City of San Diego Open Enrollment RETIREE HEALTH BENEFITS
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1 City of San Diego RETIREE HEALTH BENEFITS Open Enrollment Open Enrollment is June 6 through June 30, 2016 Call or (toll free) Review carefully for new plan offerings, rate changes and comparison charts Open Enrollment Help Day is June 14 - Details on Back
2 NON-MEDICARE PLANS HEALTH NET HMO (for those under 65 or not eligible for Medicare Coverage) Primary Care Provider within Health Net HMO Network You pay the following co-pays $1, per month (subscriber only) practic) $15 co-payment (40 visits per year combined for and Chiropractic) $15 co-payment (40 visits per year combined for Chiropractic and ) $75 co-payment per visit. Waived if admitted to hospital Annual hearing screening covered in full; $500 allowance for hearing aids (2 every 36 months) No charge (days 1-30); $20 per-day co-payment on and after day 31) Inpatient Hospital No charge (prognosis of life expectancy of 1 year or less) $100 per admit $20 co-payment per visit $100 per admit $20 co-payment $1,500 individual; $3,000 per family Generic: $15 co-payment for 30-day supply; Brand: $30 co-payment for 30-day supply; Mail order: two co-payments for 90-day supply; Out of Pocket of $1,000 Individual and $2,000 Family Skilled Nursing Facility (SNF) $100 per admit. Limited to 100 days per plan year $50 co-payment per procedure $20 co-payment per visit. Waived if admitted to hospital Annual vision screening covered in full; $20 co-payment for refractive eye exams
3 HEALTH NET PPO NON-MEDICARE PLANS (for those under 65 or $1, per month (subscriber only) not eligible for Medicare Coverage) You pay practic) the following co-pays Out-of-Network (OON) Provider Coverage Inpatient Hospital 40%. Combined maximum benefit of $1,500 (PPO/OON) per policy year; $25 maximum payable per visit $ % of covered expense 40%. Combined maximum benefit of $1,500 (PPO/OON) per policy year; $25 maximum payable per visit 40% of covered expense $ % of covered expense; $100 waived if admitted to hospital Not covered 40% of covered expense; Limited to maximum 100 visits combined PPO/OON 40% of covered expense 40% of covered expense; Limited to $600 per day OON 40% of covered expense 40% of covered expense; Limited to $600 per day OON 40% of covered expense $500 per individual; Three family members must satisfy their individual deductibles to satisfy the family deductible Non-PPO: $6,000 individual; Family = 3X individual; A separate RX out-of-pocket maximum $1,000 Individual and $2,000 Family will apply in addition to the Medical out-ofpocket maximum Generic: $15 co-payment for 30-day supply; Brand: $30 co-payment for 30-day supply; Mail Order: two co-payments for 90-day supply Skilled Nursing Facility (SNF) 40% of covered expense; Combined limit of 100 days per plan year PPO/OON 40% of covered expense 40% of covered expense; allowable amount is 50% of billed charges and maximum payable limited to $350 per day 40% of covered expense Not covered
4 NON-MEDICARE PLANS HEALTH NET PPO (for those under 65 or not eligible for Medicare $1, per month (subscriber only) Coverage) You pay practic) the following co-pays PPO Network Provider/Coverage Inpatient Hospital Psychiatric Care (outpatient) 20%. Combined maximum benefit of $1,500 (PPO/OON) per policy year $50 co-payment + 20% of negotiated rate $25 co-payment; $1,500 maximum benefit per plan year (combined PPO & OON) 20% of negotiated rate $ % of negotiated rate; $100 waived if admitted to hospital Annual hearing screening covered in full. Hearing aids not covered 20% of negotiated rate. Limited to maximum 100 visits combined PPO/OON 20% of negotiated rate 20% of negotiated rate $25 co-payment 20% of negotiated rate $25 co-payment $500 per individual; Three family members must satisfy their individual deductibles to satisfy the family deductible PPO: $3,000 individual. Family = 3X individual; A separate RX out-of-pocket maximum of $1000 Individual and $2000 Family will apply in addition to the Medical out-of-pocket maximum. Skilled Nursing Facility (SNF) Generic: $15 co-payment for 30-day supply; Brand: $30 co-payment for 30-day supply; Mail Order: two co-payments for 90-day supply 20% of negotiated rate; 100 days limit per plan year combined PPO/OON 20% of negotiated rate 20% of negotiated rate $25 co-payment Annual vision screening covered in full; $25 copay for refractive eye exams (only covered for children to age 16)
