OHSU HEALTH OPTIONS RETIREE PROGRAM SELECTION GUIDE

Transcription

1 OHSU HEALTH OPTIONS RETIREE PROGRAM SELECTION GUIDE SELECTION AND ELIGIBILITY INFORMATION 2006 Where Healing, Teaching and Discovery Come Together

2 Contact List If you have questions Call this Or visit about a plan... number... this Web site... All Benefit Options BenefitHelp Solutions OHSU Human Resources Department Benefits Office Medical Options and Group Plan Numbers OHSU PPO Regence BCBSO 250 Regence BCBSO 60/50 GPN Kaiser Permanente GPN-8553 Medicare Supplement Blue Cross Companion F GPN Medicare Part D (Prescription) Asuris Medicare Script PharmaCare (Preferred Drug Plan) GPN Vision Service Plan (VSP) GPN Dental Options Oregon Dental Service (ODS) GPN-N994 Kaiser Permanente GPN-8553 Willamette Dental Insurance Inc. GPN-Z144 Call... In Portland: Outside Portland: In and outside Portland: Call... In Portland: Outside Portland: In Portland: Outside Portland: In Portland: Outside Portland: In and outside Portland: In and outside Portland: Call... In Portland: Outside Portland: In Portland: Outside Portland: In Portland: Outside Portland: Visit the Web site at Not available Visit the Web site at... (OHSU PPO providers) (provider and benefit books) (click on Need Coverage, then Medicare Coverage, then Companion Plans) Visit the Web site at

3 3 Remember You must return a completed enrollment form within the timelines listed in the enrollment periods. The mailing address for OHSU plans is: BenefitHelp Solutions P.O. Box Portland, Oregon The mailing address for PERS plans is: Oregon Public Employees Retirement System P.O. Box Portland, Oregon

4 4 Table of Contents Introduction...5 Health Plan Options...5 Enrollment Periods...6 For More Information...6 Medical and Dental Plan Costs...7 Insurance Plan Features...10 Eligibility Guidelines...14 Qualified Dependents...14 Qualified Family Status Change...14 Highlights of Medical Plan Options for OHSU Retirees...15 Highlights of Dental Plan Options for OHSU Retirees...24 Medicare Supplement...27 Contact List...30

5 5 Introduction Health Plan Options Employees who are retiring from OHSU have multiple options for continuing insurance coverage when active group coverage no longer is available. This guide provides a summary of the medical and dental plans available to employees upon retirement from OHSU. Your medical and dental options depend on your or your dependents eligibility for Medicare. You may elect medical and dental coverage under most options. However, the individual Medicare plans available through OHSU do not offer a dental plan option. Dependents may be covered on the plans available under your retiree plan as long as your dependents were enrolled on your active plan or are consistent with a qualified family status change. Non-Medicare-eligible options are: OHSU-sponsored retiree health plans PERS-sponsored retiree health plans Medical Options 3 PPOs OHSU PPO Regence BCBSO 250 Regence BCBSO 60/50 1 HMO Kaiser Permanente Dental Options Traditional Oregon Dental Service (ODS) Managed Care Kaiser Permanente Willamette Dental Insurance Inc. Medicare-eligible options are: Individual Medicare plans (without dental) PERS-sponsored retiree health plans, if eligible If you are Medicare-eligible and your spouse/dependent is non-medicare-eligible, your spouse/dependent may continue in an OHSU or PERS retiree plan, provided your spouse/dependent had continuous OHSU coverage. This guide provides an overview of the medical and dental insurance plan options available to employees upon retirement from OHSU. Every effort has been made to ensure that the information presented in this guide is accurate. In all cases, however, it will be administered in accordance with the governing plan documents, insurance contracts, and applicable federal and state regulations. OHSU reserves the right to correct or revise this information as necessary.

6 6 Affidavit of Domestic Partnership You must return a completed Affidavit of Domestic Partnership before coverage under UniversityFlex will begin for your same-sex or opposite-sex domestic partner. This document is available from the Human Resources Department Benefits Office. The affidavit certifies that you and your domestic partner meet the listed requirements of a qualifying domestic partnership. This form must be signed by you and also must be signed and witnessed by a notary public. Enrollment Periods Enrollment timelines in the retiree plans will vary according to the option you select. A summary of the enrollment periods are: OHSU: You must enroll prior to losing other OHSU-sponsored coverage. PERS: Enrollment periods are described in the PERS Health Insurance Program booklet. Individual Medicare plan: Enrollment periods may vary according to the plan you select. Some plans require enrollment up to 60 days before you turn age 65. For More Information If you would like more information on the health benefits options available through OHSU, including a provider directory, you may contact the medical or dental providers directly. Telephone numbers and Web sites are listed on the inside back cover. You also may call: OHSU s Human Resources Department Benefits Office, PERS, or BenefitHelp Solutions, or

7 7 Medical and Dental Plan Costs Health plan options include four medical plans and three dental plans. Options differ primarily in terms of monthly costs, choice of physicians and payment of benefits. Health Options for OHSU Non-Medicare Retirees Coverage Option Plan Type Medical (Includes vision and Preferred Provider Organizations OHSU PPO prescription drug Regence BCBSO 250 benefits) Regence BCBSO 60/50 Health Maintenance Organization Kaiser Permanente (Available only to AFSCME-represented employees hired before Oct. 1, 1998, and ONA-represented and unclassified employees hired before Jan. 1, 1998.) Dental Traditional Plan Oregon Dental Service (ODS) Managed Care Plans Kaiser Permanente Willamette Dental Insurance Inc.

