GIC BENEFIT DECISION GUIDE FOR COMMONWEALTH OF MASSACHUSETTS

Transcription

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

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3 HOW TO USE THIS GUIDE The Benefit Decision Guide is an overview of GIC benefits and is not a benefit handbook. Contact the pans or visit the GIC s website for more detaied pan handbooks. A retirees and survivors shoud read: Annua Enroment Checkist Annua Enroment Overview Annua Enroment News Benefit Changes Procedure Changes and Frequenty Asked Questions Find out about your Medicare heath pan options: Medicare and Your GIC Benefits Medicare Heath Pan Locator Map Prescription Drug Benefits Medicare Heath Pans Benefits At-A-Gance Medicare Heath Pans Find out about your Non-Medicare heath pan options: Non-Medicare Deductibe Changes and Questions & Answers Prescription Drug Benefits Benefits At-A-Gance Non-Medicare Heath Pans Non-Medicare Heath Pan Locator Map Non-Medicare Limited Network Heath Pans Non-Medicare Wide Network Heath Pans Find out about your rates effective Juy 1, 2015: Retiree and Survivor Medicare Heath Pan Rates Retiree and Survivor Non-Medicare Heath Pan Rates Retired Municipa Teacher (RMT) Life Insurance Rates RMT Heath Pan Rates Life Insurance and AD&D Rates GIC Retiree Denta Pan Rates This symbo indicates that benefits are not avaiabe to GIC Retired Municipa Teachers (RMTs not participating in the municipa heath-ony program) and Edery Governmenta Retirees (EGRs). Find out about other benefit options: Life Insurance Accidenta Death & Dismemberment (AD&D) Benefits GIC Retiree Denta Pan GIC Retiree Vision Discount Pan Heath Insurance Buy-Out Resources for additiona information: Inscripción Anua 年 度 投 保 Website Heath Fair Schedue GIC Pan Contact Information Gossary IMPORTANT REMINDERS This Benefit Decision Guide contains important benefit and rate changes effective Juy 1, Review pages 5-6, and 29 for detais. Read the Annua Enroment Checkist on page 2 for information to consider when seecting a heath pan. If you want to keep your current heath pan, you do not need to fi out any paperwork. Your coverage wi continue automaticay. Once you choose a heath pan, you cannot change pans unti the next annua enroment, even if your doctor or hospita eaves the heath pan, uness you have a quaifying event, such as moving out of the pan s service area or becoming Medicare eigibe (in which case, you must enro in a Medicare pan). Your annua enroment forms or requests are due to the GIC no ater than Wednesday, May 6, Forms and appications are avaiabe on the GIC s website ( Changes go into effect Juy 1,

4 ANNUAL ENROLLMENT CHECKLIST STEP 1: X IDENTIFY which heath pan(s) you are eigibe to join: Determine if you are eigibe for Medicare (see page 9). Where you ive determines which pan(s) you may enro in. See the ocator map on page 10 for Medicare pans and page 20 for Non-Medicare pans. See the heath pan pages for eigibiity detais (see pages and 22-25). Do Your Homework During Annua Enroment Even If You Want to Stay in the Same Pan STEP 2: X STEP 3: X For the pans you are eigibe to join and are interested in REVIEW the at-a-gance charts on pages of this guide. WEIGH features that are important to you, such as out-of-network benefits, prescription drug coverage, and menta heath benefits. REVIEW their monthy rates (see pages and 29). If you are a Non-Medicare retiree/survivor, consider enroing in a imited network pan individuas who pay 20% of the premium wi save, on average, $40 per month (see page 21). CONTACT the pan to find out about benefits that are not described in this guide. Find out if your doctors and hospitas are in the pan s network. Ca the pan or visit the pan s website and search for your own and your covered famiy members doctors and hospitas. Be sure to specify the heath pan s fu name, such as Harvard Pigrim Primary Choice Pan or Harvard Pigrim Independence Pan, not just Harvard Pigrim. Your heath pan seection is binding unti the next annua enroment, even if your doctor or hospita eaves your heath pan s network during the year. The heath pan wi hep you find another provider. STEP 4: X If you are a Non-Medicare retiree/survivor, check on copay tier assignments that affect what you pay when you get physician or hospita services. (Copay tiers do not appy to GIC Medicare pans.) Physician and hospita copay tiers can change each Juy 1 for GIC Non-Medicare Retiree/Survivor pans. During annua enroment, check to see if your doctor s or hospita s tier has changed. STEP 5: X Take a ook at other benefit options: Retiree Denta and Buy-Out (see pages for eigibiity and other detais.) THREE GREAT RESOURCES 1 The pan s website: Get additiona benefit detais, information about network physicians, toos to make heath care decisions and more. See page 36 for website addresses. 2 The heath pan s customer service ine: A representative can hep you. See page 36 for phone numbers. 3 A GIC Heath Fair: Tak with pan representatives and get personaized information and answers to your questions. See page 35 for the heath fair schedue. 2

5 ANNUAL ENROLLMENT OVERVIEW Changes Become Effective Juy 1, 2015 Annua enroment gives you the opportunity to review your options and seect a new heath pan. If you want to keep your current GIC heath pan, you do not need to fi out any paperwork. Your coverage wi continue automaticay. Municipa teachers (RMTs) retiring in June 2015 have unti June 15, 2015 to seect their coverage. IF YOU HAVE MEDICARE... IF YOU DO NOT HAVE MEDICARE... Retirees, survivors, deferred retirees, and former empoyees who have continued to pay for heath coverage through the state s 39-week option or the federa COBRA option, GIC Retired Municipa Teachers (RMTs) and Edery Governmenta Retirees (EGRs) Retirees, survivors, deferred retirees, and former empoyees who have continued to pay for heath coverage through the state s 39-week option or the federa COBRA option You may enro in or change your seection of one of these heath pans: You may enro in or change your seection of one of these heath pans: Faon Senior Pan Harvard Pigrim Medicare Enhance Heath New Engand MedPus Tufts Heath Pan Medicare Compement Tufts Heath Pan Medicare Preferred UniCare State Indemnity Pan/Medicare Extension (OME) You may enro in Retiree Denta Pan Retiree Denta Pan You may appy for* Heath Insurance Buy-Out Heath Insurance Buy-Out By submitting by May 6 By submitting by May 6 Current State Retirees/Survivors: Retiree/Survivor Enroment/Change form or written request to make a heath pan change and Buy-Out and Retiree Denta forms to the GIC Retirees/Survivors of New Entities Joining the GIC: New entity initia enroment form and required documentation as outined on the Forms section of our website to the GIC Coordinator in your benefits office Retirees/Survivors of New Entities Joining the GIC: New entity initia enroment form and required documentation as outined on the Forms section of our website to the GIC Coordinator in your benefits office You may enro in or change your seection of one of these heath pans: Current State Retirees/Survivors: Retiree/Survivor Enroment/Change form or written request to make a heath pan change, Buy-Out and Retiree Denta forms to the GIC GIC Retired Municipa Teachers (RMTs) and Edery Governmenta Retirees (EGRs) Once you choose a heath pan, you cannot change pans unti the next annua enroment, even if your doctor or hospita eaves the heath pan, uness you have a quaifying status change, such as moving out of the pan s service area or becoming eigibe for Medicare (in which case you must switch to a Medicare pan). Faon Heath Direct Care Faon Heath Seect Care Harvard Pigrim Independence Pan Harvard Pigrim Primary Choice Pan Heath New Engand NHP Prime (Neighborhood Heath Pan) Tufts Heath Pan Navigator Tufts Heath Pan Spirit UniCare State Indemnity Pan/Basic UniCare State Indemnity Pan/Community Choice UniCare State Indemnity Pan/PLUS You may enro in You may appy for* APRIL 8 MAY 6, 2015 Enroment and appication forms are avaiabe on our website: at the GIC heath fairs, and by caing or writing to the GIC. Faon Heath Direct Care Faon Heath Seect Care Heath New Engand NHP Prime (Neighborhood Heath Pan) UniCare State Indemnity Pan/Basic You may enro in For written requests to make a heath pan change, incude your name, address and GIC Identification number. Retiree Denta Pan You may appy for* Heath Insurance Buy-Out By submitting by May 6 Enroment forms to the GIC Indicates a GIC Limited Network Pan. * See page 33 for eigibiity detais. 3

6 ANNUAL ENROLLMENT NEWS The Commonweath continues to face chaenging budget times. Many worthy initiatives incuding education, oca aid and transportation are competing for scarce resources as heath care costs crowd out the state budget. For this fisca year, a $765 miion shortfa is projected; the GIC has a $165 to $190 miion deficit. Most of the GIC budget shortfa is structura we have been underfunded for the ast three years because the budget base was not updated for the additiona members that we have added, the end of federa funds, and the suppementa budgets we ve received. The Fisca Year 2016 premium requests we received from the pans, especiay two of the arger ones, were not reaistic given the budget situation. Additionay, too many patients use expensive academic medica centers for routine care, further increasing costs for a of us. The Administration has committed to making the GIC s current budget whoe. However, despite the new budget base, there s no room for increased spending next year. With many pressing concerns, agencies have been asked to come in with eve funding. The GIC has been pushing hard through the Centered Care Initiative to change the way providers are paid: moving from fee for service payment arrangements that reward providers for ordering unnecessary tests and procedures to goba payments. This has been a tough sog and progress has been sower than we woud ike. We wi continue to push for these changes, but in the meantime, the Commission has had to make some difficut decisions. These were not easy decisions and they wi affect a of us who work for the state and oca communities. We encourage you to take charge of your heath and take advantage of ways to ower your out-of-pocket costs. A members: Work with your Primary Care Provider (PCP) to navigate the heath care system. Make copies and bring the prescription drug formuary from your pan s website with you to a doctor visits. Use urgent care faciities and retai minute cinics instead of the emergency room for urgent (non-emergency) care. Read about ways to take charge of your heath; the GIC s website has a weath of artices and inks to additiona resources: Eat heathy, exercise reguary, don t smoke, and find ways to de-stress. If you are a Non-Medicare Retiree or Survivor: Seek care from Tier 1 and Tier 2 speciaists. Over 164 miion caims have been anayzed for differences in how physicians perform on nationay recognized measures of quaity and/or cost efficiency. You pay the owest copay for the highest-performing doctors: HHH Tier 1 (exceent) HH Tier 2 (good) H Tier 3 (standard) If you are in a tiered hospita pan and have a panned hospita admission, tak with your doctor about whether a Tier 1 hospita woud make sense. Use your heath pan s onine cost comparison too to shop for heath care services in advance. Consider enroing in a Limited Network Pan to save money on your monthy premium. 4

