Arizona State Retirement System Plan Benefit Information for Medicare Eligible Members

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1 Arizona State Retirement System Plan Benefit Information for Medicare Eligible Members Benefits Effective January 1, 2012 UHAZ12HM _000 H0303_110818_013543

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3 Summary of the UnitedHealthcare plans available to retirees of the Arizona State Retirement System (ASRS) The following plan options are being offered for 2012: UnitedHealthcare Group Medicare Advantage (HMO) Each covered individual must choose a primary care physician (PCP) from the HMO s network of providers. Keep in mind, providers in the network may change at any time. When a covered individual needs health care, he or she must visit their PCP. The PCP will either provide care or refer the individual to a specialist in the HMO network. If care is received from the PCP or a referred network physician, you generally make a copay. If care is received from a non network provider, you ll have to pay the full cost. If your PCP refers you to a specialist or other physician, it s important that you always check first to be sure the physician is a network provider. This Medicare Advantage Plan includes a Medicare Part D drug benefit. You automatically receive prescription drug coverage when you enroll in this plan. UnitedHealthcare RxSupplement This plan provides supplemental prescription drug coverage while in the coverage gap. With this plan, your coverage remains the same. You will continue to pay the same copayment or coinsurance while in the coverage gap as you did before you entered the coverage gap. Enrollment in the supplement plan is automatically included as part of your coverage when you enroll in the UnitedHealthcare Group Medicare Advantage (HMO) plan. UnitedHealthcare Senior Supplement Plan The UnitedHealthcare Senior Supplement Plan is an indemnity health care plan that supplements Medicare coverage. This plan is designed to help pay for some or all the out of pocket costs that Medicare doesn t fully cover. In general, the plan covers services that are allowed or covered by Medicare including: Medicare deductibles for inpatient hospital stays Medicare Part B deductible Most copays and coinsurances However, enrollment in the plan does offer some additional programs not covered by Medicare such as: A fitness program Resources to help make caring for a spouse or family member easier Access to a nurseline Other features of the plan include: The ability to receive care from any health care provider who participates in Medicare and is eligible to receive payment from Medicare. No requirement to choose a primary care physician or to obtain a referral to see a specialist. You are automatically enrolled in the prescription drug plan with UnitedHealthcare MedicareRx when you enroll in the UnitedHealthcare Senior Supplement plan. 3

4 UnitedHealthcare MedicareRx for Groups (PDP) This Medicare Part D plan provides coverage for your prescription drugs. A broad formulary that covers 100% of Medicare eligible drugs. A national network of over 65,000 pharmacies. These plans are part of the Medicare program, with all the rights and protections under Original Medicare but they have been customized by ASRS to provide you with additional benefits. Please review the following pages for plan details. 4

5 UnitedHealthcare Group Medicare Advantage (HMO) Medical Benefits Annual out of pocket maximum Doctor Office Visits Primary care physician Specialist Preventive Care Annual physical Prostate cancer screening Breast cancer screening Immunizations Inpatient Care Inpatient hospital care Skilled Nursing Facility (SNF) care Home Health Care Hospice Outpatient Services Outpatient mental health care individual therapy session Outpatient mental health care group therapy session Radiation therapy Outpatient surgery and hospital services Outpatient rehabilitation services Durable medical equipment (DME) Part B Drugs Lab Services Laboratory tests X rays Diagnostic radiology services Your In Network Cost (unless otherwise noted) Your plan has an annual out of pocket maximum of $6,700 each plan year. $15 copay $30 copay $100 copay per admission, up to 100 days $30 copay $15 copay $100 copay $15 copay $50 copay 5

6 Medical Benefits Emergency Services Ambulance services Emergency care (waived if admitted to the hospital) Your In Network Cost (unless otherwise noted) $25 copay $50 copay Urgently needed care (waived if admitted to the hospital) Medicare Covered Physician Services Chiropractic services (routine chiropractic care not covered) Podiatry services Eye exam $15 copay $15 copay $30 copay $30 copay Hearing exam $30 copay Additional Benefits and Programs Not Covered Under Medicare Hearing Services Routine hearing exams (1 exam every 12 months) Hearing aids (every 36 months) Up to $500 Vision Services Routine eye exam (refraction) (1 exam every 12 months) Routine eyewear or contact lenses SilverSneakers Fitness program NurseLine SM Services UnitedHealth Passport Program $20 copay Up to $130 eyewear allowance every 12 months. Up to $105 contact lens allowance in lieu of eyewear allowance every 12 months Membership in a senior fitness program at no additional cost to you Health and well being programs provided through OptumHealth SM Your health care coverage travels with you Solutions for Caregivers* Provides support for caregivers * The product and services described above is neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the UnitedHealthcare Group Medicare Advantage grievance process. 6

