DECISION GUIDE FOR PLAN YEAR 2015 for retirees with Medicare ANNUAL ENROLLMENT OCTOBER 1 31,

Transcription

1 DECISION GUIDE FOR PLAN YEAR 2015 for retirees with Medicare ANNUAL ENROLLMENT OCTOBER 1 31,

2 RESOURCES / CONTACT INFORMATION If you have any questions about annual enrollment, visit or call us at For specific questions, contact: OGB Customer Service Annual Enrollment Hours: 7:00 AM - 7:00 PM Monday - Saturday Vendor Customer Service Website Blue Cross Blue Shield of Louisiana Hours: 8:00 AM - 5:00 PM CT Monday - Friday One Exchange Hours: 7:00 AM - 8:00 PM CT Monday - Friday Vantage Hours: 8:00 AM - 8:00 PM CT Monday - Friday People s Health Hours: 8:00 AM - 8:00 PM CT Seven days a week Medicare Generations Rx Hours: 24 Hours Seven days a week medicare.oneexchange.com/ogb Additional Information Member Services Website Centers for Medicare & Medicaid (CMS) 24 Hours a day / 7 days a week Social Security Administration Listed below are common health care acronyms that are used throughout this Enrollment Guide. BCBS Blue Cross Blue Shield of Louisiana EOB Explanation of Benefits HIPAA Health Insurance Portability & Accountability Act MA Medicare Advantage PAC Pre-Admission Certification PCP Primary Care Physician POS Point of Service CMS Centers for Medicare & Medicaid Services FSA Flexible Spending Account HRA Health Reimbursement Arrangement OGB Office of Group Benefits PBM Pharmacy Benefits Manager PHI Protected Health Information SPC Specialist 1

3 Take Charge of Your Health This Annual Enrollment Selecting the right plan is one of the most important decisions you will make all year. That s why every October, the Office of Group Benefits (OGB) allows eligible employees, retirees, and their families to select or change health coverage. This year, annual enrollment is especially important. OGB has developed a new set of offerings that provide coverage options for a variety of member needs. Whether you are looking for low (or even $0) premiums, a large coverage network, or predictable co-payments, we have options that work for you and your family and have developed tools that will help you make the best choice for your circumstances. This year you are required to make a selection during the annual enrollment period. If you have Medicare as primary coverage, have OGB secondary coverage and do not make a selection by the end of the enrollment period, you will still retain your Medicare coverage but will be moved into the Pelican HRA 1000 as your secondary coverage a new, low premium plan that offers a nationwide network and state funding that offsets out-of-pocket costs. Additionally, OGB has again partnered with Towers Watson OneExchange (formally Extend Health) to provide personalized assistance to retirees during the 2014 annual enrollment period and beyond. OneExchange s licensed benefit advisors are dedicated to helping retirees understand their options and find the coverage that is right for them. Medicare plan options through OneExchange are alternatives allowing you greater choice and flexibility when electing an insurance plan to fit your medical, prescription drug, dental and vision needs. Once you select the best plan for your situation, enroll in one of three ways: 1) The annual enrollment portal 2) The paper annual enrollment form on page 22 3) By contacting the Office of Group Benefits This guide outlines the new plans for the 2015 plan year and provides links and instructions on how to access other helpful tools you can use to better understand your options. Helping you live a better life by ensuring you and your family have affordable, quality coverage is what OGB is all about. I look forward to continuing to serve you in 2015! Warmest regards, Susan T. West, MBA, CRM Chief Executive Officer Office of Group Benefits

4 Table of Contents Resources and Contacts Letter from OGB CEO, Susan West Annual Enrollment and Your Responsibilities 13. Vantage Medicare Advantage OGB Secondary Plans 04. Your Responsibilities as an OGB Member Pelican HRA Making Your Health Benefit Election for 2015 Eligibility Dependents Qualifying Events Magnolia Local Magnolia Local Plus Magnolia Open Access Vantage Medical Home HMO 06. Dependent Verification 20. Out-of-Pocket Cost Calculator 07. Over-Age Dependents or Continued Coverage Summary of Plans Understanding Your Plan Options How to Enroll Annual Enrollment Form Live Better Louisiana 08. Medicare Advantage Plans 26. Alternative Coverage OneExchange Medicare Advantage 37. Legal People s Health Medicare Advantage 38. Terms and Conditions 3

5 Annual Enrollment & Your Responsibilities October 1 through October 31, 2014 October 15 December 7, 2014 (Medicare Advantage Plans) Important Dates October 1, OGB annual enrollment begins October 15, Medicare Advantage open enrollment begins October 31, 2014 OGB annual enrollment ends December 7, 2014 Medicare Advantage open enrollment ends January 1, 2015 Plan changes begin Your Responsibilities as an OGB Member As an OGB member with Medicare as your primary insurance, you have exceptional benefit options available to you and your family. It s your responsibility to understand your options and make the best choice for you and your family. You are responsible for: Making your selection online or through the annual enrollment form no later than October 31, If you have Medicare as primary coverage, have OGB secondary coverage and do not make a selection by the end of the enrollment period, you will still retain your Medicare coverage but will be moved into the Pelican HRA 1000 as your secondary coverage - a new, low premium plan that offers a nationwide network and state funding that offsets out-of-pocket costs. You will not have a chance to change plans until next year s annual enrollment. If you wish to discontinue your OGB coverage, contact OGB. Please note that in many cases, if you choose to cancel your OGB coverage, you cannot get it back. Enrolling and providing documentation to OGB for your dependents, including birth certificates, marriage certificates and other information if you are adding or changing dependents. Notifying OGB if you have an address change. Reviewing all communications from OGB and taking the required actions. Attending a regional meeting if you have questions or would like more information on this year s offerings. Bring this guide with you to the meeting. Verifying that your retirement pay deduction is correct. Notifying OGB if you or a covered spouse or dependent gain Medicare coverage within the time limits set by OGB, including gaining coverage as a result of End Stage Renal Disease During annual enrollment, you may: Select a health plan Drop or add dependents Discontinue OGB coverage 4