7 BENEFIT CHANGES EFFECTIVE JULY 1, 2015 MEDICARE HEALTH PLAN CHANGES Rues for Enroing in Heath Pans and Adding Dependents: In compiance with federa and state aw for pre-tax benefits, the GIC wi be tightening up our rues and instituting deadines for enroing in heath pans and adding dependents. As aways, required documentation (e.g., birth certificates and marriage certificates) must accompany the change forms. See page 7 for additiona information. Prescription Drug Copays: A prescription drug copays except for Tier 1 retai wi increase to: Tier 2 $30 and Tier 3 $65 retai up to a 30-day suppy; Tier 1 $25; Tier 2 $75 and Tier 3 $165 mai order up to a 90-day suppy. For Faon Senior Pan and Tufts Medicare Preferred, these changes wi go into effect January 1, UNICARE STATE INDEMNITY PLAN/MEDICARE EXTENSION Prescription Drug Program: CVS/caremark was seected to continue as the pharmacy benefit manager. Prior authorization wi be required for certain high-cost drugs. See page 13 for additiona information. Certain Ora, Injectabe, Infused and Inhaed Speciaty Drugs: After the first fi of certain speciaty drugs, you must get refis through CVS/caremark s speciaty pharmacy. The first fi may be imited to up to a 14-day suppy with a prorated copay. Prescription Drug Program Wi Become an Empoyer Group Waiver Pan (EGWP) Effective January 1, 2016: The prescription drug benefit wi transition to an EGWP Program, a Medicare Part D pan, with additiona coverage provided by the GIC. Members of UniCare State Indemnity/Medicare Extension and their Medicare-eigibe spouse and dependents wi automaticay be enroed. Under this program: Low-income retirees may be eigibe for subsidies and reduced copayments; The Medicare Part D premium is incuded in your monthy heath insurance rate. However, enroees deemed by Socia Security to have high income wi aso pay an Income Reated Monthy Adjustment Amount (IRMAA) for Medicare Part D. Visit Socia Security s or Medicare s website for more information; Benefits of the pan wi match or be simiar to the UniCare Non-Medicare heath pan drug program; Because of the additiona coverage provided by the GIC, your coverage wi be better than a standard Medicare prescription drug pan; and You wi have more retai pharmacy options for fiing your 90-day maintenance medications. We wi send you additiona detais about the EGWP Program in the ate summer; for Annua Enroment, you do not need to do anything if you want to stay in this heath pan. NON-MEDICARE HEALTH PLANS PCPS AND REFERRALS REQUIRED! HARVARD PILGRIM INDEPENDENCE PLAN AND TUFTS HEALTH PLAN NAVIGATOR In keeping with the Centered Care Initiative, Harvard Pigrim Independence Pan and Tufts Heath Pan Navigator wi become Point-of-Service (POS) pans. With a POS Pan, members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists to receive care at the in-network eve of coverage. Members who get care from speciaists without a PCP referra wi have higher out-of-pocket costs. Current members of these pans wi stay in the pan if they do not switch pans during Annua Enroment and wi receive additiona detais of this transition from their pan. Rues for Enroing in Heath Pans and Adding Dependents: In compiance with federa and state aw for pre-tax benefits, the GIC wi be tightening up our rues and instituting deadines for enroing in heath pans and adding dependents. As aways, required documentation (e.g., birth certificates and marriage certificates) must accompany the change forms. See page 7 for additiona information. Deductibe: The current caendar year deductibe wi increase to $300 individua; $600 two-person famiy; and $900 three- or more person famiy coverage. The carryover provision into 2016 for deductibe-reated charges incurred October December 2015 has been eiminated. The deductibe wi transition to a fisca year deductibe to make it easier for members to change heath pan carriers at future annua enroments. See page 11 for additiona detais. 5

8 BENEFIT CHANGES EFFECTIVE JULY 1, 2015 Other Benefits That Accrue on a Caendar Year: wi transition during FY16 to a fisca year accrua. For 2015, they wi accrue on a caendar year; from January 1 June 30, 2016, they wi accrue on a haf-caendar year; from Juy 1, 2016 June 30, 2017, they wi accrue on a fisca year. Detais vary sighty by pan; contact the pan for detais: Out-of-pocket maximum Inpatient copay Day imits for other inpatient medica faciities (skied nursing, rehab, etc.) Outpatient surgery copay Physica and Occupationa Therapy Outpatient menta heath Smoking cessation counseing Hearing aids Fitness reimbursement Nutritiona counseing Vision hardware for certain conditions Vision exam Chiropractic visits Speech therapy Private Duty nursing Hospita-based persona emergency response systems See the Non-Medicare at-a-gance chart on page 18 for the foowing changes: Speciaist Tiering: Copays for speciaists wi increase for a pans: $30 Tier 1; $60 Tier 2; $90 Tier 3. Faon Heath Direct Care wi tier speciaists based on quaity and/or cost efficiency for the first time. Inpatient Hospita Care Copay: For pans that do not tier hospitas (Faon Heath Direct Care, Heath New Engand, Neighborhood Heath Pan, UniCare State Indemnity Pan/Basic, and UniCare Community Choice), the copay wi increase to $275. Tufts Heath Pan Navigator wi change to three tier hospita copays and Tier 1 and Tier 3 copays wi increase or change for a pans that have three hospita tiers (Faon Heath Seect Care, Harvard Pigrim Independence Pan, Tufts Heath Pan Navigator, and UniCare PLUS): Tier 1: $275 and Tier 3: $1,500. For Harvard Pigrim Primary Choice, Tier 1 wi increase to $275. Outpatient Surgery Copay: The copay wi increase to $250 for a pans except UniCare Community Choice and PLUS. Prescription Drug Copays: A prescription drug copays except for Tier 1 retai wi increase to: Tier 2 $30 and Tier 3 $65 retai up to a 30-day suppy; Tier 1 $25; Tier 2 $75 and Tier 3 $165 mai order up to a 90-day suppy. In-Network Out-of-Pocket Maximum: The out-of-pocket maximum ($5,000 per individua and $10,000 per famiy) wi now incude prescription drugs for Harvard Independence and Primary Choice, Tufts Navigator and Spirit. (This aready appies to the other GIC HMOs.) The out-of-pocket maximum for UniCare State Indemnity Pan/Basic, Community Choice and PLUS wi change to $4,000 per individua and $8,000 per famiy for medica and menta heath benefits and $1,500 per individua and $3,000 per famiy for prescription drug benefits. Other Non-Medicare Heath Pan Changes NEIGHBORHOOD HEALTH PLAN NHP Care wi now be caed NHP Prime. Prosthetics and orthotics with Durabe Medica Equipment (DME) wi be subject to the deductibe, but not coinsurance. Hearing aid benefits for members over age 22 wi no onger be subject to coinsurance. TUFTS HEALTH PLAN NAVIGATOR AND SPIRIT Menta Heath/Substance Abuse: Outpatient menta heath visits up to 26 visits without prior authorization; thereafter, visits subject to prior authorization for medica necessity. UNICARE STATE INDEMNITY PLAN/BASIC, COMMUNITY CHOICE AND PLUS Prescription Drug Program: CVS/caremark was seected to continue as the pharmacy benefit manager. Prior authorization wi be required for certain high-cost drugs. See page 13 for additiona information. Certain Ora, Injectabe, Infused and Inhaed Speciaty Drugs: After the first fi of certain speciaty drugs, you must get refis through CVS/caremark s speciaty pharmacy. The first fi may be imited to up to a 14-day suppy with a prorated copay. Menta Heath/Substance Abuse: One visit with a PCP for menta heath/substance abuse wi now be covered. Outpatient menta heath visits up to 26 visits without prior authorization; thereafter, visits subject to prior authorization for medica necessity. Other GIC Benefit Changes RETIREE DENTAL: Composite fiings on posterior teeth wi now be covered. 6

9 PROCEDURE CHANGES AND FREQUENTLY ASKED QUESTIONS Modifications to Rues for Enroing in Heath Pans and Adding Dependents In compiance with federa and state aw for pre-tax benefits, the GIC wi be tightening up our rues and instituting deadines for enroing in heath pans and adding dependents effective Juy 1, As aways, required documentation (e.g., birth certificates and marriage certificates) must accompany the change forms. Effective Juy 1, 2015: A GIC forms have changed. Visit our website for current forms: GIC eigibe enroees can ony enro in coverage for the first time as a new hire, at Annua Enroment or during the year with a documented quaifying event: marriage, birth/adoption of chid, invountary oss of other coverage, spouse s annua enroment, or return from an approved FMLA or miitary eave. GIC members can ony change from individua to famiy or famiy to individua coverage with a quaifying event: marriage, birth/adoption of chid, change in dependent eigibiity, divorce (subject to M.G.L. Ch. 32A eigibiity requirements), death of spouse/dependent or spouse s or dependent s invountary oss of coverage esewhere. A forms and documentation for the above enroments or changes must be received at the GIC within 60 days of the quaifying event. If you miss this deadine, you must wait for the next Annua Enroment to make the change. As aways, it s important to remember that you can ony change heath pans at Annua Enroment, uness you move out of your heath pan s service area, at retirement, or are retired and become Medicare eigibe, in which case you must change pans. Frequenty Asked Questions Q I m turning age 65; what do I need to do? A If you are age 65 or over, visit Socia Security s website or your oca Socia Security office for confirmation of Socia Security and Medicare benefit eigibiity. If you are eigibe for Medicare Part A for free and if you are retired from the state, you must enro in Medicare Part A and Part B to continue coverage with the GIC. You shoud not sign up for an individua Medicare Part D on your own; prescription drug benefits are provided by your GIC heath or drug pan. Q I am retired from the state, but not yet age 65. My GIC-covered spouse is turning age 65. What does my covered spouse need to do? A If your GIC-covered spouse turns age 65 before you (the insured state retiree), your covered spouse shoud visit Socia Security s website or your oca Socia Security office for confirmation of Socia Security and Medicare benefit eigibiity. If your covered spouse is eigibe for Medicare Part A for free, he/she must enro in Medicare Part A and Part B to continue coverage with the GIC. Q I am retired from the state. I am (or my covered spouse is) age 65 or over and the other one of us is not. How does this affect our GIC heath insurance? A If you or your covered spouse is age 65 or over and eigibe for Medicare Part A for free, but the other one is under age 65, the person under age 65 wi continue to be covered under a Non-Medicare pan unti he/she becomes eigibe for Medicare coverage. The person age 65 or over must enro in a GIC Medicare Pan. If you have Medicare/Non-Medicare combination coverage, you must enro in one of the pairs of pans isted on page 9. 7

10 FREQUENTLY ASKED QUESTIONS Q I am an active GIC-eigibe empoyee and am aso retired from a state agency or participating municipaity and am eigibe for GIC retirement benefits. Can I eect both empoyee and retiree benefits? A No. You must eect active empoyee or retiree benefits. Contact the GIC to indicate whether you want empoyee or retiree benefits. Q If I die, is my surviving spouse eigibe for GIC heath insurance? A If you (the state retiree) have coverage through the GIC at the time of your death, your surviving spouse is eigibe for GIC heath insurance coverage unti he/she remarries or dies, regardess of your retirement benefit option (A, B or C). However, he/she must appy for survivor coverage by contacting the GIC for an appication; survivor coverage is not an automatic benefit. If your surviving spouse is a state or participating municipa empoyee or retiree, he or she must eect coverage through the state or participating municipaity and is not eigibe for survivor heath coverage. You MUST Notify the GIC When Your Persona or Famiy Information Changes Faiure to notify the GIC of famiy status changes, such as ega separation, divorce, remarriage, and/or addition of dependents can resut in financia iabiity to you. Pease write to the GIC when any of the foowing changes occur: Marriage or remarriage Remarriage of a former spouse Lega separation Divorce Address change Dependent age 19 to 26 who is no onger a fu-time student Dependent other than fu-time student who has moved out of your heath pan s service area Death of an insured Death of a covered spouse, dependent or beneficiary Life insurance beneficiary change See the GIC s website for answers to other frequenty asked questions: Birth or adoption of a chid Lega guardianship of a chid You have GIC COBRA coverage and become eigibe for other coverage 8

