PHIP Member Handbook & Benefit Guide. January 1, 2015, to December 31, 2015

PHIP Member Handbook & Benefit Guide January 1, 2015, to December 31, 2015

Table of contents Introduction 5 Your health plan options 8 Other important information 10 Plan change 10 Exclusions and limitations 10 Eligibility 12 Enrollment opportunities 14 How to enroll 18 After enrollment 19 Premium subsidies 20 Continuation of coverage 23 Coverage outside the service areas 24 Benefit changes, health plan service areas and plan features 27 Changes to plans 28 Health plan service areas 30 Moda Health Plans/ODS 32 Kaiser Permanente 34 PacificSource Health Plans 36 Providence Health Plan 38 Prescription drug benefit 40 Plan benefit and rate comparisons 43 2015 Medicare benefit comparison 44 2015 Medicare rate comparison 47 2015 Core Value non-medicare rate comparison 48 2015 Select Value non-medicare rate comparison 49 2015 Core Value non-medicare benefit comparison 50 2015 Select Value non-medicare benefit comparison 52 2015 Dental benefit comparison 54 Definitions 56 Acronyms and abbreviations 59 Notes 60 Please refer to the back of this handbook for important phone numbers and website addresses.

Introduction Mission statement The PERS Health Insurance Program (PHIP) provides PERS retirees with high-quality, comprehensive coverage (or benefits) at the most cost-effective rates possible to meet retiree benefit needs. Our core values are: Maintain stability of premiums Maintain stability of coverage Maintain stability of carriers PERS Health Insurance Program PHIP offers health insurance coverage for all retirees, their spouses and dependents who meet the eligibility requirements. When planning your retirement, review all health coverage options available through your or your spouse s employer to determine the best option for you. PHIP website On the PHIP website (pershealth.com), you can download the forms necessary to make changes to your account or health plan, view the latest Member Handbook or look at past issues of the quarterly HealthWise newsletter. The website is one way PHIP communicates important information to members throughout the year. Medicare basics Medicare is health insurance available to people who are 65 years of age or older, who are under 65 but receiving Social Security Disability Insurance for more than 24 months or who have end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS). Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). To enroll, PHIP requires all Medicare-eligible members and eligible Medicare dependents to be enrolled and retain both Parts A and B of Medicare. If you turn down Part B when first eligible and request to enroll at a later date, you may be penalized by Medicare. In addition, if you do not have Part B in place when you lose employer-sponsored coverage, you cannot enroll in a PHIP plan and may miss your enrollment opportunity altogether. If you stop paying your Part B premium, you will lose your ability to continue any of the PHIP plans. In most circumstances, if you do not enroll in PHIP when you are first eligible for Medicare Parts A and B, you will forfeit any future opportunity to enroll in a PHIP medical plan. Refer to enrollment opportunities on page 14 of this handbook. Enrollment in a PHIP Medicare plan includes automatic enrollment in a Medicare Part D prescription plan. 5

Medicare enrollment You will become eligible for Medicare at age 65, regardless of whether you are receiving a Social Security benefit at the time. You are entitled to Medicare the first day of the calendar month during which you turn 65. If your birthday falls on the first day of the month, you are entitled to Medicare the first day of the prior month. Medicare eligibility could occur earlier than age 65 if you are awarded Social Security Disability Insurance. Medicare eligibility because of disability would become effective the first day of the 25 th month after your Social Security benefits began. If you receive Social Security benefits prior to age 65, you will automatically be enrolled in Medicare. You should receive your Medicare information, including your Medicare Parts A and B card, approximately three months prior to your 65 th birthday or when you become eligible for Medicare because of disability. Medicare due to end-stage renal disease End-stage renal disease (ESRD) is the stage of kidney impairment that appears irreversible and permanent, which requires a regular course of dialysis or a kidney transplant to maintain life. If you currently have ESRD, your ability to enroll in a Medicare Advantage plan through PHIP may be limited. However, the Moda Health Medicare Supplement Plan is available to you. Please contact PHIP for more information. Please review your health coverage options through your employer-sponsored health plans if you become Medicare eligible because of ESRD. If you are enrolled in another health plan in addition to PHIP, please provide that information for correct coordination of benefits. If you do not receive your Social Security benefit prior to age 65, you will need to contact the Social Security Administration or visit your local Social Security office approximately three months prior to your 65 th birthday and apply for Medicare Parts A and/or B. 6

Medicare parts A, B and D description Medicare consists of several parts. Part A covers inpatient hospital expenses. In most cases, you pay no premium to maintain this coverage. Part B covers outpatient (medical) expenses, such as doctor visits, lab work and diagnostic services. You pay a premium each month to maintain this coverage. This premium is deducted from your Social Security benefit check, or if you do not yet receive a benefit, you will be billed by Social Security quarterly. You must continue to pay your Part B premium to remain eligible for all PHIP Medicare plans. For more information, contact your health plan customer service for clarification about which Part B drugs and supplies are covered by contracted or network providers. For Medicare Parts A and B enrollment, contact the Social Security Administration. You can find contact information on the back cover of this handbook. Part D covers approved prescription medications. You must pay a premium for this coverage; however, it is included in the premium you pay for coverage through PHIP. The PHIP Medicare Part D plan does not have an up-front deductible or coverage gap (doughnut hole) like some individual Medicare Part D plans sold on the commercial market. See pages 24 41 for benefit information. Medicare part D creditable coverage If you or your dependent are already Medicare-eligible when you enroll in a PHIP health plan, you may be required to show proof from your prior employer or health plan that the prior plan s prescription drug coverage was equal to or exceeded that of the basic Medicare Part D prescription drug benefit. If the coverage was not creditable, Medicare could impose a 1 percent per month penalty for the months you did not have creditable coverage. You will be automatically terminated from all PHIP coverage if you enroll in a second Medicare Part D prescription plan or Medicare Advantage plan. Once termination has occurred, you cannot re-enroll in PHIP, unless you experience a new enrollment opportunity. Part D-IRMAA Part D Income Related Monthly Adjustment Amount (Part D-IRMAA) is an assessment required by Medicare for individuals whose income is above the Medicare-defined income threshold and who are enrolled in a Part D plan. Under PHIP, you will have a Part D prescription plan. Social Security will notify and bill you if you are required to pay this additional premium. To be eligible for PHIP coverage, you must pay your Part D-IRMAA, or Medicare will notify your plan and you will be terminated from PHIP entirely. Do not contact PHIP or the health plans regarding this mandate. For additional information, see the PHIP website for a Medicare Q&A at www.pershealth.com. For questions about Part D-IRMAA, please contact either Medicare or the Social Security Administration as referenced on the back cover of this handbook. 7

Your health plan options Below are descriptions of the various types of health plans available through PHIP. You can find additional planspecific information in the benefit comparisons, premium rates and definition sections in this handbook. Medicare Supplement The Medicare Supplement plan allows you to choose any physician who is a Medicare participating provider. You can live anywhere in the United States or travel outside the U.S. and still maintain coverage as referred to on pages 30 31. You must meet your annual deductible first; then, Medicare pays its portion, and the plan pays the balance of the Medicare-allowed benefits. Medicare Supplement Moda Health Managed care plans Managed care plans contract with hospitals and physicians to provide care for enrollees. With managed care plans, you usually pay a modest fixed charge, called a "copay, at the time you receive care. Generally, you have no claim forms to file for managed care doctors, hospitals and other healthcare providers who contract with these health plans. When you join a managed care plan, you must use the providers (hospitals and physicians) that are part of the plan. You must live in a certain geographic area, known as a service area, to be eligible for benefits. You also must select a primary care physician and be referred by that physician for most specialist care. Exceptions in Medicare Advantage plans are described later in this handbook. Managed care plans for Medicare-eligible participants are called Medicare Advantage (MA) plans. When you enroll in any MA plan, that plan becomes the administrator of your Medicare Parts A and B benefits and you are locked into the managed care plan you have chosen until the plan change period or you move out of the plan s service area. PHIP offers health maintenance organization (HMO), point-of-service (POS) and Preferred Provider Organization (PPO) Medicare Advantage plans to its Medicare participants. 8

You can be enrolled in only one Medicare Advantage plan at a time. By enrolling in a PHIP Medicare Advantage plan, any prior Medicare Advantage coverage will be terminated. Medicare Advantage managed care HMO plans: y PacificSource Medicare y Kaiser Permanente y Providence Medicare Advantage plans (Providence Medicare Align Group Plan(HMO)) Medicare Advantage managed care HMO-POS plan: y Providence Medicare Advantage Plans (Providence Medicare Flex Group Plan (HMO-POS)) Medicare Advantage PPO plan: y PERS Moda Health PPORX (PPO) Non-Medicare plans Participants may select either a $500 deductible Core Value plan option or a $1,000 deductible Select Value plan option. Kaiser Permanente offers a traditional HMO plan as a Core Value plan and a $1,000 deductible plan as a Select Value plan option. Refer to pages 32 39 for more information. PHIP offers HMO, POS and PPO plans for non-medicare participants: Core Value Traditional HMO plan: Kaiser Permanente Select Value HMO plan with Deductible: Kaiser Permanente Core Value and Select Value POS plans: PacificSource Health Plans Core Value and Select Value PPO plans: Moda Health and Providence Health Plan If you are eligible for Medicare Parts A and/ or B, you will not be eligible to enroll in any of the PHIP non-medicare plans. Once enrolled under the Select Value plan ($1,000 deductible), you will not be able to move back to the Core Value plan ($500 deductible/kaiser HMO). You will be able to move within the Select Value plans ($1,000 deductible) offered by another provider within your service area during plan change. You will not be able to change to the Core Value plan midyear, even if you experience a family status change or new enrollment opportunity. Dental options PHIP offers two dental plans: Kaiser Permanente ODS You can enroll in either dental plan regardless of your medical plan selection. However, for Kaiser Permanente dental, you must reside in the Kaiser Permanente dental plan service area. Please refer to pages 32-35 for a description of dental services. For additional information on dental enrollment, refer to page 16. 9

