RETIREE OPEN ENROLLMENT 2014

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1 RETIREE OPEN ENROLLMENT 2014 The month of August 2014 is open enrollment for eligible retirees to switch from one retiree health plan to another. Open enrollment is also the time when you are allowed to add your eligible dependents to the medical plan. Eligible dependents include: Spouses (opposite or same sex) Domestic Partners Children up to age 26 Along with a SISC Membership Change Form, copies of marriage certificates/domestic partner affidavits and birth certificates for children are required to add a dependent to the health plan. EARLY RETIREES UNDER AGE 65 The SISC Blue Shield/Navitus and Kaiser plans available to retirees under age 65 are renewing with minimal changes to the coverage. Blue Shield/Navitus 90 Day Supply of Generic drugs are available from Costco at no cost! (Both Costco mail order or walk in pharmacy) Kaiser No Changes RETIREES AGE 65 & OVER Companion Care/Navitus and Kaiser Senior Advantage are renewing with no changes in coverage. If you would like to remain with your current coverage no action on your part is necessary. If you are choosing to switch your medical coverage, or add family members to your coverage enrollment forms must be completed and returned to Human Resources by August 31, The coverage you elect will remain in effect October 1, 2014 through September 30, Enrollment forms and complete summary plan descriptions will be available upon request from Louise Burke in Human Resources. This information will also be available on line mid-august at The rates listed on the reverse side of this notice are the full monthly premiums and are not offset by retiree stipends or Early Retirement Option provisions. Once open enrollment concludes you will receive a letter confirming your coverage and any monthly premium amount due from you. If you have any questions please contact Louise Burke, in the Human Resources Department at (707) or

2 RETIREE RENEWAL RATES EFFECTIVE OCTOBER 1, 2014 KAISER & SENIOR ADVANTAGE Single Kaiser (1) under 65 $ Double Kaiser (2) under 65 $1, Family Kaiser (3) or more under 65 $1, Single Sr. Advantage (1) over 65 $ Double Sr. Advantage (2) over 65 $ Sr. Advantage + 1 (1) over 65/(1) under 65 $ BLUE SHIELD & COMPANION CARE Single Blue Shield (1) under 65 $ Double Blue Shield (2) under 65 $1, Family Blue Shield (3) or more under 65 $2, Single Companion Care (1) over 65 $ Double Companion Care (2) over 65 $ Companion Care + 1 (1) over 65/(1) under 65 $1, RETIREE DENTAL * Single (1) $ Double (2) $ Family (3) $ *Although this is not a dental open enrollment year, the retiree dental plan and rates are remaining the same through September 30, 2015 for current participants.

3 SERVICES Inpatient Hospital (Part A) COMPANIONCARE/Medicare Supplement Plan NORTHERN REGION BENEFIT SUMMARY (Based on Calendar Year) MEDICARE 2014 Benefits Pays all but first $1216 for 1st 60 days COMPANIONCARE Based on 2014 Medicare Benefits Pays $1216 Skilled Nursing Facilities (Must be approved by Medicare) Deductible (Part B) Basis of Payment (Part B) Medical Services (Part B) Doctor, x-ray, appliances & ambulance Lab Physical/Speech Therapy (Part B) Blood (Part B) Travel Coverage (when outside the US for less than 6 consecutive months) Pays all but $304 a day for the 61st to 90th day Pays all but $608 a day Lifetime Reserve for 91st to 150th day Pays nothing after Lifetime Reserve is used (refer to Evidence of Coverage) Pays 100% for 1st 20 days Pays all but $ a day for 21st to 100th day Pays nothing after 100th day $147 Part B deductible per year 80% Medicare Approved (MA) charges after Part B deductible 80% MA charges 100% MA charges 80% MA charges up to the Medicare annual benefit amount. 80% MA charges after 3 pints Not covered Pays $304 a day Pays $608 a day Pays 100% for 151st day to 515th day Pays nothing Pays $ a day for 21st to 100th day Pays nothing after 100th day Pays $147 Pays 20% MA charges including 100% of Medicare Part B deductible Pays 20% MA charges Pays nothing Pays 20% MA charges up to the Medicare annual benefit amount. (PT & ST Combined) Pays 1st 3 pints un-replaced blood and 20% MA charges Pays 80% inpatient hospital, surgery, anesthetist and in hospital visits for medically necessary services for 90 days of treatment per lifetime Outpatient Prescription Drugs Due to Medicare restrictions the following programs are not available with CompanionCare: $0 generic copay at Costco & Diabetic Supplies for Generic co-pay Retail Pharmacy: Mail Order: Prescription drug plan enhanced through Navitus Health Solutions 30 day supply $9 Generic co-pay $35 Brand co-pay 90 day supply $18 Generic co-pay $90 Brand co-pay Pharmacy benefits are administered through Navitus Health Solutions MedicareRx using a Med D formulary. Some exclusions and prior authorizations may apply. Members that have questions regarding their medication coverage can call Navitus Health Solutions MedicareRx at or TYY users please call 711. COMPANIONCARE is a Medicare Supplement plan that pays for medically necessary services and procedures that are considered a Medicare Approved Expense. SISC will automatically enroll CompanionCare Members into Medicare Part D. No additional premium required. SISC plans are NOT subject to the 'doughnut hole'. Eligibility: Enrollment: Disenrollment: Member must be retired and enrolled in Medicare Part A (hospital) and Medicare Part B (medical) coverage. Retirees under age 65 with Medicare for the disabled (Parts A&B) may enroll in CompanionCare. Enrollment forms and a copy of the Medicare card must be received by SISC 45 calendar days in advance of requested effective date - NO exceptions. SISC will automatically enroll members in Medicare Part D for outpatient prescription medications. Members already enrolled in non-sisc Medicare Part D plans will be automatically disenrolled from those plans. Disenrollment throughout the year requires submission of a disenrollment form to SISC with a 45 calendar day advance notice of requested effective date. During the annual Med D Open Enrollment members can enroll into Medicare Part D plans outside of SISC with a January 1 effective date. Enrollment in a Med D plan outside of SISC will terminate the SISC medical and Rx benefits. Provider Network: Physicians who accept Medicare Assignment. For additional Medicare benefit information, please go to or call medicare ( ). For additional Navitus Medicare Rx prescription drug information, please go to or call Rate Effective October 1, 2014 Total Cost Per Person Retirees with Medicare A & B (SISC will enroll members in part D) A school district's geographic location will determine the applicable rate. Northern Region includes Monterey, Kings, Tulare, Inyo and all other counties to the north. Northern Region: $ Retiree Guidelines, Plans & Rates