8 Monthly Costs for OHSU Non-Medicare Retiree Coverage Plan Individual Individual Individual Individual Only and Spouse/ and and Domestic Child(ren) Family Partner Medical OHSU PPO $ $ $ $ Regence BCBSO Regence BCBSO 60/ Kaiser Permanente Note: Premiums include medical, prescription and vision coverage. Dental ODS Dental $40.31 $87.74 $97.98 $ Kaiser Permanente Dental Willamette Dental Insurance Inc.

9 9 Health Option for OHSU Medicare-Eligible Retirees Coverage Option Medicare Supplement Dental Option Regence BCBSO Companion F Not available 2006 Monthly Costs for OHSU Medicare-Eligible Retirees Individuals will receive separate ID cards for the medical and prescription plans. Plan Premium (per person, based on age) BCBSO Companion F Oregon: <70 $ $ $ $ $ Companion Plan F plus Medicare Part D Prescription Plan Washington: 65+ $ Retirees over age 65 are eligible for an OHSU premium contribution of $50 if they have at least eight years of service with OHSU. This contribution reduces the above premium rates by $50 for the retiree only. To compare the Medicare supplement plan: If you are PERS-eligible, visit the PERS Web site at or call in Portland; toll-free If you wish to compare plans in your area, visit the Web site Select Compare Health Plan Options in Your Area and enter your ZIP code for a list of plans, service areas, physician networks, costs and coverages.

10 Plan Feature BASICS OHSU Preferred Provider Plan (PPO) OHSU Provider Non-OHSU Provider 1 How the plan works What the plan pays for most covered services Annual deductible applies to all services unless otherwise noted Pays benefits for covered services from any qualified provider or hospital. To receive the highest level of benefits, you must use an OHSU preferred provider, hospital or clinic. 80%, after the deductible $200/person $600/family 60% of allowable charges, after the deductible Annual out-of-pocket maximum includes deductible $1,200/person $2,600/family $2,200/person $4,600/family Lifetime maximum benefit $2,000,000 IN THE DOCTOR S OFFICE Home and office visits 80% 60% of allowable charges Routine physicals (limited to the plan schedule) includes well child care 100% after $10 copayment, no deductible; up to $400 benefit per exam; up to one exam every 12 months for well child care (ages 2-18) 60% of allowable charges after $10 copayment; up to $400 benefit; up to one exam every 12 months for well child care (ages 2-18) OB/GYN annual exams Well baby care IN THE HOSPITAL Inpatient physician services Hospital/facility charges Emergency care OTHER COVERED SERVICES Maternity Chemical dependency Limits are per 24-month benefit period Outpatient Inpatient Mental Health Limits are per 24-month benefit period Outpatient Inpatient SERVICES PROVIDED BY OTHER PLANS Prescription Drug Benefits PharmaCare Preferred Drug Plan (PDP) Vision Benefits Vision Service Plan (VSP) Exam allowed every 12 months, lenses and frames every 24 months 100% after $15 copayment, no deductible subject to frequency limitations 100%, no deductible subject to frequency limitations 80% 80% $30 copayment, then 80%, copayment waived if admitted 80% 80%, up to $2,500 for children, $2,000 for adults 80%, up to $4,000 for children, $4,500 for adults 80%, up to 34 visits for children and adults 80%, up to 16 days for children and 15 days for adults Participating pharmacy Plan pays: Generic: 70% Preferred brand: 70% Non-preferred brand: 50% No deductible $1,000 out-of-pocket maximum per family $10 minimum copayment per prescription VSP providers: Exam paid in full; standard allowance for lenses and frames after $25 copayment; up to $140 allowance for elective contacts and exam No deductible 60% of allowable charges subject to frequency limitations 60% of allowable charges subject to frequency limitations 60% of allowable charges 60% of allowable charges $30 copayment, then 80% of allowable charges; copayment waived if admitted 60% of allowable charges 60% of allowable charges, up to $2,500 for children, $2,000 for adults 60% of allowable charges, up to $4,000 for children, $4,500 for adults 60% of allowable charges, up to 34 visits for children and adults 60% of allowable charges, up to 16 days for children and 15 days for adults Non-participating pharmacy Plan pays amount equivalent to PDP costs minus the applicable coinsurance amount No deductible $1,000 annual out-of-pocket maximum per family $10 minimum copayment per prescription Non-VSP providers: Exam reimbursed up to $42; lenses and frames partially reimbursed after $25 copayment; up to $140 allowance for elective contacts and exam No deductible