11 MEDICARE AND YOUR GIC BENEFITS Medicare Guideines Medicare is a federa heath insurance program for retirees age 65 or oder and certain disabed peope. Medicare Part A covers inpatient hospita care, some skied nursing faciity care and hospice care. Medicare Part B covers physician care, diagnostic x-rays and ab tests, and durabe medica equipment. Medicare Part D is a federa prescription drug program. When you or your spouse is age 65 or over, or if you or your spouse is disabed, visit Socia Security s website or your oca Socia Security Administration office to find out if you are eigibe for free Medicare Part A coverage. If you (the insured) continue working after age 65, you and/or your spouse shoud NOT enro in Medicare Part B unti you (the insured) retire. When you (the insured) retire: If you and/or your spouse is eigibe for free Part A coverage, state aw requires that you and/or your spouse enro in Medicare Part A and Part B in order to be covered by the GIC. You must join a Medicare pan sponsored by the GIC to continue heath coverage. These pans provide comprehensive coverage for some services that Medicare does not cover. If both you and your spouse are Medicare eigibe, both of you must enro in the same Medicare pan. You must continue to pay your Medicare Part B premium. Faiure to pay this premium wi resut in the oss of your GIC coverage. Retiree and Spouse Coverage if Under and Over Age 65 If you (the retiree), your spouse or other covered dependent is younger than age 65, the person or peope under age 65 wi continue to be covered under a Non-Medicare pan unti you and/or he/she becomes eigibe for Medicare. If this is the case, you must enro in one of the pairs of pans isted beow: Heath Pan Combination Choices State retirees, deferred retirees and former empoyees receiving continuation coverage NON-MEDICARE PLAN Faon Heath Direct Care Faon Heath Seect Care Harvard Pigrim Independence Pan Harvard Pigrim Primary Choice Pan Heath New Engand Tufts Heath Pan Navigator Tufts Heath Pan Navigator Tufts Heath Pan Spirit Tufts Heath Pan Spirit UniCare State Indemnity Pan/Basic UniCare State Indemnity Pan/Community Choice UniCare State Indemnity Pan/PLUS MEDICARE PLAN Faon Senior Pan Faon Senior Pan Harvard Pigrim Medicare Enhance Harvard Pigrim Medicare Enhance Heath New Engand MedPus Tufts Heath Pan Medicare Compement Tufts Heath Pan Medicare Preferred Tufts Heath Pan Medicare Compement Tufts Heath Pan Medicare Preferred UniCare State Indemnity Pan/ Medicare Extension (OME) UniCare State Indemnity Pan/ Medicare Extension (OME) UniCare State Indemnity Pan/ Medicare Extension (OME) Medicare Part D and Your Prescription Drug Benefits Most enroees shoud not enro in an individua federa Medicare drug pan. See page 13 for additiona detais. Heath Pan Combination Choices GIC Retired Municipa Teachers (RMTs who do not participate in the municipa heathony program) and Edery Governmenta Retirees (EGRs) NON-MEDICARE PLAN Faon Heath Direct Care Faon Heath Seect Care Heath New Engand UniCare State Indemnity Pan/Basic MEDICARE PLAN Faon Senior Pan Faon Senior Pan Heath New Engand MedPus UniCare State Indemnity Pan/ Medicare Extension (OME) 9

12 MEDICARE AND YOUR GIC BENEFITS How to Cacuate Your Rate See rate charts on pages and 29. Retiree and Spouse Both on Medicare Find the Retiree Pays Monthy rate for the Medicare pan in which you are enroing and doube it for your tota monthy rate. Retiree and Spouse Coverage if Under and Over Age Find the Retiree Pays Monthy premium for the Medicare Pan in which the Medicare retiree or spouse wi be enroing. 2. Find the Retiree Pays Monthy individua coverage premium for the Non-Medicare Pan in which the Non-Medicare retiree or spouse wi be enroing. 3. Add the two premiums together; this is the tota that you wi pay monthy. Hepfu Reminders Visit Socia Security s website or your oca Socia Security office for more information about Medicare benefits. HMO Medicare pans require you to ive in their service area. See the Medicare Heath Pan Locator Map beow. You may change GIC Medicare pans ony during annua enroment, uness you have a quaifying event, such as moving out of your pan s service area. Note: Even if your doctor or hospita drops out of your Medicare HMO, you must stay in the HMO unti the next annua enroment. Your Medicare HMO wi hep you find another provider. Benefits and rates of Faon Senior Pan and Tufts Heath Pan Medicare Preferred are subject to federa approva and may change January 1, 2016; you cannot change pans unti the spring Annua Enroment period. These pans, and the UniCare State Indemnity Pan/Medicare Extension (OME) Pan effective January 1, 2016, automaticay incude Medicare Part D prescription drug benefits. MEDICARE HEALTH PLAN LOCATOR MAP Where You Live Determines Which Pan You May Enro In. Is the MEDICARE Heath Pan Avaiabe Where You Live? MAINE HPME OME NEW YORK HPME TMC * OME MAP KEY FSP HPME HNMP TMC TMP OME VERMONT FRANKLIN FSP * HPME HNMP TMC OME BERKSHIRE WORCESTER HPME HAMPSHIRE FSP HPME HNMP FSP HPME HNMP HNMP TMC TMC TMC TMP OME TMP OME OME HAMPDEN FSP HPME HNMP TMC TMP OME CONNECTICUT FSP * HPME HNMP * TMC * OME NEW HAMPSHIRE HPME TMC * OME FSP * HPME TMC * OME Faon Senior Pan Harvard Pigrim Medicare Enhance Heath New Engand MedPus Tufts Heath Pan Medicare Compement Tufts Heath Pan Medicare Preferred UniCare State Indemnity Pan/ Medicare Extension (OME) RHODE ISLAND FSP * HPME TMC OME MIDDLESEX FSP HPME TMC TMP OME ESSEX FSP HPME TMC TMP OME NORFOLK FSP HPME TMC TMP PLYMOUTH OME FSP HPME TMC TMP OME BRISTOL FSP HPME TMC TMP OME SUFFOLK FSP, HPME, TMC, TMP, OME BARNSTABLE FSP HPME TMC TMP OME DUKES HPME, TMC, OME NANTUCKET HPME, TMC, OME The Harvard Pigrim Medicare Enhance Pan is avaiabe throughout the United States. The UniCare State Indemnity Pan/Medicare Extension is avaiabe throughout the United States and outside of the country. * Not every city and town is covered in this county or state; contact the pan to find out if you ive in the service area. The pan aso has a imited network in this county or state; contact the pan to find out which doctors and hospitas participate in the pan. 10

13 NON-MEDICARE DEDUCTIBLE CHANGES AND QUESTIONS & ANSWERS Information on this page does not appy to the GIC Medicare Pans. The caendar year deductibe for Non-Medicare retiree/ survivor heath pans wi increase effective Juy 1, The deductibe wi transition to a fisca year to make it easier for members to change heath pan carriers at Annua Enroment. The carryover provision of October December has been eiminated. Deductibe Questions and Answers Q What is a deductibe? A A GIC Non-Medicare Retiree/Survivor heath pans incude a deductibe. This is a fixed doar amount you must pay each year before your heath pan begins paying benefits for you or your covered dependent(s). This is a separate charge from any copays. Q How much is the in-network 2015 caendar year deductibe? A The deductibe wi increase effective Juy 1, 2015 to $300, up to a maximum of $900 per famiy. Here is how it works for each coverage eve: Individua: The individua has a $300 deductibe before benefits begin. Two-person famiy: Each person must satisfy a $300 deductibe. Three- or more person famiy: The maximum each person must satisfy is $300 unti the famiy as a whoe reaches the new $900 maximum. If you are in a POS or PPO-type pan, there is an additiona out-of-network deductibe of $400 per member, up to a maximum of $800 per famiy; this is a separate charge from the in-network deductibe. Q I ve aready satisfied my caendar year deductibe; wi I need to pay more toward my deductibe in 2015? A Yes. If you aready paid $250 for your individua caendar year deductibe, you wi be subject to another $50 for the rest of the 2015 caendar year. Two-person famiies and famiies of three or more peope that have met their deductibe may incur an additiona $100 or $150, respectivey. The caendar year deductibe wi transition to a fisca year deductibe next year to make it easier to change heath pan carriers at Annua Enroment. Here s how this wi work: For Caendar Year 2015: The deductibe wi remain on a caendar year. For January June 2016, there wi be a haf-year deductibe: Individua: The individua wi have a $150 deductibe before benefits begin. Two-person famiy: Each person must satisfy a $150 deductibe. Three- or more person famiy: The maximum each person must satisfy is $150 unti the famiy as a whoe reaches the six-month $450 maximum. Effective Juy 1, 2016: the deductibe year wi run Juy 1, 2016 June 30, Q If I change heath pans during this Annua Enroment, am I subject to another deductibe? A You wi not be subject to a new deductibe if: You stay with the same heath pan carrier but switch to one of its other options. You wi be subject to a new deductibe this annua enroment ony if: You choose a different GIC heath pan carrier. 11

14 NON-MEDICARE DEDUCTIBLE CHANGES AND QUESTIONS & ANSWERS Q Wi the deductibe-reated charges that I incur in October December 2015 be appied toward my haf-year caendar year deductibe that begins January 1, 2016? A No. The carryover provision has been eiminated. Q Which heath care services are subject to the deductibe? A The ists beow summarize expenses that generay are and are not subject to the annua deductibe. These are not exhaustive ists. You shoud check with your heath pan for detais. As with a benefits, variations in the guideines beow may occur, depending upon individua patient circumstances and a pan s schedue of benefits. Exampes of in-network expenses generay exempt from the deductibe: Prescription drug benefits Outpatient menta heath/substance abuse benefits Office visits (primary care physician, speciaist, retai cinics, preventive care, maternity and we baby care, routine eye exam, occupationa therapy, physica therapy, chiropractic care and speech therapy) Medicay necessary chid and adut immunizations Medicay necessary wigs Hearing aids Mammograms Exampes of in-network expenses generay subject to the deductibe: Emergency room visits Inpatient hospitaization Surgery Laboratory and bood tests X-rays and radioogy (incuding high-tech imaging such as MRI, PET and CT scans) Durabe medica equipment Q How wi I know how much I need to pay out of pocket? A Upon request, pans are required to te you before you incur charges the amount you wi be required to pay. Ca your pan or visit their website to get this information. When you visit a doctor or hospita, the provider shoud ask you for your copay upfront. After you receive services, your heath pan may provide you with an Expanation of Benefits, or you can ca your pan to find out which additiona portion of the costs you wi be responsibe for. The provider wi then bi you for any baance owed. Information on this page does not appy to the GIC Medicare Pans. Pap smears EKGs 12

