PHIP Member Benefit & Rate Comparison Guide. January 1, 2016 to December 31, 2016

Transcription

1 PHIP Member Benefit & Rate Comparison Guide January 1, 2016 to December 31, 2016

2 The PERS Health Insurance Program (PHIP) offers health insurance coverage for all retirees, their spouses and dependents who meet the eligibility requirements. When planning your retirement, review all health coverage options available to you to determine your best option. Mission Statement PHIP provides PERS retirees with high-quality, comprehensive coverage (or benefits) at the most cost-effective rates possible to meet retiree benefit needs. Our core values are: y Maintain stability of premiums y Maintain stability of coverage y Maintain stability of carriers

3 September 2015 Dear PERS Health Insurance Program (PHIP) member, In this guide, you will find information regarding the PERS Health Insurance Program (PHIP) for the 2016 plan year. If you do not want to make any changes to your health insurance plans for 2016, no action is required. Your current coverage will continue, and the 2016 premium rate and benefit changes will take effect January 1, If you are interested in changing your health insurance plan, the enclosed information includes updated rates, plan changes and the Plan Change meeting schedule. For more information or to view the current Member Handbook and Benefit Guide, visit our website at Important 2016 Changes Effective January 1, 2016, there are a number of changes that will take place. An outline of these changes by health plan is located on pages For our Providence and PacificSource members, effective January 1, 2016, your pharmacy benefit will be administered through your corresponding health plan. Your pharmacy benefit has not changed, just the management of your benefit. You will receive a new health identification card prior to January 1, For specific questions regarding the transition of your prescriptions from Moda to Providence or PacificSource, please contact your health plan directly at the numbers listed on page 39. This year, plan change meetings begin September 10 and end October 14. Representatives from PHIP and the health insurance plans will be there to answer your questions. Please bring your 2016 Member Benefit and Rate Comparison Guide with you. Beginning in fall 2016, annual rates and benefit changes will be available to you through the website only. However, if you prefer a copy of our Member Handbook and Benefit Guide, we will gladly mail you one upon request, by calling our customer service team. If you need assistance or have questions, contact PHIP at Sincerely, PERS Health Insurance Program

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5 Contents 2015 PHIP Plan Change Meeting Schedule... 6 Enrollment Opportunities... 8 How to Enroll After Enrollment Benefit Changes, Health Plan Service Areas & Plan Features 17 Changes to Plans Health Plan Enrollment Service Areas Coverage Outside Service Areas Plan Benefits & Rate Comparisons Medicare Benefit Comparison Medicare Rates Core Value Non-Medicare Rates Select Value Non-Medicare Rates Core Value Non-Medicare Benefit Comparison Select Value Non-Medicare Benefit Comparison Dental Benefit Comparison Required Notices Contact Information... 39

6 2015 PHIP Plan Change Meeting Schedule Represented Plans: K = Kaiser Permanente, M = Moda Health, P = Providence, PS = PacificSource Area Date Time(s) Site Plans Portland 9/10 Thursday 9:30 a.m. & 1:30 p.m. Sheraton Portland Airport Hotel 8235 NE Airport Way (Garden Room ABC) K, M, P Gresham 9/14 Monday 9:30 a.m. Four Points by Sheraton 1919 NE 181st Ave. (Starwood Room) K, M, P The Dalles 9/14 Monday 2:30 p.m. Columbia Gorge Discovery Center 5000 Discovery Dr. M, PS, P Tigard 9/15 Tuesday 9:30 a.m. Embassy Suites Washington Square 9000 SW Washington Square Rd. (Regency Two) K, M, P Oregon City 9/15 Tuesday 1:30 p.m. Providence Willamette Falls Community Center th St. (Rooms C & D) K, M, P Eugene 9/16 Wednesday 9:30 a.m. & 1:30 p.m. Lane Community College Center for Meeting & Learning 4000 E 30th Ave. (Bldg. 19 Room 102) M, P, PS Salem 9/17 Thursday 9:30 a.m. Oregon State Fair & Expo Center th St. NE (Cascade Hall, McKenzie Room) K, M, P Prineville 9/22 Tuesday 1:30 p.m. Crook County Library 175 NW Meadow Lakes Dr. (Broughton Room) M, PS, P Ontario 9/23 Wednesday 9:30 a.m. Four Rivers Cultural Center 676 SW 5th Ave. (Collins Room) M Baker City 9/23 Wednesday 2:00 p.m. Geiser Grand Hotel 1996 Main St. (Queen City Center) M Pendleton 9/24 Thursday 9:30 a.m. Red Lion 304 SE Nye Ave. (Walla Walla Room) M Roseburg 9/29 Tuesday 9:30 a.m. Douglas County Fairgrounds 2110 Frear St. M Medford 9/29 Tuesday 2:30 p.m. Inn at the Commons 200 N Riverside Ave. (Crater Lake Room) M

7 For questions regarding the meeting schedule, contact the PERS Health Insurance Program at For directions, you may contact locations directly. Meetings last approximately hours. Pre-registration is not required. Area Date Time(s) Site Plans Klamath Falls Bend Salem Corvallis Albany McMinnville Hillsboro St. Helens Astoria Lincoln City Florence Coos Bay/ N. Bend Keizer 9/30 Wednesday 10/1 Thursday 10/5 Monday 10/6 Tuesday 10/7 Wednesday 10/7 Wednesday 10/8 Thursday 10/8 Thursday 10/12 Monday 10/13 Tuesday 10/13 Tuesday 10/14 Wednesday 10/20 Tuesday 9:30 a.m. 9:30 a.m. 9:30 a.m. 9:30 a.m. 9:30 a.m. 2:30 p.m. 9:30 a.m. 2:30 p.m. 2:30 p.m. 9:30 a.m. 3:00 p.m. 9:30 a.m. 9:30 a.m. Shilo Inn 2500 Almond St. (Diamond & Klamath Room) Hampton Inn & Suites 730 SW Columbia St. (Deschutes North & South) Oregon State Fair & Expo Center th St. NE (Cascade Hall, McKenzie Room) Corvallis Country Club 1850 SW Whiteside Dr. Linn County Fair & Expo 3700 Knox Butte Rd. (Conference Rooms 3 & 4) McMinnville Community Center 600 NE Evans St. Hillsboro Civic Center 150 E Main St. (Auditorium) Columbia Learning Center 375 S 18th St. (Auditorium) Holiday Inn Express 204 W Marine Dr. (River View #2) Inn at Spanish Head 4009 SW Highway 101 (El Toro I & II) Florence Events Center 715 Quince St. Red Lion 1313 N Bayshore Dr. (South Umpqua) Keizer Civic Center 930 Chemawa Rd. NE M M, PS, P K, M, P K, M, P K, M, P K, M, P K, M, P K, M, P M M M, P, PS M, PS K, M, P Please note: Due to unforeseen circumstances, the printed schedule may change. Any changes to the schedule can be found on pershealth.com

8 Enrollment Opportunities The PHIP milestones, as defined in OAR , mark the only enrollment opportunities available. Eligible retirees and their spouses or dependents that do not choose to enroll in a PHIP health plan during one of these enrollment periods will lose their opportunity to enroll in PHIP. If you have any questions about your enrollment opportunities, or if you would like a copy of the complete OAR enrollment rules, please call PHIP at or visit New retiree New retirees can enroll up to 90 days after the effective date of their retirement. Coverage will be effective on your retirement date (if you apply before your retirement date or the date of your PERS disability approval letter) or on the first day of the month after your application is received (if you apply within 90 days of your retirement date or the date of your PERS disability approval letter). You must verify your prior employer s coverage end date to ensure that your PHIP plan does not overlap other employer-sponsored coverage. Working past Medicare eligibility If you are not drawing a Social Security benefit check and are still working and covered by an active employer-sponsored plan when you turn 65, you will need to contact the Social Security Administration to sign up for Medicare. Medicare Part A is free for most people; Medicare Part B has a premium and therefore you may want to defer enrollment into Medicare Part B while under active employer-sponsored group health coverage. When your active employer-sponsored group coverage ends, you are allotted a Special Enrollment Period (SEP) by Medicare to enroll in your Medicare Part B. Three months before your retirement date or loss of active employer-sponsored group coverage, contact the Social Security Administration to sign up for Medicare Part B. Your Medicare Part B effective date should be the first of the month after your active employer-sponsored group coverage ends. The Medicare Initial Enrollment Period (IEP) is anytime during the active group coverage or anytime during the eight months after the active coverage ends. If you do not have Part B in place when you lose your employer coverage, you cannot enroll in a PHIP plan. NOTE: If your IEP is concurrent with your SEP, the IEP enrollment timelines prevail. 8 Enrollment Opportunities