Other important information Plan change PHIP offers an annual plan change period from October 1 to November 15. Plan information and rates for the coming year are posted to the PHIP website in September. During the plan change period, you can change your medical and/or dental plan to another plan available within your residing area. This annual plan change period is not an opportunity to add dental coverage or dependents. Plan changes made during this period become effective January 1. If you are enrolled and do not want to change plans, no paperwork is required. Exclusions and limitations All available plans have some limitations and exclusions. Please contact the specific health plan administrator for more information. The plan benefit handbook you receive from your chosen health plan after enrollment will include complete information on the exclusions and limitations for the plan. Information also will be available on your health plan s website. Please refer to the back of this handbook for phone numbers and website addresses. If you want to make a change, you must fill out a Disenrollment Form for the plan you are ending as well as an Enrollment Request Form for the new coverage. Submit both forms to PHIP before the November 15 deadline. Forms can be found at pershealth.com or by calling PHIP customer service. If you do not submit a change during this period, you will be unable to change your enrollment midyear, unless you experience a family status change or new enrollment opportunity. 10

Power of Attorney/Authorization to Disclose Information PHIP requires that a Power of Attorney or Authorization to Disclose Information be on file with the program office for anyone acting on a member s behalf. PHIP is unable to release information to anyone who is not authorized by the PHIP member. To disclose or change information after the death of a member, please provide one of the following: executor, letter of probate or trustee documentation, or Last Will and Testament. Change of address You must submit all address changes through PHIP to ensure coordination of billing and effective dates with your health plans. PHIP will notify the appropriate health plans for you. Failure to notify PHIP within 30 days of moving outside a service area can result in involuntary termination of coverage if you are enrolled in a managed care plan. Address changes must be submitted in writing by the member or authorized party. Complete, sign, date and submit a Change of Address Form to PHIP. Address changes may be sent via mail or fax. (Email requests will not be accepted.) You are also required to submit your change of address in writing to the PERS Pension Office at the address listed on the back cover of this handbook. PHIP Snow Bird option For members who are enrolled in PacificSource, Providence Medicare Align Group Plan (HMO) or Kaiser Permanente, and who reside inside Oregon part of the year and outside Oregon part of the year, PHIP offers a Snow Bird option. The Snow Bird option allows members to change their health plan to Moda Health while living outside their managed care plan s service area. Members must plan on living outside the service area for more than 60 days for this option to apply. Before leaving, members should contact PHIP to request an application and Disenrollment Form to change to either the Moda Health Medicare Supplement Plan or the PERS Moda Health PPORX (PPO) Plan for the time spent living outside the managed care service area. Upon returning to Oregon, members will be eligible to change back to their managed care plan. For non-medicare members who are enrolled in Kaiser Permanente, PacificSource, or Providence plan, and who reside inside Oregon part of the year and outside Oregon part of the year, PHIP offers a Snow Bird option. You must fill out a Disenrollment Form for the plan you are ending and an Enrollment Request Form for the new coverage when leaving the area and when returning. Please contact PHIP for more information about this option. You must maintain a primary residence within the United States to be eligible for PHIP. If you reside in another country, you are not eligible to retain PHIP coverage. 11

Eligibility The information in this section is a summary of the Oregon Administrative Rule (OAR 459-035-0020) for enrolling in PHIP health plans. If you have any questions about your eligibility for enrollment or contributions to your Retirement Health Insurance Account (RHIA) or Retiree Health Insurance Premium Account (RHIPA) (see pages 21 22), or if you would like a copy of the complete OAR eligibility rules, please call PHIP at 800-768-7377 or visit arcweb.sos. state.or.us/banners/rules.html. Who s eligible? An eligible person includes an eligible PERS retiree, a spouse, a dependent domestic partner, a dependent, or a surviving spouse or dependent. PHIP reviews eligibility upon receiving enrollment forms. The categories of eligible persons are as follows: An eligible spouse is the spouse of an eligible retiree. A marriage certificate is required if the spouse has a different last name than the retiree. An IRS-eligible, dependent domestic partner, as defined by IRS Code 26 USC 105(b), refers to a person who has had a relationship with and resided with a PERS retiree for at least 12 months immediately preceding enrollment into PHIP. In addition, the PERS retiree must be providing more than one-half the financial support for the person and must have claimed that person on his or her most recent federal tax return. 12

An Affidavit of Dependent Domestic Partnership and a copy of your most recent federal tax return will be required. An eligible dependent is a dependent child who is less than 26 years old and meets one of the following requirements (the retiree must provide legal documentation of birth or adoption): ya natural child ya legally adopted child or a child placed in the home pending adoption (legal custody and guardianship do not apply) ya step-child who resides in the household of the step-parent who is an eligible retired member ya grandchild, provided at the time of birth at least one of the grandchild s parents was covered under a PHIP plan as a dependent child and resides in the household of an eligible retired member An eligible dependent also can be someone who is 26 or older and has either been continuously dependent upon the retiree since childhood because of a disability or physical handicap, or has been covered under a healthcare insurance plan as the retiree s dependent for at least 24 consecutive months immediately before enrollment in a PHIP plan. In either case, the following additional requirements must be satisfied: ythe child is not able to achieve self-support through work because of a developmental disability, mental retardation or a physical handicap as verified by a physician and accepted by the carrier. ythe incapacity is continuous and began before the date the child would otherwise have ceased to be an eligible dependent. An eligible surviving spouse or dependent refers to: ythe surviving spouse or dependent of a deceased retired PERS member ythe surviving spouse or dependent of a deceased PERS member who was not retired but was eligible to retire at the time of death In no event shall an eligible person as defined in this rule be entitled to coverage as both a retiree and as a spouse or dependent. Members and their dependents must reside in the United States to receive coverage. Upon reaching age 65 or becoming Medicare-eligible because of a disability, a retiree and/or dependents must be enrolled in and maintain Parts A and B of Medicare to be eligible for PHIP coverage. Part B premiums must be paid to Medicare. If you drop your Part B coverage through Medicare, you will no longer be eligible for coverage through PHIP. Enrollment in a PHIP Medicare plan includes enrollment in a PHIP Medicare Part D plan. PHIP enrollment appeals If you disagree with any determination related to your enrollment or eligibility in PHIP, you may submit an appeal in writing within 60 days of a determination to PERS, Attn: Appeals, 11410 SW 68th Parkway, Tigard, OR 97223. Health plan appeals Appeals related to claim and benefit payments, or Medicare plan enrollment or disenrollment issues, should be directed to the health insurance carrier of the plan in which you are enrolled. Contact information for all health plans may be found on the back of this handbook. 13

Enrollment opportunities The PHIP milestones, as defined in OAR 459-035-0070, mark the only enrollment opportunities available. Eligible retirees and their spouses or dependents who do not choose to enroll in a PHIP health plan during one of these enrollment periods will lose their opportunity to enroll in PHIP. Enrollment periods New retiree New retirees can enroll up to 90 days after the effective date of their retirement. Coverage will be effective on your retirement date (if you apply before your retirement date or the date of your PERS disability approval letter) or on the first day of the month after your application is received (if you apply within 90 days of your retirement date or the date of your PERS disability approval letter). Verify your prior employer s coverage end date to ensure that your PHIP plan does not overlap other employer-sponsored coverage. Working past Medicare eligibility If you are not drawing a Social Security benefit check and are still working and covered by an employer-sponsored plan when you turn 65, you will need to contact the Social Security Administration to sign up for Medicare Part A. Part A is free for most people. Because Medicare Part B has a premium, you may want to wait until three months before your retirement date or loss of employer-sponsored coverage to contact the Social Security Administration to sign up for Part B. The Medicare enrollment period is anytime during the active group coverage or anytime during the eight months after the active coverage ends. If you do not have Part B in place when you lose your employer coverage, you cannot enroll in a PHIP plan. Medicare eligibility PERS retirees can enroll up to 90 days after the date of their initial Medicare eligibility if they are enrolled in both Medicare Parts A and B. Enrollment in a PHIP medical plan includes enrollment in a PHIP Medicare Part D plan. PHIP coverage will take effect on the date your Medicare coverage becomes effective if you enroll before the date of your Medicare eligibility. 14