7 Prescription Drugs Network Pharmacy (for up to a 31 day supply) Tier 1 Preferred Generic Tier 2 Preferred Brand Tier 3 Non preferred Tier 4 Specialty Drug Coverage in the Gap Mail Service Pharmacy (up to a 90 day supply) Tier 1 Preferred Generic Tier 2 Preferred Brand Tier 3 Non preferred Tier 4 Specialty Drug Coverage in the gap Your Cost $20 copay $40 copay $40 copay $40 copay Yes $40 copay $80 copay $80 copay $80 copay Yes Catastrophic coverage stage (after you have paid $4,700 out of pocket) Bonus drugs included. Doctor and Hospital Choice The greater of $2.60 copay for generic, $6.50 copay for brand name, or 5% coinsurance In most cases, you must go to network doctors, specialists and hospitals in order to have services covered by the UnitedHealthcare Group Medicare Advantage (HMO) plan. You must select a Primary Care Physician (PCP) and get a referral to see network specialists. You need prior authorization to go to non network doctors, specialists or hospitals. Emergency and urgently needed services never require prior authorization. Physician Services, including doctor office visits Covered services include: Office visits, including medical and surgical care in a physician s office or certified ambulatory surgical center Consultation, diagnosis, and treatment by a specialist Hearing and balance exams, if your doctor orders it to see if you need medical treatment Telehealth office visits including consultation, diagnosis and treatment by a specialist Second opinion by another network provider prior to surgery Outpatient hospital services Non routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a doctor) Choose Your Primary Care Physician There are three ways to select a Primary Care Physician within our network: geographically, if you re looking for a Primary Care Physician (PCP) in a convenient area; hospital preference, if you would like to use a specific hospital; or physician preference, if you have a specific physician you prefer to use. Your PCP may be a family practitioner, general practitioner or an internist. 7

8 UnitedHealthcare Senior Supplement Plan Medical Benefits Annual out of pocket maximum Your In Network Cost (unless otherwise noted) $6,700 per calendar year Covered Service Medicare Pays UnitedHealthcare Pays You Pay Inpatient Care Inpatient hospital Deductible (Applies to inpatient hospital and inpatient mental health benefits only) $150 per covered person Semi private room and board, general nursing and miscellaneous services and supplies Part A Hospital first 60 days All but $1,132 $1,132 (Part A Deductible) Part A Hospital days All but $283 per day $283 per day Part A Hospital day 91 and after: While using 60 lifetime reserve days All but $566 per day $566 per day After 60 lifetime reserve days are used 365 lifetime additional days 100% of Medicare Eligible Expenses Beyond 365 lifetime additional days All costs Blood Blood First 3 pints Medicare Parts A or B Additional amounts under Medicare Part A Skilled Nursing Facility Care 100% 100% Not covered You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entering the Medicare approved facility within 30 days of leaving the hospital. Days 1 20 All approved amounts Days All but $ per day All but $ per day Days 101 and after All costs (These Medicare amounts listed are for 2011 and may change for 2012.) 8

9 Covered Service Hospice Care Available as long as your doctor certifies you are terminally ill and you elect to receive these services. Home Health Care Skilled Care Services and Medical Supplies Outpatient Services Emergency Care (waived if admitted to the hospital) Medicare Pays All but very limited coinsurance for outpatient drugs and inpatient respite care UnitedHealthcare Pays You Pay 100% All approved amounts Balance $50 Urgently Needed Services $25 Durable Medical Equipment First $162 of Medicare Approved Amounts Remainder of Medicare Approved Amounts Medical Services 80% of approved amounts $162 (Part B Deductible)* 20% of approved amounts Includes services such as Physician services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy and diagnostic tests. First $162 of Medicare Approved Amounts $162 (Part B Deductible)* Remainder of Medicare Approved Amounts Generally 80% Generally 20% Physician Office Visits Generally 80% 100% Coinsurance less $15 $15 Outpatient Hospital Services $50 Outpatient Mental Illness For most outpatient mental illness services Part B Excess Charges (above Medicare Approved Amounts) 55% 45% All costs * Once you have been billed $162 of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year. 9