9 Medicare eligibility PERS retirees can enroll up to 90 days after the date of their initial Medicare eligibility if they are enrolled in both Medicare Parts A and B. Enrollment in a PHIP medical plan includes enrollment in the PHIP Medicare Part D prescription plan. PHIP coverage will take effect on the date your Medicare coverage becomes effective if you enroll before the date of your Medicare eligibility. PHIP coverage will take effect on the first day of the month after your application is received if you apply after the date of your Medicare eligibility. If you are currently enrolled in a PHIP non-medicare plan, you will be required to fill out an Enrollment Request Form 30 days before becoming Medicare-eligible. Failure to submit a new Enrollment Request Form for Medicare coverage will result in cancellation of your non-medicare health plan coverage under PHIP, upon Medicare eligibility with the possibility of no future opportunities to enroll. Medicare disability Your eligibility to enroll in Medicare Part A and Part B, due to Social Security Disability, becomes effective the first day of the 25th month after your Social Security Disability benefits began. You are required to retain both Medicare Parts A and B to be enrolled in a PHIP Medicare plan. The 90-day Medicare eligibility enrollment opportunity also applies in these circumstances. If you miss this opportunity, becoming Medicare-eligible at age 65 will not be a new opportunity to enroll in a PHIP health plan unless you have had 24 months of continuous employer-sponsored coverage immediately preceding enrollment in PHIP. If you are currently enrolled in a PHIP non-medicare plan, you must fill out an Enrollment Request Form 30 days before becoming Medicare-eligible. Failure to submit a new Enrollment Request Form for the Medicare coverage will result in cancellation of your non-medicare health plan coverage under PHIP, upon Medicare eligibility, with the possibility of no future opportunities to enroll. Enrollment Opportunities 9

10 Continuous employersponsored coverage PERS retirees can enroll at any time if they have been covered under another employer-sponsored group health plan for 24 consecutive months immediately preceding enrollment in PHIP and within 30 days of losing prior employer-sponsored group coverage. Employer-sponsored group coverage can be: y Coverage you had as an active or retired employee that is terminating y Coverage you had under an eligible spouse s active employment or as a retired employee that is terminating y Coverage continued through COBRA following termination of employment COBRA coverage is secondary to Medicare, except when the Medicare beneficiary has ESRD COBRA coverage is primary to Medicare during the 30-month ESRD coordination period For the purposes of PHIP, healthcare coverage under worker s compensation, Medicare or any other government entitlement program (including foreign healthcare) does not qualify as employer-sponsored group health coverage. To ensure you are selecting the correct PHIP effective date, verify your current health plan coverage end date with your employer. To avoid a gap in coverage, select the first of the month after your employer-sponsored group coverage ends as the PHIP effective date. To enroll, submit your PHIP Enrollment Request Form 30 days prior to your employer-sponsored group coverage ending to prevent a gap in coverage. PHIP allows up to 30 days to enroll after loss of employer-sponsored group coverage ends, however if the Enrollment Request Form is received after your group coverage ends, your PHIP effective date will be the first of the month after receipt of your Enrollment Request Form. Any application received after 30 days of loss of employer group coverage is considered outside of the enrollment opportunity and will be ineligible. Changes to the original PHIP effective date will not be allowed once the requested effective date has passed. Dependent enrollment Dependents can enroll during any of the enrollment periods available to retirees, as described on pages If a spouse or dependent has an enrollment opportunity after the retiree is enrolled, he or she will be eligible to enroll under the retiree s account. A Medicare eligible spouse or dependent can enroll in a PHIP Medicare health plan prior to the retiree, provided the spouse or dependent is enrolled in Medicare Parts A and B and contingent on the PERS retiree enrolling in PHIP upon his or her final enrollment opportunity. If the PERS retiree does not enroll in PHIP upon his or her final enrollment opportunity, the spouse or dependents will no longer be eligible for PHIP coverage and will be disenrolled. New dependents must be enrolled within 30 days of the family status change (e.g., birth, marriage). If the spouse has a different last name than the retiree, a copy of the marriage certificate will be required. If the retiree has Medicare coverage and the dependent has non-medicare coverage, the dependent s coverage will be with the same health plan as the retiree. Notice: Effective date of coverage will be the first of the month after receipt of the PHIP Enrollment Request Form. 10 Enrollment Opportunities

11 Surviving spouses If the surviving spouse or dependent is not enrolled at the time of the PERS retiree s death, the spouse or dependent may enroll within 90 days from the date of death or by meeting other enrollment opportunities (see pages 8 11). However, in the event of remarriage, coverage cannot be extended to the new spouse. Dental plan enrollment The PHIP dental plan is only available if you are enrolled in a PHIP medical plan. If anyone in your family chooses dental coverage, everyone who is enrolled in a PHIP medical plan also must be enrolled in a PHIP dental plan. Dependents must enroll in the same dental plan as the retiree. You can enroll in either dental plan regardless of your medical plan selection. For Kaiser Permanente dental, you must reside in the Kaiser Permanente dental plan service area. Enrollment in a PHIP dental plan must be made under the same enrollment conditions as the PHIP medical plan. There may be a 12-month waiting period for some services if you have not had 12 months of continuous employer-sponsored dental coverage immediately preceding enrollment into a PHIP dental plan. Please refer to pages for a description of dental services. Enrollment Opportunities 11

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13 How to Enroll During peak enrollment times, delays may occur Please allow time for PHIP to process your application and notify your health carrier. In the event you need immediate access to your health plan information, please contact PHIP at the customer service number listed on page 39. Your coverage will start on the date described in the Enrollment Opportunities section on pages To enroll in any PHIP health plan, you must: y Meet one of the PHIP enrollment opportunities described on pages y Complete the Enrollment Request Form in its entirety. Include spouse or dependent information only if they are enrolling in PHIP. Missing information can delay your enrollment. Indicate your reason for applying for PHIP coverage and select a medical and dental plan (dental plan optional). If you are enrolled in a PHIP non-medicare plan, you must submit a new Enrollment Request Form upon Medicare eligibility. y All Medicare-eligible individuals must complete the Medicare card section. Submit a photocopy of either the Medicare card or a Letter of Entitlement (Letters of Eligibility are not accepted) showing Medicare effective dates for Parts A and B for each Medicare-eligible individual applying. y Sign and date the Enrollment Request Form. Both the retiree and spouse must sign if both are enrolling. Enrollments must be signed and received prior to the month in which coverage is to begin. y Additional documentation may be required based on your enrollment opportunity. This may include a dependent s birth certificate, adoption paperwork, PERS disability retirement approval letter, Affidavit of Dependent Domestic Partnership, or marriage license. Submit documentation with your Enrollment Request Form. However, do not delay submitting your Enrollment Request Form because you do not have the necessary documents. You will have 30 days from the requested effective date to submit any additional paperwork. If necessary documentation is not received within 30 days from requested effective date, you may be required to submit a new Enrollment Request Form. y Submit all documents to the PHIP office. The address is listed on page 39. Retain a copy of the Enrollment Request Form for your records. You can be enrolled in only one Medicare Advantage and Medicare Part D prescription drug plan at a time. Terminating your Medicare Part D prescription coverage or enrolling in another Medicare Advantage or Medicare Part D prescription plan will automatically terminate all PHIP coverage. Once termination has occurred, you may not re-enroll in PHIP, unless you experience a new enrollment opportunity. When enrolling in a PHIP Medicare plan, you will automatically be enrolled in a Medicare Part D prescription plan. How to Enroll 13