11 Plan Feature Regence BCBSO 250 (Preferred Provider Plan) BASICS Preferred Provider Non-preferred Provider How the plan works What the plan pays for most covered services Annual deductible applies to all services unless otherwise noted Pays benefits for covered services you receive from any qualified provider or hospital. To receive the highest level of benefits, you must use a Regence BCBSO Preferred Provider. 80%, after the deductible $250/person $750/family 60% of allowable charges, after the deductible Annual out-of-pocket maximum includes deductible $2,250/person $4,750/family $4,250/person $8,750/family Lifetime maximum benefit $2,000,000 IN THE DOCTOR S OFFICE Home and office visits Routine physicals (limited to the plan schedule) includes well child care OB/GYN annual exams Well baby care IN THE HOSPITAL Inpatient physician services Hospital/facility charges Emergency care OTHER COVERED SERVICES Maternity Chemical dependency Limits are per 24-month benefit period Outpatient Inpatient Mental Health Limits are per 24-month benefit period Outpatient Inpatient SERVICES PROVIDED BY OTHER PLANS Prescription Drug Benefits PharmaCare Preferred Drug Plan (PDP) Vision Benefits Vision Service Plan (VSP) Exam allowed every 12 months, lenses and frames every 24 months 80% 80%, no deductible; up to $400 benefit per exam; up to one exam every 12 months for well child care (ages 2-18) 100% after $15 copayment, no deductible subject to frequency limitations 100%, no deductible; up to 8 visits before age 2, subject to frequency limitations 80% 80% $30 copayment, then 80%, copayment waived if admitted 80% 80%, up to $2,500 for children, $2,000 for adults 80%, up to $4,000 for children, $4,500 for adults 80%, up to 34 visits for children and adults 80%, up to 16 days for children and 15 days for adults Participating pharmacy Plan pays: Generic: 70% Preferred brand: 70% Non-preferred brand: 50% No deductible $1,000 out-of-pocket maximum per family $10 minimum copayment per prescription VSP providers: Exam paid in full; standard allowance for lenses and frames after $25 copayment; up to $140 allowance for elective contacts and exam No deductible 60% of allowable charges 60% of allowable charges, no deductible; up to $400 benefit per exam; up to one exam every 12 months for well child care (ages 2-18) 100% after $15 copayment, no deductible subject to frequency limitations 100% of allowable charges, no deductible; up to 8 visits before age 2, subject to frequency limitations 60% of allowable charges 60% of allowable charges $30 copayment, then 80% of allowable charges, copayment waived if admitted 60% of allowable charges 60% of allowable charges, up to $2,500 for children, $2,000 for adults 60% of allowable charges, up to $4,000 for children, $4,500 for adults 60% of allowable charges, up to 34 visits for children and adults 60% of allowable charges, up to 16 days for children and 15 days for adults Non-participating pharmacy Plan pays amount equivalent to PDP costs minus the applicable coinsurance amount No deductible $1,000 annual out-of-pocket maximum per family $10 minimum copayment per prescription Non-VSP providers: Exam reimbursed up to $42; lenses and frames partially reimbursed after $25 copayment; up to $140 allowance for elective contacts and exam No deductible

12 Plan Feature Regence BCBSO 60/50 (Preferred Provider Plan) BASICS Preferred Provider Non-preferred Provider How the plan works What the plan pays for most covered services Pays benefits for covered services you receive from any qualified provider or hospital. To receive the highest level of benefits, you must use a Regence BCBSO Preferred Provider. 60% 50% of allowable charges, after the deductible Annual deductible applies to all services unless otherwise noted Annual out-of-pocket maximum includes deductible None $8,000/person $16,000/family None $10,000/person $20,000/family Lifetime maximum benefit $2,000,000 IN THE DOCTOR S OFFICE Home and office visits Routine physicals (limited to the plan schedule) includes well child care 60% 60%, up to $400 benefit per exam; up to one exam every 12 months for well child care (ages 2-18) 50% of allowable charges 50% of allowable charges, up to $400 benefit per exam; up to one exam every 12 months for well child care (ages 2-18) OB/GYN annual exams Well baby care IN THE HOSPITAL Inpatient physician services Hospital/facility charges Emergency care OTHER COVERED SERVICES Maternity Chemical dependency Limits are per 24-month benefit period Outpatient Inpatient Mental Health Limits are per 24-month benefit period Outpatient Inpatient SERVICES PROVIDED BY OTHER PLANS Prescription Drug Benefits PharmaCare Preferred Drug Plan (PDP) Vision Benefits Vision Service Plan (VSP) Exam allowed every 12 months, lenses and frames every 24 months 100% after $15 copayment subject to frequency limitations 60%; up to 8 visits before age 2 subject to frequency limitations 60% 60% $100 copayment (waived if admitted), then 100% 60% 60%, up to 36 visits for children, 25 visits for adults 60%, up to 27 days for children, 13 days for adults 60%, up to 34 visits for children and adults 60%, up to 16 days for children and 15 days for adults Participating pharmacy Plan pays: Generic: 70% Preferred brand: 70% Non-preferred brand: 50% No deductible $1,000 out-of-pocket maximum per family $10 minimum copayment per prescription VSP providers: Exam paid in full; standard allowance for lenses and frames after $25 copayment; up to $140 allowance for elective contacts and exam 50% of allowable charges subject to frequency limitations 50% of allowable charges; up to 8 visits before age 2, subject to frequency limitations 50% of allowable charges 50% of allowable charges $100 copayment (waived if admitted), then 100% 50% of allowable charges 50% of allowable charges, up to 36 visits for children, 25 visits for adults 50% of allowable charges, up to 27 days for children, 13 days for adults 50% of allowable charges, up to 34 visits for children and adults 50% of allowable charges, up to 16 days for children and 15 days for adults Non-participating pharmacy Plan pays amount equivalent to PDP costs minus the applicable coinsurance amount No deductible $1,000 annual out-of-pocket maximum per family $10 minimum copayment per prescription Non-VSP providers: Exam reimbursed up to $42; lenses and frames partially reimbursed after $25 copayment; up to $140 allowance for elective contacts and exam

