GIC BENEFIT DECISION GUIDE FOR COMMONWEALTH OF MASSACHUSETTS

Transcription

1 Benefits and Rates Effective Juy 1, 2015 Weigh Your Options GIC BENEFIT DECISION GUIDE FOR COMMONWEALTH OF MASSACHUSETTS EMPLOYEES See inside for benefit changes. ANNUAL ENROLLMENT: Apri 8 - May 6, 2015

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3 HOW TO USE THIS GUIDE The Benefit Decision Guide is an overview of GIC benefits and is not a benefit handbook. Contact the pans or visit the GIC s website for more detaied pan handbooks. A empoyees shoud read: Annua Enroment Checkist New Hire and Annua Enroment Overview Annua Enroment News Benefit Changes Procedure Changes and Frequenty Asked Questions Deductibe Changes and Questions & Answers State Empoyee Heath Pan Rates Effective Juy 1, Find out about your heath pan options: Prescription Drug Benefits Limited Network Pans Great Vaue; Quaity Coverage Benefits At-A-Gance Heath Pan Locator Map Wide Network Heath Pans Find out about other benefit options: Long Term Disabiity (LTD) and LTD Rates Effective Juy 1, Life Insurance and AD&D Life and AD&D Rates Effective Juy 1, Heath Insurance Buy-Out Pre-Tax Premium Deductions Fexibe Spending Accounts GIC Denta/Vision Pan for Managers GIC Denta/Vision Pan Rates Effective Juy 1, WeMASS Piot Program Resources for additiona information: Inscripción Anua 年 度 投 保 Website Heath Fair Schedue GIC Pan Contact Information Gossary NEW THIS YEAR! Watch the Annua Enroment video to find out the steps you shoud take during Annua Enroment and how to ower your out-of-pocket costs: IMPORTANT REMINDERS This Benefit Decision Guide contains important benefit and rate changes effective Juy 1, Review pages 4-5, and 9 for detais. Read the Annua Enroment Checkist on page 2 for information to consider when seecting a heath pan. Read the Limited Network Pans Great Vaue; Quaity Coverage section on page 11 to find out more about imited network pan options. If you want to keep your current heath pan, you do not need to fi out any paperwork. Your coverage wi continue automaticay. Once you choose a heath pan, you cannot change pans unti the next annua enroment, even if your doctor or hospita eaves the heath pan, uness you have a quaifying event, such as moving out of the pan s service area or retiring and becoming Medicare eigibe (in which case, you must enro in a Medicare pan). Your annua enroment forms are due to the GIC Coordinator in your benefits office no ater than Wednesday, May 6, Forms and appications are avaiabe on the GIC s website ( Changes go into effect Juy 1,

4 ANNUAL ENROLLMENT CHECKLIST STEP 1: X IDENTIFY which heath pan(s) you are eigibe to join: Where you ive determines which pan(s) you may enro in. See page 16 for the heath pan ocator map. See the heath pan pages for eigibiity detais (pages and 17-18). STEP 2: For the pans you are eigibe to join and are interested in... X REVIEW the at-a-gance charts in the center of this guide. WEIGH features that are important to you, such as out-of-network benefits, prescription drug coverage and menta heath benefits. REVIEW their monthy rates (see page 9). CONSIDER enroing in a imited network pan individuas who pay 25% of the premium wi save, on average, $50 per month (see page 11). CONTACT the pan to find out about benefits that are not described in this guide. Do Your Homework During Annua Enroment Even If You Want to Stay in the Same Pan STEP 3: X Find out if your doctors and hospitas are in the pan s network. Ca the pan or visit the pan s website and search for your own and your covered famiy members doctors and hospitas. Be sure to specify the heath pan s fu name, such as Harvard Pigrim Primary Choice Pan or Harvard Pigrim Independence Pan, not just Harvard Pigrim. Your heath pan seection is binding unti the next annua enroment, even if your doctor or hospita eaves your heath pan s network during the year. Your heath pan wi hep you find another provider. STEP 4: X Check on copay tier assignments that affect what you pay when you get physician or hospita services. Physician and hospita copay tiers can change each Juy 1. During Annua Enroment, check to see if your doctor s or hospita s tier has changed. STEP 5: X STEP 6: X Take a ook at other benefit options: Long Term Disabiity, Optiona Life Insurance, Buy-Out, and Denta/Vision (see pages and 24 for eigibiity and other detais.) Next fa, consider enroing in the Heath Care Spending Account and save on out-of-pocket heath care expenses. (See page 23 for additiona information.) THREE GREAT RESOURCES 1 The pan s website: Get additiona benefit detais, information about network physicians, toos to make heath care decisions and more. See page 28 for website addresses. 2 The heath pan s customer service ine: A representative can hep you. See page 28 for phone numbers. 3 A GIC Heath Fair: Tak with pan representatives and get personaized information and answers to your questions. See page 27 for the heath fair schedue. 2