4 SISC-SELF INSURED SCHOOLS OF CALIFORNIA Summary of Benefits for Kaiser Permanente Senior Advantage (HMO) with Part D (10/1/14 9/30/15) The Services described below are covered only if all of the following conditions are satisfied: The Services are Medically Necessary and in accord with Medicare guidelines The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Southern California Region Service Area, except where specifically noted to the contrary in the Evidence of Coverage (EOC) Annual Out-of-Pocket Maximum for Certain Services For Services subject to the maximum, you will not pay any more Cost Sharing during a calendar year if the Copayments and Coinsurance you pay for those Services add up to one of the following amounts: For self-only enrollment (a Family of one Member)... $1,500 per calendar year For any one Member in a Family of two or more Members... $1,500 per calendar year For an entire Family of two or more Members... $3,000 per calendar year Deductible None Lifetime Maximum None Professional Services (Plan Provider office visits) Most primary and specialty care consultations, exams, and treatment... $10 per visit Annual Wellness visit and the Welcome to Medicare preventive visit... No charge Routine physical exam... No charge Eye exams for refraction... $10 per visit Hearing exams... $10 per visit Urgent care consultations, exams, and treatment... $10 per visit Physical, occupational, and speech therapy... $10 per visit Outpatient Services Outpatient surgery and certain other outpatient procedures... $10 per procedure Allergy injections (including allergy serum)... $3 per visit Most immunizations (including the vaccine)... No charge Most X-rays, annual mammograms, and laboratory tests... No charge Manual manipulation of the spine... $10 per visit Hospitalization Services Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs... $200 per admission Emergency Health Coverage Emergency Department visits... $50 per visit Note: This Cost Sharing does not apply if admitted to the hospital as an inpatient within 24 hours for the same condition for covered Services or if you are admitted directly to the hospital as an inpatient (see "Hospitalization Services" for inpatient Cost Sharing). Ambulance Services Ambulance Services... $50 per trip Kaiser Foundation Health Plan, Inc., Southern California Region continues

5 continued Prescription Drug Coverage Covered outpatient items in accord with our drug formulary guidelines: Most generic items... $10 for up to a 100-day supply Most brand-name items... $20 for up to a 100-day supply Durable Medical Equipment Covered durable medical equipment for home use in accord with our durable medical equipment formulary guidelines... No charge Mental Health Services Inpatient psychiatric care... $200 per admission Individual outpatient mental health evaluation and treatment... $10 per visit Group outpatient mental health treatment... $5 per visit Chemical Dependency Services Inpatient detoxification... $200 per admission Individual outpatient chemical dependency evaluation and treatment... $10 per visit Group outpatient chemical dependency treatment... $5 per visit Home Health Services Home health care (part-time, intermittent)... No charge Other Eyewear purchased at Plan Medical Offices or plan optical sales offices every 24 months... Amount in excess of $150 Allowance Skilled nursing facility care (up to 100 days per benefit period)... No charge External prosthetic devices, orthotic devices, and ostomy and urological supplies percent Coinsurance This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Sharing, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Sharing. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies). Kaiser Foundation Health Plan, Inc., Southern California Region S

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