15 PRESCRIPTION DRUG BENEFITS Drug Copayments A GIC heath pans provide benefits for prescription drugs using a three-tier copayment structure in which your copayments vary, depending on the drug dispensed. Contact the pans you are considering with questions about your specific medications. TIER 1: You pay the owest copayment. This tier is primariy made up of generic drugs, athough some brand name drugs may be incuded. Generic drugs have the same active ingredients in the same strength as their brand name counterparts. Brand name drugs are amost aways significanty more expensive than generics. TIER 2: You pay the mid-eve copayment. This tier is primariy made up of brand name drugs, seected based on reviews of the reative safety, effectiveness and cost of the many brand name drugs on the market. Some generics may aso be incuded. TIER 3: You pay the highest copayment. This tier is primariy made up of brand name drugs not incuded in Tiers 1 or 2. Generic or brand name aternatives for Tier 3 drugs may be avaiabe in Tiers 1 or 2. Tip for Reducing Your Prescription Drug Costs Use Mai Order: Are you taking prescription drugs for a ong-term condition, such as asthma, high bood pressure, or high choestero? Switch your prescription from a retai pharmacy to mai order. It can save you money $5-$30 for three months of medication, depending on the tier. See the at-a-gance charts on pages for copay detais. Once you begin mai order, you can convenienty order refis by phone or onine. Contact your pan for detais. Prescription Drug Programs Some GIC pans have the foowing programs to encourage the use of safe, effective and ess costy prescription drugs. Contact the pans you are considering to find out detais about these programs: Mandatory Generics When fiing a prescription for a brand name drug for which there is a generic equivaent, you wi be responsibe for the cost difference between the brand name drug and the generic, pus the generic copay. Step Therapy This program requires enroees to try effective, ess costy drugs before more expensive aternatives wi be covered. Maintenance Drug Pharmacy Seection If you receive 30-day suppies of your maintenance drugs at a retai pharmacy, you must ca your prescription drug pan to te them whether or not you wish to change to 90-day suppies through either mai order or certain retai pharmacies. Speciaty Drug Pharmacies If you are prescribed injected or infused speciaty drugs, you may need to use a speciaized pharmacy which can provide you with 24-hour cinica support, education and side effect management. Medications are deivered to your home or doctor s office. Medicare Part D Prescription Drug Reminders and Warnings For most GIC Medicare enroees, the drug coverage you currenty have through your GIC heath pan is a better vaue than a basic Medicare Part D drug pan. Therefore, most individuas shoud not enro in an individua federa Medicare drug pan. A Notice of Creditabe Coverage is in your pan handbook. It provides proof that you have comparabe or better coverage than Medicare Part D. If you shoud ater enro in a Medicare drug pan because of changed circumstances, you must show the Notice of Creditabe Coverage to the Socia Security Administration to avoid paying a penaty. Keep this notice with your important papers. If you are a member of Harvard Medicare Enhance, Heath New Engand MedPus or Tufts Medicare Compement and have extremey imited income and assets, contact the Socia Security Administration to find out about subsidized Part D coverage. If you are eigibe, you may want to enro in one of the GIC s Medicare Part D Pans (Faon Senior Pan, Tufts Medicare Preferred, and, in January, UniCare State Indemnity Pan/Medicare Extension). If you are a member of one of our Medicare Advantage pans (Faon Senior Pan and Tufts Heath Pan Medicare Preferred), or the UniCare State Indemnity Pan/Medicare Extension (OME) effective January 1, 2016, your pan automaticay incudes or wi incude Medicare Part D coverage. If you enro in another Medicare Part D drug pan, the Centers for Medicare & Medicaid Services wi automaticay dis-enro you from your GIC Medicare Advantage heath pan, which means you wi no onger have a Medicare pan through the GIC. UniCare Prescription Drug Formuary and Prior Authorization Change Effective Juy 1, 2015 To contro escaating prescription drug costs, the GIC is moving to a new formuary for a UniCare members. Certain high-cost drugs with ower-cost aternatives wi ony be covered based on medica necessity. Prior authorization wi be required. For additiona detais, contact CVS/caremark. 13

16 MEDICARE HEALTH PLANS Faon Senior Pan HMO Faon Senior Pan is a Medicare Advantage HMO pan that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Physician (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Faon Senior Pan is a Medicare pan under contract with the federa government that incudes Medicare Part D prescription drug benefits. Contact the pan for detais. This Medicare pan s benefits and rates are subject to federa approva and may change January 1, Eigibiity Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents with Medicare Part A and Part B who ive in the service area are eigibe. You may change pans ony during the GIC s spring Annua Enroment period, even though the pan s providers may change on a caendar year basis. Harvard Pigrim Medicare Enhance Indemnity Harvard Pigrim Medicare Enhance is a suppementa Medicare pan, offering coverage for services provided by any icensed doctor or hospita throughout the United States that accepts Medicare payment. Eigibiity Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents with Medicare Part A and Part B who ive in the United States are eigibe. Heath New Engand MedPus HMO Heath New Engand MedPus is a Medicare HMO pan that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Physician (PCP) to manage their care; referras to network speciaists are not required. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency and urgent care. Eigibiity Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents with Medicare Part A and Part B who ive in the service area are eigibe. Tufts Heath Pan Medicare Compement HMO Tufts Heath Pan Medicare Compement is a suppementa Medicare HMO pan that provides coverage through the Pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Physician (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency and urgent care. Eigibiity Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents with Medicare Part A and Part B who ive in the service area are eigibe. 14

17 MEDICARE HEALTH PLANS Tufts Heath Pan Medicare Preferred HMO Tufts Heath Pan Medicare Preferred HMO is a Medicare Advantage pan that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Physician (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Tufts Heath Pan Medicare Preferred HMO is a Medicare Advantage pan under contract with the federa government that incudes Medicare Part D prescription drug benefits. Contact the pan for detais. This Medicare pan s benefits and rates are subject to federa approva and may change January 1, Eigibiity Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents with Medicare Part A and Part B who ive in the service area are eigibe. UniCare State Indemnity Pan/Medicare Extension (OME) Indemnity The UniCare State Indemnity Pan/Medicare Extension (OME) is a suppementa Medicare pan offering access to any icensed doctor or hospita throughout the United States and outside of the country. The menta heath benefits of this pan, administered by Beacon Heath Options, offer you in-network benefits with a copay. Or, you may seek care out-of-network, but at higher out-ofpocket costs. Prescription drug benefits are administered by CVS/caremark. Effective January 1, 2016 members wi be automaticay enroed in Medicare Part D as the drug benefit of this pan transitions to an Empoyer Group Waiver Pan (EGWP). See page 5. Eigibiity Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents with Medicare Part A and Part B are eigibe. You may change pans ony during the GIC s spring Annua Enroment period, even though the pan s providers may change on a caendar year basis. 15

18 BENEFITS AT-A-GLANCE: Medicare Heath Pan Copays and Deductibes This chart is an overview of the pan benefits. It is not a compete description. Benefits are subject to certain definitions, conditions, imitations and excusions as speed out in the respective pan documents. With the exception of emergency care, there are no out-ofnetwork benefits for the GIC s Medicare HMOs. HEALTH PLAN FALLON SENIOR PLAN HARVARD PILGRIM MEDICARE ENHANCE HEALTH NEW ENGLAND MEDPLUS PLAN TYPE HMO INDEMNITY HMO PCP Designation Required Yes No Yes PCP Referra to Speciaist Required Yes No No Caendar Year Deductibe None None None Preventive Care Office visits according to heath pan s schedue No copay No copay No copay Physician Office Visit (except menta heath) $10 per visit $10 per visit $10 per visit Retai Cinic $10 per visit $10 per visit $10 per visit Outpatient Menta Heath and Substance Abuse Care $10 per visit $10 per visit $10 per visit Inpatient Hospita Care No copay No copay No copay Hospice Care No copay No copay No copay Diagnostic Laboratory Tests and X-rays No copay No copay No copay Surgery Inpatient & Outpatient No copay No copay No copay Emergency Room Care (incudes out-of-area) Hearing Aids Prescription Drug Retai: up to 30-day suppy Tier 1 Tier 2 Tier 3 Mai order: Maintenance drugs up to a 90-day suppy Tier 1 Tier 2 Tier 3 $50 per visit (waived if admitted) $50 per visit (waived if admitted) $50 per visit (waived if admitted) First $500 covered at 100%; 80% coverage for the next $1,500 per person, per two-year period $10 $30 $65 $25 $75 $165 $10 $30 $65 $25 $75 $165 $10 $30 $65 $25 $75 $165 The amounts and terms that appear in bod in this chart are benefits that have changed effective Juy 1, Benefits and rates of Faon Senior Pan and Tufts Heath Pan Medicare Preferred are subject to federa approva and may change effective January 1, Prescription drug copays for these pans wi increase to the copays isted effective January 1,

19 For more information about a specific pan s benefits or providers, ca the pan or visit its website. TUFTS HEALTH PLAN MEDICARE COMPLEMENT TUFTS HEALTH PLAN MEDICARE PREFERRED UNICARE STATE INDEMNITY PLAN MEDICARE EXTENSION (OME) with CIC (Comprehensive) Without CIC, deductibes are higher and coverage is ony 80% for some services. Contact the pan for detais. HMO HMO INDEMNITY Yes Yes No Yes Yes No None None $35 per person No copay No copay No copay $10 per visit $10 per visit No copay $10 per visit $10 per visit No copay $10 per visit $10 per visit No copay No copay First 4 visits: no copay; visits 5 and over: $10 per visit $50 per admission (maximum one copay per person per caendar year quarter) No copay No copay No copay No copay No copay No copay No copay $50 per visit (waived if admitted) No copay $50 per visit (waived if admitted) No copay in MA and for out-of-state providers who accept Medicare; ca the pan for detais if using out-of-state providers who do not accept Medicare $25 per visit (waived if admitted) First $500 covered at 100%; 80% coverage for the next $1,500 per person, per two-year period $10 $30 $65 $10 $30 $65 $10 $30 $65 $25 $75 $165 $25 $75 $165 $25 $75 $165 You may change pans ony during the GIC s Spring Annua Enroment period, even though the pan s providers may change on a caendar year basis. 17

20 BENEFITS AT-A-GLANCE: Non-Medicare Heath Pan Copays & Deductibes This chart is a comparative overview of GIC pan benefits. See the c Pan Navigator, and UniCare State Indemnity Pan/Community Choic With the exception of emergency care, there are no out-of-network HEALTH PLAN FALLON HEALTH DIRECT CARE FALLON HEALTH SELECT CARE HARVARD PILGRIM INDEPENDENCE PLAN HARVARD PILGRIM PRIMARY CHOICE PLAN HEALTH NEW ENGLAND PLAN TYPE HMO HMO POS HMO HMO PCP Designation Required Yes Yes Yes Yes Yes PCP Referra to Speciaist Required Out-of-pocket Maximum Individua coverage Yes Yes Yes Yes No $5,000 $5,000 $5,000 $5,000 $5,000 Famiy coverage $10,000 $10,000 $10,000 $10,000 $10,000 Caendar Year Deductibe Individua Two-person famiy Three- or more person famiy $300 $600 $900 $300 $600 $900 Primary Care Provider Office Visit $15 per visit $20 per visit $20 per visit $20 per visit $20 per visit Preventive Services Speciaist Physician Office Visit HHH Tier 1 (exceent) HH Tier 2 (good) H Tier 3 (standard) Most covered at 100% no copay $30 per visit $60 per visit $90 per visit Most covered at 100% no copay $30 per visit $60 per visit $90 per visit 18 $300 $600 $900 Most covered at 100% no copay $30 per visit $60 per visit $90 per visit $300 $600 $900 Most covered at 100% no copay $30 per visit $60 per visit $90 per visit $300 $600 $900 Most covered at 100% no copay $30 per visit $60 per visit $90 per visit Retai Cinic $15 per visit $20 per visit $20 per visit $20 per visit $20 per visit Outpatient Menta Heath & Substance Abuse Care $15 per visit $20 per visit $20 per visit $20 per visit $20 per visit Emergency Room Care $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) Inpatient Hospita Care Medica Tier 1 Tier 2 Tier 3 Outpatient Surgery High-Tech Imaging (e.g., MRI, CT and PET scans) Prescription Drug Retai: up to a 30-day suppy Tier 1 Tier 2 Tier 3 Mai-order: Maintenance drugs up to a 90-day suppy Tier 1 Tier 2 Tier 3 $275 per admission with no tiering $250 per occurrence $275 per admission $500 per admission $1,500 per admission $250 per occurrence $275 per admission $500 per admission $1,500 per admission $250 per occurrence Maximum one copay per person per caenda $275 per admission $500 per admission No Tier 3 $275 per admission with no tiering Maximum one copay per caendar qu $250 per occurrence $250 per occurrence Maximum $100 per scan $100 per scan $100 per scan $100 per scan $100 per scan $10 $30 $65 $25 $75 $165 The amounts and terms that appear in bod in this chart are benefits that have changed effective Juy 1, $10 $30 $65 $25 $75 $165 $10 $30 $65 $25 $75 $165 $10 $30 $65 $25 $75 $165 $10 $30 $65 $25 $75 $165 Out-of-pocket maximums appy to medica and menta heath benefits across a heath pans. Prescription dru maximums in a heath pans except UniCare, which has one out-of-pocket maximum for medica & menta he

