicare Benefits Elections If you want to make a change to your medical and/or dental benefits, you will need to call OneExchange at (TTY: 711). When you call OneExchange, you will automatically be connected with a licensed benefit advisor. To speed up the process of connecting you to the right benefit advisor, you will be asked a few questions by the automated telephone system. You may either speak your answers, or use your telephone keypad. BEFORE YOU ARE CONNECTED TO A BENEFIT ADVISOR: 1. Speak to a licensed benefits advisor by saying or pressing 1 on your keypad. 2. Enter your ZIP code. 3. Provide the last four digits of your Social Security number.* 4. Confirm the first three letters of your last name. 5. After you make an election with a OneExchange licensed benefit advisor over the phone, a confirmation statement will be mailed to you within 10 business days indicating the selection(s) you made. * OneExchange s privacy policy can be found at SandiaRetireeBenefits.com. Click on the Privacy Policy link at the bottom of any page. PreMedicare PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 15

16 PreMedicare Page intentionally left blank 16 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

17 Sandia Total Health Program Sandia Total Health program is a health plan that offers flexibility and choice features we know are important to you. It is administered by Blue Cross and Blue Shield of New Mexico, Kaiser Permanente, and UnitedHealthcare. Sandia Total Health program has two main components comprehensive healthcare coverage and a Sandia National Laboratories-funded Health Reimbursement Account (HRA). Sandia Total Health program is a Consumer-Driven Health Plan (CDHP). It s a key element of Sandia s strategy to manage healthcare costs by encouraging healthcare consumerism and improving overall health through an integrated approach to health and wellness. PREVENTIVE CARE Preventive care includes services like annual physical exams and certain cancer screenings. Preventive care is covered at 100%, with no deductible to meet, as long as you visit an in-network provider and the provider codes the service with a preventive Current Procedural Terminology (CPT) code. ANNUAL DEDUCTIBLE Your annual deductible is the amount you pay out-of-pocket each year for medical expenses. Once your deductible is met your medical benefits begin, and you and Sandia National Laboratories start sharing the cost of covered medical services. Your deductible amount is based on your coverage tier and which network of providers you use. PreMedicare COINSURANCE Once you meet your deductible, Sandia Total Health program pays a percentage of your covered medical care costs and you pay the remaining percentage. This shared cost is called coinsurance. OUT-OF-POCKET LIMIT This is the maximum amount you ll pay out-of-pocket for medical care during a plan year. Once you reach this limit, your remaining eligible expenses for the calendar year are covered at 100%. HEALTH REIMBURSEMENT ACCOUNT (HRA) The HRA is a tax-free, Sandia National Laboratories-funded account and is provided to help offset your eligible out-of-pocket medical, prescription, dental, hearing, vision, and other 213(d) expenses. The amount of dollars allocated to your HRA depends on the coverage category you choose and if you took your health insurance vendor's health assessment in the prior year. ONLINE HEALTH ASSESSMENT PreMedicare retirees, spouses, LTD Terminees & LTD Spouses must complete an online health assessment by September 30. See page 28 for instructions on how to complete the health assessment through your health insurance vendor. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 17

18 Sandia Total Health Administered by Blue Cross Blue Shield of New Mexico (BCBSNM) PREVENTIVE CARE SHPN IN-NETWORK OUT-OF-NETWORK 100% covered (Not subject to the annual deductible) 100% covered (Not subject to the annual deductible) 60% covered (You pay 40%) ANNUAL DEDUCTIBLE (excludes prescription drug costs) RETIREE ONLY $500 $750 $2,000 PreMedicare RETIREE + SPOUSE OR CHILD(REN) RETIREE + SPOUSE & CHILD(REN) $1,000 (Max. $500 per person) $1,500 (Max. $500 per person) Up to $1,500 (Max. $750 per person) Up to $2,250 (Max. $750 per person) Up to $4,000 (Max. $2,000 per person) Up to $6,000 (Max. $2,000 per person) Note: In- and out-of-network deductibles do not cross-apply. The in-network deductible and the SHPN deductible do cross-apply. COINSURANCE You pay 10% You pay 20% You pay 40% ANNUAL CALENDAR YEAR OUT-OF-POCKET LIMIT (excludes prescription drug costs) RETIREE ONLY $2,000 (Includes deductible) $2,750 (Includes deductible) $6,500 (Includes deductible) RETIREE + SPOUSE OR CHILD(REN) $4,000 (Includes deductible; max of $2,000 per person) $5,500 (Includes deductible; max of $2,750 per person) $13,000 (Includes deductible; max of $6,500 per person) RETIREE + SPOUSE AND CHILD(REN) $6,000 (Includes deductible; max of $2,000 per person) $8,250 (Includes deductible; max of $2,750 per person) $19,500 (Includes deductible; max of $6,500 per person) Note: In- and out-of-network out-of-pocket limit do not cross-apply. The in-network out-ofpocket limit and the SHPN out-of-pocket limit do cross-apply. The SHPN is available in Albuquerque and surrounding areas. 18 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

19 Sandia Total Health Administered by Blue Cross Blue Shield of New Mexico, continued SANDIA HEALTH PARTNER NETWORK Sandia Total Health administered by Blue Cross Blue Shield of New Mexico (BCBSNM) has three network options you can access at the point of service the Sandia Health Partner Network (SHPN), in-network, and out-of-network. Improved benefits means you save money with the SHPN. If you re enrolled in BCBSNM, you have the option to visit the in-network providers, those included in the SHPN, or both. If you first visit providers in the SHPN and then providers in the PPO, or vice versa, your deductible and out-of-pocket limit/maximums will cross-apply. You enjoy all the standard benefits of Sandia Total Health, but have the additional option of saving money by visiting providers in the SHPN. The SHPN is available to BCBSNM enrollees in Albuquerque and the surrounding area. In the SHPN, you have reduced deductible coinsurance, and out-of-pocket limits. SHPN providers include Lovelace Health System, DaVita Medical Group, Heart Hospital of New Mexico, and NM Orthopedics just to name a few. To review a list of providers in the Sandia Health Partner Network (SHPN), please visit bcbsnm.com/sandia. KEY POINTS In New Mexico, this plan provides access to Lovelace facilities, UNMH, the Heart Hospital of New Mexico, DaVita Medical Group, and many independent providers. In California, this plan provides access to the John Muir physician network, San Ramon Valley Regional, Valley Care Health Systems, and many independent providers. The prescription drug program is administered through Express Scripts. See pages Includes an employer-funded Health Reimbursement Account (HRA). Prior notification to BCBSNM is required for certain medical services, procedures, and hospitalizations. Please note: members are responsible for the first $300 of covered charges for failure to follow notification and/or pre-notification procedures. Certain in-network preventive care is covered at 100%. You do not need to meet a deductible amount for covered preventive care. Coverage is available worldwide for emergency and urgent care. Behavioral health benefits are provided through the BCBSNM network of providers. PreMedicare MEMBER RESOURCES Contact BCBSNM Member Services at SNLB (7652) or online at bcbsnm.com/sandia. For plan coverage and pre-authorization information, refer to the BCBSNM Program Summary at hbe.sandia.gov. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 19

20 Sandia Total Health Administered by UnitedHealthcare (UHC) PREVENTIVE CARE IN-NETWORK 100% covered (Not subject to the annual deductible) OUT-OF-NETWORK 60% covered (You pay 40%) ANNUAL DEDUCTIBLE (excludes prescription drug costs) RETIREE ONLY $750 $2,000 RETIREE + SPOUSE OR CHILD(REN) Up to $1,500 (Max. $750 per person) Up to $4,000 (Max. $2,000 per person) PreMedicare RETIREE + SPOUSE & CHILD(REN) Up to $2,250 (Max. $750 per person) Note: In- and out-of-network deductibles do not cross-apply. Up to $6,000 (Max. $2,000 per person) COINSURANCE You pay 20% You pay 40% ANNUAL CALENDAR YEAR OUT-OF-POCKET LIMIT (excludes prescription drug costs) RETIREE ONLY $2,750 (Includes deductible) $6,500 (Includes deductible) RETIREE + SPOUSE OR CHILD(REN) RETIREE + SPOUSE AND CHILD(REN) $5,500 (Includes deductible; max of $2,750 per person) $8,250 (Includes deductible; max of $2,750 per person) $13,000 (Includes deductible; max of $6,500 per person) $19,500 (Includes deductible; max of $6,500 per person) Note: In- and out-of-network out-of-pocket limit do not cross-apply. 20 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

21 Sandia Total Health Administered by UnitedHealthcare (UHC), continued KEY POINTS In New Mexico, this plan provides access to Presbyterian facilities and providers, the University of New Mexico Hospital (UNMH), and many independent providers. In California, this plan provides access to the John Muir physician network, San Ramon Valley Regional, Valley Care Health Systems, and many independent providers. The prescription drug program is administered through Express Scripts. (See pages 22-23) Includes an employer-funded Health Reimbursement Account (HRA). Prior notification to UHC is required for certain medical services, procedures, and hospitalizations. Please note: Members are responsible for the first $300 of covered charges for failure to follow notification and/or precertification procedures. Certain in-network preventive care is covered at 100%. You do not need to meet a deductible amount for covered preventive care. Coverage is available worldwide for emergency and urgent care. Behavioral health benefits are provided through the OptumHealth Behavioral Solutions network of providers. MEMBER RESOURCES UnitedHealthcare Member Service (877) hours a day, 7 days a week. OptumHealth Behavioral Solutions (866) Optum NurseLine 24-hour advice line (800) Find health information, personal health assessments and a listing of in-network providers at myuhc.com. The username and password is SNL. For plan coverage and pre-authorization information, refer to the UHC program summary at hbe.sandia.gov. PreMedicare PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 21

22 BCBSNM and UHC Prescription Drug Coverage Administered by Express Scripts IN-NETWORK PRESCRIPTION DRUGS RETAIL (MAXIMUM 30-DAY SUPPLY) GENERIC You pay 20% $5/$10 min/max copay OUT-OF-NETWORK You pay 50% BRAND NAME PREFERRED BRAND NAME NON-PREFERRED You pay 30% $30/$45 min/max copay You pay 40% $50/$75 min/max copay You pay 50% You pay 50% PreMedicare PRESCRIPTION DRUGS SMART90 RETAIL OR MAIL ORDER (MAXIMUM 90-DAY SUPPLY) GENERIC You pay 20% $12.50/$25 min/max copay BRAND NAME PREFERRED You pay 30% $75/$ min/max copay N/A N/A BRAND NAME NON-PREFERRED You pay 40% $125/$ min/max copay There is an annual out-of-pocket maximum of $1,500 per person and $5,950 per family for in-network prescription drugs. N/A There is no out-of-pocket limit/maximum for outof-network prescription drugs. Note: There is no difference between the prescription drug benefits associated with the SHPN and the in-network benefits. Prescription drug copays and/or coinsurance do not apply to your annual deductible or medical out-of-pocket limit. ELIGIBILITY Members enrolled in the Sandia Total Health plan administered by BCBSNM and UHC are eligible for the Express Scripts Prescription Drug Program. Plan members who have primary prescription drug coverage under another group healthcare plan are not eligible to use the mail order program or to purchase drugs from retail network pharmacies at the copayment level. 22 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

