New Contact for Benefits Administration Effective July 24, 2015, Pacific Gas and Electric Company (PG&E) introduced a new partner for benefits administration. The following print version of content from the Summary of Benefits Handbook (the summary plan description ( SPD )) includes references to the old benefits administration team. (The SPD website has been updated, but not the print version of the SPD.) Where the following pages refer to the HR Service Center, you should use the following contacts, instead of the HR Service Center: PG&E Benefits Service Center at 1-866-271-8144 (open weekdays from 7:30 a.m. to 5 p.m. Pacific time) Mercer BenefitsCentral, accessible via: o PG&E@Work For Me (if on the PG&E network) or o mypgebenefits.com (for those outside the network). Other Resources In addition to the PG&E Benefits Service Center and Mercer BenefitsCentral, you have two other important benefits and human resource contacts that are not changing: PG&E Pension Call Center Xerox is still providing benefits administration for the retirement plans. Contact them online at https://pgepensioncenter.com or call 1-800-700-0057 Monday through Friday from 7:30 a.m. to 3:30 p.m. and. HR Service Center While Mercer administers most benefits other than retirement, the HR Service Center will still help you with questions about your job title, classification or changing your name or contact information. Contact them at hrbenefitsquestions@exchange.pge.com, or call 1-800-788-2363 Monday through Friday from 7:30 a.m. to 5 p.m. Pacific time. PG&E refers to Pacific Gas and Electric Company, a subsidiary of PG&E Corporation. 2015 Pacific Gas and Electric Company. All rights reserved.
This is the 2013 edition of your Summary of Benefits Handbook for Retirees and Surviving Dependents, and describes the benefits effective January 1, 2013. The Handbook contains valuable information about the following benefit programs (some that are negotiated and some that are not negotiated) that the Company offers to you and your eligible dependents. Health care plans, including medical coverage, prescription drug benefits and mental health and substance abuse benefits. Life and accident insurance. Company Defined Throughout this section, unless otherwise stated, reference to Company or PG&E means Pacific Gas and Electric Company. The plans and benefits described in this handbook are also applicable to employees who terminate at or after age 55 ( retirees ) and surviving dependents of PG&E Corporation and its designated subsidiaries, but only to the extent that such entities are participating employers with respect to the described plans or programs and such retirees and surviving dependents meet the eligibility requirements of the plans or programs. Retirement benefits including the Pacific Gas and Electric Company Retirement Plan, Retiree Medical Savings Account and the PG&E Corporation Retirement Savings Plans. Other benefits, including smoking cessation for retirees enrolled in a Company medical plan and discounts on gas and electric services for your home. The Benefits Available The Company offers certain retirees and their surviving dependents certain benefits that give you choices and may require you to make election decisions. Other benefits do not require election or enrollment decisions; you are automatically covered if you are an eligible participant. For details on the various plan provisions, see individual plan sections in this Handbook as well as: The What to Do section provides checklists of things you need to do when certain events occur or you reach certain milestones; The Health Care Participation section for health care plan enrollment information; Whether you are about to retire and choosing your retiree benefits for the first time or you are considering a change to your existing retiree benefits elections, you should evaluate your options with care. Be sure to consider your future as well as your present needs when making your benefit decisions. Questions? If you have any questions about your benefits that are not answered by this Handbook or other benefit plan documents, you can contact the HR Service Center at 415-972-7077 or toll-free at 800-700-0057. You can also send an email to the HR Service Center at hrbenefitsquestions@exchange.pge.com. Benefits Effective January 1, 2013 1