PHIP coverage will take effect on the first day of the month after your application is received if you apply after the date of your Medicare eligibility. If you are currently enrolled in a PHIP non-medicare plan, you will be required to fill out the Enrollment Request Form 30 days before becoming Medicare-eligible. Failure to submit a new Enrollment Request Form for Medicare coverage will result in cancellation of your non-medicare health plan coverage under PHIP upon Medicare eligibility with the possibility of no future opportunities to enroll. Medicare disability Your eligibility to enroll in Medicare Parts A and B, due to Social Security Disability, becomes effective the first day of the 25th month after your Social Security Disability benefits began. You are required to retain both Medicare Parts A and B to be enrolled in a PHIP Medicare plan. The 90-day Medicare eligibility enrollment opportunity also applies in these circumstances. If you miss this opportunity, becoming Medicare-eligible at age 65 will not be a new opportunity to enroll in a PHIP health plan unless you have had 24 months of continuous employer-sponsored coverage immediately preceding enrollment in PHIP. If you are currently enrolled in a PHIP non-medicare plan, you must fill out the Enrollment Request Form 30 days before becoming Medicare-eligible. Failure to submit a new Enrollment Request Form for the Medicare coverage will result in cancellation of your non-medicare health plan coverage under PHIP upon Medicare eligibility with the possibility of no future opportunities to enroll. Continuous employer-sponsored coverage PERS retirees can enroll at any time if they have been covered under another employer-sponsored group health plan for 24 consecutive months immediately preceding enrollment in PHIP and within 30 days of losing prior employer-sponsored coverage. Employer-sponsored group coverage can be: Coverage you had as an active or retired employee that is terminating Coverage you had under an eligible spouse s active employment or as a retired employee that is terminating Coverage continued through COBRA following termination of employment ycobra coverage is secondary to Medicare, except when the Medicare beneficiary has ESRD. ycobra coverage is primary to Medicare during the 30-month ESRD coordination period. For the purposes of PHIP, healthcare coverage under worker s compensation, Medicare or any other government entitlement program (including foreign healthcare) does not qualify as employer-sponsored health coverage. PHIP coverage will be effective the first of the month after employer-sponsored coverage ends, if loss of coverage is the reason for enrolling. If the PHIP enrollment form is received after the loss of coverage and within the 30-day time line, the effective date will be the first of the month after the enrollment form is received, and your Enrollment Request Form is received prior to loss of coverage. Verify your coverage end date with your employer to ensure that you enroll with PHIP on the correct effective date. Changes to the 15

original PHIP effective date will not be made once the requested effective date has passed, which can affect the premiums you pay. Dependent enrollment Dependents can enroll during any of the enrollment periods available to retirees. These include the retiree s date of retirement or Medicare eligibility and after the retiree has had at least 24 consecutive months of coverage under another employer-sponsored health plan. If a dependent has an enrollment opportunity after the retiree is enrolled, he or she will be eligible to enroll under the retiree s account. New dependents can be enrolled within 30 days of becoming a dependent through marriage. If the spouse has a different last name than the retiree, a copy of the marriage certificate will be required. Dependents must enroll in the same plan as the retiree. If the retiree has Medicare coverage and the dependent has non-medicare coverage, the dependent s coverage must be with the same health plan. As long as the retiree has applied for and received PERS retirement, a spouse or dependent can enroll in a PHIP health plan up to 90 days after his or her initial Medicare eligibility in both Medicare Parts A and B, even though the retiree remains enrolled in the employer-sponsored group plan. Enrollment in a PHIP Medicare plan includes enrollment in Medicare Part D. A spouse or dependent can enroll in a PHIP Medicare health plan when the retiree enrolls at a later time, provided the spouse or dependent also is enrolled in Medicare Parts A and B. If the retiree does not enroll in PHIP upon his or her final enrollment opportunity, dependent(s) will not be eligible for PHIP coverage. Divorced spouses of PERS retirees are not eligible for a PHIP health plan, even if receiving a PERS benefit check. If a spouse is enrolled in a PHIP health plan at the time of divorce, COBRA continuation applies. The retiree or spouse must send a copy of the divorce decree to PHIP within 60 days of the dissolution of marriage for the spouse to be eligible to continue coverage. The surviving spouse and/or dependents of a PERS member may continue enrollment as described on page 13. If the surviving spouse or dependent is not enrolled at the time of the PERS retiree s death, the spouse or dependent may enroll within 90 days of the death or by meeting other enrollment opportunities (see pages 14 16). However, in the event of remarriage, coverage cannot be extended to the new spouse. Dental plan enrollment You are eligible to enroll in a PHIP dental plan only if you also have PHIP medical coverage. If anyone in your family wants dental coverage, everyone who is enrolled in a PHIP medical plan also must be enrolled in a PHIP dental plan. Enrollment in a PHIP dental plan is limited to when you first enroll in a PHIP medical plan. You must apply for dental coverage at your initial enrollment opportunity or you will not be able to get PHIP dental coverage. The only exception is for members who have continuous dental coverage through an employer-sponsored health plan immediately preceding enrollment in PHIP. There are no other dental enrollment periods. There may be a 12-month waiting period for some services if you have not had 12 months of continuous employer-sponsored dental coverage immediately preceding enrollment into a PHIP dental plan. (See page 55 for more information.) PHIP offers two dental plans: Kaiser Permanente and ODS. You can enroll in either dental plan regardless of your medical plan selection. However, for Kaiser Permanente dental, you must reside in the Kaiser Permanente dental plan service area. Please refer to pages 54 55 for a description of dental services. 16

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How to enroll Your coverage will start on the date described in the Enrollment Opportunities section on pages 14-16. During peak enrollment times (i.e., plan change, peak retirement periods, end of month), delays may occur. Please allow time for PHIP to process your application and notify your health carrier. In the event you need immediate access to your health plan information, please contact PHIP at the customer service number listed on the back of this handbook. To enroll in any PHIP health plan, you must: Meet one of the PHIP enrollment opportunities described on pages 14 16. Complete the Enrollment Request Form in its entirety. Be sure to include your personal information. Include spouse or dependent information only if they are enrolling in PHIP. Indicate your reason for applying for PHIP coverage and select a medical and/or dental plan. If you are enrolled in a PHIP non-medicare plan, you must submit a new Enrollment Request Form upon Medicare eligibility. Complete the Medicare card section for all Medicare-eligible individuals. Make photocopies of either the Medicare card or a Letter of Entitlement showing Medicare effective dates for Parts A and B for each Medicare-eligible individual applying. Send the copy with the Enrollment Request Form. Complete the payment option section. Select only one option. The PERS pension holder must sign this section if choosing pension deduction. (See Making monthly premium payments on page 19.) Answer all questions in the section related to coordination of benefits for all enrollees. Missing information can delay your enrollment. Sign and date the Enrollment Request Form. Both the retiree and spouse must sign if both are enrolling. Enrollments must be signed and received prior to the month in which coverage is to begin. Additional documentation may be required based on your enrollment opportunity. This may include a dependent s birth certificate, adoption paperwork, PERS disability retirement approval letter, Affidavit of Dependent Domestic Partnership, or marriage license. Submit documentation with your Enrollment Request Form. However, do not delay submitting your Enrollment Request Form because you do not have the necessary documents. Enrollment will be pended until your documents are received. A Disenrollment Form is required if you are changing from one health plan to another. Submit the form to the PHIP office. The address is listed on the back cover of this handbook. You can be enrolled in only one Medicare Advantage and Medicare Part D prescription drug plan at a time. Terminating your Medicare Part D prescription coverage or enrolling in another Medicare Advantage or Medicare Part D prescription plan will automatically terminate all coverage. Once termination has occurred, you may not reenroll in PHIP, unless you experience a new enrollment opportunity. When enrolling in a PHIP Medicare plan, you will automatically be enrolled in a Part D prescription plan. 18

After enrollment Making monthly premium payments Premium payment options: Deduction from your monthly PERS pension check. This option ensures timely premium payment and prevents a lapse in coverage. If you choose pension deduction, the PERS pension holder s signature is required any time an Enrollment Request Form is submitted. Electronic funds transfer from your bank account. This also ensures timely payment and prevents a lapse in coverage. Only one payment option is allowed per PHIP account. Late payments Premium payments are due on or before the first of each month, with no grace period. If payment is not received by the first day of the month, the account is considered delinquent. If you do not pay your premium upon notification, your health plan coverage will be canceled. If your coverage is terminated because of a delinquent payment, you may be responsible for all claims incurred on or after that termination date, except to the extent that those claims are covered under Original Medicare. Voluntary disenrollment PHIP and Medicare guidelines require a written request for voluntary disenrollment from PHIP health insurance coverage. Disenrollment will occur the first of the month following receipt of your completed PHIP Disenrollment Form unless a later date is requested. Both the member and spouse must sign the written request for termination. If one member of your family wishes to terminate their dental coverage, the whole family loses dental coverage. Please submit a PHIP Disenrollment Form, which you can find on the PHIP website or through customer service. The PHIP address and fax number are listed on the back of this handbook. OAR 459-035-0090 (3) if payment is by check or money order, the check or money order must be physically received by the Third Party Administrator on or before the due date. (4) Failure to make the payment by the due date shall result in termination of a person's PERS-sponsored health insurance coverage. Once disenrollment or termination occurs, you cannot re-enroll in PHIP unless you experience a new enrollment opportunity. Death notification As a PERS retiree: Upon the death of your spouse, your PHIP coverage will continue as usual. To terminate your spouse s coverage, mail a photocopy of the death certificate to PHIP AND the PERS Pension office. As a surviving spouse or dependent of a PERS retiree: Your PHIP coverage will continue automatically. You must mail a copy of the retiree s death certificate to PHIP AND the PERS Pension office for your account to remain active. If you would like to terminate your coverage, a written request is required. If the surviving spouse is not enrolled at the time of the PERS retiree s death, the spouse may enroll within 90 days of the death or by meeting other enrollment opportunities. 19