6 OGB Medicare Advantage Enrollment and OGB Annual Enrollment - What s the Difference. Every October, retirees have the opportunity to change health plans during annual enrollment. Also during this time, retirees with both Medicare Part A and Part B can choose to transfer to a Medicare Advantage health plan or choose an OGB secondary plan. Both enrollments take place once a year with coverage beginning in January. IMPORTANT DATES OCTOBER 1 31 OGB ANNUAL ENROLLMENT OCTOBER 15 DECEMBER 7 MEDICARE OPEN ENROLLMENT JANUARY SELECTIONS TAKE EFFECT Medicare holds an open enrollment each year as well. This year, the Medicare open enrollment period begins October 15 and ends December 7. If you are selecting an OGB plan as secondary coverage, you must make your selection by October 31. If you are selecting a Medicare Advantage plan through OGB we encourage you to make your selection by October 31 to ensure accurate and timely deductions from your retirement check. Making Your Health Benefit Election for 2015 Before you finalize your selection, we encourage you to review the plans described in this guide and choose a program that is best for you. Only you can decide which plan meets your needs. How to Make Your 2015 Selection Go online today! All plan members must re-enroll by either using the annual enrollment web portal, submitting a completed annual enrollment form, or by contacting OGB. Access the web portal at The simplest way to enroll is through the enrollment portal at However, there are two specific situations that the online portal cannot accommodate. You must contact OGB if you are discontinuing your OGB coverage or if you are adding or removing dependents to your plan for The chart below details when each enrollment option is available. Annual Enrollment Portal Annual Enrollment Form OGB Enroll in a health plan with the same covered dependents as 2014 Enroll in a health plan with different or new covered dependents than 2014 Discontinue OGB Coverage If you cannot access the annual enrollment portal, you may make your plan selection on the annual enrollment form on page 22 or by contacting OGB. See the How to Enroll section on page 21 for instructions on how to use the annual enrollment portal. 5

7 Making Changes During the Plan Year Consider your benefit needs carefully and make the appropriate selection. Your selection will remain in effect for the entire calendar year. You will not have an opportunity to add or drop dependents until the next annual enrollment period, unless you experience a Qualifying Event during the plan year. Qualifying Events include, but are not limited to: Birth, or adoption of a child, or placement for adoption Death of spouse or child, only if the dependent is currently enrolled Your spouse s or dependent s loss of eligibility for other group health insurance Marriage or divorce (once divorced, your ex-spouse is not eligible for dependent coverage under OGB) Medicare eligibility Review a complete list of qualifying events at Eligibility Your health coverage must be in effect immediately prior to your retirement to be eligible for retiree coverage. Dependents The following people can be enrolled as dependents: Your legal spouse Children until they reach age 26 (Coverage ends the last day of their birthday month) Children are defined as: Natural child of employee or legal spouse until age 26 Legally adopted child until age 26 Child in employee s home under legal guardianship or custody. A grandchild whose parent is a covered dependent or for whom employee has legal guardianship or custody. Dependent Verification You must provide OGB with proof of the legal relationship of each covered dependent. Without that documentation, your enrollment cannot be completed. Acceptable documents include: your marriage license, birth letter or birth certificate, legal adoption or custody papers, if applicable, for each covered dependent. OGB will verify the eligibility of dependents. No late applications will be accepted. 6

8 Over-Age Dependents or Continued Coverage A covered child under age 26 who is or becomes incapable of self-sustaining employment is eligible to continue coverage as an over-age dependent, if OGB receives the required medical documents verifying the child s incapacity before he or she reaches age 26. See Plan Document for documentation required to establish eligibility. Summary of Plans Understanding Your Plan Options This October, OGB retirees with Medicare can choose from three OGB Medicare Advantage plans, several individual Medicare plans through OneExchange as well as the traditional OGB secondary plans. Below is a checklist that outlines some of the features available with each option. The following pages provide more detail about each plan choice and a full benefits comparison is available on page 27. Medicare Options This chart below shows the three Medicare options: Type of Plan Medicare as primary - and only- coverage Medicare as primary coverage, plus OGB secondary Medicare Advantage Effect on Future Coverage If you cancel your OGB secondary coverage, you can only get it back in special circumstances (see page 00 for details) You retain the ability to change to any OGB plan during the next annual enrollment You retain the ability to return to an OGB secondary plan during the next annual enrollment period There are two main ways to get your Medicare coverage original Medicare (Part A and Part B) or a Medicare Advantage Plan (Part C). Medicare covers services (like lab tests, surgeries, and doctor visits) and supplies (like wheelchairs and walkers) considered medically necessary to treat a disease or condition. In general, Part A covers hospital care, skilled nursing facility care, nursing home care, hospice and home health services. Part B covers two types of services: Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best. You may also decide you want to get coverage that fills gaps in original Medicare coverage. This is where OGB comes in. We can act as a secondary insurer to your Medicare Part A and B coverage. Please note that in many cases, if you choose to cancel your OGB coverage, you cannot get it back. 7