5 NON-MEDICARE PLANS (for those under 65 or KAISER HMO not eligible for Medicare Coverage) $ per month (subscriber only) You pay practic) the following co-pays Not covered Hospital Psychiatric Care (outpatient) Skilled Nursing Facility (SNF) $15 co-payment (40 visits per plan year) 100% covered per item when deemed medically necessary and when prescribed by a plan physician in accordance with durable medical equipment formulary $75 co-payment per visit $500 allowance every 36 months 100% covered per home visit when prescribed by a plan physician (services limited to inside the Service Area); limit of 3 visits per day, 100 visits per year $100 co-payment per admission $20 co-payment per visit $100 co-payment per admission; no day limit $20 co-payment; no day limit $1,500 individual/$3,000 family per plan year Generic: $15/30 days Generic Mail Order: $30/100 days; Brand: $30/30 days; Brand Mail Order: $60/100 days 100% covered for up to 100 days per benefit period $50 co-payment per procedure $20 co-payment per visit $20 co-payment for exam only
6 NON-MEDICARE PLANS SHARP HEALTH PLAN HMO (for those under 65 or not eligible for Medicare $1, per month (subscriber only) This plan is sponsored by MEA, and available to all retirees. Coverage) All questions should be directed to: You pay practic) the following co-pays Phone: or Hospital $15 co-payment (40 visits per year for and ) $15 (40 visits per year for Chiropractic and ) $50 co-payment $1,000 every 36 months $100 per admission $15 co-payment $100 per admission $15 co-payment $1,500 individual / $3,000 family Skilled Nursing Facility (SNF) Generic: $15 Preferred Brand: $30 Non-Preferred Brand $50 Mail Order (90 Day Supply) Generic: $30 Mail Order (90 Day Supply) Preferred Brand: $60 Mail Order (90 Day Supply) Non-Preferred Brand: $100 $15 co-payment Annual vision screening covered in full
7 MEDICARE PLANS (for those 65 or older and HEALTH NET SENIORITY PLUS HMO eligible for Medicare) You pay the following co-pays $ per month (subscriber only) practic) Not covered In Patient Hospital Skilled Nursing Facility (SNF) (ground and air) $10 co-payment (30 visits per plan year); Provider network: American Specialty Health Providers Covered for Medicare-approved items $50 co-payment per visit. Waived if admitted to hospital $10 co-pay for Medicare-covered diagnostic hearing exam; $500 allowance for hearing aids/24 months Covered by Medicare $10 co-payment per visit $10 co-payment per visit $3,400 per individual Health Net Pharmacy Only; Generic Preferred: $10 co-pay for 30-day supply; Brand Preferred: $20 co-pay for 30-day supply; Non-Preferred (Generic or Brand): $20 copay for 30-day supply; 25% for injectables/specialty Rx. Mail Order = 2 co-pays for up to a 90-day supply, Specialty Drugs, Tier 5 (injectibles) coinsurance of 25% that applies No charge (up to 120 days per benefit period) $50 co-payment $10 co-payment. Waived if admitted to hospital Exam co-payment: $10. Eyewear: One pair of eyeglasses or contact lenses following each cataract surgery
8 MEDICARE PLANS HEALTH NET HMO COB (for those 65 or older and eligible for Medicare) Plan is secondary to Medicare You pay the following co-pays $ per month (subscriber only) practic) $15 co-payment (40 visits per year combined for and Chiropractic) $15 co-payment (40 visits per year combined for Chiropractic and ) $50 co-payment per visit. Waived if admitted to hospital Annual hearing screening covered in full; $500 allowance for hearing aids (2 every 36 months) No charge (days 1-30); $15 per-day co-payment on and after day 31) Inpatient Hospital Skilled Nursing Facility (SNF) No charge (prognosis of life expectancy of 1 year or less) $100 per admit $15 co-payment per visit $100 per admit $15 co-payment $1,500 individual; $3,000 per family Health Net Pharmacy Only; Generic Preferred: $15 co-pay for 30-day supply; Brand Preferred: $30 co-pay for 30-day supply; Non-Preferred (Generic or Brand): $50 co-pay for 30-day supply; 25% for injectables/specialty Rx. Mail Order = 2 co-pays for up to a 90-day supply $100 per admit; Limited to 100 days per plan year $50 co-payment per procedure $15 co-payment per visit; Waived if admitted to hospital Annual vision screening covered in full; $15 co-pay for refractive eye exams
