PERACare Overview for Retirees and Benefit Recipients 2019 PERACare Plans

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1 PERACare Overview for Retirees and Benefit Recipients 2019 PERACare Plans This overview provides a brief summary of the deductibles, copayments, and coinsurance in the PERACare plans. For more detailed benefit information, please see the PERACare 2019 Health Benefits Program booklet(s) available at What is PERACare? PERACare is a health benefits program that includes health care, dental, and vision coverage for Colorado PERA retirees and benefit recipients. Choices for pre-medicare (under age 65) retirees include: Two PPO plans An HMO plan A High Deductible Health Plan (HDHP) that qualifies you to contribute to a Health Savings Account (HSA), which provides tax advantages Choices for Medicare-eligible retirees include: Two Medicare Preferred (PPO) Medicare Advantage (MA) plans A Medicare HMO plan All retirees have the following additional options for coverage: A dental HMO plan Two dental PPO plans Three vision PPO plans In addition, all retirees may participate in wellness programs offered by their plan. Who are the PERACare Carrier Partners? Anthem Blue Cross and Blue Shield (Anthem) Cigna Dental CVS Caremark Delta Dental Kaiser Permanente (Kaiser) VSP CVS Caremark provides the prescription drug coverage in Anthem s pre Medicare plans. SilverScript, an affiliate of CVS Caremark, provides prescription drug coverage in Anthem s Medicare plans. Who is Eligible to Enroll in PERACare? PERA retirees, benefit recipients, and their eligible dependents may enroll in PERACare. Eligible dependents include spouses, civil union partners, unmarried, dependent children under age 25, certain mentally or physically incapacitated adult children, and dependent parents. When Can I Enroll? You can enroll at retirement, at the end of a COBRA period of coverage, or during open enrollment. You also may become eligible to enroll based on certain other life events, such as turning age 65 or the involuntary loss of other insurance coverage. How Do I Enroll? Review the PERACare 2019 Health Benefits Program booklet(s) and complete a PERACare Enrollment/ Change Form. These materials are available on PERA s website at or you can call PERA s Customer Service Center to order copies. Either send the enrollment form to PERA or enroll online if you have a User ID and password. Where is PERACare Available? Anthem is available worldwide for pre-medicare plans and throughout the U.S. and U.S. territories for Medicare plans. Kaiser offers plans in three service areas: Denver/ Boulder, Northern Colorado (Fort Collins, Greeley, and Loveland), and Southern Colorado (Colorado Springs and Pueblo). Contact Kaiser Permanente to find out if you live within their service areas. Cigna Dental HMO is available in Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, El Paso, Jefferson, Larimer, Pueblo, and Weld counties, and major metropolitan areas in many other states. Cigna Dental PPO is available nationwide. Delta Dental PPO is available nationwide. VSP is available nationwide.

2 Anthem Deductible Individual Family Pre-Medicare Plans PPO #1 PPO #2 $3,500 $7,000 $6,000 $12,000 Not subject to deductible Not subject to deductible Tier 1: $0 copay Tier 2: $40 copay Tier 1: $40 copay Tier 2: $60 copay Tier 1: $0 copay Tier 2: $40 copay Tier 1: $60 copay Tier 2: $80 copay Inpatient Hospital 20% coinsurance 20% coinsurance Prescription Drugs Retail (up to a 31-day supply) Deductible: $300; 50% coinsurance Generic $10 $50 Preferred Brand $30 $75 Non-Preferred Brand $50 $100 Deductible: $500; 50% coinsurance Generic $20 $75 Preferred Brand $40 $100 Non-Preferred Brand $60 $125 Mail order (up to a 90-day supply) Deductible: $0; 50% coinsurance Generic $20 $100 Preferred Brand $60 $150 Non-Preferred Brand $100 $200 Deductible: $0; 50% coinsurance Generic $40 $150 Preferred Brand $80 $200 Non-Preferred Brand $120 $250 Specialty (up to 31-day supply) Specialty prescriptions must be obtained via CVS Caremark mail service pharmacy No deductible; 50% coinsurance Specialty $70 $125 No deductible; 50% coinsurance Specialty $80 $150 Kaiser Deductible Individual Family Deductible HMO $1,000 $3,000 $25 copay, not subject to deductible $45 copay, not subject to deductible HDHP $3,500 $7,000 20% coinsurance 20% coinsurance Inpatient Hospital 20% coinsurance 20% coinsurance Prescription Drugs Pharmacy (up to a 30-day supply) Preferred Generic $15 Preferred Brand $40 Non-Preferred $60 Specialty $100 Copays apply after deductible: Preferred Generic $10 Preferred Brand $25 Non-Preferred $50 Specialty $100 Mail order (up to a 90-day supply) Preferred Generic $30 Preferred Brand $80 Non-Preferred $120 Specialty $200 Copays apply after deductible: Preferred Generic $20 Preferred Brand $50 Non-Preferred $100 Specialty $200