14 After Enrollment Plan change PHIP offers an annual plan change period from October 1 to November 15. During the plan change period, you can change your medical and/or dental plan to another plan available within your residing area. This annual plan change period is not an opportunity to add dental coverage or dependents. Plan changes made during this period become effective January 1. If you are enrolled and do not want to change plans, no paperwork is required. If you want to make a change, you must fill out a Disenrollment Form for the plan you are ending as well as an Enrollment Request Form for the new plan coverage. Submit both forms to PHIP before the November 15 deadline. Forms can be found at pershealth.com or by calling PHIP customer service. If you do not submit a change during this period, you will be unable to change your enrollment midyear, unless you experience a family status change or new enrollment opportunity. Snow bird For members who are enrolled in any PHIP Medicare Advantage plan, and who reside inside Oregon part of the year and outside Oregon part of the year, PHIP offers the Snow Bird option. The Snow Bird option allows members to change their health plan to Moda Health Medicare Supplement Plan while living outside their Medicare Advantage plan s service area. Members must plan on living outside the service area for more than 60 days for this option to apply. Before leaving the service area, members should contact PHIP to request an Enrollment Request Form and Disenrollment Form to change to the Moda Health Medicare Supplement Plan for the time spent living outside the Medicare Advantage service area. Upon returning to Oregon, members will be eligible to change back to their prior Medicare Advantage plan. The Snow Bird option also applies to non-medicare members who are enrolled in Kaiser Permanente, PacificSource, or Providence Health Plans, and who reside inside Oregon part of the year and outside Oregon part of the year. You have the option to change to the Moda non-medicare plan in the same Value tier. You must fill out a Disenrollment Form for the plan you are ending and an Enrollment Request Form for the new coverage when leaving the area and when returning. Please contact PHIP for more information about this option. Change of address Address changes must be submitted in writing by the member or authorized party. Complete, sign, date and submit a Change of Address Form to PHIP. Address changes may be sent via mail or fax. ( requests will not be accepted.) PHIP will notify the appropriate health plan, however they will not update your address with the PERS pension office. To update your address with the PERS pension office, contact PERS directly at the address listed on page 39. Failure to notify PHIP within 30 days of moving outside a service area can result in involuntary termination of coverage. 14 After Enrollment

15 You must maintain a primary residence within the United States to be eligible for PHIP. If you reside in another country, you are not eligible to retain PHIP coverage. Premium payments Making monthly premium payments Premium payment options: y Deduction from your monthly PERS pension check. This option ensures timely premium payment and prevents a lapse in coverage. If you choose pension deduction, the PERS pension holder s signature is required any time an Enrollment Request Form is submitted. y Electronic Funds Transfer (EFT) from your bank account. This also ensures timely payment and prevents a lapse in coverage. Only one payment option is allowed per PHIP account. Premium rates are subject to change mid-year due to Medicare requirements such as Medicare Part D Late Enrollment Penalty or Low Income Subsidy (Extra Help) notifications. PHIP is required to adjust premiums to account for these changes. For questions regarding premium changes due to Medicare programs, contact Medicare directly. Late payments Premium payments are due on or before the first of each month, with no grace period. If payment is not received by the first day of the month, the account is considered delinquent. If you do not pay your premium upon notification, your health plan coverage will be canceled. If your coverage is terminated because of a delinquent payment, you may be responsible for all claims incurred on or after that termination date, except to the extent that those claims are covered under Original Medicare. OAR (3) If payment is by check or money order, the check or money order must be physically received by the Third Party Administrator on or before the due date. (4) Failure to make the payment by the due date shall result in termination of a person s PERS-sponsored health insurance coverage. Disenrollment Voluntary disenrollment PHIP and Medicare guidelines require a written request for voluntary disenrollment from PHIP health insurance coverage. Disenrollment will occur the first of the month following receipt of your completed PHIP Disenrollment Form unless a later date is requested. Both the member and spouse must sign the written request for termination. If one member of your family wishes to terminate their dental coverage, the whole family loses dental coverage. Please submit a PHIP Disenrollment Form, which you can find on the PHIP website or request through customer service. The PHIP address and fax number are listed on page 39. Involuntary termination In some instances, PHIP may be required to terminate your coverage. Examples of when you may lose your coverage are: y Loss of Medicare Parts A and/or B y Enrolling in another non-phip Medicare Advantage or Medicare Part D Prescription Drug Plan After Enrollment 15

16 y Loss of program eligibility due to failure to adhere to premium payment guidelines y Loss of retirement status (returning to work) If your PHIP coverage is terminated by the plan, you may not re-enroll in PHIP unless you experience a new enrollment opportunity, provided you meet the eligibility requirements as described on pages You will be required to bring your account current in the event you have any outstanding balance. Death notification y As a PERS retiree: Upon the death of your spouse, your PHIP coverage will continue as usual. To terminate your spouse s coverage, mail a photocopy of the death certificate to PHIP and the PERS Pension office. y As a surviving spouse or dependent of a PERS retiree: Your PHIP coverage will continue automatically. You must mail a copy of the retiree s death certificate to PHIP and the PERS Pension office for your account to remain active. If you would like to terminate your coverage, a written request is required. If the surviving spouse is not enrolled at the time of the PERS retiree s death, the spouse may enroll within 90 days of the death or by meeting other enrollment opportunities. Once disenrollment or termination occurs, you cannot re-enroll in PHIP unless you experience a new enrollment opportunity. PHIP appeals Pursuant to Oregon Administrative Rule (OAR) , if you receive a letter denying PHIP eligibility (program or subsidy) or enrollment and you disagree with that determination, you may request a review by writing to the PERS Director within 60 days after the date of the letter. Your request must include the following information: 1. A description of the determination you want reviewed. 2. A short statement describing how and why you think the determination is wrong. 3. A statement of facts that you believe show the determination is wrong. 4. A list of any statutes, rules, or court decisions that you believe support your position. 5. A statement of the action you seek. 6. A request for review. Oregon Revised Statutes are available from the Office of Legislative Counsel, or can be located on the Internet at Oregon Administrative Rules are available from the Oregon State Archives Mail appeal to: Public Employees Retirement System. Attn: Appeals, SW 68th Pkwy. Tigard, OR When the Director receives your request, he may ask a Division Administrator to act on it. Your request for a review may be denied if it does not contain the required information listed above. You will be mailed a response letter within 45 days after we receive your request. Health plan appeals Appeals related to claim and benefit payments, Medicare plan enrollment, or disenrollment issues should be directed to the health insurance carrier of the plan in which you are enrolled. Contact information for all health plans may be found on page After Enrollment

17 Benefit Changes, Health Plan Service Areas & Plan Features Benefit changes, health plan service areas and plan features section