13 Plan Feature BASICS Kaiser Permanente 1 How the plan works What the plan pays for most covered services Annual deductible applies to all services unless otherwise noted Annual out-of-pocket maximum includes deductible Lifetime maximum benefit IN THE DOCTOR S OFFICE Home and office visits Except for emergencies, all care must be provided by Kaiser Permanente s participating providers at Kaiser Permanente facilities. 100% after any applicable copayments None $1,000/person $2,000/family None 0 $15 copayment Routine physicals (limited to the plan schedule) includes well child care $15 copayment OB/GYN annual exams $15 copayment Well baby care $15 copayment, covered as necessary IN THE HOSPITAL Inpatient physician services Hospital/facility charges Emergency care Paid in full $200 copayment per admission $75 copayment at Kaiser and non-kaiser facilities (waived if admitted) OTHER COVERED SERVICES Maternity Covered the same as any other condition Chemical dependency Limits are per 24-month benefit period Outpatient $15 copayment, up to 40 visits Inpatient 80% up to $5,000 for children and $5,625 for adults Mental Health Limits are per 24-month benefit period Outpatient $15 copayment, up to 40 visits Inpatient $100 copayment per day up to $500 per stay, covered up to 16 days for children and adults Prescription Drug Benefits Benefit through Kaiser Permanente: $15 copayment per formulary prescription at Kaiser pharmacies Vision Benefits Exam allowed every 12 months, lenses and frames every 24 months Benefit through Kaiser Permanente: $15 copayment for exams (not limited). Lenses, frames and/or contacts covered up to $150 every 24 months.

14 14 Eligibility Guidelines Qualified Dependents Eligible dependents may vary by plan option. The OHSU retiree options generally include your: Legal spouse. Same-sex or opposite-sex domestic partner (upon submission of a signed Affidavit of Domestic Partnership). Unmarried children (including children of a domestic partner) less than 19 years of age or less than 24 years of age if the children are full-time students*. Child by adoption or court-ordered judgment. Disabled children aged 19 or older who are physically or mentally incapable of self-support. *Verification of full-time student status is required. Qualified Family Status Change Requests for changes to enrollment elections are limited to the 31-day period following a qualified family status change. A qualified family status change includes the following when loss of coverage results: Marriage or Affidavit of Domestic Partnership. Divorce or termination of domestic partnership. Birth or adoption of a child. Child by court-ordered judgment. Death of your spouse/domestic partner or other covered dependent. Change in employment status for you or your spouse/domestic partner. Please note that loss of coverage due to dropping coverage during a spouse/domestic partner s open enrollment or any other voluntary action by the retiree, spouse, domestic partner or other party is not a qualified family status change.