3 Anthem Medicare Preferred (PPO) Medicare Plans MA #1 MA #2 $0 copay $0 copay $20 copay $30 copay Hospital Care and Professional Visits $300 per admission; maximum $900 per year $500 per admission; maximum $1,500 per year Prescription Drugs (SilverScript) Not applicable to the Out-of-Pocket Maximum Retail (up to 31-day supply) No deductible; 30% coinsurance Mail (up to 90-day supply) No deductible; 30% coinsurance High Cost (up to 31-day supply) No deductible; 30% coinsurance Generic $10 $15 Preferred Brand $35 $45 Non-Preferred Brand $50 $60 Generic $20 $30 Preferred Brand $70 $90 Non-Preferred Brand $100 $120 High Cost $50 $75 Generic $10 $15 Preferred Brand $35 $45 Non-Preferred Brand $50 $60 Generic $20 $30 Preferred Brand $70 $90 Non-Preferred Brand $100 $120 High Cost $50 $75 Kaiser Permanente Senior Advantage (HMO) Hospital Care and Professional Visits $20 copay $30 copay $250 per day; maximum of $500 per admit Prescription Drugs Pharmacy (up to 30-day supply) Preferred Generic $6 Non-Preferred Generic $15 Preferred Brand $45 Non-Preferred Brand $60 Specialty $75 Mail order (up to 90-day supply) Preferred Generic $12 Non-Preferred Generic $30 Preferred Brand $90 Non-Preferred Brand $120 Specialty $150

4 Dental and Vision Plans You and your dependents may enroll in one of three dental and/or one of three vision plans. You may enroll in these plans without enrolling in a PERACare health care plan (and vice versa). Dependents must be enrolled in the same dental and/or vision plan in which you are enrolled. Dental Plans Cigna Dental HMO Cigna Dental PPO Delta Dental PPO Annual Deductible No deductible Individual $100/Family $200 Individual $100/Family $200 Annual Maximum Benefit None $1,500 $1,500 $5 copay Included in benefit for procedure Included in benefit for procedure Oral Exam and Regular Cleaning $0 copay 100% covered (not subject to deductible) 100% covered (not subject to deductible) Restorative (Fillings) $0 to $115 copay 20% of PPO Contracted Fee 20% of PPO Contracted Fee VSP Vision Plans PPO #1 PPO #2 PPO #3 Eye Exam $10 copay $25 copay $10 copay Prescription Glasses $25 copay for lenses and frame $25 copay for lenses and frame Lenses covered once every 12 months Frames covered up to $160 retail allowance once every 12 months Lenses covered once every 12 months Frames covered up to $115 retail allowance once every 24 months 20% discount off complete pair of glasses only; no discount for lenses only, frame only, or replacement parts or repair For More Information Go to PERA s website at and choose the PERACare for Retirees link under the Retirees tab. From the PERACare page you may:»view» the PERACare 2019 Health Benefits Program booklets. Access provider directories and formularies for the plans. Use the PERACare Premium Inquiry for Retirees calculator for coverage and rate information. If you have questions about PERACare: PERA through the Contact Us link on the PERA website. Call the PERA Customer Service Center at