21 orresponding overview information for each pan for more information. Benefits described beow for the Harvard Pigrim Independence Pan, Tufts Heath e and PLUS are in-network benefits with PCP referra where required. These pans aso offer out-of-network benefits with higher out-of-pocket costs. benefits for the GIC s EPO and HMOs. For providers, benefit detais, excusions, and imitations, see the pan handbook or contact the individua pan. NHP PRIME (Neighborhood Heath Pan) TUFTS HEALTH PLAN NAVIGATOR TUFTS HEALTH PLAN SPIRIT UNICARE STATE INDEMNITY PLAN/BASIC WITH CIC (Comprehensive)* UNICARE STATE INDEMNITY PLAN/ COMMUNITY CHOICE UNICARE STATE INDEMNITY PLAN/PLUS HMO POS EPO (HMO-TYPE) INDEMNITY PPO-TYPE PPO-TYPE Yes Yes No No No No Yes Yes No No No No $5,000 $10,000 $5,000 $10,000 $5,000 $10,000 $4,000 medica & menta heath/$1,500 Rx $8,000 medica & menta heath/$3,000 Rx $4,000 medica & menta heath/$1,500 Rx $8,000 medica & menta heath/$3,000 Rx $4,000 medica & menta heath/$1,500 Rx $8,000 medica & menta heath/$3,000 Rx $300 $600 $900 $300 $600 $900 $300 $600 $900 $300 $600 $900 $300 $600 $900 $300 $600 $900 $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit Most covered at 100% no copay Most covered at 100% no copay Most covered at 100% no copay Most covered at 100% no copay Most covered at 100% no copay $15 per visit for Centered Care PCPs; $20 per visit for other PCPs Most covered at 100% no copay $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $30 per visit $60 per visit $90 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $20 per visit $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) $100 per visit (waived if admitted) r year quarter. Waived if readmitted within 30 days in the same caendar year. $100 per visit (waived if admitted) $100 per visit (waived if admitted) $275 per admission with no tiering $275 per admission $500 per admission $1,500 per admission $300 per admission $700 per admission No Tier 3 arter or four per year, depending on pan. Contact the pan for detais. $250 per occurrence $250 per occurrence $250 per occurrence $275 per admission with no tiering $250 per occurrence $275 per admission with no tiering $110 per occurrence $275 per admission $500 per admission $1,500 per admission Tier 1 and Tier 2: $110 per occurrence; Tier 3: $250 per occurrence one copay per day. Contact the pan for detais. $100 per scan $100 per scan $100 per scan $100 per scan $100 per scan $100 per scan $10 $30 $65 $10 $30 $65 $10 $30 $65 $10 $30 $65 $10 $30 $65 $10 $30 $65 $25 $75 $165 $25 $75 $165 $25 $75 $165 $25 $75 $165 $25 $75 $165 $25 $75 $165 g (Rx) benefits are incuded in the out-of-pocket ath and a separate maximum for prescription drugs. * Without CIC, deductibes are higher and coverage is ony 80% for some services. Contact the pan for detais. 19

22 NON-MEDICARE HEALTH PLAN LOCATOR MAP Where You Live Determines Which Pan You May Enro In. Is the NON-MEDICARE Heath Pan Avaiabe Where You Live? MAINE Independence, Basic, PLUS NEW HAMPSHIRE VERMONT ESSEX MIDDLESEX FRANKLIN SUFFOLK Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Direct, Seect, Choice, PLUS Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Independence*, Navigator*, Basic Seect*, Independence, Navigator*, Basic, PLUS Seect, Independence, Primary Choice, HNE, Navigator, Spirit, Basic, Community Choice, PLUS NEW YORK WORCESTER Independence*, Navigator*, Basic BERKSHIRE Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS HAMPSHIRE NORFOLK Direct, Seect, Independence, Primary Choice, HNE, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Direct*, Seect, Independence, Primary Choice, HNE, Navigator, Spirit*, Basic, PLUS, Community Choice Seect, Independence, Primary Choice*, HNE, Navigator, Spirit*, Basic, Community Choice, PLUS HAMPDEN PLYMOUTH Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Direct*, Seect, Independence, Primary Choice, HNE, NHP, Navigator, Spirit, Basic, Community Choice, PLUS BRISTOL Independence, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS RHODE ISLAND CONNECTICUT Independence*, HNE*, Navigator*, Basic, PLUS* BARNSTABLE Direct, Seect, Independence, Primary Choice, NHP, Navigator, Spirit, Basic, Community Choice, PLUS Independence, Navigator, Basic, PLUS DUKES Independence, NHP, Navigator, Basic, PLUS NANTUCKET Independence, NHP, Navigator, Basic, PLUS MAP KEY Navigator Tufts Heath Pan Navigator Direct Faon Heath Direct Care The UniCare State Indemnity Pan/Basic is the ony Non- Medicare heath pan offered by the GIC that is avaiabe throughout the United States and outside of the country. Spirit Tufts Heath Pan Spirit Seect Faon Heath Seect Care Basic UniCare State Indemnity Pan/Basic Independence Harvard Pigrim Independence Pan Community Choice UniCare State Indemnity Pan/Community Choice Primary Choice Harvard Pigrim Primary Choice Pan HNE Heath New Engand PLUS UniCare State Indemnity Pan/PLUS NHP NHP Prime (Neighborhood Heath Pan) * Not every city and town is covered in this county or state; contact the pan to find out if you ive in the service area. The pan aso has a imited network of providers in this county or state; contact the pan to find out which doctors and hospitas participate in the pan. 20

23 NON-MEDICARE LIMITED NETWORK PLANS Great Vaue; Quaity Coverage Non-Medicare Retirees and Survivors: Consider Enroing in a Limited Network Pan to Save Money Every Month on Your Premiums! Limited network pans hep address differences in provider costs. You wi enjoy the same benefits as the wider network pans, but wi save money because imited network pans have a smaer network of providers (fewer doctors and hospitas). Your savings depend on: The pan you are switching from, The pan you seect, Your premium contribution percentage, and Whether you have individua or famiy coverage. For exampe, if you pay 20% of the premium and have individua coverage, by enroing in a imited network pan instead of a wide network pan, you wi save, on average, $40 per month and $480 per year. See pages 27 and 29 to determine what the savings woud be for the pans you are considering. Find out if your hospita is in a GIC imited network pan The GIC has a side-by-side comparison of the six imited network pans and their participating hospitas on our website: For participating physician and other provider detais, contact the individua pans by phone or visit their website (see page 36). The GIC s imited network pans are: Faon Heath Direct Care an HMO avaiabe throughout centra Massachusetts, Metro West, Middesex County, the North Shore and the South Shore. The pan incudes 28 area hospitas and another six Peace of Mind hospitas in Boston that provide second opinions and care for very compex cases. Harvard Pigrim Primary Choice Pan an HMO with a network of 55 hospitas. The pan is avaiabe throughout Massachusetts, except for Cape Cod, Martha s Vineyard, Nantucket, and parts of Berkshire County. Heath New Engand a western and centra Massachusettsbased HMO that incudes 20 Massachusetts hospitas. NHP Prime (Neighborhood Heath Pan) an HMO with a provider network that incudes community heath centers, independent medica groups and hospita group practices, as we as 56 hospitas. NHP Prime is avaiabe across most of the state except for Berkshire, Frankin, and Hampshire Counties. Tufts Heath Pan Spirit an EPO (HMO-type) pan with a network of 54 hospitas. The pan is avaiabe throughout Massachusetts, except for Martha s Vineyard, Nantucket and parts of Berkshire and Hampshire Counties. UniCare State Indemnity Pan/Community Choice a PPOtype pan with a network of 55 hospitas. A Massachusetts physicians participate. The pan is avaiabe throughout Massachusetts, except for Martha s Vineyard and Nantucket. Your Responsibiity Before You Enro in a Pan Once you choose a pan, you cannot change heath pans during the year, uness you move out of the pan s service area. If your doctor or hospita eaves your heath pan, you must find a new participating provider in your chosen pan. Check if your doctors participate in the pan. Find out if the doctors affiiated hospitas are in the pan. Keep in Mind: Doctors and hospitas can eave a pan during the year, usuay because of heath pan and provider contract issues, practice mergers, retirement or reocation. 21

24 NON-MEDICARE LIMITED NETWORK HEALTH PLANS Faon Heath Direct Care HMO Faon Heath Direct Care is an HMO that provides coverage through the pan s network of doctors, hospitas and other providers. Members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists. The pan offers a seective network based in a geographicay concentrated area. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist Tiering Effective Juy 1, 2015, Faon Heath Direct Care wi tier the foowing speciaists based on quaity and/or cost efficiency: Aergists/Immunoogists, Cardioogists, Endocrinoogists, Gastroenteroogists, Hematoogists/Oncoogists, Nephroogists, Neuroogists, Obstetricians/Gynecoogists, Orthopedists, Otoaryngoogists (ENTs), Podiatrists, Pumonoogists, Rheumatoogists, and Uroogists. Members wi pay ower copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see how your provider is rated. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Harvard Pigrim Primary Choice Pan HMO The Harvard Pigrim Primary Choice Pan, administered by Harvard Pigrim Heath Care, is an HMO pan that provides coverage through the pan s network of doctors, hospitas and other providers. Members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist and Hospita Tiering Harvard Pigrim Heath Care tiers the foowing Massachusetts speciaists based on quaity and/or cost efficiency: Aergists/ Immunoogists, Cardioogists, Dermatoogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Neuroogists, Obstetricians/Gynecoogists, Ophthamoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, and Rheumatoogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see if your provider is in the network and how he/she is rated. The pan aso tiers hospitas based on quaity and/or cost; members pay a ower inpatient hospita copay when they use Tier 1 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Heath New Engand HMO Heath New Engand is an HMO that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Provider (PCP) to manage their care; referras to network speciaists are not required. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist Tiering Heath New Engand tiers the foowing speciaists based on quaity and/or cost efficiency: Cardioogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Obstetricians/ Gynecoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, and Rheumatoogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see how your provider is rated. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. 22