5 NEW HIRE AND ANNUAL ENROLLMENT OVERVIEW Annua enroment gives you the opportunity to review your benefit options and enro in a heath pan or make changes if you desire. If you want to keep your current GIC heath pan, you do not need to fi out any paperwork. Your coverage wi continue automaticay. Once you choose a heath pan, you cannot change pans unti the next annua enroment, even if your doctor or hospita eaves the pan, uness you have a quaifying status change, such as moving out of the pan s service area or retiring and becoming eigibe for Medicare (in which case, you must switch to a Medicare pan). NEW EMPLOYEES within 10 caendar days of hire. CURRENT EMPLOYEES See your GIC Coordinator or the GIC s website for coverage effective date detais. During Annua Enroment Apri 8-May 6, 2015 for changes effective Juy 1, 2015 You may enro in one of these heath pans... You may enro in or change your seection of... Faon Heath Direct Care One of these heath pans: Faon Heath Direct Care Faon Heath Seect Care Harvard Pigrim Independence Pan Harvard Pigrim Primary Choice Pan Heath New Engand NHP Prime (Neighborhood Heath Pan) Tufts Heath Pan Navigator Tufts Heath Pan Spirit UniCare State Indemnity Pan/Basic UniCare State Indemnity Pan/Community Choice UniCare State Indemnity Pan/PLUS Faon Heath Seect Care Harvard Pigrim Independence Pan Harvard Pigrim Primary Choice Pan Heath New Engand NHP Prime (Neighborhood Heath Pan) Tufts Heath Pan Navigator Tufts Heath Pan Spirit UniCare State Indemnity Pan/Basic UniCare State Indemnity Pan/Community Choice UniCare State Indemnity Pan/PLUS You may enro in... GIC Denta/Vision Pan for Managers* Basic Life Insurance Optiona Life Insurance Long Term Disabiity (LTD) GIC Denta/Vision Pan for Managers* Heath Care Spending Account (HCSA) Dependent Care Assistance Program (DCAP) Pre-tax or post-tax Basic Life and Heath Insurance premium deductions You may enro in... You may appy for*... Long Term Disabiity (during annua enroment or anytime during the year) Optiona Life Insurance (during annua enroment or anytime during the year) Heath Insurance Buy-Out Opt in or out of pre-tax Basic Life and Heath Insurance premium deductions By submitting within 10 days of empoyment... Basic Life Insurance GIC enroment forms; and Required documentation for famiy coverage (if appicabe) as outined on the Forms section of our website to your GIC Coordinator By submitting by May 6... GIC enroment forms to your GIC Coordinator * See pages and 24 for eigibiity and option detais. NOTE: Active state empoyees who invountariy ose heath insurance coverage esewhere may enro in GIC heath coverage during the year with proof of invountary oss of coverage. Contact your GIC Coordinator for detais. Indicates a GIC Limited Network Pan. Enroment and appication forms are avaiabe on our website and through your GIC Coordinator. 3

6 ANNUAL ENROLLMENT NEWS The Commonweath continues to face chaenging budget times. Many worthy initiatives incuding education, oca aid and transportation are competing for scarce resources as heath care costs crowd out the state budget. For this fisca year, a $765 miion shortfa is projected; the GIC has a $165 to $190 miion deficit. Most of the GIC budget shortfa is structura we have been underfunded for the ast three years because the budget base was not updated for the additiona members that we have added, the end of federa funds, and the suppementa budgets we ve received. The Fisca Year 2016 premium requests we received from the pans, especiay two of the arger ones, were not reaistic given the budget situation. Additionay, too many patients use expensive academic medica centers for routine care, further increasing costs for a of us. The Administration has committed to making the GIC s current budget whoe. However, despite the new budget base, there s no room for increased spending next year. With many pressing concerns, agencies have been asked to come in with eve funding. The GIC has been pushing hard through the Centered Care Initiative to change the way providers are paid: moving from fee for service payment arrangements that reward providers for ordering unnecessary tests and procedures to goba payments. This has been a tough sog and progress has been sower than we woud ike. We wi continue to push for these changes, but in the meantime, the Commission has had to make some difficut decisions. These were not easy decisions and they wi affect a of us who work for the state and oca communities. We encourage you to take charge of your heath and take advantage of ways to ower your out-of-pocket costs: Work with your Primary Care Provider (PCP) to navigate the heath care system. Seek care from Tier 1 and Tier 2 speciaists. Over 164 miion caims have been anayzed for differences in how physicians perform on nationay recognized measures of quaity and/or cost efficiency. You pay the owest copay for the highestperforming doctors: HHH Tier 1 (exceent) HH Tier 2 (good) H Tier 3 (standard) If you are in a tiered hospita pan and have a panned hospita admission, tak with your doctor about whether a Tier 1 hospita woud make sense. Make copies and bring the prescription drug formuary from your pan s website with you to a doctor visits. Use urgent care faciities and retai minute cinics instead of the emergency room for urgent (non-emergency) care. Use your heath pan s onine cost comparison too to shop for heath care services in advance. Consider enroing in a Limited Network Pan to save money on your monthy premium. Read about ways to take charge of your heath; the GIC s website has a weath of artices and inks to additiona resources: Eat heathy, exercise reguary, don t smoke, and find ways to de-stress. BENEFIT CHANGES EFFECTIVE JULY 1, 2015 PCPS AND REFERRALS REQUIRED! HARVARD PILGRIM INDEPENDENCE PLAN AND TUFTS HEALTH PLAN NAVIGATOR In keeping with the Centered Care Initiative, Harvard Pigrim Independence Pan and Tufts Heath Pan Navigator wi become Point-of-Service (POS) pans. With a POS Pan, members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists to receive care at the in-network eve of coverage. Members who get care from speciaists without a PCP referra wi have higher out-of-pocket costs. Current members of these pans wi stay in the pan if they do not switch pans during Annua Enroment and wi receive additiona detais of this transition from their pan. ALL HEALTH PLANS Rues for Enroing in Heath Pans and Adding Dependents: In compiance with federa and state aw for pre-tax benefits, the GIC wi be tightening up our rues and instituting deadines for enroing in heath pans and adding dependents. As aways, required documentation (e.g., birth certificates and marriage certificates) must accompany the change forms. See page 6 for additiona information. Deductibe: The current caendar year deductibe wi increase to $300 individua; $600 two-person famiy; and $900 three- or more person famiy coverage. The carryover provision into 2016 for deductibe-reated charges incurred October December 2015 has been eiminated. The deductibe wi transition to a fisca year deductibe to make it easier for members to change heath pan carriers at future annua enroments. See page 6 for additiona detais. 4

