Underwritten by: Blue Cross Blue Shield ND

Underwritten by: Blue Cross Blue Shield ND

Eligibility Retired employees receiving a retirement benefit NDPERS TFFR TIAA CREF NDHPRS Job Service Surviving spouses receiving a retirement benefit May enroll at time of retiree s death, or May continue if currently participating Deferred retirees

Enrollment Qualifying Events Within 31 days of the following 1st retirement benefit check Rti Retiree or spouse s 65th birthday or eligibility ibilit for Medicare Loss of coverage in an employer sponsored health plan Marriage, Birth, Adoption or Legal Guardianship

General Information COBRA 18 months coverage If not drawing a retirement benefit after 18 months, coverage will end Coverage for Lifetime if drawing a retirement allowance

Copayments PPO Plan Basic Plan Office Visit Copayment $25 $30 Emergency Copayment $50 $50 PT, OT and ST $20 $25 Chiropractic Therapy and Manipulations $20 $25

Cost Sharing Amounts PPO Plan Basic Plan Deductibles: Per Person $ 400 $ 400 Per Family $1200 $1200 Coinsurance: Per Person $ 750 $1250 Per Family $1500 $2500 *Coinsurance applies on all covered services except Physician Office Visits 80/20 75/25

Out of Pocket Maximums (Deductible and coinsurance) PPO Plan Basic Plan Per Person $1150 $1650 Per Family $2700 $3700 *This does not include any Copayments you will have.

Prescriptions Non Medicare Formulary Generic $5.00 Copayment py 15% Coinsurance * Formulary Brand Name $20 Copayment 25% Coinsurance * Non Formulary Generic or Brand $25 Copayment 50% Coinsurance * $1,000 coinsurance maximum per person per benefit period. Covered at 100% after the $1,000 coinsurance maximum is met. Two Copayment Amounts per Prescription Order or refill for a 35 100 day supply.

Preventive Screening Services PPO Plan Basic Plan Office Visit Copayment : $25 $30 *Then 100% of Allowed Charge subject to a Maximum Benefit Allowance of $200 per Member per Benefit Period. Deductible Amount is waived. *Benefits include: One routine physical examination per Member per Benefit Period. Routine diagnostic screenings. Routine screening procedures for cancer. *Benefits for Mammography Screening, Routine Pap Smear, PSA, Fecal Occult Blood Testing and Immunizations do not apply to the $200 Maximum Benefit Allowance.

Employee Wellness Initiative Blue Cross Blue Shield of North Dakota is pleased to offer two wellness programs. Employees and spouses age 18 and older who are covered by the NDPERS Dakota plan are eligible to participate. Employees and eligible spouses can each qualify to receive up to a total of $250 each year that can be earned for one or both of the following programs:

Health Club Credit Employees and their eligible spouses can earn up to a $20 credit monthly for visiting a participating health club a minimum i of 12 days a month. My Health Center Employees and their eligible spouses can earn points to apply toward incentive prizes in this online program. My Health Center provides personal coaching, the QuitNet tobacco cessation program, customized plans for fitness and nutrition, and family tools for kids.

Dakota Retiree Plan Dakota Retiree Plan mirrors Supplemental Plan F benefit design with no variations (not a Qualified Supplemental Plan F product) Medicare Retirees must have BOTH Medicare Retirees must have BOTH Part A & B

Medicare Providers Providers not participating with Medicare may not be covered Provider may Accept Assignment 96% of ND providers are PAR with Medicare 4,545 total providers in ND 4,353 providers PAR / 192 non PAR 85% of ND chiropractors are PAR with Medicare 287 total Chiropractors in ND 245 Chiropractors PAR / 42 non PAR

Dakota Retiree Plan Must complete NDPERS retiree group health insurance application and Medicare Blue Rx group application If required forms are filed late there is no retroactive adjustment Must provide Medicare information Photocopy of Medicare ID card Eff ti d t t i id ith D kt R ti Pl Effective date must coincide with Dakota Retiree Plan effective date

Dakota Retiree Plan (continued) Prescription i Drug Program If you enroll in other Medicare prescription drug plan, you are not eligible for the Dakota Retiree Plan (includes both health and prescription drug benefits) No coordination of benefits with other federal drug plans (i.e. VA, Tricare coverage) Refer to the Medicare Blue Rx Summary of y Benefits for coverage details

Senior Health Insurance Counseling S H I C Contact: ND Insurance Department 1 800 247 0560 www.nd.gov/ndins/consumer/details di / /d il

Group Dental Plan Underwritten By Cigna

Eligibility Retired employees receiving a retirement benefit from: NDPERS TFFR TIAA CREF NDHPRS Job Service Surviving v v g spouses receiving a retirement benefit May enroll at time of retiree s death, or May continue if currently participating Deferred retirees 1 st check date