15 OHSU PPO OHSU PPO The OHSU PPO plan provides services through a network of OHSU preferred providers physicians, the hospital and clinics. When you need medical care, you can go to any physician, hospital or qualified provider (OHSU providers or non OHSU providers). The difference is you will receive a higher level of coverage when you use an OHSU provider. When you go to a non-ohsu provider, you will pay 40 percent of allowable charges for most services, and you may pay any amounts over and above the allowable charge. Allowable charges are charges that OHSU providers have agreed to accept as payment for medically necessary covered services. For the most current OHSU provider information, visit and click on Find a Doctor. You may also refer to the Employee Health Guide to OHSU. The OHSU PPO plan offers the same services as the Regence BCBSO 250 plan. However, the OHSU PPO plan has a lower deductible and out-of-pocket maximum. In addition, your monthly premiums will be lower if you participate in the OHSU PPO plan. Medical Bill Audit Program The OHSU PPO includes a Medical Bill Audit Program. If you find an error in your medical bills, you may receive up to 50 percent of the amount of the error if you convince the provider to correct the mistake. The minimum award is $25; the maximum award is $100. AdviCare A new disease management program providing educational materials, online tools and other services is available at no additional cost to enrollees of this plan. Exclusions and Limitations The following list shows some of the limitations and exclusions that apply to the OHSU PPO plan. For a complete list of limitations and exclusions, contact Regence BCBSO at Cosmetic surgery Treatment for obesity or weight control, including bariatric surgery Infertility services, including infertility drugs and in vitro fertilization Surgery to alter the refractive character of the eye Gender identity disorders Mental or developmental disabilities Counseling or treatment in the absence of illness Experimental or investigational services Treatment of any condition arising out of service in the armed forces of any country Some treatments for mental or nervous disorders, or chemical dependency, may be limited Orthognathic surgery for TMJ 15

16 16 Regence BCBSO 250 Regence BCBSO 250 Regence BCBSO 250 is a Preferred Provider Organization (PPO) plan. This means you can go to any physician, hospital or qualified provider (preferred or nonpreferred) when you need medical care for covered services. The difference is, you will receive a higher level of coverage and your outof-pocket expenses will be lower when you use a preferred provider. When you go to a nonpreferred provider under the Regence BCBSO 250 plan, you will pay 40 percent of allowable charges and you may have to pay any amounts over and above the allowable charges. Allowable charges are charges that Regence BCBSO 250 preferred providers have agreed to accept as payment for medically necessary covered services. When you receive covered services from Regence BCBSO 250 preferred providers, you are not responsible for any amounts that exceed allowable charges. For the most current provider directory, visit the Regence BCBSO Web site at You may also request a printed copy of the provider directory by calling Regence at or AdviCare A new disease management program providing educational materials, online tools and other services is available at no additional cost to enrollees of this plan. Medical Bill Audit Program Regence BCBSO 250 includes a Medical Bill Audit Program. If you find an error in your medical bills, you may receive up to 50 percent of the amount of the error if you convince the provider to correct the mistake. The minimum award is $25; the maximum award is $100. Exclusions and Limitations The following list shows some of the limitations and exclusions that apply to all the Regence plans. For a complete list of limitations and exclusions, contact Regence. Cosmetic surgery Treatment for obesity or weight control, including bariatric surgery Infertility services, including infertility drugs and in vitro fertilization Surgery to alter the refractive character of the eye Gender identity disorders Mental or developmental disabilities Counseling or treatment in the absence of illness Experimental or investigational services Treatment of any condition arising out of service in the armed forces of any country Some treatments for mental or nervous disorders, or chemical dependency, may be limited Orthognathic surgery for TMJ Exclusions and Limitations All the Regence plans offered by OHSU have the same exclusions and limitations.

17 Regence BCBSO 60/50 Regence BCBSO 60/50 Regence BCBSO 60/50 is a Preferred Provider Organization (PPO) plan. Of the Regence PPO plans available to OHSU employees, this one has the lowest monthly premium cost but the highest out-of-pocket costs. You may want to consider this coverage if you do not plan on using health plan benefits to a great extent. Regence BCBSO 60/50 offers the same large network of preferred providers as the Regence BCBSO 250 plan. When you need medical care, you can go to any physician, hospital or qualified provider (preferred or nonpreferred). The difference is, you will receive a higher level of coverage when you use a preferred provider. The plan pays 60 percent when you use a preferred provider and 50 percent when you use a nonpreferred provider. There is no deductible. When you go to a nonpreferred provider, you will pay 50 percent of allowable charges and you may pay any amounts over and above the allowable charges. Allowable charges are charges that preferred providers have agreed to accept as payment for medically necessary covered services. For the most current provider directory, visit the Regence BCBSO Web site at com. You may also request a printed copy of the provider directory by calling Regence at or AdviCare A new disease management program providing educational materials, online tools and other services is available at no additional cost to enrollees of this plan. Medical Bill Audit Program Regence BCBSO 60/50 includes a Medical Bill Audit Program. If you find an error in your medical bills, you may receive up to 50 percent of the amount of the error if you convince the provider to correct the mistake. The minimum award is $25; the maximum award is $100. Exclusions and Limitations The following list shows some of the limitations and exclusions that apply to the Regence plans. For a complete list of limitations and exclusions, contact Regence. Cosmetic surgery Treatment for obesity or weight control, including bariatric surgery Infertility services, including infertility drugs and in vitro fertilization Surgery to alter the refractive character of the eye Gender identity disorders Mental or developmental disabilities Counseling or treatment in the absence of illness Experimental or investigational services Treatment of any condition arising out of service in the armed forces of any country Some treatments for mental or nervous disorders, or chemical dependency, may be limited Orthognathic surgery for TMJ 17