7 BENEFIT CHANGES EFFECTIVE JULY 1, 2015 Other Benefits That Accrue on a Caendar Year: wi transition during FY16 to a fisca year accrua. For 2015, they wi accrue on a caendar year; from January 1 June 30, 2016, they wi accrue on a haf-caendar year; from Juy 1, 2016 June 30, 2017, they wi accrue on a fisca year. Detais vary sighty by pan; contact the pan for detais: Out-of-pocket maximum Inpatient copay Day imits for other inpatient medica faciities (skied nursing, rehab, etc.) Outpatient surgery copay Physica and Occupationa Therapy Outpatient menta heath Smoking cessation counseing Hearing aids Fitness reimbursement Nutritiona counseing Vision hardware for certain conditions Vision exam Chiropractic visits Speech therapy Private Duty nursing Hospita-based persona emergency response systems See the At-A-Gance Chart in the center of this guide, pages 14-15, for the foowing changes: Speciaist Tiering: Copays for speciaists wi increase for a pans: $30 Tier 1; $60 Tier 2; $90 Tier 3. Faon Heath Direct Care wi tier speciaists based on quaity and/or cost efficiency for the first time. Inpatient Hospita Care Copay: For pans that do not tier hospitas (Faon Heath Direct Care, Heath New Engand, Neighborhood Heath Pan, UniCare State Indemnity Pan/Basic, and UniCare Community Choice), the copay wi increase to $275. Tufts Heath Pan Navigator wi change to three tier hospita copays and Tier 1 and Tier 3 copays wi increase or change for a pans that have three hospita tiers (Faon Heath Seect Care, Harvard Pigrim Independence Pan, Tufts Heath Pan Navigator, and UniCare PLUS): Tier 1: $275 and Tier 3: $1,500. For Harvard Pigrim Primary Choice, Tier 1 wi increase to $275. Outpatient Surgery Copay: The copay wi increase for a pans to $250 except UniCare Community Choice and PLUS. Prescription Drug Copays: A prescription drug copays except for Tier 1 retai wi increase to: Tier 2 $30 and Tier 3 $65 retai up to a 30-day suppy; Tier 1 $25; Tier 2 $75 and Tier 3 $165 mai order up to a 90-day suppy. In-Network Out-of-Pocket Maximum: The out-of-pocket maximum ($5,000 per individua and $10,000 per famiy) wi now incude prescription drugs for Harvard Independence and Primary Choice, Tufts Navigator and Spirit. (This aready appies to the other GIC HMOs.) The out-of-pocket maximum for UniCare State Indemnity Pan/Basic, Community Choice and PLUS wi change to $4,000 per individua and $8,000 per famiy for medica and menta heath benefits and $1,500 per individua and $3,000 per famiy for prescription drug benefits. Other Heath Pan Changes NEIGHBORHOOD HEALTH PLAN NHP Care wi now be caed NHP Prime. Prosthetics and orthotics with Durabe Medica Equipment (DME) wi be subject to the deductibe, but not coinsurance. Hearing aid benefits for members over age 22 wi no onger be subject to coinsurance. TUFTS HEALTH PLAN NAVIGATOR AND SPIRIT Menta Heath/Substance Abuse: Outpatient menta heath visits up to 26 visits without prior authorization; thereafter, visits subject to prior authorization for medica necessity. UNICARE STATE INDEMNITY PLAN/BASIC, COMMUNITY CHOICE AND PLUS Prescription Drug Program: CVS/caremark was seected to continue as the pharmacy benefit manager. Prior authorization wi be required for certain high-cost drugs. See page 10 for additiona information. Certain Ora, Injectabe, Infused and Inhaed Speciaty Drugs: After the first fi of certain speciaty drugs, you must get refis through CVS/caremark s speciaty pharmacy. The first fi may be imited to up to a 14-day suppy with a prorated copay. Menta Heath/Substance Abuse: One visit with a PCP for menta heath/substance abuse wi now be covered. Outpatient menta heath visits up to 26 visits without prior authorization; thereafter, visits subject to prior authorization for medica necessity. Other GIC Benefit Changes FLEXIBLE SPENDING ACCOUNT (FSA): The FSA Program wi transition to a fisca year to coincide with other GIC benefits. In the fa, there wi be an open enroment for haf-year benefits of January 1 June 30, 2016, and then next spring there wi be an open enroment for fisca year benefits of Juy 1, 2016 June 30, See page 23 for additiona information. GIC DENTAL/VISION: Composite fiings on posterior teeth wi now be covered: 80%. 5

8 PROCEDURE CHANGES AND FREQUENTLY ASKED QUESTIONS Modifications to Rues for Enroing in Heath Pans and Adding Dependents In compiance with federa and state aw for pre-tax benefits, the GIC wi be tightening up our rues and instituting deadines for enroing in heath pans and adding dependents effective Juy 1, As aways, required documentation (e.g., birth certificates and marriage certificates) must accompany the change forms. Effective Juy 1, 2015: A GIC forms have changed. Visit our website for current forms: GIC eigibe enroees can ony enro in coverage for the first time as a new hire, at Annua Enroment or during the year with a documented quaifying event: marriage, birth/adoption of chid, invountary oss of other coverage, spouse s annua enroment, or return from an approved FMLA or miitary eave. GIC members can ony change from individua to famiy or famiy to individua coverage with a quaifying event: marriage, birth/adoption of chid, change in dependent eigibiity, divorce (subject to M.G.L. Ch. 32A eigibiity requirements), death of spouse/dependent or spouse s or dependent s invountary oss of coverage esewhere. A forms and documentation for the above enroments or changes must be received at the GIC within 60 days of the quaifying event. If you miss this deadine, you must wait for the next Annua Enroment to make the change. As aways, it s important to remember that you can ony change heath pans at Annua Enroment, uness you move out of your heath pan s service area, at retirement, or are retired and become Medicare eigibe, in which case you must change pans. Frequenty Asked Questions Q As a new empoyee, when do my GIC benefits begin? A GIC benefits begin on the first day of the month foowing 60 days or two fu caendar months of empoyment, whichever comes first. Ony the Dependent Care Assistance Program (DCAP) begins on the first day of empoyment. Q I am an active GIC-eigibe empoyee. I am aso retired from a state agency or participating municipaity and eigibe for GIC retirement benefits. Can I choose both empoyee and retiree benefits? A No. You must choose either active empoyee or retiree benefits. Contact the GIC to indicate whether you want empoyee or retiree benefits. Q I m turning age 65; what do I need to do? A If you are age 65 or over, visit Socia Security s website or your oca Socia Security office for confirmation of Socia Security and Medicare benefit eigibiity. 6 See the GIC s website for answers to other frequenty asked questions: If you are eigibe for Medicare Part A for free and you continue working after age 65, you and your covered spouse shoud not enro in Medicare Part B unti you (the insured) retire. Empoyees shoud not sign up for Medicare Part D. Your drugs are aready provided by your heath pan. Q My fu-time student goes to schoo outside of our heath pan s service area. May we remain in our current heath pan? A Yes. Your famiy may remain in your current heath pan for as ong as your chid is a fu-time student and enroed in GIC coverage as a fu-time student. However, if your chid age 19 to 26 ceases to be a fu-time student, compete and return the Dependent Age 19 to 26 Enroment/Change Form; that chid must reside within your heath pan s service area to be covered. If he or she ives outside of your heath pan s service area, the famiy must change pans. Ony UniCare Indemnity Pan/Basic is nationwide. You MUST Notify Your GIC Coordinator When Your Persona or Famiy Information Changes Faiure to notify the GIC of famiy status changes, such as ega separation, divorce, remarriage, and/or addition of dependents can resut in financia iabiity to you. Pease te your GIC Coordinator when any of the foowing changes occur: Marriage or remarriage Lega separation Divorce Address change Birth or adoption of a chid Lega guardianship of a chid Remarriage of a former spouse Dependent age 19 to 26 who is no onger a fu-time student Dependent other than fu-time student who has moved out of your heath pan s service area Death of an insured Death of a covered spouse, dependent or beneficiary Life insurance beneficiary change You have GIC COBRA coverage and become eigibe for other coverage