9 MEDICARE PLANS (for those 65 or older and HEALTH NET FLEX NET INDEMNITY PLAN eligible for Medicare) You pay the following copays $ per month (subscriber only) practic) Not covered (ground and air) In Patient Hospital in U.S.; 20% of covered expenses outside of U.S. Exam covered in full; hearing aids not covered ; limited to part-time or intermittent skilled nursing care (8 hours per day; maximum of 21 days physical therapy; or speech therapy) Days 1-60 = Health Net pays Medicare deductible; Days = Health Net pays Medicare coinsurance; Beyond 90 days =Health Net pays the Medicare coinsurance for lifetime reserve days Psychiatric Care (outpatient) Skilled Nursing Facility (SNF) Days 1-60 = Health Net pays Medicare deductible; Days = Health Net pays Medicare coinsurance; Beyond 90 days =Health Net pays the Medicare coinsurance for lifetime reserve days $6,350 Individual; $12,700 Family Generic Preferred: $10 co-pay for 30-day supply; Brand Preferred: $20 co-pay for 30- day supply; Non-Preferred (Generic or Brand): $35 co-pay for 30-day supply; 25% for injectables/specialty Rx. Mail Order = 2 co-pays for up to a 90-day supply Days 1-20 = Health Net pays no benefits (Medicare pays Medicare Allowable charges); Days = Health Net pays Medicare coinsurance; Days = Health Net pays 80% of Allowable Charges, up to an additional 265 days each benefit period days 1-90 and 60 lifetime reserve days; You pay 10% for additional days up to lifetime maximum of 365 days within the U.S.; you pay 20% outside the U.S. Exam covered in full; eyewear not covered
10 MEDICARE PLANS (for those 65 or older and KAISER SENIOR ADVANTAGE HMO eligible for Medicare) You pay the following co-pays $ per month (subscriber only) practic) Not covered Hospital Skilled Nursing Facility (SNF) $15 co-payment (up to 40 visits per plan year) 100% covered per item when deemed medically necessary and when prescribed by a plan physician in accordance with durable medical equipment formulary $50 per visit $500 allowance; every 36 months 100% covered per home visit when prescribed by a plan physician (services limited to inside the service area); limit of 3 visits per day, 100 visits per year $100 co-payment per admission $10 co-payment $100 co-payment per admission, no day limit $10 co-payment per visit; no visit limit $1,500 per member/$3,000 per family Generic: $10 for up to 100 days Brand: $20 for up to 100 days 100% covered for up to 100 days per benefit period $50 co-payment per procedure $10 co-payment $150 eyewear allowance every 24 months
11 MEDICARE PLANS SHARP ADVANTAGE HMO (Coverage for Subscribers $ per month (subscriber only) WITH Medicare) This plan is sponsored by MEA, and available to all retirees. You pay the following co-pays All questions should be directed to: practic) Phone: or Not Covered Hospital $10 (up to 30 visits per year) $50 per visit $1,000 every 36 months $10 co-payment $10 co-payment $1, Day Retail Preferred Generic: $10 30 Day Retail Non-Preferred Generic: $10 30 Day Retail Preferred Brand: $20 30 Day Retail Non-Preferred Brand: $20 30 Day Retail Specialty: 25% Mail Order (90 Day Supply) Preferred Generic: $20 Mail Order (90 Day Supply) Non-Preferred Generic: $20 Mail Order (90 Day Supply) Preferred Brand: $40 Mail Order (90 Day Supply) Non-Preferred Brand: $40 Mail Order (90 Day Supply) Specialty: 25% $50 co-payment $10 co-payment $20 exam $20 lenses $130 allowance for frames or contacts
12 OPEN ENROLLMENT HELP DAY June 14, 2016 SDCERS staff and representatives from sponsored health plans will be available to answer your questions. You may also submit your paperwork directly to SDCERS staff at the event. Tuesday, June 14, 2016, 10 a.m. - Noon Balboa Park Club Ballroom, Balboa Park 2144 Pan American Road San Diego, CA DIRECTIONS AND PARKING: From Park Boulevard, turn west on President s Way, entering Balboa Park. Continue at the stop sign, where you can either go straight to park in the Pan American Plaza parking lot or make a right and park in the Organ Pavilion lot Pan American Road is located in the South Palisades area of Balboa Park, just north of the Puppet Theater. Linkedin.com/Company/SDCERS 401 West A Street, Suite 400, San Diego, CA Please Keep This Book for - ReferenceThroughout 64 - the Year
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