9 Finally, you may decide to go with a Medicare Advantage plan (Part C). A Medicare Advantage plan includes both Part A and Part B. If you want prescription drug coverage, and it s offered by your plan, in most cases you must get it through your plan. In some types of plans that don t offer drug coverage, you can join a Medicare Prescription Drug Plan. Medicare Advantage Plans Retirees who have Medicare Part A and Part B coverage have several options available. They can select from three OGB sponsored Medicare Advantage plans: the Peoples Health HMO-POS; the Vantage HMO-POS; and the Vantage Zero-Premium HMO-POS plan. They can also choose a Medicare Advantage plan through OneExchange (formerly Extend Health) and be enrolled in a health reimbursement arrangement (HRA) receiving HRA credits of $200 to $300 per month from the state. Medicare Advantage Plans via OneExchange Medicare Advantage Plan via Vantage HMO-Plus Medicare Advantage Plan via Vantage Zero- Premium HMO-POS Advantage Plan via Peoples Health HMO-POS Zero Dollar Plan Available Employer Contribution to HRA Disease management program Wellness program Emergency Coverage IMPORTANT! If you choose a Medicare Advantage plan, you will retain the option to return to an OGB sponsored plan during the next annual enrollment period. OGB Secondary Plans Retirees who have Medicare Part A and Part B coverage can also select from four OGB plans during annual enrollment: the Pelican HRA 1000 and the Magnolia plans, administered by Blue Cross and Blue Shield of Louisiana, and the Vantage Medical Home HMO plan. These plans will act as secondary coverage to the Medicare primary insurance. 8

10 Pelican HRA 1000 Magnolia Local Magnolia Local Plus Magnolia Open Access Vantage Medical Home HMO Employer contribution to HRA Out-of-network coverage Wellness Program Wellness Visits Covered 100% Emergency Coverage Routine Vision Coverage Included Routine Dental Coverage Included IMPORTANT! There are times when a provider may work at a hospital, but not for the hospital. In those cases, health care services may be provided to you at a network health care facility by providers who are not in your health plan provider network. You may be responsible for payment of all or part of the fees for those out-of-network services, in addition to applicable amounts due for co-payments, coinsurance, deductibles, and non-covered services. Specific information about in-network and out-of-network physicians can be found at your health plan s website or by calling OGB customer service. Pharmacy Benefits Pharmacy benefits are included with all Medicare eligible plans sponsored by OGB. Medicare Advantage Plans o OneExchange Medicare Advantage o Peoples Health Medicare Advantage o Vantage Medicare Advantage OGB Secondary Plans o Pelican HRA 1000 o Magnolia Local o Magnolia Local Plus o Magnolia Open Access o Vantage Medical Home HMO 9

11 The pharmacy benefits provided in the plans above meet all Medicare Part D requirements. The selection of one of the plans offered through OGB would eliminate your need to purchase a separate Medicare Part D plan. IMPORTANT! Medicare allows you to enroll in only one Medicare eligible pharmacy plan. By enrolling in a non-ogb sponsored plan you will lose both your medical and prescription drug coverage through OGB and you will not be permitted to re-enroll in the future. What is a formulary? A formulary is a list of medications available to plan members under the plan s pharmacy benefit. Inclusion on the list is based on consideration of a medication s safety, effectiveness and associated clinical outcomes. The formulary is updated regularly and divides drugs into four main categories: generic, preferred brand, nonpreferred brand, and specialty. A generic drug is effectively equivalent to a brand name drug in intended use, dosage, strength, and safety. For a generic drug to be approved by the FDA, it must meet the same quality standards as the brand name product. Even the generic manufacturing, packaging, and testing sites must meet the same standards. Many generics are produced in the same manufacturing plant as their branded counterparts. Preferred brand drugs are generally those that have been on the market for a while and do not have a generic equivalent available. They are effective alternatives to other brands that may be more expensive. Non-preferred brand drugs are recently branded medications. In most cases, a lower cost alternative is available. Specialty medications higher cost drugs. For more information on the formulary available to you, visit or contact us at Individual Medicare Advantage Plans through OneExchange OneExchange offers the broadest range of individual Medicare coverage options for post-65 retirees, including Medigap (also known as Medicare Supplement), Medicare Advantage and Part D prescription drug plans. OneExchange has multiple plan offerings with well known insurance carriers. Additionally, OneExchange offers a full range of enrollment support services and tools to aid you in evaluating which plan choice best meets your individual health care and financial needs. You will also be enrolled in a health reimbursement arrangement (HRA) receiving HRA credits of $200 to $300 per month from the state. 10

12 The table below is a small sampling of the plans available through OneExchange. For a complete list visit: or contact us at ANT! Retirees without Medicare are not Benefits Participant Cost Medicare Advantage Option in Baton Rouge Medicare Advantage Option in New Orleans Medicare Advantage Option in Bossier City Combine Plan N & PDP (Male Aged 75)* Combine Plan F & PDP (Male Aged 75)** Premium $0 $0 $0 $202 $264 Network HMO HMO HMO Any doctor who accepts Medicare Any doctor who accepts Medicare Deductible $0 $0 $250 $147 $0 (plan pays 100%) Office Visit Primary Care / Specialist $0 / $0 - $25 $0 / $20 $7 / $50 $0 $0 (plan pays 100%) Emergency Room $65 Waived if admitted $65 Waived if admitted $65 Waived if admitted $50 $0 Hospital $25 co-pay per day for first five days, then $0 $50 co-pay per day for first five days, then $0 $335 co-pay per day for first five days, then $0 $0 (plan pays 100%) $0 (plan pays 100%) Rx $0/$10/$35/ $80/33% $0/$3/$35/ $55/33% $3/$10/$45/ $95/25% $200 ded (on Tier 4 & 5) $2/$6/$40/ $85/33% $2/$6/$40/ $85/33% The Office of Group Benefits strongly encourages you to take the time to evaluate the individual market coverage options and determine if this coverage may be right for you. *A Medicare Supplement Plan N with a Prescription Drug Plan (PDP) (pricing for a male aged 75) **A Plan F and a Prescription Drug Plan (PDP) ( pricing for a male age 75) 11