5 Premiums Monthly premiums are based on the plan and the number of persons enrolled. The rates below list the premiums for a Benefit Recipient only or a Benefit Recipient and a Spouse. For more rate information, visit the PERA website at and use the PERACare Premium Inquiry for Retirees calculator to calculate your rate(s) or view the rates in the PERACare 2019 Health Benefits Program booklet(s). You may call PERA s Customer Service Center at and request the booklet(s) be mailed to you. Information for Retirees Under the Denver Public Schools (DPS) Benefit Structure All retirees and benefit recipients under the DPS benefit structure are eligible for the plans described in this PERACare Overview. For retirees under the DPS benefit structure who are over age 65 and who do not have Medicare Part A, the premiums and PERA subsidy vary from those shown below. Additional information is available in the PERACare 2019 Health Benefits Program Medicare Coverage booklet available on PERA s website. Calculating Your Premium To determine your premium, subtract your PERA subsidy from the health care premium shown below. (The subsidy does not apply toward dental and vision premiums.) For pre Medicare benefit recipients, subtract $11.50 for each year of service up to 20 years ($230 maximum). For Medicare-eligible benefit recipients, subtract $5.75 for each year of service up to 20 years ($115 maximum). Pre-Medicare Coverage Anthem Blue Cross and Blue Shield PPO #1 Benefit Recipient $1, Benefit Recipient + Spouse 2, PPO #2 Benefit Recipient $ Benefit Recipient + Spouse 1, Kaiser Permanente Deductible HMO Benefit Recipient $1, Benefit Recipient + Spouse 2, HDHP Benefit Recipient $ Benefit Recipient + Spouse 1, Medicare Coverage Anthem Blue Cross and Blue Shield MA #1 Benefit Recipient $ Benefit Recipient + Spouse MA #2 Benefit Recipient $ Benefit Recipient + Spouse Kaiser Permanente Medicare HMO Benefit Recipient $ Benefit Recipient + Spouse Dental Coverage Cigna Dental HMO Benefit Recipient $19.63 Benefit Recipient + Spouse PPO Benefit Recipient $37.73 Benefit Recipient + Spouse Delta Dental PPO Benefit Recipient $41.03 Benefit Recipient + Spouse Vision Coverage VSP PPO #1 Benefit Recipient $7.47 Benefit Recipient + Spouse PPO #2 Benefit Recipient $4.94 Benefit Recipient + Spouse 7.94 PPO #3 Benefit Recipient $0.78 Benefit Recipient + Spouse 1.27

6 PERACare Plan Contact Information/Resources Anthem Blue Cross and Blue Shield Group # (Pre-Medicare) PERABLU ( ) Group #COEGR000 (Medicare) Pre-Enrollment: Post Enrollment: Centers for Medicare and Medicaid Services (CMS) MEDICARE ( ) Cigna Dental Dental HMO Group # Dental PPO Group # PERA (7372) CVS Caremark Group #RX BIN: PCN: ADV Delta Dental Group # Kaiser Permanente Group #1804 Denver/Boulder: or Northern Colorado: Southern Colorado: PERACare QuitLine SilverScript (affiliated with CVS Caremark) Group #RXCVSD BIN: PCN: MEDDADV SilverSneakers Social Security Administration VSP Group # Colorado PERA Contact Information Mailing Address Colorado PERA PO Box 5800 Denver, CO Customer Service Center Phone Hours (Mountain time) 7:00 a.m. 5:30 p.m. Monday Thursday 7:00 a.m. 4:30 p.m. Friday Phone/Website/ (PERA) (Fax) ( via Contact Us link on the PERA home page) Denver Main Office 1301 Pennsylvania Street Denver, CO Denver Main Office Hours (Mountain time) 7:30 a.m. 4:30 p.m. Monday Friday Lone Tree Office Park Meadows Drive, Suite 102 Lone Tree, CO Lone Tree Office Hours (Mountain time) 8:00 a.m. 5:00 p.m. Monday Friday Westminster Office 1120 W. 122nd Avenue Westminster, CO Westminster Office Hours (Mountain time) 7:30 a.m. 4:30 p.m. Monday, Tuesday, Thursday, and Friday 1:00 p.m. 4:30 p.m. Wednesday 2-65 (REV 9-18) 20M