Premium subsidies RHIA (Medicare) subsidy Oregon Revised Statute (ORS) 238.420 established a trust fund called the Retirement Health Insurance Account (RHIA). The information presented in this section is a summary of OAR 459-035-0030. RHIA pays a monthly contribution toward the cost of healthcare coverage for some PERS retirees. This contribution is applied automatically, if you are eligible, by verifying your pension service records. It is reflected in the monthly premium you pay. To have RHIA contributions applied toward PHIP premiums, retired members must meet the following requirements: Be enrolled in Parts A and B of Medicare and also meet one of these requirements: y Receive a PERS service or disability retirement allowance under Tier 1 or Tier 2 and have had eight or more years of qualifying service at the time of retirement y Receive a PERS disability retirement allowance computed as if the retiree had eight or more years of creditable service and was a Tier 1 or Tier 2 retiree Be a surviving spouse or dependent of a deceased eligible Tier 1 or Tier 2 retired member, as described on page 13, who is enrolled in Medicare Parts A and B and who also meets these requirements: y Receives a retirement allowance or benefit from PERS ywas covered under an eligible retiree member s PHIP health plan and the deceased member retired before May 1, 1991 Premium payment information Because verification is based on final pension calculations, the retiree could be invoiced the full premium amount until eligibility for the RHIA subsidy is verified. Upon verification, if the retiree is due a refund, it will be calculated and sent automatically. If you are a surviving spouse or are no longer eligible for an ongoing pension benefit, you may no longer be eligible for the RHIA subsidy. If you received a subsidy while not eligible, you will have to repay any funds you received while not eligible. 20

RHIPA (state of Oregon non-medicare) subsidy ORS 238.415 established a trust fund called the Retiree Health Insurance Premium Account (RHIPA). The information in this section is a summary of OAR 459-035-0040. RHIPA pays a monthly contribution toward the cost of healthcare coverage for some state of Oregon retirees who are not eligible for Medicare. This contribution applies only to PERS retirees who retire from a state agency, such as the Oregon Department of Transportation (ODOT), the Oregon Department of Fish and Wildlife, or any other agency of state government, and whose PERS effective retirement date is the first of the month following termination from state employment. The contribution will be applied automatically, if you are eligible, by verifying your qualifying state service time. The monthly premium amount you pay will reflect the subsidy, following verification. To have RHIPA contributions applied toward PHIP premiums, retired state employees enrolled in a PHIP health plan must meet the following requirements: Be a Tier 1 or Tier 2 retiree who is a state employee at the time of retirement and is not eligible for Medicare, and who also meets one of these requirements: y Receives a PERS service or disability retirement allowance or benefit and has had eight or more years of qualifying state service at the time of retirement (only STATE service time applies toward RHIPA subsidy) y Receives a PERS disability retirement allowance computed as if the retiree had eight or more years of creditable state service and had attained the earliest service retirement age Be a surviving spouse or dependent of a deceased eligible Tier 1 or Tier 2 retired state employee, as described on page 12, who is not eligible for Medicare and who meets one of these requirements: yis receiving a retirement allowance or benefit from PERS ywas covered under a PHIP health plan at the time of the retiree s death and the eligible retired state employee retired on or after September 29, 1991 Premium payment information Because verification is based on final pension calculations, the retiree will be sent premium notices reflecting the full premium amount until eligibility for the RHIPA subsidy is verified. Upon verification, any refunds due will be sent automatically. 2015 RHIPA subsidy rates will become available in November 2014. Updated information will be sent to all participating RHIPA members. Please direct questions about health plan premium rates applicable to RHIPAeligible members to the PHIP office. If you are a surviving spouse and are no longer eligible for an ongoing pension benefit, you may no longer be eligible for the RHIPA subsidy. If you received a subsidy while not eligible, you will have to repay any funds you received while not eligible. 21

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COBRA continuation of coverage In accordance with federal and state of Oregon guidelines, PHIP provides opportunities for the continuation of coverage through COBRA following specific qualifying events. If you experience one of the qualifying events listed below, please contact PHIP for additional information. A qualifying event will occur if eligibility for coverage is lost because of: Cancellation of PERS retirement status The divorce or legal separation of a retiree s covered spouse. PHIP must be notified within 60 days from the signed Dissolution of Marriage document. A spouse or dependent no longer meeting eligibility requirements (e.g., a child reaches the maximum age limit, or a spouse loses coverage because the retiree does not enroll in PHIP upon the last enrollment opportunity) Once COBRA has been secured, timely payment of premiums is essential. Timely COBRA premium payments The initial premium must be paid within 45 days of the date COBRA is elected. Thereafter, premiums are due the first day of each month for that month s coverage. If payment is not postmarked or received on or before the 45th day (for the initial premium) or the 30th day following the monthly due date, coverage will be terminated and cannot be reinstated. 23

Coverage outside service areas You must maintain a residence within a plan s service area and reside in the United States in order to participate in PHIP. Moda Health Moda Health PPORX (PPO) plan Members can travel for up to 12 months anywhere in the U.S. with the PERS Moda Health PPORX (PPO) plan. The travel benefit provides members the flexibility of using an in-network provider in Oregon or any out-of-network Medicare provider while paying the same copayment or coinsurance. For members enrolled in the PERS Moda Health PPORX (PPO) plan and traveling outside the U.S., emergency care is covered worldwide Moda Health Medicare Supplement Plan Coverage is limited to eligible emergency medical care expenses incurred outside the U.S. These are emergency room, urgent care and ambulance services. Non-Medicare plan Members traveling outside of the primary service area may receive the in-network benefit level by using a Travel Network provider. The in-network benefit level applies to a Travel Network provider only if members are outside the primary service area and the travel is not for the purpose of receiving treatment or benefits. Treatment of emergency medical conditions is covered worldwide. All emergency services will be reimbursed at the in-network benefit level. However, benefits are subject to our contracted rates for in-network physicians and providers. Members may be responsible for any amounts above the maximum plan allowance. Emergency/Travel Benefits for Medicare Plans Emergency room (ER) (worldwide) Urgent care (worldwide) Ambulance (worldwide; air/ground) Moda Health Supplement MEMBER pays: Covered in full (inside U.S. only) PERS Moda Health PPORX (PPO) MEMBER pays: $65 copay $20 copay $50 copay Outside service area travel (in U.S.) Covers ER, urgent care & ambulance Out-of-network copay applies Outside service area travel (outside U.S.) Covers ER, urgent care & ambulance at 80% coinsurance. Coverage limited to $50,000 lifetime per member. Covers ER, urgent care & ambulance at out-of-network copay 24

ODS Dental plan The ODS dental plan gives you the freedom to choose any licensed dentist. As part of the Delta Dental Plan, the largest dental network in the country, you can visit any of the 145,000 Delta Dental dentists in the U.S. and still be covered in-network. Kaiser Permanente Kaiser Permanente members temporarily outside the service area are covered for emergency care, urgent care and medically necessary ground or air ambulance service worldwide under Medicare and non-medicare plans. Medicare members also have a limited travel benefit that covers routine and follow-up care worldwide. Currently enrolled Medicare members who permanently move outside the Kaiser Permanente Northwest service area or who are out of the service area for six consecutive months or more must disenroll from their Medicare Advantage plan. Members temporarily visiting other Kaiser Permanente regions may receive visiting member care from designated providers in those areas for either Medicare or non-medicare plans. For information about service areas and facility locations in other regions, please call Membership Services. With Kaiser Permanente, health plans are available in California for PERS retirees who relocate to that area. Please call the PHIP office for more information. Premiums and benefits for those areas will differ from those noted in this handbook. Kaiser Permanente Senior Advantage PacificSource Medicare Essentials 801 Providence Medicare Align Group Providence Medicare Flex Group MEMBER pays: MEMBER pays: MEMBER pays: MEMBER pays: $50 copay $50 copay $50 copay $65 copay $15 copay $15 copay $25 copay $25 copay $50 copay $50 copay $50 copay $50 copay Care in other KP regions or Group Health Cooperative service area. Covers ER, urgent care and ambulance worldwide. Covers routine, preventive and follow-up care outside Kaiser network at 20% coinsurance as part of $1,000 annual worldwide travel benefit maximum. Covers ER, urgent care and ambulance worldwide. Covers routine, preventive and follow-up care outside Kaiser network at 20% coinsurance, up to $1,000 annual worldwide travel benefit maximum. Covers ER, urgent care & ambulance Covers ER, urgent care & ambulance 20% to maximum allowance of $1,000 for follow-up services Covers ER, urgent care & ambulance 20% Covers ER, urgent care & ambulance 25