9 DEDUCTIBLE CHANGES AND QUESTIONS & ANSWERS The caendar year deductibe wi increase effective Juy 1, The deductibe wi transition to a fisca year to make it easier for members to change heath pan carriers at Annua Enroment. The carryover provision of October December has been eiminated. Deductibe Questions and Answers Q What is a deductibe? A A GIC heath pans incude a deductibe. This is a fixed doar amount you must pay each year before your heath pan begins paying benefits for you or your covered dependent(s). This is a separate charge from any copays. Q How much is the in-network 2015 caendar year deductibe? A The in-network deductibe wi increase effective Juy 1, 2015 to $300 per member, up to a maximum of $900 per famiy. Here is how it works for each coverage eve: Individua: The individua has a $300 deductibe before benefits begin. Two-person famiy: Each person must satisfy a $300 deductibe. Three- or more person famiy: The maximum each person must satisfy is $300 unti the famiy as a whoe reaches the new $900 maximum. If you are in a POS or PPO-type pan, there is an additiona out-of-network deductibe of $400 per member, up to a maximum of $800 per famiy; this is a separate charge from the in-network deductibe. Q I ve aready satisfied my caendar year deductibe; wi I need to pay more toward my deductibe in 2015? A Yes. If you aready paid $250 for your individua caendar year deductibe, you wi be subject to another $50 for the rest of the 2015 caendar year. Two-person famiies and famiies of three or more peope that have met their deductibe may incur an additiona $100 or $150, respectivey. The caendar year deductibe wi transition to a fisca year deductibe next year to make it easier to change heath pan carriers at Annua Enroment. Here s how this wi work: For Caendar Year 2015: The deductibe wi remain on a caendar year. For January June 2016, there wi be a haf-year deductibe: Individua: The individua wi have a $150 deductibe before benefits begin. Two-person famiy: Each person must satisfy a $150 deductibe. Three- or more person famiy: The maximum each person must satisfy is $150 unti the famiy as a whoe reaches the six-month $450 maximum. Effective Juy 1, 2016: the deductibe year wi run Juy 1, 2016 June 30, Q If I change pans during this Annua Enroment, am I subject to another deductibe? A You wi not be subject to a new deductibe if: You stay with the same heath pan carrier but switch to one of its other options. You wi be subject to a new deductibe this annua enroment ony if: You enro in a heath pan with a different GIC heath pan carrier. 7

10 DEDUCTIBLE CHANGES AND QUESTIONS & ANSWERS Q Wi the deductibe-reated charges that I incur in October December 2015 be appied toward my haf-year caendar year deductibe that begins January 1, 2016? A No. The carryover provision has been eiminated. Q Which heath care services are subject to the deductibe? A The ists beow summarize expenses that generay are and are not subject to the annua deductibe. These are not exhaustive ists. You shoud check with your heath pan for detais. As with a benefits, variations in the guideines beow may occur, depending upon individua patient circumstances and a pan s schedue of benefits. Exampes of in-network expenses generay exempt from the deductibe: Prescription drug benefits Outpatient menta heath/substance abuse benefits Office visits (primary care physician, speciaist, retai cinics, preventive care, maternity and we baby care, routine eye exam, occupationa therapy, physica therapy, chiropractic care and speech therapy) Medicay necessary chid and adut immunizations Medicay necessary wigs Hearing aids Mammograms Pap smears EKGs Exampes of in-network expenses generay subject to the deductibe: Emergency room visits Inpatient hospitaization Surgery Laboratory and bood tests X-rays and radioogy (incuding high-tech imaging such as MRI, PET and CT scans) Durabe medica equipment Q How wi I know how much I need to pay out of pocket? A Upon request, pans are required to te you before you incur charges the amount you wi be required to pay. Ca your pan or visit their website to get this information. When you visit a doctor or hospita, the provider shoud ask you for your copay upfront. After you receive services, your heath pan may provide you with an Expanation of Benefits, or you can ca your pan to find out which additiona portion of the costs you wi be responsibe for. The provider wi then bi you for any baance owed. 8