10 Covered Service Medicare Pays UnitedHealthcare Pays You Pay Foreign Travel Medically Necessary Emergency Care services beginning during the first 6 months of each trip outside the United States First $250 each calendar year $250 $250 Remainder of charges 80% up to a lifetime maximum benefit of $50,000 20% and all amounts over the $50,000 lifetime maximum (These Medicare amounts listed are for 2011 and may change for 2012.) Supplemental Routine Vision Benefit Limited to 1 Time Every 12 Months Your In Network Costs Your Out of Network Costs Deductible $20 $20 Routine Eye Refraction (examination) after deductible satisfied Charges in excess of $80 Eyeglass Lenses (Standard single, bifocal and trifocal) Eyeglass Frames Contact Lenses (in lieu of eyeglasses) covered in full Charges in excess of $130 retail allowance Charges in excess of $105 retail allowance Charges in excess of $100 for lenses, frames, or contacts combined Please contact our vision provider OptumHealth Vision at to find a participating vision provider or visit the website at This Supplemental Routine Vision Benefit is available with the UnitedHealthcare Senior Supplement insurance plan. 10

11 UnitedHealthcare Senior Supplement Part B Prescription Drugs Medicare Part B Prescription Drugs Covered under the Medical Benefit Includes coverage for immunizing agents, biological sera, blood or blood plasma, or drugs (except insulin) prescribed for intravenous or intramuscular use or administration when authorized by your doctor and in accordance with Medicare guidelines. Medicare Part B Covered Immunosuppressive Drugs Covered according to Medicare guidelines. (Following a Medicare approved organ transplant in accordance with Medicare guidelines.) Medicare Part B Covered Oral Chemotherapy Drugs Including Anti nausea Drugs Covered according to Medicare guidelines. Medicare Part B Covered Inhalation Solutions Covered according to Medicare guidelines. 11

12 Outpatient Prescription Drugs Through UnitedHealthcare MedicareRx for Groups (PDP) Medicare Benefits UnitedHealthcare MedicareRx for Groups (PDP) Outpatient Benefits You pay: When total drug costs are: When true out of pocket costs are: You pay: Prescription Drugs 100% for most prescription drugs, unless you enroll in the Medicare Part D Prescription Drug Program Between $2,930 Retail Pharmacy $10 copay for a one month (31 day) supply of Tier 1 drugs. $30 copay for a three month (90 day) supply of Tier 1 drugs. $35 copay for a one month (31 day) supply of Tier 2, Tier 3 or Specialty Tier drugs. $105 copay for a three month (90 day) supply of Tier 2, Tier 3 or Specialty Tier drugs. Long Term Care Pharmacy $10 copay for a one month (31 day) supply of Tier 1 drugs. $35 copay for a one month (31 day) supply of Tier 2, Tier 3 or Specialty Tier drugs. Mail Service Pharmacy $20 copay for a three month (90 day) supply of Tier 1 drugs you get through mail service. $70 copay for a three month (90 day) supply of Tier 2, Tier 3 or Specialty Tier drugs you get through mail service. Greater than $2,930 Less than $4,700 You pay 86% of the cost of generic drugs and about 50% of the cost of most brand name drugs, until your True Out of Pocket costs reach $4,700 Greater than $4,700 $2.60 for generics (including brand drugs treated as generic) and $6.50 for all other drugs, or 5% coinsurance, whichever is greater 12

13 Additional Your Additional Programs Benefits and Services Programs. Your Both plan the UnitedHealthcare provides the same Group coverage Medicare as Medicare Advantage Parts (HMO) A and B, and plus the many Senior additional Supplement benefits plan and provide programs additional that contribute programs to and your services health and that wellness. contribute They to may your include: health and wellness. They include: NurseLine SM Services Speak with a registered nurse, 24 hours a day, 7 days a week. Discuss your health and diet. Review or discuss your medications. Receive information about illnesses and injuries. Get tips on working with your doctor. SilverSneakers Fitness Program Stay physically fit and active with the SilverSneakers Fitness Program. This fitness program is available to you at no additional cost. With the SilverSneakers Fitness Program you ll receive: A basic fitness center membership at more than 11,000 participating locations. Access to all amenities, programs and services that are standard with a basic fitness center membership. Nationwide access to any participating fitness location (find locations at Many women-only locations, including Curves, are available nationwide. If the nearest participating location is 15 miles or more away from your home, you can register for the SilverSneakers Steps program. This is a personalized program that provides tools such as resistance bands, exercise DVDs and how-to material to help you measure, track and increase your daily activity. The products and services described below are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the UnitedHealthcare grievance process. Solutions for Caregivers Providing care for a loved one can be demanding and overwhelming. This plan gives you access to Solutions for Caregivers a program that supports you, your family and your loved ones. 6 Services provided by Solutions for Caregivers include: On-site assessment and development of a personalized care plan for you or your loved one. Unlimited phone access to a Care Specialist who can provide counsel on individual, medical, financial, safety, emotional and social needs. Connections with professionals, including home health aides, nurses, lawyers and financial advisors. 13