13 Medicare Plan through Peoples Health Plan Peoples Health Medicare Advantage plans offer much more than Medicare, with extra benefits like vision and dental coverage, free health club membership and prescription drug coverage. As a Peoples Health Group Medicare member, you pay a premium in addition to paying your Medicare Part B premium; you receive 100 percent coverage for many services with NO Medicare deductibles. Peoples Health was founded and is based in southeast Louisiana and serves more than 55,000 members. Their plans feature a member-centered model of care that offers coordinated, personalized service. Covered Benefit People s Health HMO-POS Monthly Premium (Employee Share) Retiree with 1 Medicare Monthly Premium (Employee Share) Retiree with 2 Medicare Plan Year Deductible $0 $60.50 $ Maximum Out-of-pocket Expense (In-Network) $2,500 Maximum Out-of-pocket Expense (Out-of-Network) 20% Office Visit - Primary Care / Specialist Emergency Room $5 / $10 copay per visit $50 ER copay per visit Inpatient Hospital $50 per day (days 1-10) Prescription Drugs (Part D) Preferred Generics $0 co-pay Non-preferred Generics $0 co-pay Preferred Brand $20 co-pay (30-day supply) Non-preferred Brand $40 co-pay (30-day supply) Specialty 20% Medicare Plans through Vantage Health Plan For retirees who are 65 and over, Vantage offers several great Medicare Advantage plans as an alternative to Medicare. One benefit to Vantage s Medicare Advantage plans is that a network of providers is already contracted with the plan throughout Louisiana. These physicians, hospitals and specialty medical facilities have already agreed to provide health care services to treat Medicare Advantage members. 12

14 Medicare Plans through Vantage Health Plan Covered Benefit Monthly Premium (Employee Share) Retiree with 1 Medicare Monthly Premium (Employee Share) Retiree with 2 Medicare Vantage POS Plan (HMO-POS) No Medical Deductible $48.75 $0 $97.50 $0 Vantage Zero-Premium HMO-POS Plan Year Deductible N/A N/A Maximum Out-of-pocket Expense Office Visit Primary Care / Specialist $3,000 $6,700 $10 / $40 copay per visit $15 / $50 copay per visit Emergency Room $65 ER copay per visit - worldwide coverage; Waived if admitted $65 ER copay per visit - worldwide coverage; Waived if admitted Inpatient Hospital $300 / day for days 1-5 $345 / day for days 1-5 Prescription Drugs (Part D) Tier 1 - Preferred Generics $3 copay $3 copay Tier 2 - Non-Preferred Generics $8 copay $8 copay Tier 3 - Preferred Brand $45 copay $45 copay Tier 4 - Non-Preferred Brand $95 copay $95 copay Tier 5 - Specialty 33% coinsurance 33% coinsurance, after $125 deductible IMPORTANT! If you choose a Medicare Advantage plan, you will retain the option to return to an OGB sponsored plan during the next annual enrollment period. OGB Secondary Plans Pelican HRA 1000 OGB s Pelican HRA 1000 plan offers low premiums in combination with employer contributions to create an affordable option for many members in The HRA 1000 includes $1000 or $2000 employer contributions in a health reimbursement account that can be used to offset deductible and other out-of-pocket health care costs throughout the year. Any unused funds rollover up to the in-network out-of-pocket maximum, allowing members to build up balances that cover eligible medical expenses when they happen. The Pelican HRA 1000 plan offers coverage within Blue Cross s nationwide network as well as out-of-network benefits to ensure members have a broad network of care. View providers in Blue Cross s network at 13

15 Retiree- Only* Retiree + Spouse* Retiree + Children* Family* Monthly Premiums (employee share) Retiree with 1 Medicare Monthly Premiums (employee share) Retiree with 2 Medicare $59.61 $ $ $ $ $ Employer Contribution to HRA $1,000 $2,000 $2,000 $2,000 Deductible (In-network) $2,000 $4,000 $4,000 $4,000 Deductible (Out-of-network) $4,000 $8,000 $8,000 $8,000 Out-of-pocket max (In-network) $5,000 $10,000 $10,000 $10,000 Out-of-pocket max (Out-of-network) $10,000 $20,000 $20,000 $20,000 Coinsurance (In-network) 20% 20% 20% 20% Coinsurance (out-of-network) 40% 40% 40% 40% * Premium Rates at 75% Participation Rate. Rate sheets for all participation levels are available at Pharmacy Benefits Medicare Generation Rx The Pelican HRA 1000 uses the Medicare Generation Rx formulary to help members select the most appropriate, lowest-cost options. The formulary is reviewed regularly to reassess drug tiers based on the current prescription drug market. Members will continue to pay a portion of the cost of their prescriptions in the form of a co-pay or co-insurance. The amount members pay toward their prescription depends on whether or not they receive a generic, preferred brand, non-preferred brand name drug, or specialty drug. Tier Member Responsibility Generic 50% up to $30 Preferred 50% up to $55 Non-Preferred 65% up to $80 Specialty 50% up to $80 Once you pay $1,500, the following co-pays apply: Generic Preferred Non-Preferred Specialty $0 co-pay $20 co-pay $40 co-pay $40 co-pay 14

16 Magnolia Plans Magnolia Local plans offer lower deductibles than the Pelican HRA 1000 in exchange for higher premiums. Magnolia Local The Magnolia Local plan is a traditional plan that offers $25 primary care co-pays (excluding wellness visits) and $50 specialty care co-pays for members who live in specific coverage areas. Shreveport, New Orleans and Baton Rouge networks are currently available for OGB members. This plan is ideal for members who live in the parishes within the available networks and don t plan to utilize out-of-network care. However, out-of-network care is provided in emergencies. Community Blue Community Blue is a select, local network product designed for members who live in the Baton Rouge (East & West Baton Rouge and Ascension Parishes) and Shreveport communities (Caddo and Bossier Parishes). This means healthcare providers work as a team led by a primary care doctor. BlueConnect BlueConnect is a select, local network product designed for members who live in the New Orleans community (Orleans and Jefferson Parishes). BlueConnect is a great health plan for people who want local access, a new approach to health and a lower priced insurance plan. View providers in Blue Cross s network at Retiree- Only* Retiree + Spouse* Retiree + Children* Family* Monthly Premiums (employee share) Retiree with 1 Medicare Monthly Premiums (employee share) Retiree with 2 Medicare $80.85 $ $ $ $ $ Employer Contribution to HRA $0 $0 $0 $0 Deductible (In-network) $500 $1,500 $1,500 $1,500 Deductible (Out-of-network) No Coverage No Coverage No Coverage No Coverage Out-of-pocket max (In-network) $3,000 $9,000 $9,000 $9,000 Out-of-pocket max (Out-of-network) No Coverage No Coverage No Coverage No Coverage Co-Payment (In-network) $25 / $50 $25 / $50 $25 / $50 $25 / $50 Co-Payment (Out-of-network) No Coverage No Coverage No Coverage No Coverage * Premium Rates at 75% Participation Rate. Rate sheets for all participation levels are available at Pharmacy Benefits Medicare Generation Rx The Magnolia Local plan uses the Medicare Generation Rx formulary to help members select the most appropriate, lowest-cost options. The formulary is reviewed regularly to reassess drug tiers based on the 15