Contents Welcome!... 1 About This Handbook... 11 Benefits at a Glance... 13 Medical Coverage at a Glance... 13 NAP Medical at a Glance... 14 CAP Medical at a Glance... 17 In-Area Health Savings Account (HSA) Medical Plan at a Glance... 19 Out-of-Area Health Savings Account (HSA) Medical Plan at a Glance... 19 Retiree Optional Plan (ROP) Medical at a Glance... 20 Blue Shield HMO Medical at a Glance... 22 Health Net HMO Medical at a Glance... 25 Kaiser Permanente EPO Medical at a Glance... 28 Medicare Supplemental Plan (MSP) Medical Coverage at a Glance... 29 Medicare HMOs... 31 Life and Accident Insurance at a Glance... 46 Retirement Plans at a Glance... 47 Life Balance Benefits at a Glance... 48 What to Do... 49 Age-Related Events... 50 Under Age 65... 50 At Age 62... 50 At Age 65... 50 When Your Spouse or Registered Domestic Partner Turns 65... 50 Family Events... 51 If You Get Married or Establish a Registered Domestic Partnership... 51 If You Have New Children... 51 In the Case of Dissolution of Marriage or Termination of a Registered Domestic Partnership... 52 In Case of Death... 53 What Your Family Needs to Do in the Event of Your Death... 53 If Your Spouse or Another Dependent Dies... 54 Other Events... 54 If You Move... 54 If Your Children Become Ineligible for Coverage... 55 Changing Coverage During the Year (Change-in-Status Events)... 55 Health Care Benefits... 57 Health Care Participation... 59 Eligible Retirees... 60 Eligible Dependents... 61 Qualified Medical Child Support Orders... 62 Disabled Dependents... 63 Ineligible Dependents... 63 Penalties for Covering Ineligible Dependents... 64 Eligible Survivors of Retirees... 64 If a Surviving Dependent Dies... 65 2 Benefits Effective January 1, 2013
Cost of Coverage... 65 Retiree Medical Employer Contribution (RMEC) Program... 65 Retiree Premium Offset Account (RPOA) for RMEC Retirees... 66 Methods of Payment... 68 Non-Payment of Premium Contribution... 68 Retiree Medical Savings Account (RMSA)... 69 Enrollment and When Coverage Begins... 74 Changing Your Coverage... 75 Open Enrollment... 75 Mid-Year Health Care Enrollment Changes... 76 Cancelling Coverage... 77 Timeline for Enrollment... 77 If You Have Other Coverage... 80 Which Plan Is Primary for You?... 80 Which Plan Is Primary for Your Children?... 81 Coordination with Medicare... 81 Reductions/Exclusions for Duplicate Coverage... 82 Subrogation and Reimbursement... 82 When Coverage Ends... 85 Extended Benefits When Coverage Ends... 85 COBRA and Conversion to an Individual Medical Policy... 86 COBRA Coverage Under the Retiree Medical Plan... 87 Appeals... 89 Conversion to an Individual Medical Policy... 90 HIPAA Conversion Plan... 90 If Eligibility Is Denied... 91 Medical Coverage... 93 The Options Available... 94 PG&E s Plans Administered by Anthem Blue Cross... 94 Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)... 94 Medical Benefits for Members Under 65... 96 Medical Benefits for Medicare-Eligible Members... 98 PG&E s Medicare Plan Options General Information... 99 Medicare... 104 Medicare Part A... 105 Medicare Part B... 105 Medicare Part D... 105 When You Become Medicare-Eligible... 105 Other Things You Need to Know When You Become Medicare-Eligible... 106 Network Access Plan (NAP)... 107 NAP at a Glance... 108 How the NAP Works... 111 Network Providers... 111 Non-Network Providers... 111 Deductibles... 112 Benefits Effective January 1, 2013 3