18 Changes to Plans Effective January 1, 2016 Important notice for the 2016 plan year Effective January 1, 2016, prescription drug coverage for PacificSource and Providence members will be provided through your medical health plan. Refer to the appropriate health plan s feature page for more information. Prescription drug program Applies to all Medicare and non-medicare enrollees: y The prescription drug out-of-pocket maximum per person per calendar year will now be $4,850. Dental ODS y ODS is now doing business as Delta Dental of Oregon. y Revised the Maximum Plan Allowance (MPA) to a fee schedule for non-participating providers in Oregon. y Members with periodontal disease may receive up to a total of 4 (four) periodontal cleanings per year. Kaiser Permanente y No benefit changes for the 2016 plan year. Medical Non-Medicare plans For the 2016 plan year only, due to significant changes made to some of the $1,000 deductible Select Value plan options, we will allow members to move to a Core Value plan (lower deductible/ Kaiser HMO) during plan change only. If you choose to remain on a $1,000 deductible Select Value plan, please be aware that you will not be able to move back to the Core Value plan (lower deductible/kaiser HMO) at any time, for any reason, even with a different health plan provider. Kaiser Permanente Northwest Medicare y No benefit changes for the 2016 plan year. y The student out-of-area benefit does not apply under Medicare. Non-Medicare Core Value and Select Value Plans y Healthy diet, obesity and weight management counseling have been added. y External Prosthetic devices and Orthotic devices have been added to the list of items requiring prior authorization. y Telemedical services are covered at the appropriate cost share. y The student out-of-area coverage is now: 10 office visits, 10 x-ray and lab visits, and 10 prescriptions all covered at 20% member coinsurance. 18 Changes to Plans

19 Moda Health Medicare Supplement y No benefit changes for the 2016 plan year. PERS Moda Health PPORX (PPO) Medicare Advantage y No benefit changes for the 2016 plan year. Non-Medicare Core Value Plan y Tobacco cessation treatment is covered at no cost share in-network and 40% out-of-network. y The requirement for an originating site has been removed from Telemedical Health Services. y Kidney dialysis is covered at 100% of the Maximum Plan Allowance (MPA) for in-network and out-of-network services once the deductible has been met. y Coverage for End-Stage Renal Disease (ESRD) facilities is the contracted amount for in-network and 125% of the Medicare allowable amount for out-of-network. y Maximum Plan Allowance (MPA) for medical devices, including implanted devices, and for durable medical equipment is the contracted amount or the lesser of 100% of the Medicare allowable amount or the acquisition cost of the device plus 10% if there is no contracted amount. y Self-administered medications purchased through a retail pharmacy are now covered and subject to the pharmacy plan benefit. y Self-administered medications supplied by a physician s office, facility or clinic are excluded from the medical plan benefits. Non-Medicare Select Value Plan y In-network out-of-pocket maximum is now $3,000 + deductible per individual; out-of-network out-of-pocket maximum is now $9,000 + deductible per individual. y In-network coinsurance is now 30%; out-of-network coinsurance is now 50%. y In-network physician office visit and urgent care copay is $25. y In-network specialist copay is $35. y Ambulance coinsurance in- and out-of-network is now 30%. y Tobacco cessation treatment is covered at no cost share in-network and 40% out-of-network. y The requirement for an originating site has been removed from Telemedical Health Services. y Kidney dialysis is covered at 100% of the Maximum Plan Allowance (MPA) for in-network and out-of-network services once the deductible has been met. y Coverage for End-Stage Renal Disease (ESRD) facilities is the contracted amount for in-network and 125% of the Medicare allowable amount for out-of-network. y Maximum Plan Allowance (MPA) for medical devices, including implanted devices, and for durable medical equipment is the contracted amount, or the lesser of 100% of the Medicare allowable amount or the acquisition cost of the device plus 10% if there is no contracted amount. y Self-administered medications purchased through a retail pharmacy are now covered and subject to the pharmacy plan benefit. y Self-administered medications supplied by a physician s office, facility or clinic are excluded from the medical plan benefits. Changes to Plans 19

20 PacificSource PacificSource Prescription Drug Program applies to all Medicare and non-medicare enrollees: y Prescription drug coverage for PacificSource members is now provided through PacificSource. You will receive a new PacificSource ID card that reflects pharmacy coverage. The PacificSource formulary applies. If you were prescribed and are currently taking a specific medication under the Moda Prescription Drug plan on December 31, 2015, you may continue that medication without interruption or prior authorization, unless required by law or if there is a change to the script dosage or frequency. Some new medications may require prior authorization. Medicare y Lung cancer screening coverage for high risk members has been added. y GlobalFit is no longer a contracted PacificSource vendor. y Silver & Fit is the new contracted fitness vendor with PacificSource. Non-Medicare Core Value Plan y GlobalFit is no longer a contracted PacificSource vendor. y No benefit changes for the 2016 plan year. Non-Medicare Select Value Plan y Individual and family deductible now applies to both the in- and out-of-network benefits. y In-network out-of-pocket maximum is now $3,000 + deductible per individual and $9,000 + deductible for families; out-of-network out-of-pocket maximum is now $9,000 + deductible per individual. The family out-of-pocket maximum has been removed. y In-network coinsurance is now 30%; out-of-network coinsurance is now 50%. y In-network specialist copay is $35. y Ambulance coinsurance in- and out-of-network is now 30%. y GlobalFit is no longer a contracted PacificSource vendor. Providence Health Plans Providence Prescription Drug Program applies to all Medicare and non-medicare enrollees: y Prescription drug coverage for Providence members is now provided through Providence. You will receive a new Providence ID card that reflects pharmacy coverage. The Providence formulary applies. If you were prescribed and are currently taking a specific medication under the Moda Prescription Drug plan on December 31, 2015, you may continue that medication without interruption or prior authorization, unless required by law or if there is a change to the script dosage or frequency. Some medications may require prior authorization. 20 Changes to Plans

21 Medicare Align Plan y Routine eye exams and hardware allowance are available through VSP and the VSP Choice Network. Vision services received outside of this network will not be covered. y Telemedical services are now available through Providence Health express. Members may now video conference with a provider through a personal computer, tablet or smartphone. Medicare Flex Plan y Out-of-network cardiac outpatient rehab copay is now $30. y Out-of-network outpatient substance abuse copay is now $30. y Out-of-network Medicare covered hearing exams is now 20%. y Routine eye exams and hardware allowance are available through VSP and the VSP Choice Network. Vision services received outside of this network will be covered at the out-of-network benefit level. y Telemedical services are now available through Providence Health express. Members may now video conference with a provider through a personal computer, tablet or smartphone. Non-Medicare Core Value Plan y Colonoscopies are covered in full when billed with a preventive diagnosis. y Telemedical services are now available through Providence Health express. Members may now video conference with a provider through a personal computer, tablet or smartphone. y Provider network name has changed from Exclusive Provider Organization (EPO) to Providence Signature Network (PPO). Non-Medicare Select Value Plan y In-network out-of-pocket maximum is now $3,000 + deductible per individual and $9,000 + deductible for families; out-of-network out-of-pocket maximum is now $9,000 + deductible per individual. The family maximum has been removed. y In-network coinsurance is now 30%; out-of-network coinsurance is now 50%. y In-network physician office visit and urgent care copay is $25. y In-network specialist copay is $35. y Ambulance coinsurance in- and out-of-network is now 30%. y Colonoscopies are covered in full when billed with a preventive diagnosis. y Telemedical services are now available through Providence Health express. Members may now video conference with a provider through a personal computer, tablet or smartphone. y Provider network name has changed from Exclusive Provider Organization (EPO) to Providence Signature Network (PPO). Changes to Plans 21

22 Health Plan Enrollment Service Areas For PHIP Medicare and non-medicare plans Moda Health y Moda Health Medicare Supplement Plan and Moda Health non-medicare PPO ypers Moda Health PPORX (PPO) Kaiser Permanente Oregon Benton: 97330, 97331, 97333, 97339, 97370; Clackamas (excluding 97028); Columbia; Hood River: 97014, Linn: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389; Marion (excluding 97350); Multnomah; Polk; Washington; Yamhill Washington Clark; Cowlitz; Lewis: 98591, 98593, 98596; Skamania: 98639, 98648; Wahkiakum: 98612, PERS retirees who live in California and are interested in enrollment in a Kaiser Permanente Health Plan located in their area should call PHIP for more information. Premium rates and benefits will differ from those noted in this handbook. 22 Health Plan Enrollment Service Areas