17 current prescription drug market. Members will continue to pay a portion of the cost of their prescriptions in the form of a co-pay or co-insurance. The amount members pay toward their prescription depends on whether or not they receive a generic, preferred brand, non-preferred brand name drug, or specialty drug. Tier Generic 50% up to $30 Preferred 50% up to $55 Non-Preferred 65% up to $80 Member Responsibility Specialty 50% up to $80 Once you pay $1,500, the following co-pays apply: Generic Preferred Non-Preferred Specialty Magnolia Local Plus $0 co-pay $20 co-pay $40 co-pay $40 co-pay The Magnolia Local Plus option offers the same coverage as the Magnolia Local plan with the benefit of a nationwide network. The Local Plus option offers $25 primary care co-pays (excluding wellness visits) and $50 specialty care co-pays for OGB members in any region. The Local Plus plan is ideal for members who prefer the predictability of co-payments rather than using employer funding to offset out-of-pocket costs. This plan provides care in Blue Cross s nationwide network. Out-of-network care is provided in emergencies. View providers in Blue Cross s network at Retiree- Only* Retiree + Spouse* Retiree + Children* Family* Monthly Premiums (employee share) Retiree with 1 Medicare Monthly Premiums (employee share) Retiree with 2 Medicare $86.63 $ $ $ $ $92.26 Employer Contribution to HRA $0 $0 $0 $0 Deductible (In-network) $500 $1,500 $1,500 $1,500 Deductible (Out-of-network) No Coverage No Coverage No Coverage No Coverage Out-of-pocket max (In-network) $3,000 $9,000 $9,000 $9,000 Out-of-pocket max (Out-of-network) No Coverage No Coverage No Coverage No Coverage Co-Payment (In-network) $25 / $50 $25 / $50 $25 / $50 $25 / $50 Co-Payment (Out-of-network) No Coverage No Coverage No Coverage No Coverage * Premium Rates at 75% Participation Rate. Rate sheets for all participation levels are available at 16

18 Pharmacy Benefits Medicare Generation Rx The Magnolia Local Plus plan uses the Medicare Generation Rx to help members select the most appropriate, lowest-cost options. The formulary is reviewed regularly to reassess drug tiers based on the current prescription drug market. Members will continue to pay a portion of the cost of their prescriptions in the form of a co-pay or co-insurance. The amount members pay toward their prescription depends on whether or not they receive a generic, preferred brand, non-preferred brand name drug, or specialty drug. Tier Member Responsibility Generic 50% up to $30 Preferred 50% up to $55 Non-Preferred 65% up to $80 Specialty 50% up to $80 Once you pay $1,500, the following co-pays apply: Generic $0 co-pay Preferred $20 co-pay Non-Preferred $40 co-pay Specialty $40 co-pay Magnolia Open Access The Magnolia Open Access Plan offers coverage both inside and outside of Blue Cross s nationwide network. It differs from the other Magnolia plans in that members enrolled in the open access plan will not pay co-payments at physician visits. Instead, once a member s deductible is met, he or she will pay 20% of the overall bill for in-network and out-of-network care. Though the premiums for the open access plan are higher than OGB s other plans, its moderate deductibles combined with a nationwide network make it an attractive plan for members who live out of state or travel regularly. View providers in Blue Cross s network at Monthly Premiums (employee share) Retiree with 1 Medicare Monthly Premiums (employee share) Retiree with 2 Medicare Retiree- Only* Retiree + Spouse* Retiree + Children* Family* $89.84 $ $ $ $ $ Employer Contribution to HRA $0 $0 $0 $0 Deductible (In-network) $500 $1,500 $1,500 $1,500 Deductible (Out-of-network) No Coverage No Coverage No Coverage No Coverage Out-of-pocket max (In-network) $3,000 $9,000 $9,000 $9,000 Out-of-pocket max (Out-of-network) No Coverage No Coverage No Coverage No Coverage Co-Insurance (In-network) 20% 20% 20% 20% Co-Insurance (Out-of-network) 20% 20% 20% 20% * Premium Rates at 75% Participation Rate. Rate sheets for all participation levels are available at 17