Plan Maximums... 113 Copayments and Benefit Percentages... 113 How Benefits Are Determined... 114 Medical Management Programs... 117 Utilization Review Program... 117 Authorization Program... 119 Medical Necessity Review Process... 121 Personal Case Management (for Non-Medicare Members)... 122 What the NAP Covers... 123 Acupuncture... 124 Ambulance Services... 124 Chiropractic Care... 124 Hearing Aids Effective January 1, 2014... 124 Home Health Care and Hospice Care... 124 Hospital Care Inpatient... 125 Hospital Care Outpatient... 126 Organ and Tissue Transplants... 127 Prescription Drugs... 128 Professional Services... 128 Psychiatric Care and Substance Abuse Treatment... 128 Transportation and Lodging... 129 Skilled Nursing Facility... 129 Other Covered Services and Supplies... 130 What the NAP Doesn t Cover... 132 Third-Party Exclusion... 136 Comprehensive Access Plan (CAP)... 137 CAP at a Glance... 138 How the CAP Works... 139 Deductibles and Maximums... 140 Copayments and Benefit Percentages... 141 How Benefits Are Determined... 142 Medical Management Programs... 144 Utilization Review Program... 144 Authorization Program... 146 Medical Necessity Review Process... 148 Personal Case Management (for Non-Medicare Members)... 149 What the CAP Covers... 150 Acupuncture... 150 Ambulance Services... 150 Chiropractic Care... 150 Hearing Aids Effective January 1, 2014... 150 Home Health Care and Hospice Care... 151 Hospital Care Inpatient... 152 Hospital Care Outpatient... 152 Organ and Tissue Transplants... 153 Prescription Drugs... 154 4 Benefits Effective January 1, 2013
Professional Services... 154 Psychiatric Care and Substance Abuse Treatment... 155 Skilled Nursing Facility... 155 Transportation and Lodging... 155 Other Covered Services and Supplies... 156 What the CAP Doesn t Cover... 158 Third-Party Exclusion... 162 Retiree Optional Plan (ROP)... 163 ROP at a Glance... 164 How the Retiree Optional Plan (ROP) Works... 165 Deductibles and Maximums... 166 Copayments and Benefit Percentages... 166 How Benefits Are Determined... 167 Medical Management Programs... 169 Utilization Review Program... 169 Authorization Program... 171 Medical Necessity Review Process... 173 Personal Case Management (for Non-Medicare Members)... 174 What the ROP Covers... 175 Acupuncture... 175 Ambulance Services... 175 Chiropractic Care... 175 Hearing Aids Effective January 1, 2014... 175 Home Health Care and Hospice Care... 175 Hospital Care Inpatient... 176 Hospital Care Outpatient... 177 Mental Health Care... 178 Organ and Tissue Transplants... 178 Prescription Drugs... 179 Professional Services... 179 Psychiatric Care and Substance Abuse Treatment... 180 Skilled Nursing Facility... 180 Substance Abuse... 180 Transportation and Lodging... 181 Other Covered Services and Supplies... 181 What the ROP Does Not Cover... 184 Third-Party Exclusion... 187 Medicare Supplemental Plan (MSP)... 189 MSP at a Glance... 189 Eligibility... 190 How the MSP Works... 191 What the MSP Covers... 192 Services and Supplies... 192 Emergency Care... 194 Outpatient Prescription Drug Coverage... 194 Skilled Nursing Facility... 195 Benefits Effective January 1, 2013 5
Home Health Care... 195 Hospice Care... 195 Mental Health Conditions... 195 What the MSP Does Not Cover... 195 Third-Party Exclusion... 198 Definitions... 199 Claims and Appeals Process... 203 Filing a Claim for Benefits... 203 Required Information... 203 Payment of Benefits for Non-Network Benefits... 204 Benefit Determinations (Before an Appeal Is Filed)... 204 To Resolve a Problem... 206 Appeals... 206 How to Appeal a Claim Decision Non-Urgent... 206 PG&E s Voluntary Review Process... 208 Non-Medicare HMOs and the Kaiser EPO... 211 How HMOs and the Kaiser EPO Work... 211 Primary Care Physicians (PCPs)... 212 Service Areas... 212 Available HMOs/EPOs... 213 Summaries of Benefits (Non-Medicare)... 213 Blue Shield HMO (Access+)... 213 Health Net HMO... 216 Kaiser Permanente EPO North and South... 219 Additional Coverage Rules... 219 Claims, Appeals and Complaints... 220 Claims... 220 Appeals... 221 Complaints Process for HMOs... 221 Medicare Health Maintenance Organizations (HMOs)... 223 HMO Plan Summaries of Benefits for Medicare-Eligible Members... 224 Blue Shield Medicare COB HMO... 224 Health Net Medicare COB HMO... 227 Health Net Seniority Plus... 230 Kaiser Senior Advantage Northern and Southern California... 234 HMO (Medicare) Claims, Appeals and Complaints... 237 Eligibility & Participation... 237 Claims... 238 Mental Health and Substance Abuse Coverage... 241 Eligibility... 243 How Benefits Are Provided... 244 For NAP Members... 247 Coinsurance and Copayments for NAP Members... 247 How the Program Works for NAP Members... 248 What the Program Covers for NAP Members... 249 For CAP Members... 252 6 Benefits Effective January 1, 2013