23 Express Scripts Prescription Drug Guidelines, continued KEY POINTS You must show your Express Scripts identification card at all retail network pharmacies. If you do not show your Express Scripts identification card upon purchase to identify you as a Sandia National Laboratories participant, you will not be eligible for any reimbursement. View the Express Scripts formulary list and compare drug prices at express-scripts.com. Many drugs are subject to step therapy, quantity limits, and/or prior approvals through Express Scripts. Maximum of 30-day supply at out-of-network retail pharmacies. Under the Smart90 retail or mail order program, you must fill your 90-day prescription at Walgreens or through mail order. In order to receive coverage for specialty medications, BCBSNM, and UHC members must purchase these drugs through the Express Scripts specialty pharmacy Accredo. These drugs are delivered via mail order through Accredo. All specialty prescriptions will be limited to a 30-day supply and will be subject to the retail coinsurance/copay structure (e.g., 30% coinsurance with a $30 minimum copay and $45 maximum copay for a brand name preferred drug). Reimbursement for a paper claim submitted for purchases at in-network pharmacies will not be allowed (except for coordination of benefits). If the actual cost of the prescription through the mail or at a retail network pharmacy is less than the copayment, you will only pay the actual cost. Under the Express Scripts prescription program, prescriptions will be filled with the least expensive acceptable generic equivalent when available and permissible by law, unless your physician specifies that the prescription be dispensed as written. In order to have long-term maintenance medications covered, have your prescriptions filled at Walgreens, through Smart90, or Sandia National Laboratories mail order pharmacy. You will receive two 30-day courtesy fills before paying full price. PreMedicare MEMBER RESOURCES Express Scripts Customer Service: available 24/7 Express Scripts Hearing and Speech Impaired Service: available 24/7 Smart90: Smart90 Hearing and Speech Impaired Service: To learn more about Express Scripts, you may register online at express-scripts.com. Select For Members and follow instructions to register. For additional information on this program, refer to the BCBSNM and UHC Program Summaries at hbe.sandia.gov. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 23

24 Sandia Total Health Administered by Kaiser Permanente PreMedicare PREVENTIVE CARE IN-NETWORK 100% covered (Not subject to the annual deductible) ANNUAL DEDUCTIBLE (excludes prescription drug costs) RETIREE ONLY $750 $2,000 RETIREE + SPOUSE OR CHILD(REN) RETIREE + SPOUSE & CHILD(REN) Up to $1,500 (Max. $750 per person) Up to $2,250 (Max. $750 per person) Note: In- and out-of-network deductibles do not cross-apply. COINSURANCE OUT-OF-NETWORK 60% covered (You pay 40%) Up to $4,000 (Max. $2,000 per person) Up to $6,000 (Max. $2,000 per person) You pay 20% You pay 40% ANNUAL CALENDAR YEAR OUT-OF-POCKET LIMIT (excludes prescription drug costs) RETIREE ONLY $2,750 (Includes deductible) RETIREE + SPOUSE OR CHILD(REN) RETIREE + SPOUSE AND CHILD(REN) $5,500 (Includes deductible; max of $2,750 per person) $8,250 (Includes deductible; max of $2,750 per person) $6,500 (Includes deductible) $13,000 (Includes deductible; max of $6,500 per person) $19,500 (Includes deductible; max of $6,500 per person) Note: In- and out-of-network out-of-pocket limit do not cross-apply. 24 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

25 Sandia Total Health Administered by Kaiser Permanente, continued ELIGIBILITY This plan is available to those who live within a Northern California Kaiser-designated service area. KEY POINTS The prescription drug program is administered through Kaiser Pharmacy. (See pages 26-27) Self-referral to selected specialty departments; others require a referral from your plan physician. You must reside within a Northern California Kaiser Permanente service area to be eligible for the Plan and may only leave the service area for a maximum of 90 continuous days. Exception: Students attending school outside the service area. Certain in-network preventive care is covered at 100%. You do not need to meet a deductible amount for covered preventive care. This plan provides in- and out-of-network benefits. Coverage is available worldwide for emergency and urgent care. MEMBER RESOURCES The Kaiser Permanente Member Services Call Center is available weekdays at between 7 a.m. and 7 p.m. PT, or weekends from 7:00 a.m. - 3:00 p.m. PT. You may also visit healthy.kaiserpermanente.org, where you can make appointments, consult a nurse or pharmacist, complete the online health assessment, find healthcare information, customize online health improvement programs, and more. For complete plan coverage information, refer to the Kaiser Permanente Program Summary at the hbe.sandia.gov. PreMedicare ADDITIONAL RESOURCES Nurse Advice Line: Find your region s nurse advice line through the Kaiser Services Guide (Your Guidebook) which is provided to new members, or call for assistance. Chiropractic Benefit: American Specialty Health Plans of CA provides direct access to the American Specialty Health Plans (ASH) network of participating chiropractors. To learn more about the ASH providers, visit the website at ashcompanies.com or call Healthy Roads: This innovative health improvement program helps you take charge of your health through a variety of online tools, including a personal health assessment and a customized exercise planning program. To learn more about the discounts available, visit healthyroads.com. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 25

26 Kaiser Permanente Prescription Drug Coverage Administered by Kaiser Pharmacy ELIGIBILITY Plan members who have primary prescription drug coverage under another group healthcare plan are not eligible to use the mail order program or to purchase drugs from retail network pharmacies at the copayment level. IN-NETWORK PRESCRIPTION DRUGS RETAIL (MAXIMUM 30-DAY SUPPLY) GENERIC You pay 20% $5/$10 min/max copay OUT-OF-NETWORK You pay 50% PreMedicare BRAND NAME PREFERRED You pay 30% $30/$45 min/max copay BRAND NAME NON-PREFERRED You pay 40% $50/$75 min/max copay PRESCRIPTION DRUGS MAIL ORDER (MAXIMUM 100-DAY SUPPLY) GENERIC You pay 20% $12.50/$25 min/max copay BRAND NAME PREFERRED You pay 30% $75/$ min/max copay BRAND NAME NON-PREFERRED You pay 40% $125/$ min/max copay There is an annual out-of-pocket maximum of $1,500 per person and $5,950 per family for in-network prescription drugs. You pay 50% You pay 50% N/A N/A N/A There is no out-of-pocket limit/maximum for out-of-network prescription drugs. 26 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

27 Kaiser Pharmacy Prescription Drug Guidelines, continued KEY POINTS You can view the Kaiser Pharmacy formulary list at healthy.kaiserpermanente.org. Many drugs are subject to step therapy, quantity limits, and/or prior approvals through Kaiser Pharmacy. All specialty prescriptions will be limited to a 30-day supply and will be subject to the retail coinsurance/copay structure (e.g., 30% coinsurance with a $25 minimum copay and $40 maximum copay for a brand name preferred drug). You must show your Kaiser identification card at all retail network pharmacies. If you do not show your Kaiser identification card upon purchase to identify you as a Sandia participant, you will not be eligible for any reimbursement. Maximum of 30-day supply at retail network and out-of-network retail pharmacies. Reimbursement for a paper claim submitted for purchases at in-network pharmacies will not be allowed (except for coordination of benefits). Prescription drug copayments and/or coinsurance do not apply to your annual deductible or medical out-of-pocket limit. If the actual cost of the prescription through the mail or at a retail network pharmacy is less than the copayment, you will only pay the actual cost. Under the Kaiser mail order program, you must ask for a 100-day prescription with refills in 100-day increments. Certain prescriptions will only be dispensed with an appropriate medical diagnosis through the prior authorization process. In addition, some drugs may be subject to step therapy protocol. PreMedicare MEMBER RESOURCES Kaiser Member Services Call Center: Available weekdays 7:00 a.m. to 7:00 p.m. PT, or weekends 7:00 a.m. to 3:00 p.m. PT. Comprehensive website at healthy.kaiserpermanente.org. For additional information on this program, refer to the Kaiser Permanente Program Summary at hbe.sandia.gov. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 27

28 Health Reimbursement Account The Health Reimbursement Account (HRA) is a tax-free, Sandia National Laboratories-funded account that is provided to help offset your eligible out-of-pocket medical, prescription, dental, hearing, vision, and other 213(d) eligible expenses. COVERAGE: RETIREE ONLY 1 $250 ANNUAL ALLOCATION RETIREE + SPOUSE 1 OR CHILD(REN) RETIREE + SPOUSE 1 AND CHILD(REN) $500 $750 1 Must take health assessment PreMedicare KEY POINTS: The amount of dollars allocated to your HRA depends on the coverage category you choose and if you took your health insurance vendor's health assessment in the prior year. PreMedicare retirees and spouses, surviving spouses, LTD terminees, and spouses must complete an online health assessment through your current insurance provider. Health assessments must be completed from October 1, 2017 through September 30, 2018 in order to receive your 2019 HRA funds. Note that PreMedicare retirees, surviving spouses, LTD terminees, and PreMedicare spouses are not eligible to participate in the Virgin Pulse program. HEALTH ASSESSMENT INSTRUCTIONS: 1. Go to the newly designed Sandia National Laboratories retiree benefits site at SandiaRetireeBenefits.com/Health-Assessment. 2. Select your health insurance vendor. 3. Follow the instructions. If you have questions about the health assessment, call your health insurance company s dedicated Sandia National Laboratories number located at SandiaRetireeBenefits.com/Health-Assessment. 28 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

29 Health Reimbursement Account, continued HRA FUNDS ROLL-OVER If you have HRA funds remaining as of December 31 and remain with the same insurance provider, your funds will continue processing as the prior year. Note that your HRA rollover is subject to a capped amount. Please see the Retiree Program Summary for your medical plan. If you have HRA funds remaining as of December 31 and switch insurance providers, these funds can be used for prior year claims as late as March 31. The funds will be transferred to your new provider by April 30. HRA FUNDS AND MEDICARE If you have HRA funds remaining when you age into Medicare, these funds will transfer to any PreMedicare spouses or dependents enrolled in a PreMedicare medical plan. If you don't have PreMedicare spouses or dependents enrolled in a PreMedicare medical plan, those funds will be forfeited. For additional information, refer to the Sandia Health Benefits Plan for Retirees Summary Plan Description at hbe.sandia.gov. PreMedicare PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 29

30 For Medicare Retirees, and Spouse and/or their Medicare Dependents Medicare 30 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