19 Pharmacy Benefits Medicare Generation Rx The Magnolia Open Access plan uses the Medicare Generation Rx to help members select the most appropriate, lowest-cost options. The formulary is reviewed regularly to reassess drug tiers based on the current prescription drug market. Members will continue to pay a portion of the cost of their prescriptions in the form of a co-pay or co-insurance. The amount members pay toward their prescription depends on whether or not they receive a generic, preferred brand, non-preferred brand name drug, or specialty drug. Tier Member Responsibility Generic 50% up to $30 Preferred 50% up to $55 Non-Preferred 65% up to $80 Specialty 50% up to $80 Once you pay $1,500, the following co-pays apply: Generic $0 co-pay Preferred $20 co-pay Non-Preferred $40 co-pay Specialty $40 co-pay Retiree 100 Retired members in the Magnolia Open Access plan who have Medicare Part A and Part B as their primary insurer are eligible to participate in the Retiree 100 program. This program serves as additional coverage for members who have extensive hospital bills and/or large amounts of physician charges due to a serious illness, accident or long-term chronic condition. You are eligible to enroll in Retiree 100 if: You are a retired state employee You are a member of the Magnolia Open Access plan Medicare is your primary insurer (You have both Medicare Part A and Part B) You can also enroll your spouse if: You currently cover your spouse as a dependent Medicare is your spouse s primary health insurer (Your spouse has both Medicare Part A and Part B) Not All Expenses Are Eligible Retiree 100 coordinates only those expenses considered eligible for reimbursement by both Medicare and the Magnolia Open Access plan. Expenses not eligible for consideration include: Benefits assigned - when a provider agrees to accept what Medicare allows as full payment. (OGB does not pay for any portion of a bill in excess of the Medicare allowable amount.) Prescription drugs 18

20 Premiums The monthly premium for Retiree 100 is $39.00 per person in addition to your monthly OGB premium. There is no state contribution toward the premium amount; you must pay the entire cost for Retiree 100 coverage. Enrollment If you are already retired, you can enroll during the annual enrollment period held each year. Also, you can enroll within 30 days after the date you first became eligible for Medicare (Parts A and B). Coverage becomes effective on the first day of the month you became eligible for Medicare. Enrollment documents are available on the OGB website, Vantage Medical Home HMO Vantage s Medical Home HMO (MHHMO) is a patient-centered approach to providing cost-effective and comprehensive primary health care for children, youth and adults. The MHHMO plan creates partnerships between the individual patient and his or her personal physician and, when appropriate, the patient s family. Retiree- Only* Retiree + Spouse* Retiree + Children* Family* Monthly Premiums (employee share) Retiree with 1 Medicare Monthly Premiums (employee share) Retiree with 2 Medicare $86.62 $ $ $ $ $ Employer Contribution to HRA $0 $0 $0 $0 Deductible (In-network) $500 $1,500 $1,500 $1,500 Deductible (Out-of-network) $1,500 $3,000 $3,000 $3,000 Out-of-pocket max (In-network) Tier I: $1,000 Tier I: $3,000 Tier I: $3,000 Tier I: $3,000 Tier II: None Tier II: None Tier II: None Tier II: None Out-of-pocket max (Out-of-network) None None None None * Premium Rates at 75% Participation Rate. Rate sheets for all participation levels are available at Tier I Providers Most participating providers are Tier I providers. Members seeing Tier I providers pay the Tier I co-pays, coinsurance and deductibles as listed in the Certificate of Coverage. (Affinity Health Network Providers) 19

21 Tier II Providers Tier II providers are participating providers whose cost may be higher than other similar participating providers. Members who choose to see these providers will have to pay an additional twenty (20) % coinsurance in addition to their Tier I cost share. There is no out-of-pocket maximum for Tier II services. Pharmacy Benefits Perform Rx The Vantage Medical Home HMO prescription drug benefit for retirees has five co-pay/coinsurance levels. Tier Member Responsibility Tier 1 Low Cost Generic $3 Tier 2 Non-Preferred Generic $10 Tier 3 Preferred $45 Tier 4 Non-Preferred $95 Tier 5 Specialty 33% coinsurance up to $150 Get more information about your pharmacy benefits by reviewing the benefit comparison summary on page 27 and visiting OGB s website at Out-of-Pocket Cost Calculator There are several factors to consider when you select a health plan. Network coverage, prescription benefits and wellness programs all influence the value of the health care you receive. For many members, though, out-of-pocket cost is one of the most important considerations when selecting a plan. OGB has developed a calculator that can help you better understand the out-of-pocket costs you can expect in each of the plans available to you. It allows you to make assumptions on the types and amounts of care you and your family will need over the next year and see how that care will impact your out-of-pocket responsibilities. To use the decision tool: Visit and follow the link to the out-of-pocket calculator decision tool. Select the type of coverage you will need for the 2015 plan year: employee-only, employee + spouse, employee + children, or family coverage. Estimate the number of doctor visits, emergency visits, hospital stays and other types of care you and your family will need. Estimate the number and type of prescriptions you will fill. Estimate other types of care you may need. Once you ve made your assumptions, the calculator will provide you with an estimate for your out-ofpocket costs over the next year, including premiums, deductibles, co-pays and co-insurance. It will also show you the minimum and maximum out-of-pocket amounts for each plan as well as the funds that may rollover to the next year in your HRA. 20

22 TIP: Try several scenarios in the calculator to make sure you have a broad sense of how each type of coverage may affect your costs. Member needs typically vary from year to year, so don t assume that what you needed last year is exactly the same as what you will need in IMPORTANT! This tool is intended to give you a general idea of how each plan works in various situations. It is not a budgeting tool or a guarantee of your future costs. There are many factors that go into the cost of care, including your network, provider selection and the specific services rendered. It s also important to remember that cost is only one factor that should influence your plan decision. Access the calculator at How to Enroll There are three ways to enroll in a health plan for 2015: 1. Visit to use the annual enrollment portal. If you are enrolling in a health plan with the same covered dependents that were in your 2014 plan, you are eligible to use the annual enrollment portal to make your 2015 selection. To enroll on the annual enrollment portal: Follow the links from the OGB homepage to the annual enrollment portal Enter your Member ID from your current ID card and the last four digits of your social security number Make your selection for the next plan year Select a primary care physician; Where applicable Select Submit IMPORTANT! You will not be able to change your plan selection after October 31, However, if you wish to change your plan selection during the annual enrollment period, simply visit the annual enrollment portal and select a new plan. Your most recent choice will be considered valid. If your address is incorrect, complete your enrollment through the portal and contact OGB to update your address. 2. Complete the annual enrollment form on page 22 and return it to the address provided by November 14. Form can only be signed between October 1 and October Contact OGB to enroll in a health plan with different or new covered dependents than 2014 or discontinue OGB coverage. No matter how you choose to enroll, be sure to do it by October 31, If you have Medicare as primary coverage, have OGB secondary coverage and do not make a selection by the end of the enrollment period, you will still retain your Medicare coverage but will be moved into the Pelican HRA 1000 as your secondary coverage a new, low premium plan that offers a nationwide network and state funding that offsets out-of-pocket costs. 21