Deductibles and Limits for CAP Members... 252 Coinsurance and Copayments for CAP Members... 252 How the Program Works for CAP Members... 253 What the Program Covers for CAP Members... 254 For HMO and Kaiser EPO Members... 255 Deductibles and Limits for HMO and Kaiser EPO Members... 255 Coinsurance and Copayments for HMO and Kaiser EPO Members... 256 How the Program Works for HMO and Kaiser EPO Members... 256 What the Program Covers for HMO and Kaiser EPO Members... 257 For Members of All Medical Plans... 258 Medical Management and Authorization Programs... 258 Medically Necessary... 259 What the Program Does Not Cover... 259 More about the Program... 260 Claims and Appeals Process for ValueOptions (VO)... 261 Prescription Drug Coverage... 265 Plan Benefits... 266 Generic Incentive Provision... 268 Eligibility... 268 How the Plan Works... 269 Retail Pharmacy Service... 269 Express Scripts Mail-Order Pharmacy... 270 What the Plan Covers... 271 What the Plan Does Not Cover... 272 Coordination of Benefits... 273 Claims and Appeals... 273 Claims and Inquiries... 273 Appeals... 273 PG&E s Voluntary Review Process... 275 Postretirement Life and Accident Insurance Plans... 277 Life Insurance... 279 Eligibility, Enrollment, and Cost... 279 Imputed Income from Your Life Insurance Coverage... 279 How Your Benefit Is Paid... 280 Your Beneficiary... 280 Accelerated Benefit Option (ABO)... 281 Assignment of Benefits... 281 When Coverage Ends... 282 Converting Your Supplemental and Dependent Life Insurance Coverage to an Individual Policy... 282 Claims and Appeals... 282 Claims Relating to a Benefit... 283 Claims Relating to Eligibility... 283 Accidental Death & Dismemberment Insurance... 285 Eligibility, Enrollment, and Cost... 285 How Your Benefit Is Paid... 285 Benefits Effective January 1, 2013 7
Beneficiary Designation... 286 Claims and Appeals... 286 Claims Relating to a Benefit... 287 Claims Relating to Eligibility... 288 State Legal Notices... 289 Retirement Benefits... 291 Retirement Plan... 294 If You Are a Current Employee Thinking About Retirement... 294 Plan Highlights for Retirees and Survivors... 295 Pension Checks... 295 Payment Options... 296 Other Retirement Benefit Provisions... 298 Other Important Plan Information... 299 Claims and Appeals... 300 The Pension Benefit Guaranty Corporation... 301 Retirement Savings Plan... 303 Participating in the Plan... 303 Beneficiary Designation... 303 Investing... 304 PG&E Corporation Stock Fund Dividends... 310 Monitoring and Making Changes to Your Investments... 310 Financial Engines... 312 Fidelity Education and Modeling Tools... 314 Distributions After Your Employment Has Ended... 315 What Happens... 317 If You Leave PG&E or Retire... 317 If You Die... 318 If You Get Divorced... 318 If You Get Rehired... 318 Additional Plan Information... 319 Significant Accounting Policies and Investment Disclosure... 319 Fees and Expenses... 319 Plan Administration and the Corporation s Power and Duties... 320 Participant Account Activity and Plan Service Provider... 320 Claims and Appeals Procedures... 320 Borrowing, Pledging, and Assigning Interests in the Plan... 321 Future of the Plan... 321 Qualified Domestic Relations Orders (QDROs)... 321 Facility of Payment... 322 Other Benefits... 323 Retiree Discount... 324 Smoking Cessation Program... 324 Rules, Regulations & Administrative Information... 325 Plan Amendment and Termination... 326 Your Rights Under ERISA... 326 Health Information Privacy and Data Security... 327 8 Benefits Effective January 1, 2013
Forfeiture of Unclaimed Benefit Payments... 333 Facility of Payment... 334 Administrative Information... 334 The Pacific Gas and Electric Company Health Care Plan for Retirees and Surviving Dependents... 334 The Pacific Gas and Electric Company Postretirement Life Insurance Plan... 337 The Pacific Gas and Electric Company Retirement Plan... 338 PG&E Corporation Retirement Savings Plan and Retirement Savings Plan for Union- Represented Employees... 340 Contacts... 343 Benefits Effective January 1, 2013 9
10 Benefits Effective January 1, 2013