31 Eligibility Guidelines for Medicare The Sandia National Laboratories Medicare Retiree must maintain coverage in a Sandia plan in order for a spouse and/or dependents to have coverage. If you are the primary member under the plan, your Class I dependents eligible for membership include your: Spouse, not legally separated or divorced from you Child under age 26 Child who is recognized as an alternate recipient in a Qualified Medical Child Support Order Child of any age who is incapacitated as determined by the claims administrator Note 1: The claims administrator determines if the applicant is considered an incapacitated dependent. Please contact OneExchange for more information. Note 2: For survivors, no new dependents can be added, except for children born or adopted (including placement for adoption that occurred) before the employee s or retiree s death. CHILD INCLUDES: Primary covered member s own children, step-children, and legally adopted children Child for whom the primary covered member has legal guardianship Natural child, legally adopted child, or child for whom the primary covered member has legal guardianship if a court decree requires coverage Eligibility for coverage under the Kaiser Permanente Senior Advantage Plan (Medicare) has the same eligibility requirements as stated above, however, they also include: Other unmarried dependent persons who meet all of the following requirements (excluding foster children) He or she receives from you or your spouse all of his or her support and maintenance He or she permanently resides with you (the primary member) You or your spouse is the court-appointed guardian (or was before the person reached age 18), or whose parent is an enrolled dependent under your family coverage Medicare A Kaiser Permanente disabled dependent requires the following additional requirements: The dependent is incapable of self-sustaining employment because of a mental or physical handicap that occurred prior to reaching the age limit for dependents Receives the majority of their support and maintenance from you and your spouse You can provide Kaiser proof of their incapacity within 31 days of Kaiser's request Note: Kaiser Permanente determines if the applicant is disabled. Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 31

32 Medicare Eligibility Guidelines, continued CLASS II DEPENDENTS No additional Class II Dependents can be enrolled in any of the Sandia medical plans. To continue to qualify for medical coverage, a Class II dependent must: Be financially dependent on you; financially dependent means that a person receives greater than 50% of their financial support for the calendar year from the primary member, Have a total income from all sources of less than $15,000/year other than the support you provide, and Have lived in your home, or one provided by you in the United States, for the most recent 6 months. INELIGIBLE DEPENDENTS You must disenroll your ineligible dependents within 31 calendar days. Your dependents would become ineligible through: Divorce or annulment Legal separation Child reaches age 26 Incapacitated child no longer meets incapacitation criteria Child, step-child, grandchild, brother, sister, parent, step-parent or grandparent no longer meets Class II eligibility requirement criteria Class II dependent becomes Medicare-eligible Medicare 32 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

33 Retiree Medical Premium Sharing and Your Spending Arrangement (YSA) Credits Sandia-Sponsored Group Medicare Advantage Plans Medical Premium Sharing Employees who retired prior to January 1, 1995 will not be required to pay a premium share for themselves or any eligible Class I dependents for the Kaiser Senior Advantage Plan, the Humana Medicare Employer HMO Plan, or the Presbyterian Senior Care HMO-POS at this time. (Exception: Retirees who retired prior to January 1, 1995, but who currently pay a portion of their medical coverage will continue to do so.) Employees who retired after December 31, 1994 and before January 1, 2003 pay a monthly premium for coverage in the Kaiser Senior Advantage Plan, the Humana Medicare Employer HMO Plan, or the Presbyterian Senior Care HMO-POS. Use Table B to find your monthly rate for your selected plan(s). Employees who retired after December 31, 2002 and before January 1, 2012 pay a monthly premium for coverage in the Kaiser Senior Advantage Plan, the Humana Medicare National HMO Plan, or the Presbyterian Senior Care HMO-POS based on a percentage of the full premium based on years of service. Use Tables B through F on this and the next page to find your monthly rate for your selected plan(s). If you choose the YSA, you will become responsible for paying for your own health coverage. You will then be reimbursed by OneExchange, using YSA funds. The annual credit amounts you are eligible to receive are based on when you retired and/or your years of service and are provided in the table on this and the next page. Note: Annual YSA credit amounts will be prorated for individuals who retire mid-year or who age-in to Medicare. TABLE A: Employees Who Retired Prior to January 1, Medicare-eligible 2 Medicare-eligibles Medicare Your Spending Arrangement Annual Credit Amount $1, $3, TABLE B: Employees Who Retired After 12/31/1994 and Before 1/1/2003 OR After 12/31/2002 With 30+ Years Presbyterian Senior Care HMO Monthly Premium Humana Medicare Employer HMO Plan Monthly Premium Kaiser Senior Advantage Plan Monthly Premium Your Spending Arrangement Annual Credit Amount $23.00 $46.00 $13.34 $26.68 $29.43 $58.86 $1, $3, Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 33

34 TABLE C: Employees Who Retired After 12/31/2002 With Years 1 Medicare-eligible 2 Medicare-eligibles Presbyterian Senior Care HMO Monthly Premium Humana Medicare Employer HMO Plan Monthly Premium Kaiser Senior Advantage Plan Monthly Premium Your Spending Arrangement Annual Credit Amount $34.50 $69.00 $ $44.15 $88.30 $1, $3, TABLE D: Employees Who Retired After 12/31/2002 With Years Presbyterian Senior Care HMO Monthly Premium Humana Medicare Employer HMO Plan Monthly Premium Kaiser Senior Advantage Plan Monthly Premium Your Spending Arrangement Annual Credit Amount $57.50 $ $33.36 $66.72 $73.59 $ $1, $2, TABLE E: Employees Who Retired After 12/31/2002 With Years Medicare Presbyterian Senior Care HMO Monthly Premium Humana Medicare Employer HMO Plan Monthly Premium Kaiser Senior Advantage Plan Monthly Premium Your Spending Arrangement Annual Credit Amount $80.50 $ $46.70 $93.40 $ $ $1, $2, TABLE F: Employees Who Retired After 12/31/2002 With Years Presbyterian Senior Care HMO Monthly Premium Humana Medicare Employer HMO Plan Monthly Premium Kaiser Senior Advantage Plan Monthly Premium Your Spending Arrangement Annual Credit Amount $ $ $60.04 $ $ $ $1, $2, Note: The Your Spending Arrangement annual credit amount listed will be prorated for the number of months left in the year for the new coverage you elect. The Centers for Medicare and Medicaid (CMS) regulate the premiums for the various individual market Medicare supplemental health options under YSA. 34 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

35 About OneExchange OneExchange is not an insurance company. We are a resource that offers the country s largest Medicare marketplace, allowing you to select from a wide variety of Medicare plans from national and regional insurance companies. Our marketplace has Medicare Supplement (Medigap), Medicare Advantage, and Medicare Part D Prescription Drug plans, as well as vision and dental plans. Since Medicare can be complex and your healthcare decisions are important, we offer personalized assistance from a certified and licensed benefit advisor who will help you find coverage that fits your medical and financial needs. In addition, our online marketplace makes it simple for you to search, compare, and select plans with a number of helpful tools. WHAT TO EXPECT FROM US OneExchange not only gives you access to the nation s largest Medicare marketplace, but also provides you with personalized assistance from our licensed benefit advisors, all at no cost. PERSONALIZED, STEP-BY-STEP GUIDANCE Our licensed benefit advisors and easy-to-use online tools will guide you step by step through the OneExchange marketplace. By the time you re ready to enroll, you can feel confident that you re choosing the right coverage to fit your needs. UNBIASED, OBJECTIVE SUPPORT Our licensed benefit advisors are objective advocates. They are paid a salary and have no incentive to steer you into signing up for any specific type of plan or insurance company. QUALITY PLAN OPTIONS We work with leading national and regional insurance companies to ensure you have quality plans to choose from. Since we offer a range of options, you may find coverage that is better than your current plan at a lower cost. Medicare EFFICIENT, ACCURATE ENROLLMENT Once you have selected a plan, you will work with an application data processor to complete your application to ensure accurate processing. After your application is submitted, you may track its status on our website. SUPPORT AFTER YOU ENROLL We are here to help throughout the year when you have questions about anything related to your coverage. Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 35

36 Working with OneExchange When you work with OneExchange to select and enroll in additional Medicare coverage, you can take advantage of all of our services. You can call and talk to a licensed benefits advisor to evaluate and enroll in a new plan. You can also go online to Medicare.OneExchange.com/Sandia to shop and compare plans and get an idea of costs and coverage, and enroll without speaking to anyone. You are also welcome to do a combination of both. ENROLLING IN ADDITIONAL MEDICARE COVERAGE Whichever direction you take, you will want to have the following information with you when you call or create your OneExchange online account: Your Social Security number: We take your security very seriously and use your Social Security number to verify your identity. Your Medicare ID card: We will want to know the number and the Parts A and B effective dates Prescription drug information: This includes name, dosage and quantity for a 30-day period. We ask for this information to insure if you need a drug plan that it covers your current medications. IF YOU CHOOSE TO CALL AND ENROLL, BE AWARE THAT THE CALL CAN LAST UP TO 90 MINUTES PER PERSON. ON THE CALL YOU WILL: Medicare Verify your identity and information. Creating an online account and updating your information before the call will help reduce the time on phone, although you will still need to verify your information for accuracy and security. Talk to a licensed benefit advisor who will answer questions about plans and coverage. Speak with an application data processor, who will complete and submit your application. Two weeks after you submit your application you will receive a Selection Confirmation letter that will outline the choices you made during your call, or online if you didn t call. AFTER ENROLLMENT The insurance company may contact you via phone, , or letter concerning your new plan prior to receiving your new ID cards. Once you are accepted into the plan you chose, you are covered from the coverage start date (January 1, 2018) regardless of whether you have received new cards. You can check your application status by signing in to your OneExchange account, or calling our automatic voice system. It may take 4-6 weeks to receive your new cards for your new plan. If you have any questions, please talk to OneExchange. We are your advocates, and are available to help when you have questions. 36 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

37 Changing Your Benefits Elections Call OneExchange at (TTY: 711). When you call OneExchange you will be connected with a benefit advisor who is licensed and trained to find additional Medicare coverage for you. To speed up the process of connecting you to the right benefit advisor, you will be asked a few questions by the automated telephone system. You may either speak your answers or use the numbers on your telephone keypad. If you are already enrolled in a Medicare plan and you are calling to review new plan options, you will have the option to connect with a benefit advisor who is licensed and trained to find individualized coverage for you. You may schedule an appointment with a licensed benefit advisor for a date and time during the annual enrollment period. Information and appointment scheduling is also available using the online services at Medicare.OneExchange.com/Sandia. BEFORE YOU ARE CONNECTED TO A LICENSED BENEFIT ADVISOR: 1. Speak to a licensed benefit advisor by saying or pressing 1 on your keypad. 2. Enter your ZIP code. 3. Provide the last four digits of your Social Security number Confirm the first three letters of your last name. When an advisor answers the phone he or she will already have your information and be ready to help you evaluate your options and help you enroll in a Medicare plan that best fits your needs ONLINE TOOLS In addition to working with our licensed benefit advisors over the phone, you may access online tools at Medicare.OneExchange.com/Sandia that will help you compare and evaluate the plan options available to you. ENROLLING OR CHANGING YOUR MEDICAL COVERAGE Please have this information in hand when you speak with OneExchange. Your current phone number(s), address(es), Social Security number, and a Medicare ID number. These will be required to enroll you in a plan for Make a list of your prescription medications. Since very specific information about your prescriptions is required, it may be helpful to gather your medications together and have the bottles or boxes with you when you sign in online or call OneExchange. Refer to a label or bill for correct spelling. OneExchange can help you find a cost-effective plan based on the information you give us about your prescription drugs, including dosage, form, and frequency. Remember to include any medications you have ordered by mail. Make a list of your doctors names, addresses, and phone number. 1 Our privacy policy can be found at Medicare.OneExchange.com/Sandia. Click on the Privacy Policy link at the bottom of any web page. Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 37

