Arlington County Government 2015 Medicare Retiree Health Care Program Your Retiree Health Benefits

c/o AmWINS Group Benefits 50 Whitecap Drive North Kingstown, RI 02852 Arlington County Government 2015 Medicare Retiree Health Care Program Your Retiree Health Benefits

Your 2015 Arlington County Retiree Medicare Benefits Arlington County Government knows how important your healthcare coverage is to you, and we strive to provide our retirees with comprehensive coverage and outstanding customer service at a reasonable cost. Following an extensive procurement and selection process, the County has made a decision to switch to a new supplemental Medicare Plan effective January 1, 2015. This plan replaces your current coverage under Cigna's Medicare Surround Plan. We are pleased to introduce you to AmWINS, who will administer the Medicare Supplement and Prescription Drug plan for retirees who are currently enrolled in Medicare Parts A and B and the Cigna Medicare Surround Plan. AmWINS' outstanding reputation and commitment to exceptional customer service are among the reasons they were selected to administer this plan. AmWINS has established a dedicated customer care center specifically for Arlington County retirees. You will have one toll-free number to call, 1-877-809-7361, for answers to questions regarding your medical and prescription drug benefits, as well as Medicare. They will be available to assist you Monday through Friday, 8:00 am to 8:00 pm Eastern Standard Time. When you call during business hours, you will speak directly to a person - no complicated menus of options or numbers to press. You will continue to be able to use any doctor, hospital, or healthcare provider who accepts Medicare. In addition, there are over 60,000 participating pharmacies in AmWINS' network. You will find AmWINS' coverage to be similar to your current Cigna Medicare Surround Plan. There are some changes to copays: a primary care office visit will be $20 and a specialist visit will be $40. Prescription drug copays have also increased. You will find all the details on the next few pages. In addition, because AmWINS' prescription drug formulary is different than Cigna's, you may find that a medication is in a different tier (generic, preferred brand, non-preferred brand) than it was with Cigna. Like any formulary, it is also subject to change each year. How to Enroll To participate, you must be either retired from Arlington County, an eligible dependent of an Arlington County retiree, or the surviving spouse of an Arlington County retiree and enrolled in Medicare Parts A and B by January 1, 2015. If you are currently enrolled in Cigna's Medicare Surround Plan, you will automatically be enrolled in the AmWINS plan as of January 1, 2015. No action is required at this time. You will receive your medical and prescription drug plan ID cards in a separate mailing. Please review your 2015 benefits enclosed in this packet. If you choose not to participate, complete the enclosed Waiver of Coverage and return in the enclosed postage-paid envelope by October 17, 2014. For questions on your new Medicare Health Plan, please call AmWINS toll-free at 1-877-809-7361, Monday through Friday, 8 a.m. to 8 p.m. (Eastern).

Out-of-Pocket Maximum: $1,500 Lifetime Maximum: Unlimited 2015 MEDICAL PLAN SUMMARY Arlington County Government/AmWINS Medicare Plan Services MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD Medicare Pays Plan Pays Hospitalization*: Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days 61st through 90th day 91st day and after: While using 60 lifetime reserve days: Once lifetime reserve days are used: Additional 365 days: Beyond Additional 365 days: All but $1,216 All but $304 per day All but $608 per day after per admission copay $304 per day of Medicare- Eligible expenses of Medicare eligible expenses for additional 365 days You Pay $150 per admission copay for additional 365 days, then all costs Skilled Nursing Facility Care*: You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days 21st through 100th day 101st day and after Blood: First 3 pints Additional Amounts All approved amounts All but $152 per day after $150 copay per benefit period Hospice Care: Available as long as your doctor certifies that you are terminally ill and you elect to receive these services. Available as long as your doctor certifies that you are terminally ill and you elect to receive these services. All but very limited co-payment/co-insurance for outpatient drugs and inpatient respite care Medicare co-payment/co-insurance $150 copay per benefit period All Costs