11 STATE EMPLOYEE HEALTH PLAN RATES GIC PLAN RATES as of Juy 1, 2015 Compare the rates of these pans with the other options and see how much you wi save every month! For Empoyees Hired Before Juy 1, 2003 For Empoyees Hired On or After Juy 1, % 25% Empoyee Pays Monthy Empoyee Pays Monthy BASIC LIFE INSURANCE ONLY $5,000 Coverage $1.26 $1.58 HEALTH PLAN (Premium incudes Basic Life Insurance) PLAN TYPE INDIVIDUAL FAMILY INDIVIDUAL FAMILY Faon Heath Direct Care HMO $ $ $ $ Faon Heath Seect Care HMO Harvard Pigrim Independence Pan POS Harvard Pigrim Primary Choice Pan HMO Heath New Engand HMO NHP Prime (Neighborhood Heath Pan) HMO Tufts Heath Pan Navigator POS Tufts Heath Pan Spirit UniCare State Indemnity Pan/Basic with CIC * (Comprehensive) UniCare State Indemnity Pan/Basic without CIC (Non-Comprehensive) UniCare State Indemnity Pan/ Community Choice EPO (HMO-type) Indemnity Indemnity PPO-type UniCare State Indemnity Pan/PLUS PPO-type * CIC is an enroee-pay-a benefit. The House 1 budget proposes changing a EMPLOYEE contributions to 25% regardess of date of hire. However, whether or not this takes pace wi not be known unti the Commonweath s FY16 budget is enacted. Pease keep this in mind as you are weighing your heath pan options. For other things to consider, see page 2. 9

12 PRESCRIPTION DRUG BENEFITS Drug Copayments A GIC heath pans provide benefits for prescription drugs using a three-tier copayment structure in which your copayments vary, depending on the drug dispensed. Contact the pans you are considering with questions about your specific medications. TIER 1: You pay the owest copayment. This tier is primariy made up of generic drugs, athough some brand name drugs may be incuded. Generic drugs have the same active ingredients in the same strength as their brand name counterparts. Brand name drugs are amost aways significanty more expensive than generics. TIER 2: You pay the mid-eve copayment. This tier is primariy made up of brand name drugs, seected based on reviews of the reative safety, effectiveness and cost of the many brand name drugs on the market. Some generics may aso be incuded. TIER 3: You pay the highest copayment. This tier is primariy made up of brand name drugs not incuded in Tiers 1 or 2. Generic or brand name aternatives for Tier 3 drugs may be avaiabe in Tiers 1 or 2. Tip for Reducing Your Prescription Drug Costs Use Mai Order: Are you taking prescription drugs for a ong-term condition, such as asthma, high bood pressure, or high choestero? Switch your prescription from a retai pharmacy to mai order. It can save you money $5-$30 for three months of medication, depending on the tier. See the at-a-gance chart on pages for copay detais. Prescription Drug Programs Some GIC pans have the foowing programs to encourage the use of safe, effective and ess costy prescription drugs. Contact the pans you are considering to find out detais about these programs: Mandatory Generics When fiing a prescription for a brand name drug for which there is a generic equivaent, you wi be responsibe for the cost difference between the brand name drug and the generic, pus the generic copay. Step Therapy This program requires enroees to try effective, ess costy drugs before more expensive aternatives wi be covered. Maintenance Drug Pharmacy Seection If you receive 30-day suppies of your maintenance drugs at a retai pharmacy, you must ca your prescription drug pan to te them whether you wish to continue to use a retai pharmacy or change to 90-day suppies through either mai order or certain retai pharmacies. Speciaty Drug Pharmacies If you are prescribed injected or infused speciaty drugs, you may need to use a speciaty pharmacy which can provide you with 24-hour cinica support, education and side effect management. Medications are deivered to your home or doctor s office. Once you begin mai order, you can convenienty order refis by phone or onine. Contact your pan for detais. UniCare Prescription Drug Formuary and Prior Authorization Change Effective Juy 1, 2015 To contro escaating prescription drug costs, the GIC is moving to a new formuary for a UniCare members. Certain high-cost drugs with ower-cost aternatives wi ony be covered based on medica necessity. Prior authorization wi be required. For additiona detais, contact CVS/caremark. 10

13 LIMITED NETWORK PLANS Great Vaue; Quaity Coverage Consider Enroing in a Limited Network Pan to Save Money Every Month on Your Premiums! Limited network pans hep address differences in provider costs. You wi enjoy the same benefits as the wider network pans, but wi save money because imited network pans have a smaer network of providers (fewer doctors and hospitas). Your savings depend on: The pan you are switching from, The pan you seect, Your premium contribution percentage, and Whether you have individua or famiy coverage. For exampe, if you pay 25% of the premium and have individua coverage, by enroing in a imited network pan instead of a wide network pan, you wi save, on average, $50 per month and $600 per year. See page 9 to determine what the savings woud be for the pans you are considering. Find out if your hospita is in a GIC imited network pan The GIC has a side-by-side comparison of the six imited network pans and their participating hospitas on our website: For participating physician and other provider detais, contact the individua pans by phone or visit their website (see page 28). The GIC s imited network pans are: Faon Heath Direct Care an HMO avaiabe throughout centra Massachusetts, Metro West, Middesex County, the North Shore and the South Shore. The pan incudes 28 area hospitas and another six Peace of Mind hospitas in Boston that provide second opinions and care for very compex cases. Harvard Pigrim Primary Choice Pan an HMO with a network of 55 hospitas. The pan is avaiabe throughout Massachusetts, except for Cape Cod, Martha s Vineyard, Nantucket, and parts of Berkshire County. Heath New Engand a western and centra Massachusettsbased HMO that incudes 20 Massachusetts hospitas. NHP Prime (Neighborhood Heath Pan) an HMO with a provider network that incudes community heath centers, independent medica groups and hospita group practices, as we as 56 hospitas. NHP Prime is avaiabe across most of the state except for Berkshire, Frankin, and Hampshire Counties. Tufts Heath Pan Spirit an EPO (HMO-type) pan with a network of 54 hospitas. The pan is avaiabe throughout Massachusetts, except for Martha s Vineyard, Nantucket and parts of Berkshire and Hampshire Counties. UniCare State Indemnity Pan/Community Choice a PPOtype pan with a network of 55 hospitas. A Massachusetts physicians participate. The pan is avaiabe throughout Massachusetts, except for Martha s Vineyard and Nantucket. Your Responsibiity Before You Enro in a Pan Once you choose a pan, you cannot change heath pans during the year, uness you move out of the pan s service area. If your doctor or hospita eaves your heath pan, you must find a new participating provider in your chosen pan. Check if your doctors participate in the pan. Find out if the doctors affiiated hospitas are in the pan. Keep in Mind: Doctors and hospitas can eave a pan during the year, usuay because of heath pan and provider contract issues, practice mergers, retirement or reocation. 11