18 18 Kaiser Permanente Kaiser Permanente Kaiser Permanente is available only to AFSCME-represented employees hired before Oct. 1, 1998, and ONA-represented, academic and unclassified employees hired before Jan. 1, Kaiser Permanente facilities are located in the Portland metropolitan area, and in Vancouver and Longview, Wash. Except for emergencies (a life- or limb-threatening situation) or by referral, you must receive services at a Kaiser facility or affiliated facility to be covered. Call Kaiser at or to request a list of Kaiser facilities. You also may visit Kaiser s Web site at Exclusions and Limitations The following list shows some of the limitations and exclusions that apply to the Kaiser Permanente plan. For a complete list, contact the insurance carrier. Treatment for obesity or weight control Reversal of sterilization Services to induce pregnancy, such as fertility drugs and in vitro fertilization Acupuncture Cosmetic surgery Experimental or investigational treatment Disabilities connected to military service Organ and bone marrow transplants (in some situations)

19 19 Vision Benefits Your vision care services are insured through Vision Service Plan (VSP). This applies to all plans except Kaiser Permanente, which will maintain its existing vision plan. You must use a VSP network doctor to receive the highest level of benefits. You can locate a VSP doctor by calling You also may visit the VSP Web site at to select a doctor. You must enter your member number (your Social Security number), last name and ZIP code to generate a personal network directory. You or your dependents may receive care for your vision needs through the excellent providers at OHSU s Casey Eye Institute. Both the contact lens and optical services at CEI participate in the VSP program. To schedule an eye exam, call for adults and for children up to age 16. VSP allows annual exams as well as additional vision-related benefits. Providers at Casey Eye Institute may be available to provide medical services related to illness, injury or disease not covered by VSP for patients with OHSU Preferred Provider Plan and Regence BlueCross BlueShield of Oregon insurance coverage. Once you have located a VSP doctor, you may call the office to make an appointment. You do not need an ID card to access services. Identify yourself as a VSP member and provide the covered member s Social Security number. The member physician will call VSP to verify eligibility and plan coverage.

20 20 VSP Benefits Services From a VSP Member Doctor Maximum Reimbursement for Services From Non-Member Doctors Examination Paid in full Paid up to $42 Every 12 months, from last date of service Materials $25 copayment; lenses and frames every 24 months from last date of service Single vision lenses Paid in Full $40 a pair Bifocal lenses Paid in Full $60 a pair Trifocal lenses Paid in Full $80 a pair Lenticular lenses Paid in Full $125 a pair Frames $115 retail $45 allowance Contact lenses (in lieu of lenses and a frame) Elective Up to $140 allowance Up to $140 allowance (materials copay does (materials copay does not apply) not apply) Medically necessary Paid in Full $210 Laser eye surgery Discounted fees are None available; call VSP or visit the VSP Web site for more information on discounts and participating laser eye surgery centers

21 21 Preferred Drug Plan: When you receive services from a VSP doctor, you will not need to submit a claim form. You will have no out-of-pocket expense other than your copayment, unless optional items are selected that are not covered. Optional items include, but are not limited to, oversized lenses, coated lenses, no-line multifocal lenses, or a frame that exceeds the wholesale allowance. If you obtain services from a non-vsp doctor, you must request reimbursement from VSP by submitting the bill to VSP within six months from your date of service. The copayment applies to both member and non-member services. Include the name, address, phone number and Social Security number of the member, as well as the patient s name, date of birth and relationship to the member. Include OHSU as your employer. Generic: 70% Preferred brand: 70% Non-preferred brand: 50% No deductible $1,000 out-of-pocket maximum per family $10 minimum copayment per prescription All prescriptions have a mandatory generic drug substitution, if available Examples 1. Bob purchases an $8 prescription drug. Bob s cost: $8 Plan benefit: $0 2. Bob purchases an $18 prescription drug. Bob s cost: $10 minimum copayment Plan benefit: $8 3. Bob purchases a $60 prescription drug. Bob s cost: $18 (30% of cost) Plan benefit: $42 (70% of cost)

22 22 Prescription Benefits Prescription drug benefits are administered through Pharma- Care. This applies to all medical plans except the Kaiser Permanente plan. You will receive a PharmaCare prescription drug card and a partial list of participating pharmacies when you enroll. You must present this card at a member pharmacy to receive the highest level of benefits. If you have a prescription filled by an out-of-network pharmacy, you will be required to pay the full cost of the prescription at the time of your purchase. You then must file a claim with PharmaCare to be reimbursed for covered medications. If you or one of your covered dependents regularly take medication for a chronic condition, you may receive up to a 90- day supply for two times your usual 30-day coinsurance amount if you use the mail service program or the OHSU Pharmacy. If you use the mail service program, your medication will be delivered postage-paid to your home address from PharmaCare. PharmaCare uses a preferred drug list. Your out-of-pocket cost for drugs on the preferred drug list is lower than for those drugs not on the list. The PharmaCare preferred drug list includes hundreds of brand-name and generic drugs. These drugs are selected for the preferred drug list based on the recommendations of practicing physicians and pharmacists using national treatment guidelines. OHSU representatives participated in the review of drugs selected for the PharmaCare preferred drug list. For more information about PharmaCare, a comprehensive list of participating pharmacies, the preferred drug list, or to order additional prescription drug cards, call PharmaCare at or visit the PharmaCare Web site at Click on Member Services for the Formulary Drug List.