Office Visits Primary Care Specialist Allergy Injections Services Preventative Care Services Annual Routine physicals, Welcome to Medicare exam, and Immunizations MEDICARE (PART B)- MEDICAL SERVICES-PER CALENDAR YEAR Medicare Pays 80% after Part B deductible 80% after Part B deductible 80% after Part B deductible Generally except certain services may be paid at 80% Early Cancer Detection Screenings: follows Medicare standard guidelines. Mammograms, Colorectal Screenings, Pap Tests, and Prostate Screenings Emergency Services Emergency Room Urgent Care Facility Ambulance Laboratory and Radiology Services: Clinical Laboratory Services Radiology Services Outpatient Hospital Services Surgical Non-Surgical (includes services such as x-ray, PET/CAT/MRI, and radiation therapy when done in an outpatient hospital facility.) Non-Surgical (includes services such as dialysis, chemotherapy, and laboratory services when done in an outpatient hospital facility.) 2015 MEDICAL PLAN SUMMARY Arlington County Government/AmWINS Medicare Plan Generally except certain services may be paid at 80% 80% after Part B Deductible 80% after Part B Deductible 80% after Part B Deductible 80% after Part B deductible 80% after Part B deductible 80% after Part B deductible 80% after Part B deductible Plan Pays after $20 per visit copay after $40 per visit copay after $200 per visit copay (1) after $50 per visit copay after $50 per visit copay after $50 per visit copay after $25 per visit copay You Pay $20 per visit $40 per visit $200 per visit (1) $50 per visit $50 per visit $50 per visit $25 per visit

Inpatient and Outpatient Professional Services 2015 MEDICAL PLAN SUMMARY Arlington County Government/AmWINS Medicare Plan Medicare approved amounts 80% after Part B deductible Medical Equipment, External Prosthetics, Part B Prescription Drugs and Supplies Medicare approved amounts Blood First 3 pints Remainder of Medicare-approved amounts Services Home Health Care: Medicare Approved Services Medically necessary skilled care services and medical supplies 80% after Part B deductible 80% after Part B deductible MEDICARE PARTS A & B Medicare Pays All Costs Plan Pays You Pay Services Foreign Travel (medically necessary emergency services beginning during the first 60 days of each trip outside the USA) Part B Excess Charges (Above Medicare approved amounts) Routine Hearing Exam (once per year) Routine Vision Exam (once per year) OTHER BENEFITS NOT COVERED BY MEDICARE Medicare Pays Plan Pays 80% after deductible to a lifetime maximum benefit of $50,000 after $30 per visit copay up to a maximum of $300 after $10 copay You Pay 20% after $250 deductible and all amounts over the $50,000 lifetime maximum All costs $30 per visit and all amounts over the plan maximum of $300 $10 per visit Vision Hardware (per calendar year per person) up to a total of $75 toward lenses, frames and contacts All costs over $75 *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ** Once you have been billed $147 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Medicare Part B Deductible, which is paid by Arlington County, will have been met for the calendar year. (1) The Emergency Room per visit copay is waived if you are admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. The summary of benefits described herein is for illustrative purposes only. In case of differences or errors, the Group Policy governs. Please Note: The Medicare deductible amounts for Parts A and B services (which are paid by Arlington County) in this summary are the 2014 deductible amounts and are subject to change by Medicare for the 2015 plan year.