14 LIMITED NETWORK HEALTH PLANS Faon Heath Direct Care HMO Faon Heath Direct Care is an HMO that provides coverage through the pan s network of doctors, hospitas and other providers. Members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists. The pan offers a seective network based in a geographicay concentrated area. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist Tiering Effective Juy 1, 2015, Faon Heath Direct Care wi tier the foowing speciaists based on quaity and/or cost efficiency: Aergists/Immunoogists, Cardioogists, Endocrinoogists, Gastroenteroogists, Hematoogists/Oncoogists, Nephroogists, Neuroogists, Obstetricians/Gynecoogists, Orthopedists, Otoaryngoogists (ENTs), Podiatrists, Pumonoogists, Rheumatoogists, and Uroogists. Members wi pay ower copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see how your provider is rated. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Harvard Pigrim Primary Choice Pan HMO The Harvard Pigrim Primary Choice Pan, administered by Harvard Pigrim Heath Care, is an HMO pan that provides coverage through the pan s network of doctors, hospitas and other providers. Members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, and Rheumatoogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see if your provider is in the network and how he/she is rated. The pan aso tiers hospitas based on quaity and/or cost; members pay a ower inpatient hospita copay when they use Tier 1 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Heath New Engand HMO Heath New Engand is an HMO that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Provider (PCP) to manage their care; referras to network speciaists are not required. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist Tiering Heath New Engand tiers the foowing speciaists based on quaity and/or cost efficiency: Cardioogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Obstetricians/ Gynecoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, and Rheumatoogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see how your provider is rated. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Speciaist and Hospita Tiering Harvard Pigrim Heath Care tiers the foowing Massachusetts speciaists based on quaity and/or cost efficiency: Aergists/Immunoogists, Cardioogists, Dermatoogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Neuroogists, Obstetricians/Gynecoogists, Ophthamoogists, 12

15 LIMITED NETWORK HEALTH PLANS NHP Prime (Neighborhood Heath Pan) HMO NHP Prime, formery known as NHP Care, is administered by Neighborhood Heath Pan. The pan is an HMO that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist Tiering Neighborhood Heath Pan tiers the foowing speciaists based on quaity and/or cost efficiency: Cardioogists, Endocrinoogists, Gastroenteroogists, Obstetricians/ Gynecoogists, Otoaryngoogists (ENTs), Orthopedists, Pumonoogists, and Rheumatoogists. Members pay ower office visit copays when they see Tier 1 and Tier 2 speciaists. Contact the pan to see how your provider is rated. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Tufts Heath Pan Spirit EPO (HMO-type) Tufts Heath Pan Spirit is an Excusive Provider Organization (EPO) pan that provides coverage through the pan s network of doctors, hospitas and other providers. The pan encourages members to seect a Primary Care Provider (PCP). The menta heath benefits of this pan are administered by Beacon Heath Options. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist and Hospita Tiering Tufts Heath Pan tiers the foowing Massachusetts speciaists based on quaity and/or cost efficiency: Cardioogists, Dermatoogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Neuroogists, Obstetricians/Gynecoogists, Ophthamoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, Rheumatoogists, and Uroogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see if your provider is in the network and how he/she is rated. The pan aso tiers hospitas based on quaity and/or cost; members pay a ower inpatient hospita copay when they use Tier 1 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. UniCare State Indemnity Pan/ Community Choice PPO-Type The UniCare State Indemnity Pan/Community Choice is a PPOtype pan with a hospita network based at community and some tertiary hospitas at 100% coverage, after a copayment. Or, you may seek care from an out-of-network hospita for 80% coverage of the aowed amount for inpatient care and outpatient surgery, after you pay a copay. Contact the pan to find out if your hospita is in the network. The pan offers access to a Massachusetts physicians and members are encouraged to seect a Primary Care Provider (PCP). The menta heath benefits of this pan, administered by Beacon Heath Options, offer you a choice of using network providers and paying a copayment, or seeking care from out-of-network providers at higher out-of-pocket costs. Prescription drug benefits are administered by CVS/caremark. Speciaist Tiering UniCare tiers Massachusetts speciaists based on quaity and/or cost efficiency. Members pay ower office visit copays when they see Tier 1 and Tier 2 speciaists. Contact the pan to see how a physician is rated. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. 13