23 In selecting a PHIP health plan, your primary residence (not mailing address) must be within the United States and the health plan s service area. PacificSource Coos; Crook; Curry; Deschutes; Grant; Hood River; Jefferson; Klamath: 97731, 97733, 97737, 97739; Lake: 97638, 97641, 97735, 97739; Lane; Sherman; Wasco; Wheeler Providence Health Plans Oregon Benton, Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Linn, Marion, Multnomah, Polk, Washington, Wheeler and Yamhill Washington Clark County Health Plan Enrollment Service Areas 23

24 Coverage Outside Service Areas Moda Health Moda Health PPORX (PPO) plan Members may stay enrolled on the Moda Health PPORX (PPO) plan for up to 12 months when traveling outside of the state of Oregon. This travel benefit allows members to receive services from out-of-state Medicare providers. For members enrolled in the PERS Moda Health PPORX (PPO) plan and traveling outside the U.S., emergency care is covered worldwide. Moda Health Medicare Supplement Plan Coverage is limited to eligible emergency medical care expenses incurred outside the U.S. These are emergency room, urgent care and ambulance services. Coverage for emergency and urgent services outside of the United States is limited to $50,000 lifetime per member. Non-Medicare plan Members traveling outside of the primary service area may receive the in-network benefit level by using a Travel Network provider. The in-network benefit level applies to a Travel Network provider only if members are outside the primary service area and the travel is not for the purpose of receiving treatment or benefits. Treatment of emergency medical conditions is covered worldwide. Medicare Plans Only Emergency/Travel Benefits Urgent care (worldwide) Emergency room (ER) (worldwide) Ambulance (worldwide; air/ground) Outside service area travel (in U.S.) Outside service area travel (outside U.S.) Moda Health Supplement MEMBER pays: Covered in full (inside U.S. only) Covers ER, urgent care & ambulance Covers ER, urgent care & ambulance at 80% coinsurance. Coverage limited to $50,000 lifetime per member. PERS Moda Health PPORX (PPO) MEMBER pays: $20 copay $65 copay $50 copay Out-of-network provider copay for ER, urgent care and ambulance applies. Providers are paid up to the Medicare limiting charge. Out-of-network provider copay for ER, urgent care and ambulance applies. Providers are paid up to the Medicare limiting charge. Time frame 6 months* 12 months* *Per CMS guidelines for travel within and outside U.S. 24 Coverage Outside Service Areas

25 You must maintain a residence within a plan s service area and reside in the United States in order to participate in PHIP. All emergency services will be reimbursed at the in-network benefit level. However, benefits are subject to our contracted rates for in-network physicians and providers. Members may be responsible for any amounts above the maximum plan allowance. Delta Dental of Oregon Dental plan The Delta Dental dental plan gives you the freedom to choose any licensed dentist. Delta Dental Premier Network is the largest dental network in the country; you can visit any of the 151,000 Delta Dental dentists in the U.S. and still be covered in-network. Kaiser Permanente Kaiser Permanente members temporarily outside the service area are covered for emergency care, urgent care, and medically necessary ground or air ambulance service worldwide under Medicare and non-medicare plans. Medicare members also have a limited travel benefit that covers routine and follow-up care worldwide. Currently enrolled Medicare members who permanently move outside the Kaiser Permanente Northwest service area or who are out of the service area for six consecutive months or more must disenroll from their Kaiser Medicare Advantage plan. Kaiser Permanente Senior Advantage (HMO) PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Providence Medicare Flex Group MEMBER pays: MEMBER pays: MEMBER pays: MEMBER pays: $15 copay $15 copay $25 copay $25 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay $50 copay Covers routine, preventive and follow-up care outside Kaiser network at 20% coinsurance as part of $1,000 annual worldwide travel benefit maximum. Covers routine, preventive and follow-up care outside Kaiser network at 20% coinsurance, up to $1,000 annual worldwide travel benefit maximum. Covers ER, urgent care and ambulance at copays listed above Covers ER, urgent care and ambulance at copays listed above 20% to maximum allowance of $1,000 for follow-up services Covers ER, urgent care and ambulance at copays listed above 20% coinsurance Covers ER, urgent care and ambulance at copays listed above 6 months* 6 months* 6 months* 6 months* This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. Coverage Outside Service Areas 25

26 Members temporarily visiting other Kaiser Permanente regions may receive visiting member care from designated providers in those areas for either Medicare or non-medicare plans. For information about service areas and facility locations in other regions, please call Membership Services. With Kaiser Permanente, health plans are available in California for PERS retirees who relocate to that area. Please call the PHIP office for more information. Premiums and benefits for those areas will differ from those noted in this handbook. If you do not use Kaiser Permanente s physicians and hospitals, neither Kaiser Permanente nor Medicare will cover your services, except for emergency and urgent care, authorized referrals, renal dialysis outside the service area per Medicare criteria and travel benefits. Kaiser Permanente Dental plan If you have a dental emergency while traveling outside the service area, you may go to the nearest dental office. You have limited coverage for qualifying emergency dental care. PacificSource Medicare plan The PacificSource Essentials Rx 803 plan provides worldwide coverage for the following four services: y Emergency services y Urgently needed services y Medically necessary ground or air ambulance services y Out-of-area dialysis services These services do not require prior authorization. Non-Medicare plan The PacificSource plans give you the freedom to see either in-network or out-of-network providers for covered services. Travelers have the added protection of worldwide coverage for: y Emergency services y Urgently needed services y Medically necessary ground or air ambulance services y Out-of-area dialysis services These services do not require prior authorization. Providence Health Plans All plans offer worldwide coverage for urgent and emergency care and include ambulance coverage (air and ground). Providence Medicare Align Group Plan (HMO) + Rx Group Plan Includes a travel benefit for necessary follow-up care from any Medicare provider outside the plan service area. Providence pays 80% and the member pays 20%, up to a combined $1,000 annual limit. Providence Medicare Flex Group Plan (HMO-POS) + Rx Group Plan The Providence Medicare Flex Group Plan out-of-network benefit allows you to see any Medicare-approved provider. Non-Medicare PPO plan Providence Health Plans gives members access to nearly one million providers nationwide. 26 Coverage Outside Service Areas

27 Plan Benefits & Rate Comparisons Benefit changes, health plan service areas and plan features section

28 2016 Medicare Benefit Comparison Supplement Plan Moda Health Medicare Supplement Plan 1 PERS Moda Health PPORX (PPO) In-network 3 Out-of-network 4 Service area Refer to page 22 Refer to page 22 Eligible providers Any licensed Medicare provider Advantage network providers Any licensed Medicare provider MEMBER pays: MEMBER pays: Calendar year deductible $147 per individual 5 None Calendar year medical out-of-pocket maximum Inpatient Care y Inpatient hospital care y Skilled nursing facility Outpatient Care y Physician office visits y Specialist office visits y Outpatient surgery y Ambulance y Emergency services y Urgent care y DME y Lab test y X-Ray y Diagnostic procedures (CT/MRI) y Physical therapy Preventive Care y Annual wellness exam y Women s preventive y Prostate cancer screening y Immunizations Other Services y Chiropractic care 9 y Vision routine eye exam y Vision hardware None y Discounts available, contact Moda Health y$100 copay per day; $300 max per admit ycovered in full y$15 copay y$20 copay y$125 copay y$50 copay (one way) y$65 copay y$20 copay y10% 6 ycovered in full y10% y10% y$20 copay ycovered in full ycovered in full ycovered in full ycovered in full y$20 copay y$20 copay ydiscounts available, contact Moda Health $2,500 per individual y$100 copay per day; $300 max per admit ycovered in full y$15 copay y$20 copay y$125 copay y$50 copay (one way) y$65 copay y$20 copay y10% 6 ycovered in full y10% y10% y$20 copay ycovered in full ycovered in full ycovered in full ycovered in full y$20 copay y$20 copay ydiscounts available, contact Moda Health Prescription Drugs Retail and mail order y Brand and generic y Rx out-of-pocket max y40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y$4,850 out-of-pocket maximum per member per calendar year, no deductible 28 Medicare Benefit Comparison