23 23 Prescription Plan Limits With OHSU PPO and Regence BCBSO Medical Plans Days Supply Maximum supply through retail pharmacy: days Maximum supply through mail-order service or OHSU Pharmacy: days Required Utilization Prior to Refill Retail Pharmacy 0 10 days of supply: Refill after 50 percent utilization days of supply: Refill after 70 percent utilization days of supply: Refill after 80 percent utilization Mail-Order Service: Duration Expiration date of prescriptions: Refill after 60 percent utilization 365 days Maximum number of refills allowed: The lesser of one year or the number of refills stated on the prescription.

24 24 Highlights of Dental Plan Options for OHSU Retirees The chart on page 26 lists the main features of your dental plan op-tions. Please review the information carefully before selecting your dental plan. Oregon Dental Service ODS is a traditional dental plan. This means you may receive care from any licensed dentist. Please note that a small percentage of licensed dentists in Oregon do not participate in ODS. If you receive care from a nonparticipating dentist, you may pay more for covered services if the dentist charges more than ODS will pay. For more information about participating dentists, call ODS at or , or visit the ODS Web site at If you did not enroll your dependents in ODS when you first were eligible to participate, ODS will cover only emergency and preventive care during the first 12 months of coverage. In addition, you must wait 24 months to be eligible for orthodontia benefits. The plan also will not cover orthodontic work you received before you were eligible for benefits. Kaiser Permanente Kaiser Permanente is a managed dental care plan. This means you must receive dental treatment from a Kaiser dentist at a Kaiser Permanente office to receive benefits from the plan. Dental offices are located from Salem, Ore., to Longview, Wash. To see if there is a Kaiser Permanente dental office near you, call Kaiser Permanente at or and request a provider directory, or visit the Kaiser Web site at If you receive emergency dental care and are out of the Kaiser Permanente service area, you must pay the full cost. To request reimbursement for the cost of the care, you must submit a claim form and receipt to a Kaiser Permanente office. Kaiser Permanente will reimburse you for up to $100.

25 Willamette Dental Insurance Inc. Willamette Dental Insurance Inc. is a managed dental care plan. Willamette Dental administers and provides dental benefits through Willamette Dental Group (WDG) and Columbia Dental Group (CDG) primary care dentists. WDG and CDG have clinics throughout Oregon and Washington. When you enroll in the Willamette Dental Insurance plan, you may select a primary care dentist at any of the WDG or CDG clinics. You may choose different clinics or dentists for each family member. To find a WDG or CDG clinic or dentist near you, call Willamette Dental Insurance at or and request a provider directory, or visit the Willamette Dental Insurance Web site at If you require emergency dental care when you are out of the Willamette Dental Insurance service area, you pay the full cost. To request reimbursement for the cost of that care, you must submit a copy of your receipt to the Willamette Dental Insurance Patient Account Services Department. Willamette Dental Insurance will reimburse you for up to $150 in expenses. Follow-up care should be scheduled with your primary care dentist. 25 Things to Consider As you decide which dental plan is right for your individual and family situation, you may want to consider the following: Which dental plan best fits your family s needs? Do you require only annual exams and cleanings? Or do you anticipate any significant dental expenses in 2006, such as orthodontic services? Remember, ODS and Willamette Dental Insurance provide orthodontic benefits; Kaiser Permanente does not offer those benefits. Are Kaiser Permanente and Willamette Dental Insurance dentists conveniently located for you? Is it important to have the freedom to choose any dentist? Under ODS, you can see any licensed dentist, but your out-of-pocket costs usually are higher. If you select Kaiser Permanente or Willamette Dental Insurance, you must see a participating dentist to receive benefits under the plan. However, your costs usually are lower in a managed care dental plan. If you have dental work in progress, check with the new insurance company you are considering using before you change dental insurance plans.