38 What to Expect After You Enroll CONFIRMATIONS After you make or change an election with OneExchange, a confirmation letter will be mailed to you within 10 business days indicating the plan selection(s) you made. The health plan or insurance company through which you selected the Your Spending Arrangement (YSA) option will directly send you a membership packet, including your ID card(s) from the plan(s) you selected directly. YSA GUIDE With the YSA option, OneExchange will mail a YSA Guide to you within 10 business days of your YSA plan effective date. This guide explains how to access and manage the funds in Your Spending Arrangement. PREMIUM SHARE BILLING If you enroll in the Sandia Dental Care program that requires a premium share, you will receive the premium information on the billing statement included in the welcome packet mailed to you from OneExchange by mid-december. At that time, you may choose to have your monthly premium payments automatically deducted from your checking or savings account. If you are already enrolled in the automatic premium payment process, any premium change will be automatically updated in the beginning of January every year. Medicare 38 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

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40 Become Familiar with Medicare HOW THE MEDICARE PARTS PROVIDE YOU COVERAGE The simple outline shown here will familiarize you with the parts of Medicare and assist you in choosing what is best for you. Visit medicare.gov for more detailed descriptions. ORIGINAL MEDICARE (WHAT YOU GET): Part A & Part B Original Medicare consists of Part A and Part B. You automatically receive Part A and become eligible for Part B when you qualify for Medicare either due to age or disability. Part A provides you with inpatient care, and covers inpatient hospital stays, home healthcare, stays in skilled nursing facilities, and hospice care. The Part A deductible for 2018 is $1,316 per benefit period. Coinsurance is not applicable for your first 60 days of inpatient care. Enrollment is automatic when you become Medicare-eligible. There is no premium if you have more than 10 years of Medicare-covered employment. 1 Part B provides you with outpatient care, and covers physician fees and other medical services not requiring hospitalization. The 2018 deductible for Part B is $183. Part B covers 80% of medically necessary services. You are responsible for the remaining 20%. You must actively enroll in Part B. The monthly premium for 2018 is $134 for most individuals, depending on income (adjustment rates may apply). Medicare 1 If your dependent is a foreign national and/or has not worked enough to qualify for Medicare Part A on his or her own, your dependent can purchase Medicare Part A. The cost for Part A for 2018 is $413 per month. However, if your dependent does not qualify for no-cost Part A due to insufficient Medicare-covered employment, once you turn 62, your dependent is then eligible for Part A at no cost. 40 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

41 Become Familiar with Medicare, continued TYPES OF MEDICARE SUPPLEMENTAL PLANS: Medicare Advantage, Medigap, & Part D Medicare Advantage plans are offered by private companies to provide you with all your Medicare Part A and Part B benefits plus additional benefits. There are two versions of Medicare Advantage plans: Medicare Advantage Prescription Drug (MAPD) and Medicare Advantage (MA). MAPD plans include prescription drug coverage; MA plans do not. Within these two Medicare Advantage types there are three doctor networks: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Private Fee-for-Service Plans (PFFS). Medicare Advantage is also referred to as Part C. The Presbyterian Senior Care HMO-POS, the Humana Medicare Employer HMO Plan, and the Kaiser Senior Advantage Plan are all MAPD plans being offered by Sandia. Note: You cannot enroll in a Medicare Advantage plan offered by Sandia National Laboratories in addition to another Medicare plan such as Part D. Medigap is supplemental insurance sold by private insurance companies to fill gaps in Original Medicare plan coverage. These 10 plans (labeled Plans A, B, C, D, F, G, K, L, M and N) offer standardized menus of benefits. (Massachusetts, Minnesota, and Wisconsin have their own versions of these plans). Medigap policies only work in conjunction with the Original Medicare plans. Generally, prescription drugs are not covered by Medicare. Part D refers to optional prescription drug coverage, which is available to everyone who is Medicare-eligible. Medicare Plans are offered through private insurance companies. Part D covers generic and brand name drugs included in the plan s formulary, which is a list of drugs the plan will cover. Prescription drug plans may be purchased separately or as an add-on for Medicare Advantage plans that do not offer a prescription drug benefit (MA) or Medigap plans. (Refer to the Sandia Prescription Drug Program Creditable Coverage Notice on page 78.) Note: MAPD = Medicare Advantage Prescription Drug, MA = Medicare Advantage, HMO = Health Maintenance Organization, PPO = Preferred Provider Organization. Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 41

42 Understanding Your Sandia National Laboratories Benefits Choices Important: You cannot enroll in a Sandia-sponsored group Medicare Advantage Plan and elect the Your Spending Arrangement (YSA) option. You must select one or the other. The options listed below are available to Medicare-primary retirees, surviving spouses, LTD terminees (who are enrolled in both Medicare A and B and continue to pay Medicare Part A if applicable, and Part B premiums). The options are also available to eligible Medicare-primary Class I dependents who are enrolled in both Medicare Part A and Part B and continue to pay Medicare Part A (if applicable) and Part B premiums. If you have not yet already enrolled in Medicare Part A and Part B, contact your local Social Security Administration office. For more information on eligibility, contact OneExchange. Each Medicare individual will make an independent election. For example, if a retiree and his spouse live in New Mexico and they are both Medicare-eligible, the retiree can elect the Blue Cross Medicare Advantage (HMO) Plan and the spouse can elect the Presbyterian Senior Care HMO-POS. Keep in mind, the retiree must be enrolled in a Sandia National Laboratories group or individual plan in order for the spouse and/or dependents to have Sandia National Laboratories coverage. (See plan descriptions on page 43) Medicare NEW MEXICO PLAN OPTIONS Presbyterian Senior Care HMO-POS Humana Medicare Employer HMO Plan Your Spending Arrangement Waive coverage Dental - Sandia-sponsored (only for retirees) NORTHERN CALIFORNIA PLAN OPTIONS Kaiser Senior Advantage Plan Your Spending Arrangement Waive coverage Dental - Sandia-sponsored (only for retirees) OUTSIDE OF NEW MEXICO AND NORTHERN CALIFORNIA PLAN OPTIONS Your Spending Arrangement Waive coverage Dental - Sandia-sponsored (only for retirees) 42 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

43 Sandia-Sponsored Medicare Advantage Plans Overview HUMANA MEDICARE EMPLOYER HMO PLAN This plan is fully insured through Humana for eligible Medicare-primary participants residing in the Humana Medicare Employer HMO service area within New Mexico. Benefits are available only from providers who are in the Humana Medicare Employer HMO network. You can obtain information on this plan (including a provider directory, drug formulary list, etc.) by contacting Humana Customer Care at (TTY: 711) Monday - Friday 6 a.m. - 7 p.m., Mountain Standard Time. PRESBYTERIAN SENIOR CARE HMO-POS This Medicare Advantage plan with prescription drug benefits is fully-insured through the Presbyterian Health Plan, Inc. for eligible Medicare-primary participants who live in New Mexico. This HMO-POS provides both in-and out-of-network benefits. In-network benefits are available only from providers who are in the Presbyterian HMO-POS network. KAISER SENIOR ADVANTAGE PLAN This HMO Medicare Advantage plan with prescription drug benefits is fully-insured through Kaiser Permanente for eligible Medicare-primary participants who live in Northern California, within Kaiser-designated service areas. Enrolling in one of the Sandia-sponsored Medicare Advantage plans is not affected by your current or past health status. In general, if you enroll during the specified enrollment period you are guaranteed coverage by one of the plans available in your area, regardless of your current medical conditions. Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 43

44 Humana Medicare Employer HMO Plan ELIGIBILITY This plan is available to Medicare-primary retirees, surviving spouses, LTD terminees, and their eligible Medicare-primary Class I dependents who: Reside in the Humana Medicare Employer HMO service area within New Mexico; Are enrolled in both Medicare Part A and Part B; and Continue to pay Medicare Part A and Part B premiums By enrolling in this plan, you will automatically be enrolled in the Medicare Part D prescription drug benefit and will receive all of your precription drug benefits through this plan. You will not be required to enroll in an individual Medicare Part D or pay the additional Medicare Part D premium. Note: Plans are pending Centers for Medicare & Medicaid Services (CMS) approval HUMANA PLAN WITH PRESCRIPTION DRUG BENEFITS This plan is fully-insured through Humana for eligible Medicare-primary participants residing in New Mexico TYPE OF PLAN (HMO) Medicare Advantage HMO: Requires assignment of Medicare benefits. (Must be enrolled in Medicare Parts A and B) Medicare ANNUAL CALENDAR YEAR DEDUCTIBLE IN-NETWORK ONLY None ANNUAL CALENDAR YEAR OUT-OF-POCKET MAXIMUM $1,500 per person (Does not apply to Part D Pharmacy, extra services and the plan premium) 44 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

45 Humana Medicare Employer HMO Plan, continued PREVENTIVE CARE ANNUAL ROUTINE PHYSICAL CERTAIN CANCER SCREENINGS VISION SCREENING No copay No copay No copay for 1 screening per year OUTPATIENT SERVICES OFFICE VISIT-PCP OFFICE VISIT- SPECIALIST URGENT CARE EMERGENCY ROOM OUTPATIENT SURGERY $10 copay $30 copay $30 copay per visit $50 copay per visit (Waived if admitted) $150 copay CHIROPRACTIC ACUPUNCTURE Medicare Covered - $20 copay Routine - $30 copay (36 visits per year) $15 copay (20 visits per year) Medicare SPEECH, PHYSICAL, & OCCUPATIONAL THERAPY LAB/RADIOLOGY (OUTPATIENT) HOSPITAL SERVICES INPATIENT ADMIT AMBULANCE $10 copay No copay $175 copay per day for days 1-3 per admission (Prior authorization required) $75 copay (Limited to emergency Medicare-covered services) HOSPICE (INPATIENT) Covered by Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 45