Deductible: Tier 1: Generic Tier 2: Preferred Brand Copay Tier Tier 3: Non-Preferred Generic & Non-Preferred Brand Tier 4: Some Generic, Brand, & Specialty Coverage in Gap*: 2015 PRESCRIPTION DRUG PLAN SUMMARY Arlington County Government/AmWINS Medicare Plan 2015 Enhanced Medicare Part D plan with no annual deductible 30-Day Retail Pharmacy** Copay $10 $30 $55 $55 Same copay schedule as above. 90-Day Mail Order** Copay Catastrophic Coverage: Greater of 5% or $2.65 for generic and multi-source drugs. Total out-of-pocket expenses of $4,700.00+ Greater of 5% or $6.60 for all other covered drugs. Prescription Drug Coverage is administered by AmWINS Rx, an approved Medicare Part D plan provider. This plan offers a four-tier copay plan for prescription drugs. This is an enhanced Medicare Part D plan with no annual deductible and provides prescription drug coverage through the coverage gap. Throughout 2015, you will be responsible for a copay for your prescription drugs as noted above. Once your out-of-pocket costs reach $4,700 ("Catastrophic Limit") your co-payment will be reduced to the greater of $2.65 copay for generic drugs (including brand drugs treated as generic) and a $6.60 copay for all other drugs, or a 5% coinsurance. Formulary (drug list): Includes nearly all generic drugs covered by Medicare Part D and most commonly used brand name drugs. Plan Service Area: All 50 states of the United States along with most U.S. Territories Network Pharmacies: More than 60,000 network pharmacies nationwide, including Walgreens, CVS, Rite-Aid, Wal-Mart and Target. *Your coverage Gap copay already includes the 50% manufacturers discount on covered brand name drugs to Part D enrollees not already receiving extra help. **Up to a 34 day supply on prescriptions is available through participating retail pharmacy locations. Up to a 93 day supply on prescriptions is available through mail order and may be available through participating retail pharmacy locations. Note: In the event the Employer Group terminates coverage before the end of the year, 90 day prescriptions will be reduced to a 30 day prescription. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact AmWINS at 1-877-809-7361. Benefits, formulary, pharmacy network, provider network, premium and/or copays/co-insurance may change on January 1 of each year. Limitations, copays and restrictions may apply. This information is available for free in different formats including other languages, large print and Braille. Please contact our Customer Care number at 1-877-809-7361 for additional information (TTY users should call 1-800-313-7667). Hours are Monday through Friday, 8:00 AM to 8:00 PM EST. $20 $60 $110 $110

ADDRESS UPDATE FORM If you would like to update your contact information, please complete and return to AmWINS in the enclosed postage paid envelope Name: Retiree Address: City: Phone: Name: Address: City: Phone: State: Email Address: Spouse (or Surviving Spouse) State: Email Address: Additional Comments Zip: Zip: AmWINS: 1-877-809-7361 50 Whitecap Drive North Kingstown, RI 02852

WAIVER of COVERAGE If you DO NOT wish to enroll in the Arlington County Government/AmWINS Medicare and Prescription Drug Plans, please complete, sign and return this Waiver of Coverage form. Please Note: if you waive coverage, your enrollment in any and all Arlington County Medical plans will be terminated effective December 31, 2014. Retiree Spouse (or Surviving Spouse) Name: Name: Address: Address: City: City: State: Zip Code: State: Zip Code: Please Sign & Date Below NO, DO NOT ENROLL ME (us) in the Arlington County Government Plan(s). for Medicare eligible retirees. I (we) understand that by choosing this option I am (we are) declining medical and prescription drug coverage for 2015. Retiree: Date: Spouse (or Surviving Spouse): Date: All applicable signatures are required for individuals declining coverage in the Plan. Reason for Declining Coverage:

HIPAA Privacy Rules AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION The following information is required to ensure compliance with the Health Insurance Portability & Accountability Act of 1996, Public Law 104-191, regarding the standards for privacy of individually identifiable health information. The written authorization of the insured, named under the insurance policy or insurance plan, is required when a third party representative of the insured, such as a spouse or other family member is authorized to communicate related Protected Health Information (PHI). Insurance Co. Name Print Insurance Co. Name Insured Name (Your Name) Insured s Address & Phone Number Policy Number Print Name Street Address City, State, Zip Code Insured ID # Insured Signature Authorized Party s Name Authorized Party s Address & Phone Number Phone Number Last four digits of your Social Security # Sign here authorizing the individual named below Print Name Street Address City, State, Zip Code Authorized Party s ID # Authorized Party s signature Phone Number Last four digits of your Social Security # Authorized Party sign here FOR INTERNAL USE ONLY HIPAA PRIVACY OFFICE Date Received Insured Account # HIPAA 0004 4/24/03