If you do not use Kaiser Permanente s physicians and hospitals, neither Kaiser Permanente nor Medicare will cover your services, except for emergency and urgent care, authorized referrals, renal dialysis outside the service area per Medicare criteria and travel benefits. Kaiser Permanente Dental plan If you have a dental emergency while traveling outside the service area, you may go to the nearest dental office. You have limited coverage for qualifying emergency dental care. PacificSource Medicare plan The PacificSource Essentials 801 plan provides worldwide coverage for the following four services: Emergency services Urgently needed services Medically necessary ground or air ambulance services Out-of-area dialysis services These services do not require prior authorization. Non-Medicare plan The PacificSource plans give you the freedom to see either in-network or out-of-network providers for covered services. This includes access to in-network providers nationwide through the First Health Network. You will generally pay less for services from providers in the PacificSource network. Travelers have the added protection of worldwide coverage for: Urgently needed services Medically necessary ground or air ambulance services Out-of-area dialysis services These services do not require prior authorization. Providence Health Plan All plans offer worldwide coverage for urgent and emergency care and include ambulance coverage (air and ground). Providence Medicare Align Group Plan (HMO) Includes a travel benefit for necessary follow-up care from any Medicare provider outside the plan service area. Providence pays 80 percent and the member pays 20 percent, up to a combined $1,000 annual limit. Providence Medicare Flex Group Plan (HMO-POS) If you are a snowbird or are out of the service area, the Providence Medicare Flex Group Plan out-of-network benefit allows you to see any Medicare-approved provider. Non-Medicare PPO plan Providence Health Plan gives members access to nearly one million providers nationwide. If you are traveling and use a national network provider such as First Choice Health Network or MultiPlan/PHCS network, benefits are paid at the in-network level. If you choose an out-of-network provider, benefits are paid at the out-of-network level. 26

Benefit changes, health plan service areas and plan features 27

Changes to plans Effective January 1, 2015 Prescription drug program Applies to all enrollees Medicare and non-medicare The Prescription drug out-ofpocket maximum per person per calendar year is now $4,700. No other benefit changes for the 2015 plan year. Medical Moda Health Medicare Supplement Plan No benefit changes for the 2015 plan year. PERS Moda Health PPORX (PPO) Medicare Advantage No benefit changes for the 2015 plan year. Non-Medicare Core Value and Select Value Plans y The ambulance out-of-network coinsurance will now match the in-network level of 20%; the deductible still applies. y No other benefit changes for the 2015 plan year. Kaiser Permanente Medicare For members who had a Medicare covered transplant, post-surgical Immunosuppressive drugs used in transplant services are now subject to the applicable plan coinsurance amount. Self-administered clotting factors for the treatment of hemophilia are now subject to the applicable Part B copayment or coinsurance. Clinically administered medications in all outpatient settings, including those given in a medical office setting, are now subject to the applicable Part B copayment or coinsurance. No other benefit changes for the 2015 plan year. Non-Medicare Core Value and Select Value Plans yclinically administered medications in all outpatient settings, including those given in a medical office setting, are now subject to 10% coinsurance. ythe definition of Usual and Customary Fee has been deleted and replaced with Allowed Amount. y No other benefit changes for the 2015 plan year. PacificSource Medicare No benefit changes for the 2015 plan year. Non-Medicare Core Value and Select Value Plans ythe provider network name is changing from the Choice network to the Prime network. y No other benefit changes for the 2015 plan year. Providence Health Plan Providence will be expanding into the following Oregon counties for both Medicare and non-medicare: Crook, Deschutes, Hood River, Jefferson, and Wheeler. Medicare Choice (Flex) Plan Name of the plan is changing to Medicare Flex Plan. New ID cards will be issued. SilverSneakers has been replaced with Silver&Fit. No other benefit changes for the 2015 plan year. 28

Medicare Extra (Align) Plan Name of the plan is changing to Medicare Align Plan. New ID cards will be issued. SilverSneakers has been replaced with Silver&Fit. No other benefit changes for the 2015 plan year. Non-Medicare Core Value and Select Value Plans y Benefits for sleep studies have been clarified and now require prior authorization. yclarifying coverage for immediate care; immediate care has been separated from urgent care. Whenever you need immediate care, call your personal physician/provider first. Your personal physician/provider will direct you to where coverage should be received. yclarifying coverage for urgent care. Whenever you need urgent care, call your personal physician/provider first. Your personal physician/ provider will direct you to where coverage should be received. y Payment parameters for ESRD in coordination with Medicare have been clarified. ythe transplant waiting period has been removed. y No other benefit changes for the 2015 plan year. Dental ODS No benefit changes for the 2015 plan year. Kaiser Permanente No benefit changes for the 2015 plan year. 29

Health plan service areas Moda Health Service area for Medicare and non-medicare Nationwide Moda Health Medicare Supplement Plan and Moda Health non-medicare PPO Oregon PERS Moda Health PPORX (PPO) Kaiser Permanente Service area for Medicare and non-medicare *Medicare only Benton: 97330, 97331, 97333, 97339, 97370; Clackamas; Clark; Columbia; Cowlitz; Hood River: 97014, 97031*, 97041*, 97044*; Lewis: 98591, 98593, 98596; Linn: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389; Marion; Multnomah; Polk; Skamania: 98605*, 98610*, 98639, 98648, 98651*, 98671*; Wahkiakum: 98612, 98647; Washington; Yamhill PERS retirees who live in California and are interested in enrollment in a Kaiser Permanente Health Plan located in their area should call PHIP for more information. Premium rates and benefits will differ from those noted in this handbook. In-network Out-of-network 30

In selecting a PHIP health plan, your primary residence (not mailing address) must be within the United States and the health plan s service area. PacificSource Service area for Medicare and non-medicare Coos; Crook; Curry; Deschutes; Grant; Hood River; Jefferson; Klamath: 97731, 97733, 97737, 97739; Lake: 97638, 97641, 97735, 97739; Lane; Sherman; Wasco; Wheeler In-network Out-of-network Providence Health Plan Service area for Medicare and non-medicare Oregon Benton, Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Linn, Marion, Multnomah, Polk, Washington, Wheeler and Yamhill Washington Clark County In-network Out-of-network 31

Moda Health and ODS Rooted in the Pacific Northwest, we are a company dedicated to partnering with and caring for our members. We re proud to provide you with evidence-based plans, diverse provider networks, innovative member programs and exceptional customer service. PERS Moda Health PPORX (PPO) PERS Moda Health PPORX (PPO) is a Medicare Advantage plan that is offered to all eligible PERS retirees and their dependents who reside in the state of Oregon. Members can choose any Medicare provider or a provider from the Moda Health Advantage statewide network. You are not required to select a primary care provider, and you can seek care from a specialist without a referral. Moda Health Medicare Supplement Plan Moda Health offers a Medicare Supplement plan to all eligible PERS retirees. This is a traditional Medicare Supplement insurance program that pays secondary to Medicare. Members can choose any Medicare provider. Members also can live anywhere in the United States. Non-Medicare PPO plan Moda Health offers a Preferred Provider Organization (PPO) plan for non-medicare retirees and dependents. Four networks are available to members. The state in which you reside will determine the PPO network as follows: 32

ODS Plus Network This network includes Legacy Health System, Oregon Health & Science University (OHSU), Providence Health & Services and Adventist Health. The ODS Plus Network provides access to providers, hospitals and pharmacies in Oregon, Idaho, Southern Washington and Northern California. First Choice Health Network This network is available to members who reside in Washington state and do not live in Benton, Clark, Cowlitz, Klickitat, Pacific, Skamania, Wahkiakum or Walla Walla counties. PHCS Network This network is available to members who reside in a state other than Oregon, Washington or Idaho. Travel Network* This network allows medical plan members to receive emergency and nonemergency care outside of their primary service area while traveling. As an eligible member seeking care through a PHCS Healthy Directions provider, you will receive in-network benefits. If you have dependents living outside the primary network area, your dependents also can use the Travel Network to receive care at an in-network benefit level. *The Travel Network is not an alternative primary network. If you are wondering whether your physician is in the Travel Network, please call us at 503-243-3880 or toll-free at 800-962-1533, or visit modahealth.com and click on Find Care. Moda Health additional Medicare benefit Silver&Fit The Silver&Fit program will empower you to get active and stay fit, regardless of your fitness level. Your membership includes access to a participating fitness facility, or if you prefer to work out at home, you can order up to two Silver&Fit Home Fitness kits. In addition, all enrolled Silver&Fit members will receive Healthy Aging educational materials available online or, if requested, by mail. Members can also track their exercise through more than 70 wearable fitness devices using the Silver Fit Connected!, program, sign up for the Silver Slate newsletter, which provides useful information about health and fitness, and access www.silverandfit. com. Silver&Fit is a federally registered trademark of American Specialty Health Incorporated and used with permission herein. Moda Health value-added services mymoda This personalized website is designed to help you manage your health. With mymoda, you can: View your benefits, claim information, eligibility and history Access health tools Find a physician, dentist, pharmacist or clinic Access Dental Optimizer View our prescription price check tool (pharmacy members only) Access your digital ID card Be Better tools Access tools and get individualized support to help you improve your health. Available through mymoda, Be Better tools include: Health coaching for PERS Moda Health PPORX (PPO) enrollees only Care coordination and case management for PERS Moda Health PPORX (PPO) only Registered Nurse Advice Line call 866-321-7580 anytime of the day or night. Vision and hearing discounts available at TruVision and VisionWorks in Oregon and Southwest Washington. Dental plan The ODS dental plan gives you access to the Delta Dental Premier Network, one of the largest dental networks available in Oregon and across the nation. Oral Health, Total Health Oral health research has shown a strong link between oral health and overall health. ODS believes that when you see a dentist regularly and maintain a healthy mouth, it can help keep the rest of your body healthy too. Through our Oral Health, Total Health program, ODS offers additional preventive benefits to members with diabetes and pregnant women in their third trimester. Passport Dental No matter where in the world you roam, Passport Dental gives you access to great care through your ODS dental plan. 33