25 NON-MEDICARE LIMITED NETWORK HEALTH PLANS NHP Prime (Neighborhood Heath Pan) HMO NHP Prime, formery known as NHP Care, is administered by Neighborhood Heath Pan. The pan is an HMO that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist Tiering Neighborhood Heath Pan tiers the foowing speciaists based on quaity and/or cost efficiency: Cardioogists, Endocrinoogists, Gastroenteroogists, Obstetricians/Gynecoogists, Otoaryngoogists (ENTs), Orthopedists, Pumonoogists, and Rheumatoogists. Members pay ower office visit copays when they see Tier 1 and Tier 2 speciaists. Contact the pan to see how your provider is rated. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Tufts Heath Pan Spirit EPO (HMO-type) Tufts Heath Pan Spirit is an Excusive Provider Organization (EPO) pan that provides coverage through the pan s network of doctors, hospitas and other providers. The pan encourages members to seect a Primary Care Provider (PCP). The menta heath benefits of this pan are administered by Beacon Heath Options. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist and Hospita Tiering Tufts Heath Pan tiers the foowing Massachusetts speciaists based on quaity and/or cost efficiency: Cardioogists, Dermatoogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Neuroogists, Obstetricians/Gynecoogists, Ophthamoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, Rheumatoogists, and Uroogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see if your provider is in the network and how he/she is rated. The pan aso tiers hospitas based on quaity and/or cost; members pay a ower inpatient hospita copay when they use Tier 1 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. UniCare State Indemnity Pan/ Community Choice PPO-Type The UniCare State Indemnity Pan/Community Choice is a PPOtype pan with a hospita network based at community and some tertiary hospitas at 100% coverage, after a copayment. Or, you may seek care from an out-of-network hospita for 80% coverage of the aowed amount for inpatient care and outpatient surgery, after you pay a copay. Contact the pan to find out if your hospita is in the network. The pan offers access to a Massachusetts physicians and members are encouraged to seect a Primary Care Provider (PCP). The menta heath benefits of this pan, administered by Beacon Heath Options, offer you a choice of using network providers and paying a copayment, or seeking care from out-of-network providers at higher out-of-pocket costs. Prescription drug benefits are administered by CVS/caremark. Speciaist Tiering UniCare tiers Massachusetts speciaists based on quaity and/or cost efficiency. Members pay ower office visit copays when they see Tier 1 and Tier 2 speciaists. Contact the pan to see how a physician is rated. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. 23

26 NON-MEDICARE WIDE NETWORK HEALTH PLANS Faon Heath Seect Care HMO Faon Heath Seect Care is an HMO that provides coverage through the pan s network of doctors, hospitas, and other providers. Members must seect a Primary Care Provider (PCP) to manage their care and obtain referras to speciaists. Contact the pan to see if your doctors and hospitas are in the network. There are no out-of-network benefits, with the exception of emergency care. Speciaist and Hospita Tiering Faon Heath tiers the foowing speciaists based on quaity and/or cost efficiency: Aergists/Immunoogists, Cardioogists, Endocrinoogists, Gastroenteroogists, Hematoogists/ Oncoogists, Nephroogists, Neuroogists, Obstetricians/ Gynecoogists, Orthopedists, Otoaryngoogists (ENTs), Podiatrists, Pumonoogists, Rheumatoogists, and Uroogists. Members pay ower copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see how your provider is rated. The pan aso tiers hospitas based on quaity and/or cost; members pay a ower inpatient hospita copay when they use Tier 1 or Tier 2 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Harvard Independence and Tufts Navigator wi become POS Pans Effective Juy 1, New PCP & Referra Requirements Harvard Pigrim Independence Pan POS Effective Juy 1, 2015, the Harvard Pigrim Independence Pan, administered by Harvard Pigrim Heath Care, wi become a POS pan that provides coverage for treatment by a network of doctors, hospitas and other heath care providers. Members must seect a PCP to manage their care and obtain referras to speciaists to receive care at the in-network eve of coverage. It aso aows treatment by out-of-network providers or in-network care without a Primary Care Provider (PCP) referra, but with higher out-ofpocket costs. Speciaist and Hospita Tiering Harvard Pigrim Heath Care tiers the foowing Massachusetts speciaists based on quaity and/or cost efficiency: Aergists/Immunoogists, Cardioogists, Dermatoogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Neuroogists, Obstetricians/Gynecoogists, Ophthamoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, and Rheumatoogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see if your provider is in the network and how he/she is rated. The pan aso tiers hospitas based on quaity and/or cost. Members pay a ower inpatient hospita copay when they use Tier 1 or Tier 2 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. Has the same wide network of doctors, hospitas and other providers and incudes out-of-network benefits as the current PPO offering does. Requires a PCP designation and referras from your PCP for speciaty care. If you do not get a referra to a speciaist, you wi have heath care benefits, but with higher out-ofpocket costs. 24

27 NON-MEDICARE WIDE NETWORK HEALTH PLANS Tufts Heath Pan Navigator POS Effective Juy 1, 2015, Navigator by Tufts Heath Pan wi become a POS pan that provides coverage for treatment by a network of doctors, hospitas and other heath care providers. Members must seect a PCP to manage their care and obtain referras to speciaists to receive care at the in-network eve of coverage. It aso aows treatment by out-of-network providers or in-network care without a Primary Care Provider (PCP) referra, but with higher out-of-pocket costs. The menta heath benefits of this pan, administered by Beacon Heath Options, offer you in-network benefits with a copay. Or, you may seek care from out-of-network providers, but at higher out-of-pocket costs. Speciaist and Hospita Tiering Tufts Heath Pan tiers the foowing Massachusetts speciaists based on quaity and/or cost efficiency: Cardioogists, Dermatoogists, Endocrinoogists, Gastroenteroogists, Genera Surgeons, Neuroogists, Obstetricians/Gynecoogists, Ophthamoogists, Orthopedists, Otoaryngoogists (ENTs), Pumonoogists, Rheumatoogists, and Uroogists. Members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see if your provider is in the network and how he/she is rated. The pan aso tiers hospitas based on quaity and/or cost. Effective Juy 1, 2015, the pan wi change from two to three hospita tiers. Members pay a ower inpatient hospita copay when they use Tier 1 or Tier 2 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. UniCare State Indemnity Pan/Basic Indemnity The UniCare State Indemnity Pan/Basic offers access to any icensed doctor or hospita throughout the United States and outside of the country. The pan determines aowed amounts for out-of-state providers; you may be responsibe for a portion of the tota charge. To avoid these additiona provider charges, if you use non-massachusetts doctors or hospitas, contact the pan to find out which doctors and hospitas in your area participate in UniCare s nationa network of providers. The menta heath benefits of this pan, administered by Beacon Heath Options, offer you a choice of using network providers and paying a copayment, or seeking care from out-of-network providers at higher out-of-pocket costs. Prescription drug benefits are administered by CVS/caremark. Speciaist Tiering UniCare tiers Massachusetts speciaists based on quaity and/or cost efficiency. Massachusetts members pay ower office visit copays when they see Tier 1 or Tier 2 speciaists. Contact the pan to see how a physician is rated. Eigibiity Empoyees, Retirees, GIC Retired Municipa Teachers (RMTs), Edery Governmenta Retirees (EGRs), Survivors, and their eigibe dependents without Medicare are eigibe. UniCare State Indemnity Pan/PLUS PPO-Type The UniCare State Indemnity Pan/PLUS is a PPO-type pan that provides access to a Massachusetts physicians and hospitas and out-of-state UniCare providers at 100% coverage, after a copayment. Out-of-state non-unicare providers have 80% coverage of aowed charges. Members are encouraged to seect a Primary Care Provider (PCP) to manage their care and pay a ower copay if they see a Centered Care PCP. Contact the pan to find out if your PCP is a Centered Care provider. The menta heath benefits of this pan, administered by Beacon Heath Options, offer you a choice of using network providers and paying a copayment, or seeking care from out-of-network providers at higher out-of-pocket costs. Prescription drug benefits are administered by CVS/caremark. Speciaist and Hospita Tiering UniCare tiers Massachusetts speciaists based on quaity and/or cost efficiency. Members pay ower office visit copays when they see Tier 1 and Tier 2 speciaists. Contact the pan to see how a physician is rated. The pan aso tiers hospitas based on quaity and/or cost; members pay a ower inpatient hospita and outpatient surgery copay when they use Tier 1 or Tier 2 hospitas. Contact the pan to see which tier your hospita is in. Eigibiity Empoyees, Retirees, Survivors, and their eigibe dependents without Medicare who ive in the service area are eigibe. 25

28 RETIREE AND SURVIVOR MEDICARE HEALTH PLAN RATES Monthy GIC Pan Rates Effective Juy 1, 2015 MEDICARE PLANS BASIC LIFE INSURANCE ONLY $5,000 Coverage HEALTH PLAN (Premium incudes Basic Life Insurance) PLAN TYPE MEDICARE RETIREES MEDICARE RETIREES MEDICARE RETIREES Retired on or before Retired after Juy 1, who fied for Juy 1, and who fied retirement after and SURVIVORS 1, 2 for retirement on or October 1, 2009 before October 1, % 15% 20% Retiree/Survivor Retiree Retiree Pays Monthy Pays Monthy Pays Monthy $0.63 $0.95 $1.26 Per Person Per Person Per Person Faon Senior Pan 3 HMO $30.72 $46.09 $61.45 Harvard Pigrim Medicare Enhance Indemnity Heath New Engand MedPus HMO Tufts Heath Pan Medicare Compement HMO Tufts Heath Pan Medicare Preferred 3 HMO UniCare State Indemnity Pan/ Medicare Extension (OME) with CIC 4 Indemnity (Comprehensive) UniCare State Indemnity Pan/ Medicare Extension (OME) without CIC Indemnity (Non-comprehensive) 1 Survivors are not eigibe for ife insurance. For monthy heath insurance premium cost, deduct $0.63 from Retiree/Survivor Pays Monthy premium. 2 Edery Governmenta Retirees (EGRs) ca the GIC for monthy rates. 3 Benefits and rates of Faon Senior Pan and Tufts Heath Pan Medicare Preferred are subject to federa approva and may change January 1, CIC is an enroee-pay-a benefit. Contribution percentages may change after the Commonweath s FY16 budget is enacted. For other things to consider, see page 2. 26

29 RETIREE AND SURVIVOR NON-MEDICARE HEALTH PLAN RATES Monthy GIC Pan Rates Effective Juy 1, 2015 NON-MEDICARE PLANS Compare the rates of these pans with other options and see how much you wi save every month! BASIC LIFE INSURANCE ONLY $5,000 Coverage NON-MEDICARE NON-MEDICARE NON-MEDICARE RETIREES RETIREES RETIREES Retired on or before Retired after Juy 1, who fied for Juy 1, and who retirement after and SURVIVORS 1, 2 fied for retirement October 1, 2009 on or before October 1, % 15% 20% Retiree/Survivor Retiree Retiree Pays Monthy Pays Monthy Pays Monthy $0.63 $0.95 $1.26 HEALTH PLAN PLAN Individua Famiy Individua Famiy Individua Famiy (Premium incudes Basic Life Insurance) TYPE Coverage Coverage Coverage Coverage Coverage Coverage Faon Heath Direct Care HMO $49.72 $ $74.59 $ $99.45 $ Faon Heath Seect Care HMO Harvard Pigrim Independence Pan POS Harvard Pigrim Primary Choice HMO Heath New Engand HMO NHP Prime (Neighborhood Heath Pan) HMO Tufts Heath Pan Navigator POS Tufts Heath Pan Spirit EPO (HMO-type) UniCare State Indemnity Pan/ Basic with CIC 3 (Comprehensive) UniCare State Indemnity Pan/ Basic without CIC (Non-comprehensive) UniCare State Indemnity Pan/ Community Choice Indemnity Indemnity PPO-type UniCare State Indemnity Pan/PLUS PPO-type Survivors are not eigibe for ife insurance. For monthy heath insurance premium cost, deduct $0.63 from Retiree/Survivor Pays Monthy premium. 2 Edery Governmenta Retirees (EGRs) ca the GIC for monthy rates. 3 CIC is an enroee-pay-a benefit. Contribution percentages may change after the Commonweath s FY16 budget is enacted. For other things to consider, see page 2. 27