29 This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. Kaiser Permanente Medicare Advantage Plans PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Providence Medicare Flex Group 2 In-network Refer to page 22 Refer to page 23 Refer to page 23 Refer to page 23 Kaiser Permanente and The Portland Clinic physicians and hospitals Plan physicians and hospitals Plan physicians and hospitals Plan physicians and hospitals MEMBER pays: MEMBER pays: MEMBER pays: MEMBER pays: Out-of-network Any licensed Medicare provider None None None None None $1,000 per individual $3,400 per individual $1,500 per individual $3,000 per individual y $200 copay per admit y $15 copay y $15 copay y $15 copay y $50 copay y $50 copay y $15 copay y 20% 6 y $125 copay per day (days 1-4 only); $500 max per admit y $10 copay y $15 copay y $125 copay y $50 copay y $50 copay y $15 copay 6 y $100 copay per day; $500 max per admit y $15 copay y $15 copay y $75 copay y $50 copay (one way) y $50 copay y $25 copay y 10% 6 y $125 copay per day; $500 max per admit y $20 copay y $20 copay 7 y $150 copay y $50 copay (one way) y $65 copay y $25 copay y 10% 6 y 10% y 10% y 20% y 20% y $30 copay y $30 copay y 20% y $50 copay (one way) y $65 copay y $25 copay y 20% 6 y 20% y 20% y 20% 1. Medicare covered services only. 2. Member must select a Primary Care Physician (PCP) from network in order to receive in-network benefits. Certain out-of-network services may require prior-authorization. If services received from out-of-network provider, excess charges may apply if the provider does not accept Medicare assignment. 3. Prior Authorization required for hospital inpatient services, skilled nursing, home health care, outpatient surgery, chiropractic, outpatient rehab, DME, prosthetic services and diagnostic procedures. 4. Out-of-network Medicare providers are paid up to the Medicare limiting charge. 5. Part B deductible, required by Medicare, listed in above comparison is the 2015 Part B deductible; 2016 Part B deductible was not available when this handbook went to print. Please refer to your 2016 Medicare & You handbook, when available, for the new Part B deductible. Deductible and coinsurance applies to all Medicare Part B approved services only. 6. Applies to Medicare approved supplies/equipment only and may require Pre-Authorization. Some diabetic supplies are covered in full. 7. If no referral is in place when seeing an in-network specialist, $30 copay applies. 8. An office visit copayment may apply if non-preventive issues and services are managed during a scheduled preventive visit. 9. Medicare covered chiropractic services only. 10. Must use VSP Choice Network providers in order to receive benefits. y $15 copay y $15 copay y $15 copay y $20 copay y $30 copay y $15 copay y $15 copay y $100 credit every 2 years for lenses, frames and/or contacts y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible y $15 copay y $15 copay y $100 credit every 24 months for lenses, frames and/or contacts y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible y $15 copay y $15 copay 10 y $100 credit every 2 years for lenses, frames and/or contacts 10 y $20 copay y $20 copay 10 y $100 credit every 2 years for lenses, frames and/or contacts 10 y $30 copay y $20 copay or up to a $45 allowance y $100 credit every 2 years for lenses, frames and/or contacts y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible Medicare Benefit Comparison 29

30 2016 Medicare Rates Medical & prescription drug monthly premium rate comparison Retirement Health Insurance Account (RHIA) Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are AFTER the $60 Retirement Health Insurance Account contribution. More information on the Retirement Health Insurance Account (RHIA) contribution and eligibility is on our website at pershealth.com, or contact PHIP at Retiree with Medicare Retiree with Medicare, family with Medicare Retiree with Medicare, family without Medicare (Core Value) Retiree with Medicare, family without Medicare (Select Value) Moda Health Medicare Supplement Plan PERS Moda Health PPORX (PPO) Kaiser Permanente Senior Advantage PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Providence Medicare Flex Group $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $1, $1, $1, $1, $1, $ $1, $ $ Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contribution from RHIA. More information on RHIA contributions and eligibility is on our website at pershealth.com, or contact PHIP at Core Value non-medicare Rates Medical & prescription drug monthly premium rate comparison Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contributions from the Retiree Health Insurance Premium Account (RHIPA). More information on RHIPA contributions and eligibility is on our website at pershealth.com, or contact PHIP at Moda Health PPO Plans Kaiser Permanente PacificSource Choice POS Providence Health Plans Retiree without Medicare $1, $ $ $ Retiree without Medicare, family* without Medicare Retiree without Medicare, family* with Medicare Retiree without Medicare, family* with Medicare (Moda Health Medicare Supplement Plan) Retiree without Medicare, family* with Medicare (PERS Moda Health PPORX (PPO) Retiree without Medicare, family* with Medicare (PHP Medicare Align) Retiree without Medicare, family* with Medicare (PHP Medicare Flex) $1, $1, $1, $1, N/A $1, $1, N/A $1, N/A N/A N/A $1, N/A N/A N/A N/A N/A N/A $1, N/A N/A N/A $1, Retiree with Medicare Retiree with Medicare, family with Medicare Retiree with Medicare, family without Medicare (Core Value) Retiree with Medicare, family without Medicare (Select Value) Moda Health Medicare Supplement Plan PERS Moda Health PPORX (PPO) Kaiser Permanente Senior Advantage PacificSource Medicare Essentials RX 803 Providence Medicare Align Group Providence Medicare Flex Group $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $1, $1, $1, $1, $1, $ $1, $1, $1, Premium rates are subject to change mid-year due to Medicare requirements such as Medicare Part D Late Enrollment Penalty or Low Income Subsidy (Extra Help) notifications. PHIP is required to adjust premiums to account for these changes. For questions regarding premium changes due to Medicare programs, contact Medicare directly. 30 Medicare Rates & Core Value non-medicare Rates

31 2016 Select Value non-medicare Rates Medical & prescription drug monthly premium rate comparison Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contributions from the Retiree Health Insurance Premium Account (RHIPA). More information on RHIPA contributions and eligibility is on our website at pershealth.com, or contact PHIP at Moda Health PPO Plans Kaiser Permanente PacificSource Choice POS Providence Health Plans Retiree without Medicare $ $ $ $ Retiree without Medicare, family* without Medicare Retiree without Medicare, family* with Medicare Retiree without Medicare, family* with Medicare (Moda Health Medicare Supplement Plan) Retiree without Medicare, family* with Medicare (PERS Moda Health PPORX (PPO) Retiree without Medicare, family* with Medicare (PHP Medicare Align) Retiree without Medicare, family* with Medicare (PHP Medicare Flex) $1, $1, $1, $1, N/A $ $1, N/A $1, N/A N/A N/A $1, N/A N/A N/A N/A N/A N/A $ N/A N/A N/A $ Premium rates are subject to change mid-year due to Medicare requirements such as Medicare Part D Late Enrollment Penalty or Low Income Subsidy (Extra Help) notifications. PHIP is required to adjust premiums to account for these changes. For questions regarding premium changes due to Medicare programs, contact Medicare directly. Select Value non-medicare Rates 31