26 26 A Comparison of Your Dental Options Oregon Dental Kaiser Willamette Dental Plan Features Service Permanente Insurance Inc. Basics How the plan works Pays benefits for covered Pays benefits for Pays benefits for services you receive from covered services you covered services any licensed dentist. receive from a provided by a Diagnostic and preventive participating Kaiser participating services are covered in dentist at a Kaiser Willamette Dental full. For other covered Permanente facility. Group (WDG) or services, the plan pays a Supplemental charge Columbia Dental percentage of the cost of $25 for emergency Group (CDG) after you meet the or urgent services. dentist. annual deductible. Annual deductible $50 per person None None $150 per family Annual max benefit $1,500 None None Covered Services Diagnostic and Paid in full, Paid in full Paid in full preventive services no deductible (such as exams, X-rays and cleanings) Routine fillings 80%, after deductible Paid in full Paid in full is met Root canals 80%, after deductible Paid in full Paid in full is met Prosthodontic care 50%, after deductible Balance paid in full Balance paid in full (such as crowns, is met after $75 copayment after $75 copayment bridges and dentures) per unit; $25 copayment per unit for relines and rebases Orthodontia 50%, after deductible Not covered Balance paid in full services is met, up to $1,500 after $1,200 copaylifetime maximum ment; no lifetime maximum; adult orthodontia covered; copay $25 for initial orthodontic exam, $125 for study models and X-rays

27 27 Medicare Supplement Individual Plans Regence BCBSO Companion F Regence BCBSO Companion F is a traditional plan. This means it offers you the opportunity to go to a Medicare approved health care provider of your choice. When you need medical care, you can go to any physician, hospital or qualified provider. Regence BlueCross BlueShield offers Companion F to residents of Oregon and Clark County, Washington. Eligible Medicare beneficiaries with Medicare Part A and B may apply. About Regence BCBSO Companion F Choice You are free to use any health care provider. Coverage The plan offers a comprehensive range of services and prescription drug coverage. Benefits General After you meet the annual Part B deductible, the plan generally pays 80 percent of Medicare-eligible expenses, if the physician accepts Medicare assignment. Prescription Drugs Prescription drug policy is separate from the medical policy. You will receive separate ID cards from Asuris. Member pays a $250 annual individual deductible for prescription drugs. After the deductible is met, the member pays a $5 copay for generic drugs, $18 copay for formulary brand name drugs, and a $35 copay for non-formulary brand name drugs. Once the member s annual out-of-pocket costs reach $2,250, the member pays in full for prescriptions until their annual out-of-pocket costs reach $5,100. Once the member s annual out-of-pocket costs reach $5,100, Regence will pay 95 percent for all prescriptions for the remainder of the calendar year. Vision Vision expenses are not covered, except for the treatment of glaucoma or cataracts.

28 28 Plan F Medicare (Part A) - Hospital Services - Per Benefit Period Services Medicare Pays Plan Pays You Pay Hospitalization 1 Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $912 $912 (Part A $0 deductible) 2 61st through 90th day All but $228 a $228 a day $0 day 91st day and after: - While using 60 lifetime All but $456 a $456 a day $0 reserve days - Once lifetime reserve days are used day Additional 365 days $0 100% of Medicare $0 eligible expenses Beyond the additional 365 days $0 $0 All costs Skilled Nursing Facility Care 1 You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved $0 $0 amounts 21st through 100th day All but $114 a day All but $114 a day $0 101st day and after $0 $0 All costs Blood First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 Hospice Care Available as long as your doctor All but very limit- $0 Balance certifies you are terminally ill ed coinsurance and you elect to receive these for outpatient services drugs and inpatient respite care

29 29 Medicare (Part B) - Medical Services - Per Calendar Year Services Medicare Pays Plan Pays You Pay Medical Expenses In or out of the hospital and outpatient hospital treatment, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $110 of Medicare-approved $0 $110 (Part B $0 amounts 3 deductible) Remainder of Medicare-approved Generally, 80% Generally, 20% $0 amounts Part B Excess Charges (above Medicare-approved amounts) $0 100% $0 Blood First 3 pints $0 All costs $0 Next $110 of Medicare-approved $0 $110 (Part B $0 amounts 3 deductible) Remainder of Medicare-approved 80% 20% $0 amounts Clinical Laboratory Services Blood tests for diagnostic services 100% $0 $0 1 A benefit period begins on the first day you receive services as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. 2 Medicare coinsurance and deductible amounts are subject to annual revision. 3 Once you have been billed $110 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.

30 30 Medicare (Parts A & B) Services Medicare Pays Plan Pays You Pay Home Health Care Medicare-approved services Medically necessary skilled care 100% $0 $0 services and medical supplies Durable medical equipment - First $110 of Medicare-approved $0 $110 (Part B $0 amounts 3 deductible) - Remainder of Medicare-approved 80% 20% $0 amounts Other Benefits - Not Covered by Medicare Services Medicare Pays Plan Pays You Pay Foreign Travel Not Covered by Medicare Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime 20% and amounts maximum benefit over the $50,000 of $50,000 lifetime maximum 3 Once you have been billed $110 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.

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32 Human Resources Department Benefits Office, mail code HR Oregon Health & Science University 3181 S.W. Sam Jackson Park Road Portland, Oregon Oregon Health & Science University includes four schools; OHSU Hospital and Doernbecher Children s Hospital; numerous primary care and specialty clinics; multiple research institutes and centers; and several public service and outreach units. OHSU is an equal opportunity, affirmative action institution. OHSU and Oregon Health & Science University are registered trademarks. 11/05(10)