Retiree Health Care Program Understanding the Insurance Companies and Vendors that manage your benefits In order to provide competitive healthcare options with comprehensive coverage and exceptional service, your employer contracts with a program administrator to manage the retiree medical plan, the Medicare Part D prescription drug plan, claims adjudication (claims processing and payments), and all your customer service needs. The Program Administrator is NEBCO (National Employee Benefits Companies, a division of AmWINS Group Benefits). As the program administrator, NEBCO/AmWINS Group Benefits works with other divisions of AmWINS Group Benefits to provide your benefits. We know the names of these different vendors can be confusing. We hope this summary will help you better understand the divisions of AmWINS Group Benefits and their role in your healthcare program. Please remember that NEBCO/AmWINS Group Benefits is the Program Administrator, and they should be your first point of contact, should you have questions regarding any issues with your retiree healthcare program. Program Administration: Program Administration They handle all retiree customer service, annual enrollment, plan changes, billing services, eligibility, Medicare Part D questions, claims issues, billing issues, and any general questions you may have regarding your healthcare program. Please familiarize yourself with the companies and vendors listed on the following page.

Prescription Drug Benefits: AmWINS Rx is the Pharmacy Benefit Management division of AmWINS Group Benefits. They provide pharmacy benefit services including pharmacy claims adjudication, national pharmacy networks, preferred drug lists, mail order services, clinical services, and customer service for both retirees and pharmacies. Precise RxCare PDP offered by Heartland Fidelity Insurance Company is a Medicare Part D Plan Sponsor utilized by AmWINS Rx. They provide access to all of the Medicare prescription services. Heartland, in conjunction with AmWINS Rx, work to ensure that providers are treating their patients responsibly and within the requirements of US law. Medical Claims Processing and Adjudication: WebTPA is the medical claims administrator for AmWINS Group Benefits. They process claims, mostly after Medicare has applied primary benefits. They work with Medicare to receive claims electronically and they send payments and Explanation of Benefits (EOB) statements to providers and members.