46 Humana Medicare Employer HMO Plan, continued HOSPITAL SERVICES, CONTINUED SKILLED NURSING FACILITY OTHER BENEFITS: DURABLE MEDICAL EQUIPMENT/EXTERNAL PROSTHETIC APPLIANCES Days 1-20: no copay Days : $75 copay per day No copay PRESCRIPTION DRUGS - UNLIMITED OUTPATIENT PRESCRIPTION DRUGS TIER 1 (GENERIC OR PREFERRED GENERIC) Retail: $4 copay (Maximum 30 days) / $8 copay (Maximum 90 days) Mail order: $4 copay (Maximum 30 Days) / $8 copay (Maximum 90 Days) Medicare TIER 2 (PREFERRED BRAND) TIER 3 (NON-PREFERRED DRUG) Retail: $20 copay (Maximum 30 Days) / $40 copay (Maximum 90 Days) Mail order: $20 copay (Maximum 30 Days) / $40 copay (Maximum 90 Days) Retail: $40 copay (Maximum 30 Days) / $80 copay (Maximum 90 Days) Mail order: $40 copay (Maximum 30 Days) / $80 copay (Maximum 90 Days) TIER 4 (SPECIALTY DRUGS) Retail: 25% copay (Maximum 30 Days) Mail Order: 25% copay (Maximum 30 Days) 46 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

47 Humana Medicare Employer HMO Plan, continued BEHAVIORAL HEALTH INPATIENT MENTAL HEALTH OUTPATIENT MENTAL HEALTH INPATIENT / OUTPATIENT SUBSTANCE ABUSE OUTPATIENT SUBSTANCE ABUSE $175 copay per day for days 1-3 per admission (Prior authorization required) $20 copay $175 copay per day for days 1-3 per admission (Prior authorization required) $20 copay KEY POINTS Primary Care Physician (PCP) is required. You must select a PCP and provide this information to Humana or one will be assigned to you. You can change your PCP at any time. For PCP listings, go to Humana.com to find a doctor or you can contact Humana Customer service for assistance or to request a directory be mailed to you. Unlimited prescription drug coverage is available under this plan. By enrolling in this plan, you will automatically be enrolled in the Medicare Part D prescription drug benefit and will receive all of your prescription drug benefits through this Plan. You will be required to assign your Medicare benefits to the Humana Medicare Employer HMO Plan; herefore, you cannot be enrolled in this plan and another Medicare Advantage plan or another Medicare Part D plan at the same time. When you select the Humana Medicare Employer HMO Plan, your regular Medicare benefits are provided by this plan. You must maintain your Medicare Parts A and B enrollment in order to keep your coverage. You must inform Humana Medicare Employer HMO Plan and OneExchange before moving or leaving the service area. Outside the service area, this plan covers emergency and urgent care. If you are hospitalized in a non-participating hospital for emergency care, you or your family member must call Customer Care within 48 hours (or as soon as reasonably possible). Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 47

48 Presbyterian Senior Care HMO-POS ELIGIBILITY This plan is available to Medicare-primary retirees, surviving spouses, LTD terminees, and their eligible Medicare-primary Class I dependents who: Reside in the state of New Mexico; Are enrolled in both Medicare Part A and Part B; and Continue to pay Medicare Part A (if applicable) and Part B premiums. By enrolling in this plan, you will automatically be enrolled in the Medicare Part D prescription drug benefit and will receive all of your prescription drug benefits through this plan. You will not be required to enroll in an individual Medicare Part D or pay the additional Medicare Part D premium. You will be required to assign your Medicare benefits to Presbyterian Senior CareHMO-POS plan; therefore, you cannot be enrolled in the Presbyterian Senior Care HMO-POS plan and another Medicare Advantage plan or another Medicare Part D plan at the same time. Note: Plans are pending Centers for Medicare & Medicaid Services (CMS) approval PRESBYTERIAN MEDICARE HMO POS A Medicare Advantage Plan with Prescription Drug Benefits This plan is fully-insured through the Presbyterian Health Plan, Inc. for eligible Medicare-prmary participants who live in New Mexico. Medicare TYPE OF PLAN (PPO) Medicare Advantage PPO: Requires assignment of Medicare benefits. (Must be enrolled in Medicare Parts A and B) IN-NETWORK OUT-OF-NETWORK ANNUAL CALENDAR YEAR DEDUCTIBLE None ANNUAL CALENDAR YEAR OUT-OF-POCKET MAXIMUM $1,500 per person (Doesn t apply to Part D prescription drugs.) $10,000 per person (Combined in-network & out-of-network maximum. Does not apply to Part D prescription drugs.) 48 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

49 Presbyterian Senior Care HMO-POS, continued IN-NETWORK OUT-OF-NETWORK PREVENTIVE CARE ANNUAL ROUTINE PHYSICAL CERTAIN CANCER SCREENINGS No copay No copay $35 copay $35 copay VISION SCREENING No copay $55 copay OUTPATIENT SERVICES OFFICE VISIT-PCP $10 copay $35 copay OFFICE VISIT- SPECIALIST $30 copay $55 copay URGENT CARE $10 copay per visit $50 copay per visit EMERGENCY ROOM $50 copay per visit (Waived if admitted) $50 copay per visit (Waived if admitted) OUTPATIENT SURGERY $150 copay 20% of Medicare allowable CHIROPRACTIC ACUPUNCTURE $20 copay (Manual manipulation of the spine to correct subluxation only) $15 copay (20 visits per year) $55 copay (Manual manipulation of the spine to correct subluxation only) $55 copay (20 visits per year) Medicare SPEECH, PHYSICAL, & OCCUPATIONAL THERAPY $10 copay (Prior authorization required) $35 copay (See Evidence of Coverage for Prior authorization.) LAB/RADIOLOGY (OUTPATIENT) No copay 10% lab/xray 20% radiological services Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 49

50 Presbyterian Senior Care HMO-POS, continued IN-NETWORK OUT-OF-NETWORK HOSPITAL SERVICES INPATIENT ADMIT $175 copay per day for days 1-3 per admission (Prior authorization required) $750 (per admit) AMBULANCE $75 copay $75 copay HOSPICE (INPATIENT) Covered by Medicare Covered by Medicare SKILLED NURSING FACILITY Days 1-20: $0 copay per day Days : $40 copay per day (Prior authorization required) Days 1-20: $0 copay per day Days : $125 copay per day Benefit period begins 1st day of hospitalization or skilled nursing facility confinement; new benefit period begins with 60 day lapse between confinements. 100 days per benefit period. Medicare OTHER BENEFITS: DURABLE MEDICAL EQUIPMENT/EXTERNAL PROSTHETIC APPLIANCES $10 (DME) $10 (EPA) $50 50 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

51 Presbyterian Senior Care HMO-POS, continued IN-NETWORK OUT-OF-NETWORK PRESCRIPTION DRUGS - UNLIMITED OUTPATIENT PRESCRIPTION DRUG COVERAGE Copays until you reach $4,850 in out-of-pocket costs. Beyond the $4,850, refer to Evidence of Coverage. RETAIL GENERIC RETAIL BRAND NAME MAIL ORDER GENERIC MAIL ORDER BRAND NAME SPECIALTY DRUGS Preferred: $4 copay (Maximum of 30 days) Preferred: $12 copay (Maximum of 90 days) Non-preferred: $12 copay (Maximum of 30 days) Non-preferred: $36 copay (Maximum of 90 days) Preferred: $20 copay (Maximum of 30 days) Preferred: $60 copay (Maximum of 90 days) Non-preferred: $40 copay (Maximum of 30 days) Non-preferred: $120 copay (Maximum of 90 days) Preferred: $8 copay (Maximum of 90 days) Non-preferred: $24 copay (Maximum of 90 days) Preferred: $40 copay (Maximum of 90 days) Non-preferred: $36 copay (Maximum of 90 days) 25% copay (Maximum of 30 days) Generally, prescription drugs are only covered at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. Please refer to the Evidence of Coverage for these limited circumstances. See Evidence of Coverage Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 51

52 Presbyterian Senior Care HMO-POS, continued IN-NETWORK OUT-OF-NETWORK BEHAVIORAL HEALTH INPATIENT MENTAL HEALTH OUTPATIENT MENTAL HEALTH INPATIENT / OUTPATIENT SUBSTANCE ABUSE $175/day for days 1-3 (per admit) (Prior authorization required) $750 (per admit) $30 copay 50% of Medicare allowable See Evidence of Coverage Medicare KEY POINTS When you select Presbyterian Senior Care HMO-POS, your regular Medicare benefits are provided by this Plan. You must inform the Presbyterian Health Plan and OneExchange before moving or leaving the service area for more than 6 months. Your permanent residence must be in the Presbyterian Senior Care HMO-POS service area, which is the state of New Mexico. Primary Care Physician (PCP) is required. You must select a PCP or one will be assigned to you. Referrals to specialists are not required. You may go to any provider out of network that will accept Medicare. Coverage is available worldwide for emergency and urgent care. If you are hospitalized in a non-participating hospital for emergency care, you or a family member must call Presbyterian Customer Service within 48 hours (or as soon as reasonably possible). You can obtain information on this plan (including a provider directory, drug formulary list, etc.) by contacting Presbyterian at or , M-F, 8 a.m. to 8 p.m. For additional information, refer to the Presbyterian Senior Care HMO-POS Evidence of Coverage at hbe.sandia.gov. If there are any discrepancies between this information and the Evidence of Coverage, then the Evidence of Coverage supersedes. 52 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

53 Kaiser Senior Advantage ELIGIBILITY This plan is available to those who meet the following criteria and who live within a Kaiser-designated service area. This plan is available to Medicare-primary retirees, surviving spouses, LTD terminees, and their eligible Medicare-primary Class I dependents who: Are enrolled in both Medicare Part A and Part B, and Continue to pay Medicare Part A (if applicable) and Part B premiums. You must reside within a Kaiser Permanente service area to be eligible for the Plan and may only leave the service area for a maximum of 90 continuous days. Medicare benefits must be assigned to Kaiser Permanente. Therefore, you cannot be enrolled in another Medicare Advantage Plan or Medicare Part D Plan at the same time you are enrolled in Kaiser Senior Advantage Plan. When you select Senior Advantage, your regular Medicare benefits are provided by Kaiser Permanente. By enrolling in this plan, you will automatically be enrolled in the Medicare Part D prescription drug benefit and will receive all of your prescription drug benefits through this Plan. Note: Plans are pending Centers for Medicare & Medicaid Services (CMS) approval KAISER SENIOR ADVANTAGE PLAN A Medicare Advantage Plan with Prescription Drug Benefits This plan is fully-insured through Kaiser Permanente for eligible Medicare-primary participants who live in Northern California, within Kaiser-designated service areas. Medicare TYPE OF PLAN (HMO) Medicare Advantage HMO: Requires assignment of Medicare benefits. (Must be enrolled in Medicare Parts A and B) IN-NETWORK ONLY ANNUAL CALENDAR YEAR DEDUCTIBLE None Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 53