16 BENEFITS AT-A-GLANCE Heath Pan Copays and Deductibes This chart is a comparative overview of GIC pan benefits. See the correspon Pan Navigator, and UniCare State Indemnity Pan/Community Choice and PL With the exception of emergency care, there are no out-of-network benefits HEALTH PLAN FALLON HEALTH DIRECT CARE FALLON HEALTH SELECT CARE HARVARD PILGRIM INDEPENDENCE PLAN HARVARD PILGRIM PRIMARY CHOICE PLAN HEALTH NEW ENGLAND PLAN TYPE HMO HMO POS HMO HMO PCP Designation Required Yes Yes Yes Yes Yes PCP Referra to Speciaist Required Out-of-pocket Maximum Individua coverage Yes Yes Yes Yes No $5,000 $5,000 $5,000 $5,000 $5,000 Famiy coverage $10,000 $10,000 $10,000 $10,000 $10,000 Caendar Year Deductibe Individua Two-person famiy Three- or more person famiy $300 $600 $900 $300 $600 $900 Primary Care Provider Office Visit $15 per visit $20 per visit $20 per visit $20 per visit $20 per visit Preventive Services Speciaist Physician Office Visit HHH Tier 1 (exceent) HH Tier 2 (good) H Tier 3 (standard) Most covered at 100% no copay $30 per visit $60 per visit $90 per visit Most covered at 100% no copay $30 per visit $60 per visit $90 per visit 14 $300 $600 $900 Most covered at 100% no copay $30 per visit $60 per visit $90 per visit $300 $600 $900 Most covered at 100% no copay $30 per visit $60 per visit $90 per visit $300 $600 $900 Most covered at 100% no copay $30 per visit $60 per visit $90 per visit Retai Cinic $15 per visit $20 per visit $20 per visit $20 per visit $20 per visit Outpatient Menta Heath & Substance Abuse Care $15 per visit $20 per visit $20 per visit $20 per visit $20 per visit Emergency Room Care $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) Inpatient Hospita Care Medica Tier 1 Tier 2 Tier 3 Outpatient Surgery High-Tech Imaging (e.g., MRI, CT and PET scans) Prescription Drug Retai: up to a 30-day suppy Tier 1 Tier 2 Tier 3 Mai-order: Maintenance drugs up to a 90-day suppy Tier 1 Tier 2 Tier 3 $275 per admission with no tiering $250 per occurrence $275 per admission $500 per admission $1,500 per admission $250 per occurrence $275 per admission $500 per admission $1,500 per admission $250 per occurrence Maximum one copay per person per caenda $275 per admission $500 per admission No Tier 3 $250 per occurrence $275 per admission with no tiering Maximum four copays per caendar $250 per occurrence Maximum $100 per scan $100 per scan $100 per scan $100 per scan $100 per scan $10 $30 $65 $25 $75 $165 The amounts and terms that appear in bod in this chart are benefits that have changed effective Juy 1, $10 $30 $65 $25 $75 $165 $10 $30 $65 $25 $75 $165 $10 $30 $65 $25 $75 $165 $10 $30 $65 $25 $75 $165 Out-of-pocket maximums appy to medica and menta heath benefits across a heath pans. Prescription dru maximums in a heath pans except UniCare, which has one out-of-pocket maximum for medica & menta hea

17 ding overview information for each pan for more information. Benefits described beow for the Harvard Pigrim Independence Pan, Tufts Heath S are in-network benefits with PCP referra where required. These pans aso offer out-of-network benefits with higher out-of-pocket costs. for the GIC s EPO and HMOs. For providers, benefit detais, excusions, and imitations, see the pan handbook or contact the individua pan. NHP PRIME (Neighborhood Heath Pan) TUFTS HEALTH PLAN NAVIGATOR TUFTS HEALTH PLAN SPIRIT UNICARE STATE INDEMNITY PLAN/BASIC WITH CIC (Comprehensive)* UNICARE STATE INDEMNITY PLAN/ COMMUNITY CHOICE UNICARE STATE INDEMNITY PLAN/PLUS HMO POS EPO (HMO-TYPE) INDEMNITY PPO-TYPE PPO-TYPE Yes Yes No No No No Yes Yes No No No No $5,000 $10,000 $5,000 $10,000 $5,000 $10,000 $4,000 medica & menta heath/$1,500 Rx $8,000 medica & menta heath/$3,000 Rx $4,000 medica & menta heath/$1,500 Rx $8,000 medica & menta heath/$3,000 Rx $4,000 medica & menta heath/$1,500 Rx $8,000 medica & menta heath/$3,000 Rx $300 $600 $900 $300 $600 $900 $300 $600 $900 $300 $600 $900 $300 $600 $900 $300 $600 $900 $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit Most covered at 100% no copay Most covered at 100% no copay Most covered at 100% no copay Most covered at 100% no copay Most covered at 100% no copay $15 per visit for Centered Care PCPs; $20 per visit for other PCPs Most covered at 100% no copay $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) year quarter. Waived if readmitted within 30 days in the same caendar year. $100 per visit (waived if admitted) $100 per visit (waived if admitted) $275 per admission with no tiering $275 per admission $500 per admission $1,500 per admission $300 per admission $700 per admission No Tier 3 quarter or per year, depending on pan. Contact the pan for detais. $250 per occurrence $250 per occurrence $250 per occurrence $275 per admission with no tiering $250 per occurrence $275 per admission with no tiering $110 per occurrence $275 per admission $500 per admission $1,500 per admission Tier 1 and Tier 2: $110 per occurrence; Tier 3: $250 per occurrence one copay per day. Contact the pan for detais. $100 per scan $100 per scan $100 per scan $100 per scan $100 per scan $100 per scan $10 $30 $65 $10 $30 $65 $10 $30 $65 $10 $30 $65 $10 $30 $65 $10 $30 $65 $25 $75 $165 $25 $75 $165 $25 $75 $165 $25 $75 $165 $25 $75 $165 $25 $75 $165 g (Rx) benefits are incuded in the out-of-pocket th and a separate maximum for prescription drugs. * Without CIC, deductibes are higher and coverage is ony 80% for some services. Contact the pan for detais. 15

18 HEALTH PLAN LOCATOR MAP Where You Live Determines Which Pan You May Enro In. Is the Heath Pan Avaiabe Where You Live? MAINE Independence, Basic, PLUS NEW HAMPSHIRE VERMONT ESSEX MIDDLESEX FRANKLIN SUFFOLK Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Direct, Seect, Choice, PLUS Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Independence*, Navigator*, Basic Seect*, Independence, Navigator*, Basic, PLUS Seect, Independence, Primary Choice, HNE, Navigator, Spirit, Basic, Community Choice, PLUS NEW YORK WORCESTER Independence*, Navigator*, Basic BERKSHIRE Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS HAMPSHIRE NORFOLK Direct, Seect, Independence, Primary Choice, HNE, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Direct*, Seect, Independence, Primary Choice, HNE, Navigator, Spirit*, Basic, PLUS, Community Choice Seect, Independence, Primary Choice*, HNE, Navigator, Spirit*, Basic, Community Choice, PLUS HAMPDEN PLYMOUTH Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Direct*, Seect, Independence, Primary Choice, HNE, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS BRISTOL Independence, NHP, Navigator, Spirit, Basic, Community Choice, PLUS RHODE ISLAND CONNECTICUT Independence*, HNE*, Navigator*, Basic, PLUS* BARNSTABLE Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Independence, Navigator, Basic, PLUS DUKES Independence, NHP, Navigator, Basic, PLUS NANTUCKET Independence, NHP, Navigator, Basic, PLUS MAP KEY The UniCare State Indemnity Pan/Basic is the ony heath pan offered by the GIC that is avaiabe throughout the United States and outside of the country. Navigator Tufts Heath Pan Navigator Spirit Tufts Heath Pan Spirit Basic UniCare State Indemnity Pan/Basic Community Choice UniCare State Indemnity Pan/Community Choice PLUS UniCare State Indemnity Pan/PLUS Direct Faon Heath Direct Care Seect Faon Heath Seect Care Independence Harvard Pigrim Independence Pan Primary Choice Harvard Pigrim Primary Choice Pan HNE Heath New Engand NHP NHP Prime (Neighborhood Heath Pan) * Not every city and town is covered in this county or state; contact the pan to find out if you ive in the service area. The pan aso has a imited network of providers in this county or state; contact the pan to find out which doctors and hospitas participate in the pan. 16