Q: Who can I call if I have questions? A: AmWINS Customer Care Center has established a dedicated toll-free telephone number for Arlington's Medicare eligible retirees and their eligible dependents. Please contact AmWINS Customer Service at 1-877-809-7361, Monday through Friday, from 8 a.m. to 8 p.m. EST. Q: Will I have to change doctors or hospitals? A: No. You may continue to go to any doctor, specialist, or hospital that accepts Medicare. Q: Have the copays changed? A: Yes. Some copays have increased for medical coverage. Primary care office visits have gone from $15 to $20 and Specialist visits have gone from $20 to $40. Prescription drug copays have also increased. You can see the full list of copays in the 2015 Medical Plan and Prescription Drug Summaries in this packet. ANSWERS to YOUR QUESTIONS Q: Are there any other differences in the prescription drug benefits besides the copay increase? A: Yes. Every pharmacy has its own formulary - a list of generic and name-brand prescription drugs that are covered by the plan. AmWINS' formulary is different than Cigna's. As a result, you may find that your prescription is in a different tier (generic, preferred brand, non-preferred brand) than it was with Cigna. If you have specific questions about a medication, please contact AmWINS Customer Care Center at 1-877-809-7361. Q: How do I get my prescriptions filled? A: Simply present your Prescription ID card and prescription to a participating pharmacy. You may receive up to a 90-day supply at retail pharmacies. Q: What about refills for existing prescriptions? A: You DO NOT need to get a new prescription for medication with refills available at a retail pharmacy. Simply show them your new Prescription ID card and you may get a refill if available. Q: Can I keep my Cigna Medicare Surround Coverage? A: No. The County's contract with the Cigna Medicare plans ends December 31, 2014. Your coverage with AmWINS is effective January 1, 2015. Q: Can I continue using my local pharmacy? Q: What should I do with my Cigna Medicare Surround and Medicare Rx cards? A: We recommend that you keep those cards for at least one year, until all of your claims have been processed, and then you may destroy them. Q: When will I receive my new ID cards? A: ID cards will be mailed by December 15, 2014 if you did not waive coverage. Medical and Prescription Drug ID cards will arrive in two separate mailings. Q: Do I still need my Medicare ID Card? A: Yes. You will continue to use your Medicare ID card, along with your new AmWINS ID cards. Q: How are my medical claims paid? A: Medicare has coverage gaps, which are costs that you must pay such as coinsurance, copayments, and deductibles. This plan helps fill those gaps. You may go to any provider that accepts Medicare. Medicare will pay its share and then your plan will pay the claim based on your plan's benefits. You will receive a Medicare Summary Notice in the mail (usually every 3 months) that includes information on amounts Medicare has paid on your behalf and any additional amounts due. Q: Do I need to submit claims to AmWINS? A: No. As long as your provider accepts Medicare, you will not have to send in any claim forms. Simply present your AmWINS ID card along with your Medicare card when you see a provider. Medicare pays the provider its portion of your claim and forwards the balance due to the AmWINS claims administration department. You will receive an Explanation of Benefits (EOB) from AmWINS describing your payment responsibilities to your provider. A: Most likely yes. AmWNS Rx works with all the major chains, including CVS, Walgreens, Wal-Mart, Target, Costco, Publix, and Winn-Dixie, as well as thousands of regional and independent pharmacies. To find a specific pharmacy, contact AmWINS Customer Care at 1-877-809-7361 or visit www.amwinsrx.com. Q: Can I receive prescriptions by mail? A: Yes. You will receive information about MedVantx Home Delivery with your Prescription ID card and in your welcome materials. After January 1, 2015, you must use MedVantx for your mail order prescriptions. Q: How do I start using MedVantx? A: You may register for home delivery by calling MedVantx at 1-866-744-0621 or going online at www.medvantx.com. Once you have registered, your doctor can call in a prescription or you can ask MedVantx to contact your doctor directly. You may also mail in a NEW prescription with the registration form provided in your welcome materials. Q: Will I get a reminder about refilling my medication? A: Yes. MedVantx will send you a reminder regarding your refills in ample time to have them processed. They do not automatically refill your medication because there could be a situation you don't need/want the refill - this eliminates sending out medicine and charging the retiree for unwanted refills. Q: Do my prescription drug costs count toward my medical plan deductible? A: No. Copayments for prescription drugs to not count toward deductibles or out-of-pocket maximums for your medical plan. Continued on next page

Q: How can I lower my drug expenses? A: Generic medications often cost less than brand-name counterparts. Talk to your doctor to determine if a generic is available. You may also have the option of using mail order, where you can receive up to a 90-day supply for one mail order copayment. Q: My spouse is not yet 65. What will happen to coverage for my spouse after I enroll in this plan? A: If your spouse is not Medicare eligible and is under age 65, he/she will continue coverage under the pre-medicare retiree plan with Cigna. Q: I am on Medicare and my spouse will turn 65 next year. How will we know when to enroll in AmWINS? A: Two months prior to your spouse attaining age 65, a Medicare enrollment packet will be mailed from AmWINS. At that time, your spouse should contact Social Security to enroll in Medicare Parts A and B. Medicare enrollment is required to participate in the County's Medicare Supplement and Prescription Drug plans. Failure to enroll will result in loss of medical coverage, as your spouse's coverage with Cigna will end the last day of the month prior to his/her birth month. Q: Can my age 65 spouse enroll if I am not yet age 65? A: Yes, your spouse MUST enroll in Medicare Parts A and B and the County's AmWINS Medicare Supplemental plan as soon as they are eligible to participate, either through age or disability. Your spouse's enrollment should be effective on the first day of the month in which he/she reaches their 65th birthday. Failure to enroll means your spouse will lose all County health insurance, as your spouse's coverage with Cigna will end the last day of the month prior to their birth month.

Disclaimer: The benefit information contained in this brochure is subject to change at any time, and Arlington County Government reserves the unlimited right to make benefit plan changes at any time. Any changes to the benefit plans implemented by Arlington County Govenrment will be considered effective, regardless of whether notice has been given, on the date set by the Company. If you are ever in doubt about your retiree medical benefits, please contact AmWINS at 1-877-809-7361.