32 2016 Core Value non-medicare Benefit Comparison In-plan Moda Health Out-of-plan Kaiser Permanente Service area Refer to page 22 Refer to page 22 Eligible providers Preferred physicians and providers MEMBER pays: Any licensed physician or facility Kaiser Permanente and The Portland Clinic physicians and hospitals MEMBER pays: Calendar year deductible $500 per individual None Calendar year medical out-of-pocket maximum $2,000 + deductible per individual $6,000 + deductible per individual $2,000 per individual; $4,000 per family Inpatient Care y Inpatient hospital care y Skilled nursing facility Outpatient Care y Physician office visits y Specialist office visits y Outpatient surgery y Ambulance y Emergency services y Urgent care y DME y Lab test y X-Ray y Diagnostic procedures (CT/MRI) y Physical therapy Preventive Care y Preventive physical exam 5 y Women s preventive y Prostate cancer screening y Immunizations Other Services y Alternative care y Vision routine eye exam y Vision hardware Prescription Drugs Retail and mail order y Brand and generic y Rx out-of-pocket max y20% after deductible y20% after deductible y$20 copay, no deductible y$20 copay, no deductible y20% after deductible y20% after deductible y$200 copay, then 20% y$20 copay, no deductible y20% after deductible y20% after deductible y20% after deductible y20% after deductible y20% after deductible 4 ycovered in full ycovered in full y$20 copay, no deductible ycovered in full y$25 copay, no deductible 7 ydiscounts available, contact Moda Health 1. Member must select a Primary Care Physician (PCP). 2. Benefit is limited to 20 visits per calendar year. 3. Urgent/Immediate Care ancillary charges billed separately will be subject to the applicable cost share. The deductible will apply to diagnostics (lab, x-rays, etc) received during the visit. 4. Limited to 30 visits per calendar year; this 30-visit limitation encompasses all therapy modalities combined. 5. Preventive services 32 Core Value non-medicare Benefit Comparison y40% after deductible y40% after deductible y40% after deductible y40% after deductible y40% after deductible y20% after deductible y$200 copay, then 20% y40% after deductible y40% after deductible y40% after deductible y40% after deductible y40% after deductible y40% after deductible 4 y40% after deductible y40% after deductible y40% after deductible y40% after deductible y40% after deductible 7 ydiscounts available, contact Moda Health y40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y$4,850 out-of-pocket maximum per member per calendar year, no deductible y $200 copay per day; $1,000 max per admit y $30 copay y $40 copay y $200 copay y $100 copay y $200 copay y $30 copay y 20% y $30 copay per visit y $30 copay per visit y 20% y $40 copay 2 y $25 copay 7 y $30 copay y Not covered y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible

33 This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. PacificSource Health Plans 1 Providence Health Plans In-plan Out-of-plan In-plan Out-of-plan Refer to page 23 Refer to page 23 Plan physicians and hospitals Any licensed physician or facility Plan physicians and hospitals Any licensed physician or facility $500 per individual; $1,500 per family $2,000 + deductible per individual; $6,000 + deductible per family MEMBER pays: $1,000 per individual; $3,000 per family $6,000 + deductible per individual; $18,000 + deductible per family MEMBER pays: $500 per individual; $1,500 per family (3 or more) $2,000 + deductible per individual; $6,000 + deductible per family (3 or more) $6,000 + deductible per individual; $18,000 + deductible per family (3 or more) y 20% after deductible y 20% after deductible y 20% after deductible y 20% after deductible y $20 copay, no deductible y $20 copay, no deductible y 20% after deductible y 20%, no deductible y $200 copay, then 20% y $20 copay, no deductible y 20% after deductible y 20% after deductible y 20% after deductible y 20% after deductible y 20%, no deductible y $200 copay, then 20% y 40%, no deductible y $20 copay, no deductible y $20 copay, no deductible y 20% after deductible y 20% after deductible y $200 copay, then 20% y $20 copay, no deductible 3 y 20% after deductible y 20% after deductible y 20% after deductible y 20% after deductible y 40%, no deductible y 40%, no deductible y 20% after deductible y $200 copay, then 20% y 40%, no deductible 3 y $20 copay, no deductible 4 4 y 20% after deductible 4 4 y 40%, no deductible y 40%, no deductible y $20 copay, no deductible 6 y 40%, no deductible y $25 copay, no deductible 7 y Not covered y Not covered 7 y Not covered y Not covered y $25 copay 7 y Discounts available, contact Providence Health Plans y Not covered y Discounts available, contact Providence Health Plans y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible will be covered in accordance with ACA guidelines. This applies to Kaiser and in-network services under Moda Health, PacificSource, and Providence. 6. Prostate cancer screening lab work is subject to the lab benefit. 7. Chiropractic/spinal manipulation and acupuncture office visits are limited to 12 combined visits per calendar year. Coverage for naturopaths is included, no visit limitations. No massage therapy coverage. Core Value non-medicare Benefit Comparison 33

34 2016 Select Value non-medicare Benefit Comparison In-plan Moda Health Out-of-plan Kaiser Permanente Service area Refer to page 22 Refer to page 22 Eligible providers Calendar year deductible Calendar year medical out-of-pocket maximum Inpatient Care y Inpatient hospital care y Skilled nursing facility Outpatient Care y Physician office visits y Specialist office visits y Outpatient surgery y Ambulance y Emergency services y Urgent care y DME y Lab test y X-Ray y Diagnostic procedures (CT/MRI) y Physical therapy Preventive Care y Preventive physical exam 5 y Women s preventive y Prostate cancer screening y Immunizations Other Services y Alternative care y Vision routine eye exam y Vision hardware Prescription Drugs Retail and mail order y Brand and generic y Rx out-of-pocket max Preferred physicians and providers $3,000 + deductible per individual y30% after deductible y30% after deductible MEMBER pays: $1,000 per individual y$25 copay, no deductible y$35 copay, no deductible y30% after deductible y30% after deductible y$200 copay, then 20% y$25 copay, no deductible y30% after deductible y30% after deductible y30% after deductible y30% after deductible y$25 copay, no deductible 4 ycovered in full ycovered in full y$25 copay, no deductible ycovered in full y$25 copay, no deductible 7 ydiscounts available, contact Moda Health Any licensed physician or facility $9,000 + deductible per individual y50% after deductible y50% after deductible y50% after deductible y50% after deductible y50% after deductible y30% after deductible y$200 copay, then 20% y50% after deductible y50% after deductible y50% after deductible y50% after deductible y50% after deductible y50% after deductible 4 y50% after deductible y50% after deductible y50% after deductible y50% after deductible y50% after deductible 7 ydiscounts available, contact Moda Health y40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y$4,850 out-of-pocket maximum per member per calendar year, no deductible Kaiser Permanente and The Portland Clinic physicians and hospitals MEMBER pays: $1,000 per individual; $3,000 per family $3,000 + deductible per individual; $9,000 + deductible per family y $25 copay, no deductible y $35 copay, no deductible y $25 copay, no deductible y $35 copay after deductible 2 y $25 copay, no deductible y $25 copay, no deductible y Not covered y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible 1. Member must select a Primary Care Physician (PCP). 2. Benefit is limited to 20 visits per calendar year. 3. Urgent/Immediate Care ancillary charges billed separately will be subject to the applicable cost share. The deductible will apply to diagnostics (lab, x-rays, etc) received during the visit. 4. Limited to 30 visits per calendar year; this 30-visit limitation encompasses all therapy modalities combined. 5. Preventive services 34 Select Value non-medicare Benefit Comparison

35 This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. PacificSource Health Plans 1 Providence Health Plans In-plan Out-of-plan In-plan Out-of-plan Refer to page 23 Refer to page 23 Plan physicians and hospitals Any licensed physician or facility Plan physicians and hospitals Any licensed physician or facility MEMBER pays: MEMBER pays: $1,000 per individual; $3,000 per family $1,000 per individual; $3,000 per family (3 or more) $3,000 + deductible per individual; $9,000 + deductible per family $9,000 + deductible per individual; no family maximum $3,000 + deductible per individual; $9,000 + deductible per family $9,000 + deductible per individual; no family maximum y $25 copay, no deductible y $35 copay, no deductible y 30%, no deductible y $200 copay, then 20% y $25 copay, no deductible y 30%, no deductible y $200 copay, then 20% y 50%, no deductible y $25 copay, no deductible y $35 copay, no deductible y $200 copay, then 20% y $25 copay, no deductible 3 y 50%, no deductible y 50%, no deductible y $200 copay, then 20% y 50%, no deductible 3 y $25 copay, no deductible 4 4 y $25 copay, no deductible 4 y 50%, no deductible y 50%, no deductible y $25 copay, no deductible 6 y 50%, no deductible y $25 copay, no deductible 7 y Not covered y Not covered 7 y Not covered y Not covered y $25 copay, no deductible 7 y Discounts available, contact Providence Health Plans y Not covered y Discounts available, contact Providence Health Plans y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible y 40% of charge up to a $150 maximum per prescription for a 31-day supply, no deductible y $4,850 out-of-pocket maximum per member per calendar year, no deductible will be covered in accordance with ACA guidelines. This applies to Kaiser and in-network services under Moda Health, PacificSource, and Providence. 6. Prostate cancer screening lab work is subject to the lab benefit. 7. Chiropractic/spinal manipulation and acupuncture limited to 12 combined visits per calendar year. Coverage for naturopaths is included, no visit limitation. No massage therapy coverage. Select Value non-medicare Benefit Comparison 35