Kaiser Permanente Proudly serving the Northwest for 68 years, Kaiser Permanente is uniquely designed to give you the prevention, wellness and healthcare resources you need to live well, with everything working seamlessly together. Senior Advantage Get more control, convenience and quality with a plan that goes beyond Original Medicare. Kaiser Permanente s Medicare Advantage and Medicare Cost plans provide comprehensive care with built-in wellness programs and supportive services that help promote your total health. By staying with us, you keep the advantages and convenience of being a Kaiser Permanente member: most services under one roof, online tools to manager your health, worldwide emergency coverage and more. Non-Medicare plans Core value traditional HMO plan With your Traditional Plan, you get a wide range of care and support to help you stay healthy and get the most out of life. You don t have to keep track of deductibles or worry about paperwork for the services you receive. And when you come in for care, you ll pay just a copay for most services covered by your plan. 34

Select value HMO plan with deductible With your Kaiser Permanente Deductible plan, you receive a wide range of care and support to help you stay healthy and get the most out of life. Even before you reach your deductible, most preventative care services, such as routine physical exams, routine mammograms and cholesterol screenings, are covered at little or no additional cost to you. For most other covered services, you ll pay just a copay or coinsurance after you reach your deductible. Your choice of doctors Your choice of primary care doctors and experienced specialists are here when you need them. We have 34 medical offices offering you personalized care. In addition, you have access to The Portland Clinic providers. Everything under one roof Fifty medical and dental offices located from Salem to Longview provide pharmacy, lab, X-ray, dental and vision services, so you can do more and drive less. Same-day appointments and after-hours urgent care are available for life s unexpected moments. Online access Use your computer, smartphone or mobile device to email your doctor s office, schedule routine appointments, view lab test results, refill prescriptions and more. Kaiser Permanente additional benefits 24-hour advice nurse benefit Contact a Kaiser Permanente advice nurse if you re not sure when to go in for care or where to be seen. Call 503-813-2000 in Portland or 800-813-2000 from elsewhere. Health fitness benefit We offer the Silver&Fit program as part of your Senior Advantage HMO Plan. You can choose to become a member at a contracted fitness club or exercise facility, or you can choose the Silver&Fit Home Fitness program. Dental plan The Kaiser Permanente dental plan offers 17 dental offices in the Northwest region. Work directly with your dentist to plan your treatment and identify any needed follow-up appointments, including cleanings. All of your dental care will be under the direction of your personal dentist. Kaiser Permanente healthy extras * Kaiser Permanente offers health resources and discounts* on alternative care, wellness classes and a variety of other activities. Comfort Keepers * Members who live in the Northwest are eligible for a 5 percent discount on services from Comfort Keepers, a leader in nonmedical, in-home services. LifeStation medical alert * Members who permanently live in the Northwest qualify for a discounted rate on 24/7 medical alert services from LifeStation, one of the nation s largest and most trusted medical alert service providers. Call 866-745-7575 for more information. Health coaching Get one-onone help setting health goals and developing a wellness plan. Coaching consultations free to members. Go to kp.org to learn more about Kaiser Permanente. *The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes related to these products and services may be subject to the Kaiser Permanente grievance process. 35

PacificSource PacificSource Community Health Plans Inc. offers Medicare Advantage plans under the name PacificSource Medicare. Our parent company, PacificSource Health Plans, is an independent not-for-profit community health plan founded by a group of physicians in Oregon with the goal of improving healthcare quality and access in the community. Our Medicare Advantage plans The PacificSource Medicare Essentials 801 Plan is a Medicare Advantage managed care plan. Members use in-network providers for most services. You can see any Medicare-approved provider in the PacificSource Medicare network. You can choose your own primary care provider, and you have the freedom to see specialists without a referral. Our Medicare Advantage plan covers more than Medicare alone and includes the PERS Moda Health Rx (PDP). Extra benefits Routine hearing exams: $15 copay Hearing aids: $250 reimbursement every two calendar years Non-Medicare point of service (POS) plans PacificSource Core Value and Select Value POS Plans give you the freedom to see either in-network or out-of-network providers for covered services. PacificSource non-medicare plans include access to in-network providers nationwide through the First Health Network. 36

You will generally pay less for services from providers in the PacificSource network. And you have the freedom to see specialists without a referral. Travelers have the added protection of worldwide coverage for ambulance services, urgent and emergency care, and dialysis services. For more details, see the 2015 non-medicare benefit comparison on pages 50-53. PacificSource Medicare value-added services The following value-added services are available to PacificSource Medicare members at no additional cost. InTouch for members Our secure website for members gives you 24-hour access to plan materials, authorizations and referrals. Click InTouch Login at the top of our website to register once you re a member. 24-Hour NurseLine You can call the 24-Hour NurseLine any time of the night or day from the comfort of you home to receive trusted health information and advice. GlobalFit discounted gym memberships New members get discounted rates from more than 10,000 gyms in GlobalFit s nationwide network. Gyms include 24 Hour Fitness, Anytime Fitness, Curves, Jazzercise and more. Jenny Craig discounts Get a free 30-day trial program and 25 percent off of a one-year Premium Success Program. This tailored program provides one-onone support to help you develop a healthy relationship with food, an active lifestyle and a balanced approach to living. HealthCoach4Me You have online access to educational information, assessments, diaries, checklists, a health library and prevention action plans. This online health coaching program will help you meet your goals and live a healthier life. Care programs If you have a chronic health condition such as diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure or asthma, you can get personal help to improve your health, overcome barriers and coordinate your care. Quality improvement programs Our in-network providers partner with us to improve your care and services. We utilize objective and subjective benchmarks to measure and evaluate quality and safety to ensure that you re getting the right care. Health screenings, events and immunization programs You can get free health screenings, educational events, immunization programs and health risk assessments to help you manage chronic conditions and live the life you want. 37

Providence Health Plan Providence Health Plan is part of one of the largest healthcare systems in the Pacific Northwest, Providence Health & Services. Providence Medicare Advantage Plans We offer two different plans to meet your needs. Both plans include: Access to nearly 10,000 in-network providers No deductible and low out-of-pocket maximum Free gym membership Providence exclusive discounts and programs Worldwide urgent care, emergency care and ambulance coverage Vision hardware allowance The chart on the next page illustrates highlights of each plan offering. Non-Medicare Plans Providence offers a Preferred Provider Organization (PPO) plan that provides in- and out-of-network benefits to non-medicare beneficiaries and their dependents. Providence Health Plan gives members access to nearly one million providers nationwide. 38

Providence Medicare Align Group HMO Providence Medicare Flex Group HMO-POS Benefits and premium Richer benefits Lower premium Provider access In-network only In-network and out-of-network Primary care physician Required Required Referrals Required Optional Travel benefits (non-urgent/emergency care) $1,000 allowance Covered at the out-of-network benefit Worldwide urgent care, emergency care and ambulance Included Included If you are traveling and use a national network provider, it is paid at the in-network level. If you choose an out-of-network provider, benefits are paid at the out-of-network level. Providence additional Medicare benefits and value-added services Free Gym Member through Silver&Fit and Healthy Aging Program With the Silver&Fit Exercise and Healthy Aging Program, you have access to: No-cost membership at over 10,000 participating fitness facilities or exercise centers The no-cost Silver&Fit Home Exercise Program Health tools and resources at SilverandFit.com The Silver Slate quarterly newsletter Silver&Fit exercise classes Find participating gyms at silverandfit.com. Providence RN Free medical advice 24 hours a day, seven days a week at 503-574-6520 or 800-700-0481. Exclusive discounts Discounts on recreational activities, apparel and more through the LifeBalance Program: Tickets and admission to movies, theater, sporting events, concerts and museums Hotel stays, air travel and car rentals Golf, lift tickets and sporting goods retailers Health and wellness 25 percent off at participating chiropractors, acupuncturists, massage therapists and dietitians Health and fitness classes Glasses and contacts Lasik eye surgery Hearing aids and hearing-aid batteries Lifeline life alert system Providence Healthcare Services Providence Care Management registered nurses offer personalized support to members with complex health issues or chronic conditions: Diabetes Asthma Chronic obstructive pulmonary disease (COPD) Congestive heart failure Coronary artery disease Post-hospital follow-up care Support of family and loved ones For more information, visit the Providence PHIP web page at providencehealthplan.com/phip. 39