Enrollment Qualifying Events Must apply within 31 days of the following: 1st retirement t benefit check Retiree s or spouse s 65th birthday or eligibility for Medicare Loss of coverage in an employer sponsored dental plan M i Bi th Ad ti L l Marriage, Birth, Adoption or Legal Guardianship

Plan Features No waiting periods Freedom to use any dentist Claims paid at the 90 th percentile of Reasonable and Customary charges

Plan Highlights Dental plan annual maximum benefit per person: $1,000 Orthodontia lifetime maximum benefit per person: $1,500 The deductible includes total expenditures per person for all basic and major treatment combined. Services Deductible Coinsurance Preventive and Diagnostic Care: oral exam, cleaning, bitewing X-rays, fluoride application, sealants, full-mouth X-rays, panoramic X-rays, emergency care to relieve pain, histopathologic exams. None 100% Basic Restorative e Care: oral surgery, surgical $50 80% extraction of impacted teeth, anesthetics, major & minor periodontics, root canal/therapy, relines, rebases, and adjustments, repairs to bridges, crowns & inlays, and repairs to dentures. Per person, per year Major Restorative Care: crowns, bridges, dentures. Orthodontia: Coverage for eligible children and adults. $50 Per person, per year 50% None 50%

Premium Information Retiree Individual id only $ 39.82 Individual & spouse $ 76.88 Individual & child(ren) $ 89.22 Family $127.04 Rates guaranteed through December 2011

Group Vision Plan Underwritten By Superior Vision

Eligibilityibilit Retired employees receiving a retirement benefit from: NDPERS TFFR Job Service NDHPRS TIAA CREF Surviving i spouses receiving ii a retirement benefit May enroll at time of retiree s death, or May continue if currently participating Deferred retirees 1 st check date

Enrollment Qualifying Events Within 31 days of the following 1st retirement benefit check Retiree s or spouse s 65th birthday or eligibility for Medicare Loss of coverage in an employer er sponsored vision plan Marriage, Birth, Adoption or Legal Marriage, Birth, Adoption or Legal Guardianship

Plan Highlights Co payments $0 Comprehensive Eye Exam $35 Materials $35 Contact Lens Fitting In network co pays are paid directly to the provider. Materials co pay applies to lenses and/or frames, not contact lenses For Detailed description please see plan handbook

Plan Highlights Continued Services In Network Out of Network Comprehensive Eye Exam: Ophthalmologist (MD) Covered in Full Up to $45 Optometrist (OD) Covered in Full Up to $45 Standard Lenses (Per Pair): Single Vision Covered in Full Up to $35 Bifocal Covered in Full Up to $50 Trifocal Covered in Full Up to $70 Lenticular Covered in Full Up to $70 Progressives Covered to providers retail Progressives trifocal amount Up to $70

Plan Highlights Continued Contact Lenses (Per In Network Pair): Out Of Network Medically Necessary Covered in Full Up to $210 Elective Up to $100 Up to $100 Contact Lens Fitting Standard Covered in Full Not Covered Specialty Up to $50 Not Covered Frames Standard Up to $75 Up to $40 Plan Services Comprehensive Eye Exam Contact Lens Fitting Exam Lenses Frequency 1 per Calendar Year 1 per Calendar Year 1 Pair per Calendar Year Frames 1 per Calendar Year Contact Lenses 1 Allowance per Calendar Year

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In Network Claims In Network Provider Provider gets approval from SVS Member pays Provider for Copay and Upgrades Provider files Claim with SVS SVS pays Provider for services Member Member

Out of Network Claims Member Member Out of Network Provider Member pays Provider in full Member sends Claim/Receipt to SVS SVS reimburses Member at OON rates

Premium Information 2011 Premium Amounts Individual only $ 4.92 Individual & spouse $9.84 Individual & child(ren) $ 8.96 Family $13.88

Term Life Insurance Underwritten by Prudential

Eligibility Employees who participated in the NDPERS life insurance as an active employee Retired, receiving a retirement benefit 4NDPERS 4NDHPRS 4TIAA CREF 4TFFR 4Job Service

Levels of Coverage Retiree may maintain their current level of coverage or decrease coverage Basic = $1,300 coverage ($4.32 monthly premium) Employee Supplemental * Basic Dependent * Spouse Supplemental * *Premium is based on age and level of coverage. *Coverage ends at age 65, retiree may apply for conversion of coverage at age 65

Conversion Rights Loss of Coverage Rates are age rated at date of conversion Obtain form and rate information from Prudential