54 Kaiser Senior Advantage, continued KAISER SENIOR ADVANTAGE PLAN, CONTINUE ANNUAL CALENDAR YEAR OUT-OF-POCKET MAXIMUM MAXIMUM $1,500 per person Family: $3,000 (two or more) Member is responsible for tracking annual out-of-pocket costs through accumulation of Kaiser receipts. Prescription copays do not apply to out-of-pocket maximum. PREVENTIVE CARE ANNUAL ROUTINE PHYSICAL CERTAIN CANCER SCREENINGS VISION SCREENING No copay No copay No copay OUTPATIENT SERVICES OFFICE VISIT-PCP $10 copay Medicare OFFICE VISIT- SPECIALIST URGENT CARE EMERGENCY ROOM $30 copay $30 copay - $50 copay $50 copay per visit (Waived if admitted within 24 hours with same condition) OUTPATIENT SURGERY CHIROPRACTIC ACUPUNCTURE SPEECH, PHYSICAL, & OCCUPATIONAL THERAPY LAB/RADIOLOGY (OUTPATIENT) $100 copay $15 copay $15 copay $15 copay No copay 54 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

55 Kaiser Senior Advantage, continued HOSPITAL SERVICES INPATIENT ADMIT $500 copay AMBULANCE HOSPICE (INPATIENT) SKILLED NURSING FACILITY OTHER BENEFITS: DURABLE MEDICAL EQUIPMENT/EXTERNAL PROSTHETIC APPLIANCES $75 copay No copay Days 1-20: no copay Days : $75 copay per day (Prior authorization required.) No copay PRESCRIPTION DRUGS Copays until you reach $4,850 in out-of-pocket costs. Beyond the $4,850, refer to Evidence of Coverage. RETAIL GENERIC RETAIL BRAND NAME 10 copay for a 30 day supply $20 copay for a day supply $30 copay for a day supply $20 copay for a 30 day supply $40 copay for a day supply $60 copay for a day supply Medicare MAIL ORDER GENERIC MAIL ORDER BRAND NAME $10 copay for a 30 day supply $20 copay for a day supply $20 copay for a 30 day supply $40 copay for a day supply $20 copay for a 30 day supply $40 copay for a day supply SPECIALTY DRUGS See Evidence of Coverage Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 55

56 Kaiser Senior Advantage, continued BEHAVIORAL HEALTH INPATIENT MENTAL HEALTH OUTPATIENT MENTAL HEALTH INPATIENT / OUTPATIENT SUBSTANCE ABUSE $500 copay $15 copay See Evidence of Coverage KEY POINTS Kaiser Permanente providers and facilities must be used. If you access care outside Kaiser Permanente, your services may not be covered. Coverage is available worldwide for emergency and urgent care. Medicare will not pay for any medical care you receive from a non-kaiser Permanente healthcare provider unless you have been referred to the outside provider by a Kaiser Permanente physician. When you enroll in Senior Advantage, you agree to receive all your medical services through Kaiser Permanente, except for emergencies, urgent out-of-area care, or authorized referrals. Self-referral to selected specialty departments; others require a referral from your plan physician. Medicare You can obtain information on this plan by contacting the Kaiser Permanente Member Services Call Center at , M-F, 7 a.m. to 7 p.m., weekends 7 a.m. to 3 p.m., or by visiting healthy.kaiserpermanente.org. For additional information, refer to the Kaiser Senior Advantage Plan with Part D Evidence of Coverage at hbe.sandia.gov. If there are any discrepancies between this and the Evidence of Coverage, then the Evidence of Coverage supersedes. 56 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

57 Your Spending Arrangement (YSA) Important: You must purchase your Medicare and Prescription Drug plans through OneExchange to access your YSA funds (except TriCare and VA). ELIGIBILITY The YSA option is available to Medicare retirees, surviving spouses, LTD terminees, and their eligible Medicare Class I dependents who: Are enrolled in both Medicare Part A and Part B, and Continue to pay Medicare Part A (if applicable) and Part B premiums Enroll into a qualified individual Medicare medical plan(s) through OneExchange; or Enroll in TriCare, Veterans Administration, a Kaiser Individual plan, have an OneExchange account through Lawrence Livermore National Laboratories; or Reside in an area with limited or no access to individual Medicare plans through the OneExchange Exchange (enrollment must be approved by OneExchange). YSA OVERVIEW YSA is a Sandia-funded account that is used to purchase individual Medicare plans through the OneExchange Marketplace. OneExchange offers a variety of individual Medicare Advantage, Medigap (also known as Medicare Supplement), and Prescription Drug coverage options on their Exchange from more than 100 of the nation s largest and most popular health insurance companies. Annual credits are provided to you through YSA to use towards payment for these plans as outlined on pages 33 and 34. Funds are provided on a tax-free basis and are prorated for the number of months left in the year for the new coverage you elect. Licensed benefit advisors from OneExchange will assist you with finding the most cost-effective Medicare coverage that fits your individual needs. Under this arrangement, you, not Sandia, will be responsible for choosing your own medical coverage. The following are some of the qualified healthcare expenses that can be reimbursed: Medicare Premiums for Medicare Part A (if applicable) and Part B. Premiums to pay for Tricare insurance. Dental premiums for individual dental plans or the Sandia-sponsored group Dental Care Plan. Premiums for Individual Medicare supplemental insurance purchased through the OneExchange marketplace such as Medicare Advantage, Medigap, and Prescription Drug plans. Out-of-pocket medical expenses like medical and prescription drug deductibles and copays. Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 57

58 Your Spending Arrangement (YSA) continued Many OneExchange plans offer Automatic Reimbursement (AR). You pay your premiums to the insurance carrier for the month or quarter, and the insurance carrier notifies OneExchange through an electronic file that your payment has been received. This notification will trigger a release of payment from the YSA funds to reimburse you for the premium payment (as long as funds are available in your account). You do not need to file a paper claim form. AR is not available with all carriers and does not cover expenses outside of the premiums for medical or prescription drug coverage. For quicker payment, have your reimbursements deposited directly to your bank account. Otherwise, all reimbursements will be made by check and mailed to the address on file with OneExchange. Direct Deposit information will be provided in the OneExchange YSA Guide. YSA accounts are set up as joint accounts. If your Medicare-eligible spouse elects YSA, you and your spouse will have one account which you can use toward any allowable expenses between the two of you. Any unused balance in your account rolls over and is available to use the following year. There is no maximum on your unused balance. Left over funds from the prior year will roll over to next year. Refer to the YSA Program Summary on hbe.sandia.gov for more information. COMPARE YOUR MEDICAL CHOICES If you choose to use the YSA to purchase an individual plan, it is helpful to understand your options. OneExchange offers enrollment assistance and advice in selecting from a variety of Medicare supplemental and prescription drug coverage options. Medicare For example, you may choose to remain in original Medicare and select a Medigap policy and Part D prescription drug plan. Or, you may choose a Medicare Advantage plan that covers prescription drugs, and use your YSA funds to pay your Medicare Advantage and Part B premiums. See page 61 for examples of plan choices accessible through OneExchange. Don t delay, since you must enroll within 63 days from the loss of your Sandia-sponsored group coverage. Whether it is one of the Sandia-sponsored group Medicare Advantage plans or one of the Sandia-sponsored employee or PreMedicare medical plans. If you wait to enroll until after the 63-day window, you can be declined coverage or be charged more for the coverage based on your health history. Please note: If you are enrolled in an individual plan through the YSA Program and want to upgrade your Medigap plan (e.g., from Plan F to Plan N) or want to change carriers, you may be subject to underwriting, which is based on your health condition. 58 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

59 Evaluate Your Options What are the differences between Medicare supplemental plans? WHAT ARE MY OUT-OF- POCKET COSTS? MONTHLY PREMIUM MEDIGAP PLAN PART D PLAN MEDICARE ADVANTAGE The out-of-pocket cost of each plan will vary. Below is a general summary of what to expect with each plan. A OneExchange licensed benefit advisor will be able to provide more information, including premium rates in your area. The range of plan premiums varies widely. If you elect to enroll in a Medicare Advantage plan, Medigap plan, and/or Part D plan, you must continue to pay your Medicare Part A (if applicable), Part B premium and any additional premium charged by the plan(s). DEDUCTIBLES, COPAYMENTS, COINSURANCE Most Medigap services are covered with no additional out-of-pocket cost to you. There are no deductibles or coinsurance. Part D plans offer a wide range of copayments, deductibles, and coinsurance for prescription medications. Most Medicare Advantage plans require a copayment or coinsurance at the time of service. HOSPITAL COVERAGE? DOES IT COVER DOCTORS AND SPECIALISTS? Yes, included Not applicable Yes, included Doctors and specialists are covered. Any doctor that accepts Original Medicare accepts these plans. Not applicable Doctors and specialists are covered. There are three types of Medicare Advantage doctor networks: HMO, PPO, and PFFS. Please note: If you do not wish to change your current doctors you must know which plans they accept prior to enrolling. Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 59

60 Evaluate Your Options, continued MEDIGAP PLAN PART D PLAN MEDICARE ADVANTAGE DOES IT HAVE PRESCRIPTION DRUG COVERAGE? Prescription drugs are not covered. You must enroll separately in a Part D plan to have prescription drug coverage. Prescription drugs are covered. There are two versions of Medicare Advantage Plans: MAPD, which includes prescription drug coverage, and MA, which does not. DOES IT HAVE DENTAL AND VISION BENEFITS? Dental and vision are not covered. However, separate dental and vision plans are available. Dental and vision are not covered. Dental and vision coverage varies by plan. DOES IT COVER ME WHEN I TRAVEL? Medigap plans are accepted by every Medicareparticipating provider in the U.S., with some emergency benefits worldwide. If you travel frequently or live part of the year out-of-state, these plans may be right for you. Part D plans provide nationwide coverage from participating pharmacies. Medicare Advantage plans cover urgent and emergency services nationwide, but some may not provide nationwide coverage for non-emergency services. If you live part of the year out-of-state, these plans may not be right for you. Medicare 60 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

61 Examples of Plan Choices What can be purchased using Your Spending Arrangement (YSA)? Below are samples of plan choices which can be purchased using YSA funds and are accessible through OneExchange MEDIGAP PLAN PART D PLAN MEDICARE ADVANTAGE Sample of plan choices available through OneExchange in Bernalillo Co., New Mexico: NUMBER OF PLANS OFFERED 2017 MONTHLY PREMIUM PROVIDER $49 - $184 $17 - $92 $0 - $192 2 or more insurance companies to choose from Sample of plan choices available through OneExchange in Alameda Co., California: NUMBER OF PLANS OFFERED 2017 MONTHLY PREMIUM PROVIDER $48 - $184 $17 - $160 $86 - $157 2 or more insurance companies to choose from Medicare Sample of plan choices available through OneExchange in Maricopa Co., Arizona: NUMBER OF PLANS OFFERED 2017 MONTHLY PREMIUM PROVIDER $77 - $300 $17 - $115 $0 - $192 2 or more insurance companies to choose from Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 61