19 WIDE NETWORK HEALTH PLANS Faon Heath Seect Care HMO Faon Heath Seect Care is an HMO that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist and Hospita Tiering Faon Heath tiers the foowing speciaists based on quaity and/or cost efficiency: Aergists/Immunoogists, Cardioogists, Endocrinoogists, Gastroenteroogists, Hematoogists/ Oncoogists, Nephroogists, Neuroogists, Obstetricians/ Gynecoogists, Orthopedists, Otoaryngoogists (ENTs), Podiatrists, Pumonoogists, Rheumatoogists, and Uroogists. Members pay ower copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see how your provider is rated. The pan aso tiers hospitas based on quaity and/or cost; members pay a ower inpatient hospita copay when they use Tier 1 or Tier 2 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Harvard Pigrim Independence Pan POS Effective Juy 1, 2015, the Harvard Pigrim Independence Pan, administered by Harvard Pigrim Heath Care, wi become a POS pan that provides coverage for treatment by a network of doctors, hospitas and other heath care providers. Members must seect a PCP to manage their care and obtain referras to speciaists to receive care at the in-network eve of coverage. It aso aows treatment by out-of-network providers or in-network care without a Primary Care Provider (PCP) referra, but with higher out-ofpocket costs. Speciaist and Hospita Tiering Harvard Pigrim Heath Care tiers the foowing Massachusetts speciaists based on quaity and/or cost efficiency: Aergists/ Immunoogists, Cardioogists, Dermatoogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Neuroogists, Obstetricians/Gynecoogists, Ophthamoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, and Rheumatoogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see if your provider is in the network and how he/she is rated. The pan aso tiers hospitas based on quaity and/or cost. Members pay a ower inpatient hospita copay when they use Tier 1 or Tier 2 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Harvard Independence and Tufts Navigator wi become POS Pans Effective Juy 1, New PCP & Referra Requirements Has the same wide network of doctors, hospitas and other providers and incudes out-of-network benefits as the current PPO offering does. Requires a PCP designation and referras from your PCP for speciaty care. If you do not get a referra to a speciaist, you wi have heath care benefits, but with higher out-ofpocket costs. 17

20 WIDE NETWORK HEALTH PLANS Tufts Heath Pan Navigator POS Effective Juy 1, 2015, Navigator by Tufts Heath Pan wi become a POS pan that provides coverage for treatment by a network of doctors, hospitas and other heath care providers. Members must seect a PCP to manage their care and obtain referras to speciaists to receive care at the in-network eve of coverage. It aso aows treatment by out-of-network providers or in-network care without a Primary Care Provider (PCP) referra, but at higher out-of-pocket costs. The menta heath benefits of this pan, administered by Beacon Heath Options, offer you in-network benefits with a copay. Or, you may seek care from out-of-network providers, but with higher out-of-pocket costs. Speciaist and Hospita Tiering Tufts Heath Pan tiers the foowing Massachusetts speciaists based on quaity and/or cost efficiency: Cardioogists, Dermatoogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Neuroogists, Obstetricians/Gynecoogists, Ophthamoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, Rheumatoogists, and Uroogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see if your provider is in the network and how he/she is rated. The pan aso tiers hospitas based on quaity and/or cost. Effective Juy 1, 2015, the pan wi change from two to three hospita tiers. Members pay a ower inpatient hospita copay when they use Tier 1 or Tier 2 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. UniCare State Indemnity Pan/Basic Indemnity The UniCare State Indemnity Pan/Basic offers access to any icensed doctor or hospita throughout the United States and outside of the country. The pan determines aowed amounts for out-of-state providers; you may be responsibe for a portion of the tota charge. To avoid these additiona provider charges, if you use non-massachusetts doctors or hospitas, contact the pan to find out which doctors and hospitas in your area participate in UniCare s nationa network of providers. paying a copayment, or seeking care from out-of-network providers at higher out-of-pocket costs. Prescription drug benefits are administered by CVS/caremark. Speciaist Tiering UniCare tiers Massachusetts speciaists based on quaity and/or cost efficiency. Massachusetts members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see how a physician is rated. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare are eigibe. UniCare State Indemnity Pan/PLUS PPO-Type The UniCare State Indemnity Pan/PLUS is a PPO-type pan that provides access to a Massachusetts physicians and hospitas and out-of-state UniCare providers at 100% coverage, after a copayment. Out-of-state non-unicare providers have 80% coverage of aowed charges. Members are encouraged to seect a Primary Care Provider (PCP) to manage their care and pay a ower copay if they see a Centered Care PCP. Contact the pan to find out if your PCP is a Centered Care provider. The menta heath benefits of this pan, administered by Beacon Heath Options, offer you a choice of using network providers and paying a copayment, or seeking care from out-of-network providers at higher out-of-pocket costs. Prescription drug benefits are administered by CVS/caremark. Speciaist and Hospita Tiering UniCare tiers Massachusetts speciaists based on quaity and/or cost efficiency. Members pay ower office visit copays when they see Tier 1 and Tier 2 speciaists. Contact the pan to see how a physician is rated. The pan aso tiers hospitas based on quaity and/or cost; members pay a ower inpatient hospita and outpatient surgery copay when they use Tier 1 or Tier 2 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. The menta heath benefits of this pan, administered by Beacon Heath Options, offer you a choice of using network providers and 18