23 OFFICE OF GROUP BENEFITS 2015 ANNUAL ENROLLMENT FORM ( Please PRINT Clearly ) Plan Member s Name: Address: City, State, ZIP: SSN: Phone: ( ) PLEASE MARK ONE AND ONLY ONE SELECTION BY PLACING AN (X) IN THE APPROPRIATE BOX If you are currently enrolled in a plan and do not make a selection by the end of the enrollment period, you will be moved into the Pelican HRA 1000 a new, low premium plan that offers a nationwide network and employer contribution that can be used to offset out-of-pocket costs. (Visit your Human Resources department to elect FSA and HSA payroll deductions.) OGB Primary Plans for Active Employees & Non-Medicare Retirees (Secondary Plans for Retirees with Medicare) R Pelican HRA 1000 Administered by Blue Cross L Magnolia Local Plan Administered by Blue Cross S Pelican HSA 775 (for Active only) Administered by Blue Cross P Magnolia Local Plus Administered by Blue Cross M Vantage Medical Home Health HMO (MHHP) Administered by Vantage Health A Magnolia Open Access Administered by Blue Cross OGB Plans for Retirees with Medicare Part A & Part B V Vantage Medicare Advantage HMO65 Plan Z Vantage Medicare Advantage Zero Premium Plan Retiree and all covered dependents must have both Medicare A and Medicare B Retiree and all covered dependents must have both Medicare A and Medicare B T Peoples Health Medicare Advantage Plan Retiree and all covered dependents must have both Medicare A and Medicare B O One Exchange* Retiree and all covered dependents must have both Medicare A and Medicare B (*Enrollment is conducted through One Exchange) PLEASE MAIL OR FAX THIS FORM TO OGB BY NOVEMBER 14. FORM CAN ONLY BE SIGNED BETWEEN OCT. 1 & OCT. 31. CUT ALONG DOTTED LINES By Mail: Office of Group Benefits Eligibility Division P.O. Box Baton Rouge, LA Plan Member s Signature (required) By Fax: Office of Group Benefits Eligibility Division (225) or (225) Date

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25 NOTES 24

26 Live Better Louisiana One of the keys to living a better life is managing your health. Preventing chronic disease can help you live a longer, more active life as well as save you thousands of dollars on health care. That s why OGB launched the Live Better Louisiana program to its Blue Cross plan members in Live Better Louisiana provides resources to help you better monitor your health, understand your risk factors and make educated choices that keep you healthier in addition to providing you with a discount on your insurance premiums beginning in 2016! Participating in the Live Better program is simple. Just complete a questionnaire online and then visit one of the clinics happening in your area to receive a comprehensive personal health checkup. It s absolutely no cost to you, and it could help you catch an illness or chronic condition before it becomes more serious. Our Game Plan for Better Health: Fill out your Personal Health Assessment (PHA) This confidential online questionnaire provides you with a picture of your overall health and measures health risks and behaviors. It also gives you a personalized risk report and action plan for health improvement, with recommendations and access to the appropriate resources. HOW DO I GET THERE? If you have an online account, go to If you haven t yet activated your online account, go to first. Take your Preventive Onsite Health Checkup Blue Cross and Blue Shield of Louisiana has partnered with an industry leader, Catapult Health, to bring preventive checkups to sites near you all over the state. Access the calendar of events right here where you can schedule a checkup with a licensed nurse practitioner and technician. You ll get lab-accurate diagnostic tests and receive a full, printed Personal Health Report with checkup results and recommendations. HOW DO I GET THERE? Download and review this flier with more details and frequently asked questions about your checkup. Visit to schedule your appointment. Take Charge of your Own Health with a Wealth of Resources Live Better Louisiana gives you access to a wide range of healthful activities some of which may even be suggested in your personal action plan. Blue Cross and Blue Shield of Louisiana also brings OGB plan members a number of wellness-related Discounts and Deals. HOW DO I GET THERE? Explore the Live Better Louisiana program offerings on the Blue Cross Blue Shield web page, as well as reading your Personal Health Report. 25

27 Alternative Coverage LaCHIP LaCHIP is a health insurance program designed to bring quality health care to currently uninsured children and youth up to the age of 19 in Louisiana. Children can qualify for coverage under LaCHIP using higher income standards. LaCHIP provides Medicaid coverage for doctor visits for primary care as well as preventive and emergency care, immunizations, prescription medications, hospitalization, home health care and many other health services. LaCHIP provides health care coverage for the children of Louisiana s working families with moderate and low incomes. A renewal of coverage is done after each 12-month period. For complete information about eligibility and benefits, call toll-free LaCHIP ( ). Representatives are available Monday-Friday 7:30 a.m. to 4:30 p.m. Central Time. Health Insurance Marketplace You may also qualify for a lower cost health insurance plan through the Health Insurance Marketplace under the Affordable Care Act. To find out if you qualify, visit Medicare Advantage Plans Benefit Comparison Charts on next page: For 2015, retirees who have Medicare Part A and Part B coverage have several options available: Choose a Medicare plan through One Exchange, the largest private Medicare exchange in the United States, and be enrolled in a health reimbursement arrangement (HRA) associated with those plans to receive HRA credits of $200 to $300 per month from the state. Select from the 3 OGB sponsored Medicare Advantage health plans: Peoples Health HMO-POS; Vantage HMO-POS; and the Vantage Zero - Premium HMO-POS. Select from 5 OGB standard plans during OGB Annual Enrollment: Pelican HRA1000, Magnolia Local, Magnolia Local Plus, Magnolia Open Access- administered by Blue Cross and Blue Shield of Louisiana and Vantage Medical Home - insured by Vantage Health Plan. How Do I Choose? The answers to these questions can help you decide which OGB health plan is right for you.. Are my hospitals and doctors included in the plan? Does the plan have an open or closed (restricted) drug formulary If the formulary is closed (restricted), are my prescription drugs covered? What is the monthly premium cost? How do the plan s costs and benefits compare to my current plan? If I need out-of-state coverage, does the plan have it? 26