Prescription drug benefit PHIP plans, including the prescription drug benefit, are among the most cost-effective benefit plans available to retirees. Each of the health plans available through PHIP includes a comprehensive prescription drug benefit plan. PHIP prescription drug benefit for PacificSource, Moda Health and Providence Health Plan This program is administered by PERS Moda Health Rx (PDP) for all three health plans. For information or questions about this program, contact Moda Health at the pharmacy number listed on the back cover of this handbook. Moda Health has negotiated discounted prices for prescriptions through participating pharmacies, including all major chain pharmacies in Oregon and throughout the United States. Most independent pharmacies in Oregon also participate. Moda Health Plan, PacificSource Health Plans and Providence Health Plan members who purchase prescription drugs at a nonparticipating pharmacy may be reimbursed for less than 40 percent of the amount paid because negotiated discounts are not applied. If you are Medicare-eligible, you are automatically enrolled in the PHIP Part D plan, which is PERS Moda Health Rx (PDP). You cannot be enrolled in two Medicare Part D plans. If you terminate your Medicare Part D coverage directly through Medicare or enroll in another Part D plan, this will disenroll you completely from PHIP, including your medical and optional dental coverage. Out-of-pocket maximum This program has a calendar year out-of-pocket maximum. Once a member has paid $4,700 out of pocket for eligible prescription drugs, the plan will pay 100 percent for covered prescription drugs for the remainder of the calendar year. 40

Prescription drugs purchased at the pharmacy Members prescription drug coinsurance for brand name drugs is 40 percent of the discounted prescription charge, up to a maximum coinsurance of $150 for each prescription filled for up to a 31-day supply (even if the prescription is written for less than a 31-day supply). A 93-day supply of generic drugs may be obtained for up to a maximum coinsurance of $150. The maximum coinsurance amount for a 93-day supply of brand name drugs is $450. Mail-order prescription drugs Prescription drug benefits and copayments for these plans are the same as described above. Claims for foreign mail-order pharmacies are not covered. Moda Health Plan does not cover medications imported from foreign countries because this practice is in violation of the Federal Food, Drug and Cosmetic Act. Medications obtained from foreign sources that are represented as U.S.-approved prescription drugs may be of unknown origin and quality and may create a potential safety risk to individuals. Mail-order prescriptions can be obtained through any mail order company that is not associated with another insurance carrier. Payless Drug Special Service Pharmacy To ensure prescription drug adherence, we offer a mail-order program through Payless Drug Special Service Pharmacy. The program helps members take their medications at the right time throughout the day: Your pills are put in easy-to-use cards, grouped together into days and times they need to be taken. We mail your cards directly to you each month no more standing in line at the pharmacy. We help you keep track of when you ve taken your pills, so you don t miss a day or take them twice. Work with your doctors to coordinate your prescriptions. Payless is affordable and simple: This service is provided to you at no extra cost. Medications are set up on a 28-day cycle. Cards contain all of your pills for one week. Refills are mailed to you each month with four new cards. If you have questions about this program, please call the Moda Health Pharmacy Customer Service phone number on the back of this book. Prescriptions for Moda Health members residing in long-term-care facilities Patients residing in nursing homes or other long-term care facilities will pay 40 percent of the prescription charge at the time of dispensing or upon receiving a bill from the institutional pharmacy servicing the facility. 41

PHIP prescription drug benefit for Kaiser Permanente Members enrolled with Kaiser Permanente through PHIP are covered under the Kaiser prescription drug benefit. Kaiser Permanente members must use Kaiser facilities and pharmacies to obtain prescription drugs. The Kaiser Permanente prescription drug benefit covers drugs that have been approved through the Kaiser Permanente formulary process. The Kaiser Permanente formulary is continually updated and developed. Kaiser Permanente physicians and pharmacists evaluate scientific literature to identify the drugs best suited to treat specific medical conditions. Drugs are added to or subtracted from the formulary whenever new drugs or new information warrant this change. Kaiser Permanente physicians remain responsible for deciding which drugs meet the individual needs of each patient. For information about the Kaiser Permanente drug formulary and covered drugs, please contact Kaiser Permanente Membership Services at the number found on the back cover of this handbook. Kaiser Permanente Mail Delivery Kaiser Permanente Mail Delivery Pharmacy can save you a trip to the medical office. The service is free, easy-to-use and fast. Orders arrive within 7 to 10 days. Members can order prescription refills by phone, via the website or by mail. For covered Part D maintenance drugs*, you can order up to a 90-day supply for 40 percent of the prescription charge with a maximum limit of $300 per prescription. Prescriptions for members residing in long-term care facilities Patients residing in nursing homes or other long-term care facilities will pay 40 percent of the prescription charge for Part D covered drugs, up to a maximum of $150 per prescription for up to a 31-day supply. Specialty packaging costs are not covered. *See page 57 for a definition of maintenance drug. Out-of-pocket maximum This plan has a calendar year out-of-pocket maximum. Once a member has paid $4,700 out of pocket for eligible prescription drugs, the plan will pay 100 percent for covered prescription drugs for the remainder of the calendar year. Prescription drugs purchased at the Kaiser Permanente pharmacy Your prescription drug coinsurance is 40 percent of the prescription charge for covered Part D drugs, up to a maximum of $150 per prescription for up to a 30-day supply. Up to a 90-day supply may be purchased at the pharmacy. The 40 percent coinsurance limit of $150 applies to each 30-day supply of covered drugs. 42

Plan benefit and rate comparisons 43

2015 Medicare benefit comparison Supplement Plan Moda Health Medicare Supplement Plan PERS Moda Health PPORX (PPO) In-network 2 Out-of-network 3 Service area Refer to page 30 Refer to page 30 Eligible providers Any licensed Medicare provider Advantage network providers Any licensed Medicare provider MEMBER pays: MEMBER pays: MEMBER pays: Calendar year deductible $147 per individual 4 None Calendar year medical out-of-pocket maximum None $2,500 per individual Inpatient Care Inpatient hospital care Skilled nursing facility 5 $100 copay per day; $300 max per admit 6 $100 copay per day; $300 max per admit 6 Outpatient Care Physician office visits Specialist office visits Outpatient surgery Ambulance Emergency services 8 Urgent care DME Lab test Diagnostic procedures (CT/MRI) Physical therapy $15 copay $20 copay $125 copay $50 copay (one way) $65 copay $20 copay 10% 9 10% $20 copay $15 copay $20 copay $125 copay $50 copay (one way) $65 copay $20 copay 10% 9 10% $20 copay Preventive Care Annual wellness exam Women s preventive Prostate cancer screening Immunizations 12 12 12 12 Other Services Chiropractic care 14 Vision routine eye exam Vision hardware Discounts available, contact Moda Health $20 copay $20 copay Discounts available, contact Moda Health $20 copay $20 copay Discounts available, contact Moda Health Prescription Drugs 15 Retail Brand and generic Rx out-of-pocket max This is a Medicare Part D Prescription Drug Plan included with all Medicare medical Refer to pages 40-42 40% of charge, up to a $150 max per prescription for a 30-day supply, no deductible $4,700 out-of-pocket max per member, per calendar year, no deductible 44

This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. Managed Care Plans Kaiser Permanente PacificSource Medicare Essentials 801 Providence Medicare Align Group Providence M In-network Refer to page 30 Refer to page 31 Refer to page 31 Refer Kaiser Permanente and the Portland Clinic physicians and hospitals Plan physicians and hospitals Plan physicians and hospitals Plan physicians and hospitals MEMBER pays: MEMBER pays: MEMBER pays: MEMBER pays: None None None None $1,000 per individual $3,400 per individual $1,500 per individual $3,000 p $200 copay per admit $125 copay per day (days 1-4 only); $500 max per admit 5 5 $100 copay per day; $500 max per admit 5 $125 copay per day; $500 max per admit 7 $15 copay $15 copay $15 copay $50 copay $50 copay $15 copay 20% 10 $10 copay $15 copay $125 copay $50 copay $50 copay $15 copay 10 $15 copay $15 copay $75 copay $50 copay (one way) $50 copay $25 copay 10% 10 $20 copay $20 copay 11 $150 copay $50 copay (one way) $65 copay $25 copay 10% 10 10% $15 copay $15 copay $15 copay $20 copay 13 13 13 13 $15 copay $15 copay $100 credit every 2 years for lenses, frames and/or contacts $15 copay $15 copay $100 credit every 2 years for lenses, frames and/or contacts $15 copay $15 copay $100 credit every 2 years for lenses, frames and/or contacts $20 copay $20 copay $100 credit every 2 years for lenses, frames and/or contacts plans 45