62 PreMedicare & Medicare Benefits for Surviving Spouses of Employees or Retirees PreMedicare + Medicare 62 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

63 PreMedicare Surviving Spouse Medical Premium Sharing ELIGIBILITY You are eligible to enroll in the surviving spouse medical plan as long as you are enrolled as a covered dependent at the time of your Sandia spouse's death. You (and any dependents enrolled at the time of Sandia spouse's death) may continue medical coverage by paying the premiums shown below If you remarry, you are no longer eligible for survivor benefits with a Sandia-sponsored medical plan. You are not eligible for coverage under the Sandia Group Dental plan after COBRA has expired, and may contact OneExchange to enroll into an individual plan at full cost. You are not eligible for the Davis Vision Affinity Discount Program. If your coverage terminates for any reason, you and any dependents (if applicable) may not return to the plan at any time. Note: If you are covered under the medical plan through a retiree, upon the death of the retiree, contact OneExchange if you would like to continue coverage through the surviving spouse medical plan option. If you are covered under the medical plan through the employee, upon death of the employee, Sandia will notify OneExchange on your behalf. PreMedicare PARTIAL PREMIUMS Surviving spouses of employees will pay 50% of the full experience-rated premium. SURVIVING SPOUSES OF EMPLOYEES COVERAGE PREMIUM SHARE Survivor - only coverage $370 Survivor + 1 coverage $740 Survivor + 2 coverage $1,110 Note: Family contributions are capped at three times the applicable rate. For more detailed information, refer to the Sandia Health Benefits Plan for Retirees Summary Plan Description (SPD) located at hbe.sandia.gov. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 63

64 Medicare Surviving Spouse Medical Premium Sharing and YSA Credits Your surviving spouse is eligible to enroll in the surviving spouse medical plan as long as he/ she is your covered dependent at the time of your death. The surviving spouse (and any dependents enrolled at the time of death) may continue coverage by paying the premiums shown below. If your surviving spouse remarries, he/she is no longer eligible for survivor benefits with a Sandia-sponsored medical plan or YSA and must notify OneExchange within 31 calendar days of the marriage. The CMS regulates the premiums for the various individual market Medicare supplemental health options under YSA. TABLE A: Surviving spouse of a retiree or regular employee with 15 or more years of service Presbyterian Senior Care HMO monthly premium $ Humana Medicare Employer HMO Plan monthly premium $66.72 Kaiser Senior Advantage Plan monthly premium $ Your Spending Arrangement annual credit amount $ Note: The Your Spending Arrangement annual credit amount will be prorated for the number of months left in the year for the new coverage you elect. Medicare TABLE B: Surviving spouse of a regular employee with less than 15 years of service Presbyterian Senior Care HMO monthly premium $ Humana Medicare Employer HMO Plan monthly premium $ Kaiser Senior Advantage Plan monthly premium $ Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

65 Medicare Surviving Spouse Medical Premium Sharing and YSA Credits, continued SANDIA-SPONSORED GROUP MEDICARE ADVANTAGE PLANS MEDICAL PREMIUM SHARING The surviving spouse pays a monthly premium for coverage in Kaiser Senior Advantage Plan, the Humana Medicare Employer HMO Plan, or the Presbyterian Senior Care HMO-POS. The surviving spouse of a regular employee with 15 or more years of service pays a monthly premium for coverage in the Kaiser Senior Advantage Plan, the Humana Medicare Employer HMO Plan, or the Presbyterian Senior Care HMO-POS. Use Table A on the previous page to determine your monthly premium amount as well as the annual credit amounts you are eligible to receive for the YSA option. The surviving spouse of a regular employee with less than 15 years of service pays 100% of the premium for coverage in the Kaiser Senior Advantage Plan, the Humana Medicare Employer HMO Plan, or the Presbyterian Senior Care HMO-POS. Use Table B on the previous page to determine your monthly premium amount. Surviving spouses in this category are not eligible for the YSA. YSA CREDITS If you choose the YSA option, you will become responsible for paying for your own health coverage. You will then be reimbursed by OneExchange, using YSA funds. Note: Annual YSA credit amounts will be prorated for individuals who become a surviving spouse mid-year or who age-in to Medicare. Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 65

66 PreMedicare & Medicare Long-Term Disability (LTD) Terminees PreMedicare + Medicare 66 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

67 PreMedicare Long-Term Disability (LTD) Terminee Medical Premium Sharing PARTIAL PREMIUM SHARE Employees who were hired (or rehired) as listed below and became an LTD Terminee will pay the cost indicated in the table below of the Sandia-sponsored medical plan. Employees who became an LTD Terminee after December 31, 1994, but prior to January 1, 2003, pay 10% of the full experience-rated premium for you and your covered dependents. Employees who became an LTD Terminee after December 31, 2002, pay 35% of the full experience-rated premium for you and your covered dependents. COVERAGE 35% Member - only coverage $259 Member + 1 coverage $518 PreMedicare Member + 2 coverage $777 Note: Family contributions are capped at three times the applicable rate. PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 67

68 PreMedicare LTD Terminee Medical Premium Sharing, continued FULL PREMIUM SHARE Employees who were hired (or rehired) as listed below and became an LTD Terminee will pay 100% of the cost of the Sandia-sponsored medical plan (outlined in the table below). PreMedicare Non-represented employees who were hired or rehired on or after January 1, 2009 OPEIU-represented employees who were hired or rehired on or after July 1, 2009 MTC- and SPA-represented employees who were hired or rehired on or after July 1, 2010 Note: If you and/or your covered dependents become Medicare-eligible, you and/or your covered dependents will lose medical coverage through Sandia at the end of the month prior to the month in you/they become Medicare-eligible. If you and/or your covered dependents become Medicare-eligible, notify OneExchange COVERAGE 100% Member - only coverage $740 Member + 1 coverage $1,480 Member + 2 coverage $2,220 Note: Family contributions are capped at three times the applicable rate. 68 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

69 Medicare Long-Term Disability Terminee Premium Sharing and Your Spending Arrangement (YSA) Credits Sandia-Sponsored Group Medicare Advantage Plans Medical Premium Sharing TABLE A: Employee who became an LTD Terminee prior to January 1, 1995 YSA annual credit amount $1, $3, TABLE B: Employees who became an LTD Terminee after December 31, 1994 and prior to January 1, 2003 Presbyterian Senior Care HMO monthly premium Humana Medicare Employer HMO Plan monthly premium Kaiser Senior Advantage Plan monthly premium 1 Medicare-eligible 2 Medicare-eligibles $23.00 $46.00 $13.34 $26.68 $29.43 $58.86 YSA annual credit amount $1,706 $3,412 TABLE C: Employees Who Became an LTD Terminee after December 31, 2002 Presbyterian Senior Care HMO monthly premium Humana Medicare Employer HMO Plan monthly premium Kaiser Senior Advantage Plan monthly premium $80.50 $ $46.70 $93.40 $ $ YSA annual credit amount $1, $2, Medicare Note: The YSA annual credit amounts listed will be prorated for the number of months left in the year for the new coverage you elect. Medicare: PreMedicare: Medicare.OneExchange.com/Sandia SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m p.m. MT 69

70 Medicare Long-Term Disability Terminee Premium Sharing and Your Spending Arrangement (YSA) Credits Employees who became an LTD Terminee prior to January 1, 1995 will not be required to pay a premium share for themselves or any eligible Class I dependents for the Kaiser Senior Advantage Plan, Humana Medicare Employer HMO Plan, or Presbyterian Senior Care HMO-POS at this time. Employees who became an LTD Terminee after December 31, 1994 and before January 1, 2003 pay a monthly premium for coverage in the Kaiser Senior Advantage Plan, Humana Medicare Employer HMO Plan, or Presbyterian Senior Care HMO-POS equal to 10% of the cost. Use Table B on the previous page to find the monthly rate for your selected plan(s). Employees who became an LTD Terminee after December 31, 2002 and before January 1, 2012 pay a monthly premium for coverage in the Kaiser Senior Advantage Plan, Humana Medicare Employer HMO Plan, or Presbyterian Senior Care HMO-POS equal to 35% of the cost. Use Table C on the previous page to find the monthly rate for your selected plan(s). YSA CREDITS If you choose the YSA, you will become responsible for paying for your own health coverage. You will then be reimbursed by OneExchange, using YSA funds. The annual credit amounts you are eligible to receive are based on when you became an LTD Terminee. Note: Annual YSA credit amounts will be prorated for individuals who become an LTD Terminee mid-year or who age-in to Medicare. Medicare The Centers for Medicare and Medicaid (CMS) regulates the premiums for the various individual market Medicare supplemental health options. 70 Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT

71 Dental Care Program & Vision Affinity Discount Program PreMedicare + Medicare PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT 71

72 Dental Care Plan Program Overview The Sandia Dental Care Program is administered by Delta Dental of New Mexico. This plan is available to retired employees and their eligible dependents. PreMedicare + Medicare KEY POINTS Deductible: $50 per individual up to a family annual maximum deductible of $150 Annual maximum benefit for non-orthodontic covered services: $1,500 Lifetime maximum benefit for orthodontic covered services: $1,800 DENTAL SERVICES AND COINSURANCE AMOUNTS Coinsurance is coverage based on a percentage of the maximum approved fee for the following types of services: EMPLOYEES NOT ELIGIBLE SERVICE TYPE YOU PAY Employees who were hired (or rehired) as stated below do not have access to the Sandia Dental Care Program upon becoming Medicare-eligible: Preventive services such as oral examinations, routine cleanings, No Charge and Non-represented x-rays employees who were hired (or rehired) on or after January 1, OPEIU-represented employees who were hired (or rehired) on or after July 1, Basic and restorative services that include fillings, extractions, MTC- and SPA-represented employees who were hired (or rehired) on or after July 1, 20% endodontic, and periodontal services Surviving spouses and LTD participants. Major services such as crowns, prosthodontics, and specified implant 50% procedures Orthodontic services 50% MAKE THE MOST OF YOUR DENTAL BENEFITS ID Cards: Delta Dental issues identification cards under the primary subscriber with a unique ID number. This card lists only the primary subscriber and the alternate ID, which is used by all family members. Additional cards can be printed from toolkitsonline.com. Pre-Treatment Estimate: Request this free report from your dentist before undergoing extensive or expensive treatment. RETIREES WHO PAY NO DENTAL PREMIUM Employees who retired prior to January 1, 2009 will not be required to pay a dental premium share for themselves or any eligible Class I dependents at this time. RETIREES WHO PAY A PARTIAL MONTHLY DENTAL PREMIUM Employees who were hired or rehired prior to January 1, 2009, and retired January 1, 2009 through December 31, 2011, pay a partial monthly dental premium share. 72 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