28 Medicare Advantage Plans Benefits Comparison January 1, December 31, 2015 Vantage HMO-POS Vantage Zero - Premium HMO-POS People s Health HMO-POS Network Network Network You Pay You Pay You Pay Deductible You $0 $0 $0 You + Spouse $0 $0 $0 You + Child (ren) $0 $0 $0 You + Family $0 $0 $0 Out-of-Pocket Maximum You $3,000 $6,700 You + Spouse $3,000 $6,700 You + Child (ren) $3,000 $6,700 You + Family $3,000 $6,700 $2,500 per member State Funding The Plan Pays The Plan Pays The Plan Pays You You + Spouse You + Child (ren) Not Available Not Available Not Available You + Family Physicians Services The Plan Pays The Plan Pays The Plan Pays Primary Care Physician or Specialist Office Treatment of illness or injury Preventative Care Primary Care Physician or Specialist Office or Clinic For a complete list of benefits, refer to the Preventive and Wellness/ Routine Care in the Benefit Plan Physician Services for Emergency Room Care 100% coverage after a $10 PCP or $40 SPC copayment per visit. 100% coverage after a $15 PCP or $50 SPC copayment per visit. 100% coverage after a $5 PCP or $10 SPC copayment per visit. 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage 100% coverage Allergy Shots and Serum 80% coverage 80% coverage 95% coverage Outpatient Surgery/Services when billed as office visits 100% coverage 100% coverage 100% coverage Inpatient Services 100% coverage after 100% coverage after 100% coverage after Inpatient care, delivery and $300 co-payment per day $345 co-payment per day $50 co-payment per day inpatient short-term acute rehabilitation services (days 1-5) (days 1-5) (days 1-10) Outpatient Surgery/Services Hospital/Facility Emergency Room Care - Hospital Treatment of an emergency medical condition or injury 100% coverage after $300 co-payment per visit 100% coverage after $65 co-payment per visit; waived if admitted 100% coverage $450 copayment per visit 100% coverage after $65 co-payment per visit; waived if admitted 100% coverage 100% coverage after $50 co-payment per visit; waived if admitted 27

29 Medicare Advantage Plans Benefits Comparison January 1, December 31, 2015 Vantage HMO-POS Vantage Zero - Premium HMO-POS People s Health HMO-POS Network Network Network Behavioral Health The Plan Pays The Plan Pays The Plan Pays Mental Health and Substance Abuse Inpatient Facility Mental Health and Substance Abuse Outpatient Visits - Professional 100% coverage after $380 co-payment per day (days 1-4) 100% coverage after $40 co-payment per visit 100% coverage after $380 co-payment per day (days 1-4) 100% coverage after $40 co-payment per visit 100% coverage after $50 co-payment per day (days 1-10) 100% coverage Other Coverage The Plan Pays The Plan Pays The Plan Pays Outpatient Acute Short-Term Rehabilitation Services Physical Therapy, Speech Therapy, Occupational Therapy, Other short term rehabilitative services Chiropractic Care Vision Exam (routine) Urgent Care Center 100% coverage after $40 co-payment per visit subject to Medicare maximum 100% coverage after a $20 co-payment per visit 100% coverage; 1 exam per year 100% coverage after $65 co-payment per visit 100% coverage after $40 co-payment per visit subject to Medicare maximum 100% coverage after a $20 co-payment per visit. 100% coverage; 1 exam per year 100% coverage after $65 co-payment per visit 100% coverage; subject to Medicare maximum 100% coverage after a $10 co-payment per visit. 100% coverage after $15 co-payment; 1 exam per year 100% coverage after $10 co-payment per visit Home Health Care Services 100% coverage 100% coverage 100% coverage Skilled Nursing Facility Services 100% coverage after $0 co-payment (days 1-20); $156 co-payment per day (days ) 100% coverage after $0 co-payment (days 1-20); $156 co-payment per day (days ) 100% coverage after $0 co-payment (days 1-20); $25 co-payment per day (days 21+) Hospice Care Covered by Medicare Covered by Medicare Covered by Medicare Durable Medical Equipment (DME) Rental or Purchase Transplant Services 80% coverage 80% coverage 95% coverage 100% coverage after $150/300 co-payment per day (days 1-5) 100% coverage after $200/345 co-payment per day (days 1-5) 100% coverage after $50 co-payment per day (days 1-10) Pharmacy You Pay You Pay You Pay Tier 1 - Preferred Generic $3 co-payment $3 co-payment $0 co-payment Tier 2 - Non-Preferred Generic $8 co-payment $8 co-payment $0 co-payment Tier 3 - Preferred Brand $45 co-payment $45 co-payment $20 co-payment Tier 4 - Non-Preferred Brand $95 co-payment $95* co-payment; after $125 deductible $40 co-payment Tier 5 - Specialty 33% co-insurance 33%* co-insurance; after $125 deductible 20% co-insurance This comparison chart is a summary of plan features and is presented for general information only. It is not a guarantee of coverage. For full details of the plan, refer to the official plan document. The benefits outlined in this document were provided by Peoples Health and Vantage Health Plan. OGB is not responsible for the accuracy of this information. NOTE: Prior authorizations, visit limits and age and/or time restrictions may apply to some benefits - refer to your official plan document for details. All services are s/co-payments/coinsurance, if Medicare Deductibles have not been met. 28