36 2016 Dental Benefit Comparison You can enroll in either dental plan regardless of your medical plan selection. However, for Kaiser Permanente dental, you must reside in the Kaiser Permanente service area. Please refer to pages for information regarding the Kaiser service plan area (Kaiser s medical and dental plan service areas are the same). Medical plan enrollment Providers Delta Dental of Oregon 1 PacificSource, Kaiser Permanente, Moda Health, Providence Health Plans Any licensed dentist, hygienist and certified denturist working within the scope of their license Kaiser Permanente Kaiser Permanente, Moda Health, Providence Health Plans Kaiser Permanente Dental Associates Calendar year deductible $25 per individual None Calendar year benefit maximum (plan pays) Preventive Care y Exams y Cleanings y Diagnostic Basic Services y Restorative y Oral surgery (extractions) y Endodontic/periodontic Major Services y Crowns y Cast restorations y Dentures/bridge work y Implants $1,500 per individual 2 $1,500 per individual 2 MEMBER pays: Available twice in a calendar year ycovered in full 2 ycovered in full 2 ycovered in full 2,3 y20% after deductible 4 y20% after deductible 4 y20% after deductible 4 y50% after deductible 4 y50% after deductible 4 y50% after deductible 4 y50% after deductible 4 MEMBER pays: Limit of two cleanings per year y $10 copay per visit 2 y $10 copay per visit 2 y $10 copay per visit 2 y $10 copay, then 20% y $10 copay, then 20% y $10 copay, then 20% y $10 copay, then 50% y $10 copay, then 50% y $10 copay, then 50% y Not covered Orthodontic services Not covered Not covered Out-of-area coverage Exclusions and limitations Rates y Retiree only y Retiree and family 36 Dental Benefit Comparison Worldwide for emergency services only Some services are limited or not covered at all, including congenital or developmental malformations, cosmetic services and experimental procedures. Also, there may be limitations for procedures for which you might receive payment from other insurance or government programs. y$65.76 y$ Kaiser Permanente allows a benefit of up to $100 of reimbursement on an approved out-of-area emergency claim Certain services are limited or not covered at all. Some exclusions include congenital or developmental malformations, dental implants, cosmetic services and experimental procedures. Also, there may be limitations for procedures for which you might receive payment from other insurance or government programs. y $63.33 y $126.53

37 1. A higher level of benefits are paid to providers who participate in the Delta Dental Premier Network. As the Delta Dental Plan of Oregon, members who live or travel outside Oregon have access to more than 151,000 dental professionals nationwide through the Delta Dental Network. Services provided by licensed dentist and certified denturists not participating with Delta Dental are paid at the out-of-network fee. 2. Charges for preventive services do not apply to the calendar year benefit maximum. 3. Some limitations may apply month waiting period for basic and major services following enrollment unless member has had continuous employer-sponsored dental coverage for the previous 12 months. This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. Premium rates are subject to change mid-year due to Medicare requirements such as Medicare Part D Late Enrollment Penalty or Low Income Subsidy (Extra Help) notifications. PHIP is required to adjust premiums to account for these changes. For questions regarding premium changes due to Medicare programs, contact Medicare directly. Dental Benefit Comparison 37

38 Required Notices Women s Health and Cancer Rights Act Beginning in 1999, federal law requires group health plans to provide coverage for the following services to an individual receiving plan benefits in connection with a mastectomy: y Reconstruction on the breast on which the mastectomy has been performed; y Surgery and reconstruction of the other breast to produce a symmetrical appearance; and y Prostheses and coverage for physical complications for all stages of a mastectomy, including lymphedemas (swelling associated with the removal of lymph nodes). The health plan must determine the manner of coverage in consultation with the attending physician and patient. Coverage for breast reconstruction and related services will be subject to deductibles, coinsurance amounts and copayments that are consistent with those that apply to other benefits under the plan. Power of Attorney/Authorization to Disclose Information PHIP requires that a Power of Attorney or Authorization to Disclose Information be on file with the program office for anyone acting on a member s behalf. PHIP is unable to release information to anyone who is not authorized by the PHIP member. To disclose or change information after the death of a member, please provide one of the following: executor, letter of probate or trustee documentation, or Last Will and Testament. COBRA continuation of coverage In accordance with federal and state of Oregon guidelines, PHIP provides opportunities for the continuation of coverage through COBRA following specific qualifying events. If you experience one of the qualifying events listed below, please contact PHIP for additional information. A qualifying event will occur if eligibility for coverage is lost because of: y Cancellation of PERS retirement status y The divorce or legal separation of a retiree s covered spouse; PHIP must be notified within 60 days from the signed Dissolution of Marriage document y A spouse or dependent no longer meeting eligibility requirements (e.g., a child reaches the maximum age limit, or a spouse loses coverage because the retiree does not enroll in PHIP upon the last enrollment opportunity) Once COBRA has been secured, timely payment of premiums is essential. In accordance with federal and state of Oregon guidelines, PHIP provides opportunities for the continuation of coverage through COBRA following specific qualifying events. Timely COBRA premium payments The initial premium must be paid within 45 days of the date COBRA is elected. Thereafter, premiums are due the first day of each month for that month s coverage. If payment is not postmarked or received on or before the 45th day (for the initial premium) or the 30th day following the monthly due date, coverage will be terminated and cannot be reinstated. 38 Required Notices

39 Contact Information PERS Health Insurance Program (PHIP) In Portland: Toll-free: Fax: or Mailing address: P.O. Box 40187, Portland, OR PERS Pension Office Pension questions only In Portland: Toll-free: Mailing address: P.O. Box 23700, Tigard, OR Moda Health Medical questions: (Medicare supplement and non-medicare PPO) In Portland: Toll-free: PERS Moda Health PPORX (PPO) (Medicare): In Portland: Toll-free: TTY: 711 Delta Dental of Oregon questions: In Portland: Toll-free: Moda Health Pharmacy Program: In Portland: Toll-free: Medicare Centers for Medicare and Medicaid Services Toll-free: 800-Medicare ( ) Social Security Administration Toll-free: Other websites noted within banners/rules.htm Kaiser Permanente my.kp.org/pers In Portland: Toll-free: TTY: Medicare members: Mail-order pharmacy: In Portland: Toll-free: Pacificsource Health Plans Non-Medicare plans: pacificsource.com/pers In Oregon: Toll-free: Medicare plans: medicare.pacificsource.com/or/ Member/2015/MA/Essentials803.aspx In Oregon: Toll-free: TTY: PacificSource Pharmacy Program: Medicare members: Toll-free: Non-Medicare members: Toll-free: Medicare and non-medicare TTY: Providence Health Plans Prospective members: In Portland: Toll-free: Enrolled Medicare members: In Portland: Toll-free: Enrolled non-medicare members: In Portland: Toll-free: TTY: 711 Providence Pharmacy Program In-Portland: Toll-free: Contact Information 39

40 P.O. Box Portland, OR PRST STD US POSTAGE PAID PORTLAND, OR PERMIT NO Important plan information about your enrollment (8/15)