73 Dental Care Plan Program Overview, continued COVERAGE RETIREE ONLY $9 RETIREE + 1 $17 RETIREE + 2 (OR MORE) $26 EMPLOYEES NOT ELIGIBLE MONTHLY PREMIUM Employees who were hired (or rehired) as stated below do not have access to the Sandia Dental Care Program upon becoming Medicare-eligible: PreMedicare + Medicare Non-represented employees who were hired or rehired on or after January 1, OPEIU-represented employees who were hired or rehired on or after July 1, MTC- and SPA-represented employees who were hired or rehired on or after July 1, Surviving spouses and LTD participants. CUSTOMER SERVICE DELTA DENTAL OF NEW MEXICO CUSTOMER SERVICE Can help you with your dental coverage, including: Benefits Coinsurance Deductible Annual Maximum Phone: M-F 6:30 a.m. - 6:00 p.m. MT In-Person: 2500 Louisiana Blvd. NE STE. 600, Albuquerque, NM, M-F 8:00 a.m. - 5:00 p.m. MT ONEEXCHANGE Can help you with administration of your dental plan, including: Eligibility Changing a name or address Adding or removing dependents Paying your premium Phone: (TTY: 711) M-F 6:00 a.m. - 7:00 p.m. MT Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 73

74 Vision Affinity Discount Program Overview PreMedicare + Medicare The Davis Vision Affinity Discount Program (DVAD) is available to PreMedicare and Medicare retirees. The DVAD Program is not available to Surviving Spouses and LTD Terminees. WHAT ARE THE SERVICES? Through special arrangements, Sandia National Laboratories makes discounts on examinations, eyewear and contact lenses available to members. All existing vision benefits, if any, associated with your health plan still apply. See the schedule on page 75 for discounts and fixed charges. WHO ARE THE NETWORK PROVIDERS? You may choose from Davis Vision contracting providers or contracted retail locations for discounted services. Use any ophthalmologist for your eye examination. Then, use a Davis Vision contracted network provider for your hardware purchases (eyeglasses) and maximize your savings. Please note: you should verify whether or not the Davis Vision provider accepts outside prescriptions. All Davis Vision contracted network providers are licensed providers who are extensively reviewed and credentialed to ensure that stringent standards for quality service are maintained. Please call Davis Vision at to access the Interactive Voice Response (IVR) Unit, which will supply you with the names and addresses of the network provider nearest you, or you may access our website at davisvision.com. HOW DO I RECEIVE SERVICES FROM A DAVIS VISION NETWORK PROVIDER? Call the network provider of your choice to schedule an appointment. Identify yourself as a Davis Vision plan participant and a Sandia National Laboratories retiree or dependent. Provide the office with the retiree s Davis Vision issued ID number or card, as well as the name(s) and date(s) of birth of any covered dependent(s) needing services. FOR ADDITIONAL INFORMATION Visit Davis Vision at davisvision.com or call When visiting the web prior to enrollment, enter client code Accessing the website or phone number will allow you to: Locate a network provider in your area. Speak with a member service representative. Ask questions about your vision care benefits. MEMBER SERVICE REPRESENTATIVES ARE AVAILABLE: Monday through Friday, 6:00 a.m. to 9:00 p.m. MT Saturday, 7:00 a.m. to 2:00 p.m. MT Sunday, 10:00 a.m. to 2:00 p.m. MT Individuals who use a TTY (teletypewriter) because of a hearing or speech disability may access TTY services by calling PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

75 Vision Member Discount Fee Schedule 1 EYE EXAMINATIONS YOU PAY: Complete Examination 15% off Usual and Customary Contact Lens Examination 15% off Usual and Customary FRAMES 2 Priced up to $70 retail $40 Priced above $70 retail $40, plus 10% off the amount over $70 LENSES (UNCOATED PLASTIC) 2 Single Vision $35 Bifocal $55 Trifocal $65 Lenticular $110 LENS OPTIONS (ADD TO LENS PRICES ABOVE) 2 Standard Progressive $75 3 Premium Progressive $125 3 Glass Lenses $18 Polycarbonate Lenses $30 Scratch-Resistant Coating $20 ARC (Anti-reflective coating) $45 Ultraviolet (UV) Coating $15 Solid Tint $10 Gradient Tint $12 Plastic Photosensitive Lenses $35 Polarized Lenses $75 High Index Lenses $55 Intermediate Lenses $30 Blended Lenses $20 CONTACT LENSES Conventional 20% off Usual and Customary Disposable/Planned Replacement 10% off Usual and Customary OTHER PRODUCTS DavisVisionContacts.com Up to 50% off retail prices Laser Vision Correction Discount Up to 25% off providers Usual and Customary PreMedicare + Medicare 1 Eye wear discounts are not applicable at Walmart or Sam s Club locations. 2 Special lens designs, materials, powers and frames may require additional cost. 3 Or receive an additional 5% discount on any advertised specials whichever is lower. Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 75

76 Required Notices PreMedicare + Medicare 76 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

77 Women s Health and Cancer Rights Act THE MEDICAL PROGRAMS SPONSORED BY SANDIA NATIONAL LABORATORIES WILL NOT RESTRICT BENEFITS IF YOU OR YOUR DEPENDENT: Receives benefits for a mastectomy; and Elects breast reconstruction in connection with the mastectomy. BENEFITS WILL NOT BE RESTRICTED PROVIDED THAT THE BREAST RECONSTRUCTION IS PERFORMED IN A MANNER DETERMINED IN CONSULTATION WITH YOU OR YOUR DEPENDENT S PHYSICIAN AND MAY INCLUDE: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; and Prostheses and treatment of physical complications of all stages of mastectomy, including lymphedemas. Benefits for breast reconstruction will be subject to annual deductibles and coinsurance amounts consistent with benefits for other covered services under the program. PreMedicare + Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 77

78 Sandia Prescription Drug Program Creditable Coverage Notice PreMedicare + Medicare SANDIA NATIONAL LABORATORIES HEALTH BENEFITS PARTICIPANT: Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Sandia National Laboratories 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 prescription drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what costs, 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 (Part D) or join a Medicare Advantage Plan (like a HMO and 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. Sandia National Laboratories has determined that the prescription drug coverage offered by Sandia Total Health is, on average for all plan participants, expected to pay out as much as 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 prescription drug plan. Note: The Medicare Advantage Plans offered by Sandia National Laboratories provide prescription drug (Part D) coverage. These employer group plans include the Presbyterian Medicare PPO, Lovelace Employer Group Medicare Plan (HMO) provided by BCBSNM, and Kaiser Permanente Senior Advantage Plan. This Notice does not apply to those enrolled in a Sandia-sponsored Medicare Advantage Plan as you will receive this information from Presbyterian Medicare PPO, the Lovelace Employer Group Medicare Plan provided by BCBSNM, or Kaiser Permanente Senior Advantage Plan. In addition, this Notice does not apply to those who enroll in the Your Spending Account option. If you enroll in a Medicare Advantage Plan with prescription drug coverage or a Medicare Part D Prescription Drug Plan through the Your Spending Account option, you will receive explanation of whether or not the prescription drug coverage is creditable from the Plan. If you do not receive this information, you will need to contact the plan in which you enrolled. 78 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

79 Sandia Prescription Drug Program Creditable Coverage Notice, continued WHEN CAN YOU JOIN A MEDICARE PRESCRIPTION DRUG PLAN? You can join a Medicare prescription drug plan when you first become eligible for Medicare and each year from October 15 to December 7. 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 (SEP) to join a Medicare prescription drug plan. WHAT HAPPENS TO YOUR CURRENT COVERAGE IF YOU DECIDE TO JOIN A MEDICARE PRESCRIPTION DRUG PLAN? If you are an active employee or a dependent of an active employee and you and/or your dependents join a Medicare prescription drug plan, you and/or your dependents will still be eligible to receive medical and prescription drug benefits through your active Sandia medical plan as follows: PreMedicare + Medicare If you and your dependents (if applicable) are enrolled in Sandia Total Health program, you are required to obtain your outpatient prescription drug benefits through your Sandia National Laboratories plan first. You can then file your claims on a secondary basis with your Medicare prescription drug plan. If you are a Medicare retiree or a Medicare dependent of a retiree and are enrolled in the Presbyterian Medicare PPO, the Lovelace Employer Group Medicare Plan provided by BCBSNM, or the Kaiser Permanente Senior Advantage Plan, and you enroll in another Medicare Prescription Drug Plan; please note that you may lose your Sandia-sponsored medical plan coverage. Note: There are exceptions for Medicare domestic partners of employees as well as those plan participants who have End Stage Renal Disease. Please contact Sandia at the number listed below for more information. Important: You can only waive prescription drug coverage by waiving the entire medical plan coverage for yourself and your dependents. Remember, if you waive your coverage, you can only re-enroll in the Sandia National Laboratories medical plan: During the next Open Enrollment Period with coverage effective January 1 of the following calendar year. At any time if you have an eligible mid-year election change event. WHEN WILL YOU PAY A HIGHER PREMIUM (PENALTY) TO JOIN A MEDICARE PRESCRIPTION DRUG PLAN? Important: You should also know that if you drop or lose your current coverage with Sandia National Laboratories and don t join a Medicare prescription drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare prescription drug plan later. Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 79

80 Sandia Prescription Drug Program Creditable Coverage Notice, continued PreMedicare + Medicare If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) for as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. FOR MORE INFORMATION ABOUT THIS NOTICE OR YOUR CURRENT PRESCRIPTION DRUG COVERAGE Contact the Sandia National Laboratories Benefits Customer Service at (505) , press option 2. Note: You ll get this notice each year. You will also get it before the next period you can join a Medicare prescription drug plan, and if this coverage through Sandia National Laboratories changes. You also may request a copy of this notice. FOR MORE INFORMATION ABOUT YOUR OPTIONS UNDER MEDICARE PRESCRIPTION DRUG COVERAGE More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. FOR MORE INFORMATION ABOUT MEDICARE PRESCRIPTION DRUG COVERAGE: Visit medicare.gov. Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help. Call MEDICARE ( ). TTY/TDD users should call If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at socialsecurity.gov or call them at (TTY ). Remember: Keep this Creditable Coverage Notice. If you decide to join one of the Medicare prescription drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: October 1, 2018 Name of Entity/Sender: Sandia National Laboratories Contact Position/Office: Benefits Department Address: 1515 Eubank SE, Albuquerque, NM Phone Number: , option 2 80 PreMedicare: SandiaRetireeBenefits.com (TTY: 711) M-F 6 a.m. - 7 p.m. MT

81 Frequently Asked Questions (FAQ) PreMedicare + Medicare Medicare: Medicare.OneExchange.com/Sandia (TTY: 711) M-F 6 a.m. - 7 p.m. MT 81