30 RETIRED MUNICIPAL TEACHER (RMT) LIFE INSURANCE RATES Monthy GIC Pan Rates Effective Juy 1, 2015 BASIC LIFE INSURANCE CITY/TOWN/SCHOOL DISTRICT (SD) RMT Pays Monthy BASIC LIFE: $1,000 Coverage $0.90 Backstone Vaey Regiona SD Narragansett Regiona SD Painvie Bridgewater Newbury Saisbury Granby Paxton Wibraham Hampden-Wibraham Regiona SD Pioneer Vaey Regiona SD BASIC LIFE: $2,000 Coverage $0.90 Barnstabe Quabbin Regiona SD Stoughton Dennis Rehoboth Upper Cape Cod Regiona SD Martha s Vineyard Regiona SD Rockand West Springfied Miton Shawsheen Vaey Regiona SD Whitman-Hanson SD BASIC LIFE: $4,000 Coverage $1.80 Rockport BASIC LIFE: $5,000 Coverage $2.25 Amesbury Hoyoke Revere Bierica Hudson Rutand Bourne Montague Spencer Dedham North Adams Wareham Eastham North Atteboro West Bridgewater Everett North Middesex Regiona SD Westfied Greater Lawrence Regiona SD Norwe Woburn Harvard BASIC LIFE: $10,000 Coverage $4.50 Braintree 28

31 RETIRED MUNICIPAL TEACHER (RMT) HEALTH PLAN RATES How to Cacuate your Monthy Premium Effective Juy 1, Find the city, town or the schoo district from which you retired on the ife insurance rate chart on page Locate your RMT Pays Monthy rate for ife insurance. 3. Add that amount to the RMT Pays Monthy rate beow for the heath pan you are interested in to determine your monthy combined ife and heath insurance premium. MEDICARE PLANS RETIRED MUNICIPAL TEACHERS (RMTs) RMTs who retired on or before RMTs who retired Juy 1, 1990 and Survivors 1 after Juy 1, % 15% HEALTH PLAN PLAN RMT/Survivor Pays Monthy RMT Pays Monthy TYPE Per Person Coverage Per Person Coverage Faon Senior Pan 2 HMO $30.09 $45.14 Harvard Pigrim Medicare Enhance Indemnity Heath New Engand MedPus HMO Tufts Heath Pan Medicare Compement HMO Tufts Heath Pan Medicare Preferred 2 HMO UniCare State Indemnity Pan/ Medicare Extension (OME) with CIC Indemnity (Comprehensive) 3, 4 UniCare State Indemnity Pan/ Medicare Extension (OME) without CIC Indemnity (Non-comprehensive) 4 NON-MEDICARE PLANS HEALTH PLAN RETIRED MUNICIPAL TEACHERS (RMTs) RMTs who retired on or before RMTs who retired Juy 1, 1990 and Survivors 1 after Juy 1, % 15% RMT/Survivor RMT/Survivor RMT RMT PLAN Pays Monthy Pays Monthy Pays Monthy Pays Monthy TYPE Individua Coverage Famiy Coverage Individua Coverage Famiy Coverage Faon Heath Direct Care HMO $49.09 $ $73.64 $ Faon Heath Seect Care HMO Heath New Engand HMO NHP Prime (Neighborhood Heath Pan) HMO UniCare State Indemnity Pan/ Basic with CIC (Comprehensive) 3, 4 UniCare State Indemnity Pan/Basic without CIC (Non-comprehensive) 4 Indemnity Indemnity Survivors are not eigibe for basic ife insurance. Do not add the basic ife insurance premium to cacuate your monthy premium. 2 Benefits and rates of Faon Senior Pan and Tufts Heath Pan Medicare Preferred are subject to federa approva and may change January 1, CIC is an enroee-pay-a benefit. 4 The RMT share of the rate for these pans has been subsidized for FY16 using funds from the GIC UniCare Rate Stabiization Reserve. 29

32 LIFE INSURANCE AND AD&D Life insurance, insured by The Hartford Life and Accident Insurance Company, heps provide for your famiy s economic we-being in the event of your death. This benefit is paid to your designated beneficiaries. GIC Retired Municipa Teachers (RMTs) are eigibe for basic ife insurance ony in an amount determined by the city or town from which they retire. See page 28 for detais. Survivors, Edery Governmenta Retirees (EGRs), COBRA enroees, and retirees in the GIC municipa heath-ony program are not eigibe for GIC basic or optiona ife insurance. Basic Life Insurance (Retired State Empoyees Ony) The Commonweath requires $5,000 of Basic Life Insurance for most retirees who have heath coverage through the GIC. Optiona Life Insurance After Retirement (Retired State Empoyees Ony) At retirement, you shoud review the amount of your Optiona Life Insurance coverage and its cost to determine whether it wi make economic sense for you to keep it or reduce your amount of coverage. Tak with a financia advisor about other programs that might be more beneficia at retirement. If you make no change to your optiona ife coverage at retirement, you wi be responsibe for the retiree optiona ife insurance premium, which can be substantia. Optiona Life Insurance rates significanty increase when you retire, and continue to increase based on your age. If you have paid off your home and other debts, such as student oans, a financia advisor might recommend other programs that might be more beneficia. You may decrease but cannot increase your amount of ife insurance after you retire. If you decrease coverage and then ater want to increase up to the amount you carried at the time of retirement, you may do so ony with proof of good heath acceptabe to The Hartford. Optiona Life Insurance Non-Smoker Benefit (Retired State Empoyees Ony) During annua enroment, retired state empoyees who have been tobacco-free (have not smoked cigarettes, cigars or a pipe nor used snuff, chewing tobacco or a nicotine deivery system) for at east the past 12 months are eigibe for reduced non-smoker Optiona Life Insurance rates effective Juy 1, Request an enroment form by writing to the GIC, visiting us at a heath fair, or downoading it from our website. You wi be required to periodicay re-certify your non-smoking status in order to quaify for the ower rates. Acceerated Life Benefit (Retired State Empoyees and GIC RMTs Ony) This one-time benefit aows you to eect an advance payment of 25% to 75% of your ife insurance death benefit if you have been diagnosed with a termina iness. Insured retirees are eigibe for this benefit if the attending physician provides satisfactory evidence that you have a ife expectancy of 12 months or ess. Upon payment of the acceerated ife benefit, future ife insurance premiums wi be waived regardess of your age. The remaining baance is paid to your beneficiary when you die. Life Insurance and AD&D Questions? Contact the GIC: ext

33 LIFE INSURANCE AND AD&D Accidenta Death & Dismemberment (AD&D) Benefits (Retired State Empoyees and GIC RMTs with $2,000 or more Basic Life Ony) In the event you are injured or die as a resut of an accident whie insured for ife insurance, there are benefits for the foowing osses: Life Hands, Feet, Eyes Speech and/or Hearing Thumb and Index Finger of the Same Hand Quadripegia Parapegia Hemipegia Coma Brain Damage Added benefits for oss of ife whie using an airbag or seat bet GIC Retired Municipa Teachers with Basic Life Insurance of $1,000 do not have Accidenta Death & Dismemberment benefits. STATE RETIREE OPTIONAL LIFE INSURANCE RATES Incuding Accidenta Death & Dismemberment MONTHLY GIC Pan Rates Effective Juy 1, 2015 RETIRED STATE EMPLOYEE AGE RETIREE SMOKER RATE Per $1,000 of Coverage RETIREE NON-SMOKER RATE Per $1,000 of Coverage Under Age 70 $1.64 $ Ages 100 and over

34 RETIREE DENTAL AND VISION GIC Retiree Denta Pan Metropoitan Life Insurance Company (MetLife) is the provider of the GIC Retiree Denta Pan. The pan offers a fixed reimbursement of up to $1,250 per member per year for denta services: Denta examinations Denta ceanings Fiings Crowns Dentures Denta impants Benefit Enhancement Effective Juy 1, 2015: Composite fiings on posterior teeth As a member of this pan, you may go to the dentist of your choice. However, you wi save money by visiting one of the over 293,000 nationwide network of participating dentists. When you visit a MetLife provider, your out-of-pocket expenses wi be ower, as you usuay pay the ower negotiated fee, even after you have exceeded your annua maximum. This is an entirey vountary pan (retiree-pay-a) that provides GIC members with coverage at discounted group insurance rates through convenient pension deductions. Retiree Denta Questions? Contact MetLife: Eigibiity A state retirees, Edery Governmenta Retirees (EGRs), survivors and GIC Retired Municipa Teachers (RMTs who do not participate in the municipa heath-ony program) are eigibe for the GIC Retiree Denta Pan. Enroment Eigibe retirees and survivors may join during annua enroment, or if you experience a quaifying status change, such as when COBRA denta coverage ends, when you become a survivor of a GIC member, or at retirement. However, if you have ever dropped coverage, you can never re-enro in the pan. GIC RETIREE DENTAL PLAN MONTHLY GIC Pan Rates Effective Juy 1, 2015 $1,250 Maximum Annua Benefit per Member COVERAGE TYPE RETIREE PAYS MONTHLY SINGLE $28.94 FAMILY $69.70 GIC Retiree Vision Discount Pan Davis Vision is the carrier for the Retiree Vision Discount Pan. The pan is avaiabe at any of the over 30,500 nationwide Davis Vision providers. The pan offers significant discounts on: Eye examinations; Frames; Spectaces; and Contact enses. A eyegasses purchased through the Retiree Vision Discount Pan are covered by a two-year unconditiona warranty against breakage at no additiona cost. There is no monthy premium or fee to use the program; you pay for the services at the discounted price when they are needed. However, you must ca Davis Vision before visiting the provider s office in order to participate. Eigibiity To be eigibe for this program, you, as the insured, must have GIC coverage. Your famiy members are ony eigibe if they are covered under your GIC heath pan. Retiree Vision Questions? Contact Davis Vision: (cient code: 7621) 32

35 HEALTH INSURANCE BUY-OUT If you have access to non-gic heath insurance through your spouse or another source, it may pay to participate in the buy-out program. During Annua Enroment If you were insured with the GIC on January 1, 2015 or before and continue your coverage through June 30, 2015, you may appy to buy out your heath pan coverage effective Juy 1, 2015, during annua enroment. October 5 November 6, 2015 If you are insured with the GIC on Juy 1, 2015 or before, and continue your coverage through December 31, 2015, you may appy to buy out your heath pan coverage effective January 1, The enroment period for this buy-out wi be October 5 - November 6, You must have other non-gic heath insurance coverage that is comparabe to the heath insurance you now receive through the Group Insurance Commission and must maintain basic ife insurance. Under the buy-out pan, eigibe state retirees receive 25% of the fu-cost monthy premium in ieu of heath insurance benefits for one 12-month period. You wi receive a monthy check. The amount of payment depends on your heath pan and coverage. FOR EXAMPLE: Buy-Out Questions? Contact the GIC: ext. 1 Retiree with UniCare State Indemnity Pan/ Medicare Extension (OME) individua coverage Fu-cost premium on Juy 1, 2015: $ Monthy 12-month benefit = 25% of this premium Retiree receives 12 monthy checks of $68.34 (after federa and state taxes) 33