14 The UnitedHealth Passport program. The UnitedHealth Passport program offers coverage for members who travel or live away from home up to nine consecutive months during the year. Whether you plan a scenic road trip or extended stay, when you travel within the UnitedHealth Passport service area, you will have health care coverage in the event you need it. This program is included with your plan. You pay no additional charge for health care coverage when you travel within the UnitedHealth Passport service area. You simply pay the same copay or coinsurance as you would at home. Enrolling in Your Selected Plan(s) Health Plan Premium In most cases, ASRS is responsible for making payment of any applicable Health Plan Premium directly to us on behalf of its enrolled Plan Members and their eligible dependent(s). ASRS determines the amount of any retiree subscriber contribution toward Health Plan Premiums. Some Plan Sponsors, however, have made arrangements with us to bill you, the Member, directly for Health Plan Premiums. If this is the case, your monthly Health Plan Premium is due on the first day of each month for the prior month s coverage. Refer to the ASRS Enrollment Guide for your Monthly Health Plan Premium amount. Complete the Enrollment Form Having determined the plan or plans that meet your needs, you are now ready to complete the ASRS enrollment form(s). These forms are available in this enrollment kit or from ASRS. Keep in mind it is important to press firmly with your pen when completing the enrollment form. We need to be able to read all copies. Return the Enrollment Form Now mail the completed form to the address listed below. Arizona State Retirement System ASRS/PSPRS Attn: Health Insurance P.O. Box Phoenix, AZ Public Safety Personnel Retirement System Attn: Health Insurance 3010 E. Camelback Rd., Suite 200 Phoenix, AZ

15 Questions? Call Customer Service toll free: UnitedHealthcare Group Medicare Advantage (HMO) , TTY a.m. 8 p.m. local time, 7 days a week UnitedHealthcare Senior Supplement Insurance Plan , TTY a.m. 8 p.m. local time, 7 days a week UnitedHealthcare MedicareRx for Groups (PDP) , TTY a.m. 8 p.m. local time, 7 days a week 15

16 UnitedHealthcare Senior Supplement is not a Medicare Supplement plan. This is an employer group retiree plan and may provide coverage that is different from a Medicare Supplement plan. UnitedHealthcare Senior Supplement and Senior Security group retiree plans are underwritten by UnitedHealthcare Insurance Company, a private insurance company not connected with or endorsed by the U.S. Government or the federal Medicare program. Senior Supplement and Senior Security plans may not be available in all states. UnitedHealthcare is part of the UnitedHealth Group family of companies. UnitedHealthcare Medicare Advantage plans are insured through UnitedHealthcare Insurance Company and its affiliated companies, a Medicare Advantage organization with a Medicare contract. Members may enroll in the plan only during specific times of the year. Contact UnitedHealthcare for more information. You must have both Medicare Parts A and B to enroll in the plan. Retiree plan prospects must meet the eligibility requirements to enroll for group coverage. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. Limitations, copayments, and restrictions may apply. HMO members must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor UnitedHealthcare Medicare Advantage plans will be responsible for the costs. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: MEDICARE ( ). TTY users should call , 24 hours a day/7 days a week; the Social Security Office at between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call ; or your Medicaid Office. You must use contracted network pharmacies to access your Part D prescription drug benefit except under non routine circumstances, in which case quantity limitations and restrictions may apply. OptumHealth` is a health and well being company that provides information and support as part of your health plan. NurseLine` nurses cannot diagnose problems or recommend specific treatment and are not a substitute for your doctor s care. NurseLine services are not an insurance program and may be discontinued at any time. Solutions for Caregivers assists in coordinating community and in home resources. The final decision about your care arrangements must be made by you. In addition, the quality of a particular provider must be solely determined and monitored by you. Information provided to you about a particular provider does not imply and is in no way an endorsement of that particular provider by Solutions for Caregivers. The information on and the selection of a particular provider has been supplied by the provider and is subject to change without written consent of Solutions for Caregivers. SilverSneakers is a registered mark of Healthways, Inc. Consult a health care professional before beginning any exercise program. 16

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