36 NEED MORE HELP? Attend a Heath Fair Retirees and survivors who are thinking about changing heath pans, or ooking at other benefit options, can attend one of the GIC s heath fairs to: Speak with heath and other benefit pan representatives; Pick up detaied materias and provider directories; Ask GIC staff about your benefit options; Change your heath pan or appy for other GIC retiree/survivor benefits; and Take advantage of compimentary heath screenings. See page 35 for the schedue. Inscripción Anua La inscripción anua es de 8 de abri a 6 de mayo, y os cambios entrarán en vigor e 1 de juio de Comuníquese con Group Insurance Commission (Comisión de Seguros de Grupo) amando a , ext. 1 para obtener ayuda. 年 度 投 保 年 度 投 保 的 時 間 為 2015 年 4 月 8 日 至 5 月 6 日, 變 更 則 於 7 月 1 日 生 效 如 需 協 助, 請 聯 絡 團 體 保 險 委 員 會 (GIC), 電 話 轉 分 機 1 Our Website Provides Additiona Hepfu Information See our website for: Benefit Decision Guide content in HTML and XML-accessibe formats; Information about and inks to a GIC pans convenienty search for participating heath pan doctors and hospitas onine; The atest annua enroment news; Forms to expedite your annua enroment decisions; Answers to frequenty asked questions incuding what to do when you turn age 65; GIC pubications incuding the Turning Age 65 Q&A brochures and For Your Benefit newsetters; Benefits At-A-Gance charts for menta heath and substance abuse benefits for a UniCare State Indemnity pans and Tufts Heath Pan Navigator and Spirit members; and Heath artices and inks to hep you take charge of your heath. Thời gian ghi danh hàng năm Thời gian ghi danh hàng năm à từ ngày 8 tháng 4 đến ngày 6 tháng 5 và những thay đổi sẽ có hiệu ực kể từ ngày 1 tháng 7 năm Vui òng iên ạc với GIC tại số , số nội bộ à 1, để được trợ giúp. 34

37 FOR MORE INFORMATION, ATTEND A GIC HEALTH FAIR APRIL FRIDAY 11:00-2:00 Berkshire Community Coege Paterson Fied House 1350 West Street PITTSFIELD 11 SATURDAY 11:00-2:00 North Shore Community Coege Math and Science Buiding, 1st Foor Lobby 1 Ferncroft Road DANVERS 13 MONDAY 11:00-4:00 Oiver Ames High Schoo Nixon Gym 100 Lothrop Street EASTON 14 TUESDAY 11:00-4:00 Ashand Community Center 162 West Union Street Route 135 ASHLAND 15 WEDNESDAY 11:00-3:00 State Transportation Buiding 10 Park Paza, 2nd Foor Conference Rooms 1, 2 and 3 BOSTON 16 THURSDAY 11:00-3:00 Wrentham Deveopmenta Center Graves Auditorium Littefied Street WRENTHAM 18 SATURDAY 10:00-2:00 Mass Maritime Academy Gymnasium 101 Academy Drive BUZZARDS BAY 22 WEDNESDAY 11:00-3:00 U-Mass Amherst Student Union Baroom AMHERST 23 THURSDAY 10:00-2:00 Hampden County Sheriff s Department Hampden County Correctiona Center 627 Randa Road LUDLOW 28 TUESDAY 10:00-3:00 McCormack State Office Buiding One Ashburton Pace 21st Foor BOSTON 29 WEDNESDAY 11:00-4:00 Westwood High Schoo Gym 200 Nahatan Street WESTWOOD 30 THURSDAY 11:00-3:00 Quinsigamond Community Coege Harrington Learning Center Rooms 109 A & B 670 West Boyston Street WORCESTER 17 FRIDAY 11:00-4:00 Middesex Community Coege Cafeteria 591 Springs Road BEDFORD 35

38 FOR MORE INFORMATION, CONTACT THE PLANS For more information about specific pan benefits, ca a pan representative. Be sure to indicate you are a GIC insured. HEALTH INSURANCE Faon Heath Direct Care Seect Care Senior Pan Harvard Pigrim Heath Care Independence Pan Primary Choice Pan Medicare Enhance Heath New Engand HMO MedPus Neighborhood Heath Pan NHP Prime Tufts Heath Pan Navigator Spirit Menta Heath/Substance Abuse and EAP (Beacon Heath Options) Medicare Compement Medicare Preferred UniCare State Indemnity Pan/ Basic Community Choice Medicare Extension (OME) PLUS For a UniCare Pans Prescription Drugs (CVS/caremark) Menta Heath/Substance Abuse and EAP (Beacon Heath Options) OTHER BENEFITS GIC Retiree Denta Pan (MetLife) GIC Retiree Vision Discount Pan (Davis Vision) (cient code: 7621) Life/AD&D Insurance (The Hartford) Contact the GIC ext. 1 WeMASS Weness Piot Program (StayWe Heath Management) ADDITIONAL RESOURCES Interna Revenue Service (IRS) Massachusetts Teachers Retirement System (Eastern MA) (Western MA) Medicare Socia Security Administration State Board of Retirement OTHER QUESTIONS? Ca the GIC: , ext. 1, TDD/TTY:

39 GLOSSARY Centered Care a GIC program that seeks to improve heath care coordination and quaity whie reducing costs. Primary Care Providers pay a critica roe in heping their patients get the right care at the right pace with the right provider. The centra idea is to coordinate heath care services around the needs of you, the patient. Because heath care is so expensive, Centered Care aso seeks to engage providers and heath pans on managing these doars more efficienty. CIC (Catastrophic Iness Coverage) an optiona part of the UniCare State Indemnity Pan/Basic and Medicare Extension (OME) pans. CIC increases the benefits for most covered services to 100%, subject to deductibes and copayments. It is a Commonweath of Massachusetts enroee-pay-a benefit. Enroees without CIC receive ony 80% coverage for some services and pay higher deductibes. Over 99% of current Indemnity Pan Basic and Medicare Extension Pan members seect CIC. COBRA (Consoidated Omnibus Budget Reconciiation Act) a federa aw that aows enroees to continue their heath coverage for a imited period of time after their group coverage ends as the resut of certain empoyment or ife event changes. CPI (Cinica Performance Improvement) Initiative a GIC program which seeks to improve heath care quaity whie containing costs for the Commonweath and our members. Caims data from a six GIC heath carriers are aggregated to identify differences in physician quaity and cost efficiency, and this information is given back to the pans to tier speciaists. Members who choose to see high-performing doctors pay ower copays. Deductibe a set doar amount which must be satisfied within a caendar year before the heath pan begins making payments on caims. Deferred Retirement aows you to continue your group heath insurance after you eave state service with vested pension rights unti you begin to coect a pension. Unti you receive a retirement aowance, you wi be responsibe for the entire ife and heath insurance premium costs, for which you are bied directy. If you withdraw your pension money, you are not eigibe for GIC coverage. EAP (Enroee Assistance Program) menta heath services that incude hep for depression, marita issues, famiy probems, acoho and drug abuse, and grief. Aso incudes referra services for ega, financia, famiy mediation, and eder care assistance. EGR (Edery Governmenta Retiree) a state empoyee who retired from state service prior to January 1, EGRs aso incude certain municipa empoyees who retired prior to the date their city or town eected to provide heath insurance benefits to their empoyees/ retirees and whose municipaity has eected to participate in the EGR program. EGWP (Empoyer Group Waiver Pan) an empoyer-provided Medicare Part D prescription drug pan. Effective January 1, 2016, members of the UniCare State Indemnity/Medicare Extension (OME) Pan wi be automaticay enroed in an EGWP. Due to the additiona coverage provided by the GIC, under EGWP, you have simiar coverage to Non-Medicare pan retirees, better coverage than offered by a standard Medicare prescription drug pan, and ow-income retirees may be eigibe for subsidies and reduced copayments. EPO (Excusive Provider Organization) a heath pan that provides coverage for treatment by a network of doctors, hospitas and other heath care providers within a certain geographic area. EPOs do not offer out-of-network benefits, with the exception of emergency care. Seection of a Primary Care Provider (PCP) is encouraged. GIC (Group Insurance Commission) a quasi-independent state agency governed by a 17-member commission appointed by the Governor. The mission of the GIC is to provide high-vaue heath insurance and certain other benefits to state, particuar authority, and participating municipaity empoyees, retirees, and their survivors and dependents. HMO (Heath Maintenance Organization) a heath pan that provides coverage for treatment by a network of doctors, hospitas and other heath care providers within a certain geographic area. HMOs do not offer out-of-network benefits, with the exception of emergency care. Seection of a Primary Care Provider (PCP) is required. Limited Network Pan a ess expensive heath pan that offers essentiay the same benefits as more expensive, wider network pans, but with fewer physicians, hospitas, and other providers. Networks groups of doctors, hospitas and other heath care providers that contract with a benefit pan. If you are in a pan that offers both network and non-network coverage, you wi receive a higher eve of benefits when you are treated by network providers. PCP (Primary Care Provider) physicians with speciaties in interna medicine, famiy practice, and pediatrics as we as nurse practitioners and physician assistants who coordinate their patients heath care. POS (Point of Service) a heath pan that provides coverage for treatment by a network of doctors, hospitas and other heath care providers. Seection of a Primary Care Provider (PCP) is required. To get the owest out-of-pocket cost, a member must get a referra to a speciaist. PPO (Preferred Provider Organization) a heath pan that provides coverage by network doctors, hospitas, and other heath care providers. It aows treatment by out-of-network providers, but at a ower eve of coverage. A PPO pan encourages the seection of a Primary Care Provider (PCP). Preventive Services heath care services that do not treat an iness, injury or a condition (e.g., routine physicas). RMT (GIC Retired Municipa Teacher) a retired teacher from a city, town or schoo district who is receiving a pension from the Teacher s Retirement Board and whose municipaity has eected to participate in the GIC RMT program. Retired teachers who transfer to municipa coverage as part of the municipaity joining the GIC are no onger GIC RMTs. 39-Week Layoff Coverage aows aid-off empoyees to continue their group heath and ife insurance for up to 39 weeks (about 9 months) by paying the fu cost of the premium. 37

40 P.O. Box 8747 Boston, MA PRSRT. STD. U.S. POSTAGE PAID HARTFORD, CT PERMIT NO COMMONWEALTH OF MASSACHUSETTS Website: Charie Baker, Governor Karyn Poito, Lieutenant Governor Group Insurance Commission Doores L. Mitche, Executive Director 19 Staniford Street, 4th Foor Boston, Massachusetts Teephone: TDD/TTY: MAILING ADDRESS Group Insurance Commission P.O. Box 8747 Boston, MA COMMISSIONERS Katherine Baicker (Heath Economist), Chair Richard E. Waring (NAGE), Vice Chair Theron R. Bradey (Pubic Member) Ray A. Campbe III (Pubic Member) Edward T. Choate (Pubic Member) Robert J. Doan (Massachusetts Municipa Association) Kevin Drake (Counci 93, AFSCME, AFL-CIO) Edward A. Key (President, Professiona Fire Fighters of Massachusetts) Dougas Howgate (Pubic Member) Mevin A. Keckner (Massachusetts Municipa Association) Rache Madden, Designee (for Secretary of Administration and Finance, Kristen Lepore) Eieen P. McAnneny (Pubic Member) Anne M. Pausen (Retiree Member) Timothy D. Suivan, Ed. D. (Massachusetts Teachers Association) Margaret Thompson (Loca 5000, S.E.I.U., NAGE) Jean Yang (Pubic Member) Renu Wadhwa, Designee (for Gary Anderson, Acting Commissioner of Insurance)