edicare Flex Group 1 to page 31 er individual 20% 20% Out-of-network Any licensed Medicare provider MEMBER pays: None $30 copay $30 copay 20% $50 copay (one way) $65 copay $25 copay 20% 10 20% 20% $30 copay $30 copay $20 copay or up to a $45 allowance $100 credit every 2 years for lenses, frames and/or contacts 1. Member must select a primary care physician from our network of contract providers in order to receive in-network benefits. Certain out-of-network services may require prior authorization; please contact Providence Health Plan for a list of those services. If services received from out-of-network provider, excess charges may apply if the provider does not accept Medicare assignment. 2. Prior authorization required for hospital inpatient services, skilled nursing, home health care, outpatient surgery, chiropractic, outpatient rehab, DME, prosthetic services and diagnostic procedures. 3. Out-of-network Medicare providers are paid up to the Medicare limiting charge. 4. Part B deductible, required by Medicare, listed in this comparison is the 2014 Part B deductible; 2015 Part B deductible was not available when this handbook went to print. Please refer to your 2015 Medicare & You handbook, when available, for the new Part B deductible. Deductible and coinsurance apply to only Medicare Part B approved services. 5. Coverage applies to a Medicare-certified facility for up to 100 days/medicare benefit period. 6. Skilled nursing: In-Plan: 1 20 days: covered in full. 21 100 days: $40 copay per day. Out-of-Plan: 1 20 days: covered in full. 21 100 days: $40 copay per day. No prior hospitalization required. 7. Coverage applies to a Medicare certified facility for up to 100/days Medicare benefit period. In-Plan: 1 20 days: covered in full. 21 100 days: $50 copay per day. 8. ER copays and coinsurance waived if admitted within 24 hours; applies to all health plans. 9. Applies to Medicare-approved supplies/equipment only. Some diabetic supplies are covered in full. 10. Applies to Medicare-approved supplies/equipment only and may require pre-authorization. Some diabetic supplies are covered in full. 11. If no referral is in place when seeing an in-network specialist, $30 copay applies. 12. Medicare-covered services only. 13. An office visit copayment may apply if non-preventive issues and services are managed during a scheduled preventive visit. 14. Medicare-covered chiropractic services only. Kaiser and Providence offer discounts for other alternative care services. Contact health plan customer service for more details. 15. Under Moda Health, at retail, brand drugs are covered up to a 31-day supply and generic drugs up to a 93-day supply. 46

2015 Medicare Medical & prescription drug monthly premium rate comparison Retirement Health Insurance Account (RHIA) Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are AFTER the $60 Retirement Health Insurance Account contribution. More information on the Retirement Health Insurance Account (RHIA) contribution and eligibility can be found on page 20 of this handbook. Moda Health Medicare Supplement Plan PERS Moda Health PPORX (PPO) Kaiser Permanente Senior Advantage PacificSource Medicare Essentials 801 Providence Medicare Align Group Providence Medicare Flex Group Retiree with Medicare $155.18 $214.96 $161.37 $177.30 $156.20 $131.20 Retiree with Medicare, family with Medicare Retiree with Medicare, family without Medicare (Core Value) Retiree with Medicare, family without Medicare (Select Value) $355.51 $487.67 $380.74 $412.60 $370.40 $320.40 $983.17 $1,028.89 $894.34 $1,117.42 $976.54 $951.54 $947.56 $993.28 $755.22 $1,007.75 $866.80 $841.80 Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contribution from RHIA. More information on RHIA contributions and eligibility can be found on page 20 of this handbook. Moda Health Medicare Supplement Plan PERS Moda Health PPORX (PPO) Kaiser Permanente Senior Advantage PacificSource Medicare Essentials 801 Providence Medicare Align Group Providence Medicare Flex Group Retiree with Medicare $215.18 $274.96 $221.37 $237.30 $216.20 $191.20 Retiree with Medicare, family with Medicare Retiree with Medicare, family without Medicare (Core Value) Retiree with Medicare, family without Medicare (Select Value) $415.51 $547.67 $440.74 $472.60 $430.40 $380.40 $1,043.17 $1,088.89 $954.34 $1,177.42 $1,036.54 $1,011.54 $1,007.56 $1,053.28 $815.22 $1,067.75 $926.80 $901.80 47

2015 Core Value non-medicare Medical & prescription drug monthly premium rate comparison Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contributions from the Retiree Health Insurance Premium Account (RHIPA). More information on RHIPA contributions and eligibility can be found on page 21. Moda Health PPO Plans Kaiser Permanente PacificSource Choice POS Providence Health Plan Retiree without Medicare $879.34 734.97 $870.76 $774.46 Retiree without Medicare, family* without Medicare Retiree without Medicare, family* with Medicare Retiree without Medicare, family* with Medicare (Moda Health Medicare Supplement Plan) Retiree without Medicare, family* with Medicare (PERS Moda Health PPORX (PPO) Retiree without Medicare, family* with Medicare (PHP Medicare Align) Retiree without Medicare, family* with Medicare (PHP Medicare Flex) $1,651.21 1,467.94 $1,810.85 $1,594.77 N/A 954.34 $1,090.01 N/A $1,063.62 N/A N/A N/A $1,038.06 N/A N/A N/A N/A N/A N/A $972.61 N/A N/A N/A $947.61 PHIP LONG-TERM CARE INSURANCE (Detailed information not included in this guide.) Long-term care is the type of care received either at home or in a facility when someone needs assistance with the activities of daily living. Health insurance does not pay for the cost of long-term care. The PHIP long-term care insurance carrier is Unum Life Insurance Company of America. Information on Unum enrollment and eligibility is available online. All eligible PERS retirees, spouses and dependents may apply for long-term care insurance by contacting Unum at the numbers listed on the back of this handbook. *For the purposes of determining the premium under the PERS Health Insurance Program (PHIP) a Family includes an eligible spouse and/or dependents as defined in OAR 459-035-0020. The non-medicare Family rate will apply in any instance where there is at least one non-medicare Family member. 48

2015 Select Value non-medicare Medical & prescription drug monthly premium rate comparison Non-Contribution Premium Rates (applies to all health plans) The monthly premiums shown below are WITHOUT contributions from the Retiree Health Insurance Premium Account (RHIPA). More information on RHIPA contributions and eligibility can be found on page 21. Moda Health PPO Plans Kaiser Permanente PacificSource Choice POS Providence Health Plan Retiree without Medicare $843.73 $595.85 $771.06 $672.85 Retiree without Medicare, family* without Medicare Retiree without Medicare, family* with Medicare Retiree without Medicare, family* with Medicare (Moda Health Medicare Supplement Plan) Retiree without Medicare, family* with Medicare (PERS Moda Health PPORX (PPO) Retiree without Medicare, family* with Medicare (PHP Medicare Align) Retiree without Medicare, family* with Medicare (PHP Medicare Flex) $1,579.99 $1,189.70 $1,601.48 $1,383.42 N/A $815.22 $990.31 N/A $1,028.01 N/A N/A N/A $1,002.45 N/A N/A N/A N/A N/A N/A $871.00 N/A N/A N/A $846.00 *For the purposes of determining the premium under the PERS Health Insurance Program (PHIP) a Family includes an eligible spouse and/or dependents as defined in OAR 459-035-0020. The non-medicare Family rate will apply in any instance where there is at least one non-medicare Family member. 49

2015 Core Value non-medicare benefit comparison Moda Health In-plan Out-of-plan Kaiser Permanente Service area Refer to page 30 Refer to page 30 Eligible providers Preferred physicians and providers MEMBER pays: Any licensed physician or facility Kaiser Permanente and the Portland Clinic physicians and hospitals MEMBER pays: Calendar year deductible $500 per individual None Calendar year medical out-of-pocket maximum $2,000 + deductible per individual $6,000 + deductible per individual $2,000 per individual; $4,000 per family Inpatient care Inpatient hospital care Skilled nursing facility $200 copay per day; $1,000 max per admit 2 Outpatient care Physician office visits Specialist office visits Outpatient surgery Ambulance Emergency services Urgent care DME Lab test Diagnostic procedures Physical therapy $20 copay, no deductible $20 copay, no deductible $200 copay, then 20% 4 $20 copay, no deductible 9 $200 copay, then 20% 4 9 $30 copay $40 copay $200 copay $100 copay $200 copay $30 copay 20% $30 copay per visit 20% $40 copay 3 Preventive care Preventive physical exam 10 Women s preventive Prostate cancer screening Immunizations $20 copay, no deductible Other services Alternative care Vision routine eye exam Vision hardware $25 copay, no deductible 13 Discounts available, contact Moda Health 13 Discounts available, contact Moda Health $25 copay 12 $30 copay Not covered Prescription drugs 15 Retail Brand and generic Rx out-of-pocket max Refer to pages 40-42 40% of charge up to a $150 max per prescription for a 30-day supply, no deductible $4,700 out-of-pocket max per member per calendar year, no deductible 1. Must select a Primary Care Physician (PCP). 2. Covered in Full in a Medicare certified facility for up to 100 days per calendar year. 3. Limited to 20 visits per calendar year. 4. ER copay waived if admitted. Coinsurance is still required. 5. Prenatal, delivery & postnatal physician services require a $200 copay, deductible does not apply. 6. If admitted to the hospital, copayment is not applied; all services are subject to inpatient benefits. 7. Urgent/Immediate Care ancillary charges billed separately will be subject to the applicable cost share. The deductible will apply to diagnostics (lab, x-rays, etc) received during the visit. 8. Deductible does not apply to diabetic supplies. 9 Limited to 30 visits per calendar year; this 30 visit limitation encompasses all therapy modalities combined. 10. Preventive services will be covered in accordance with ACA guidelines. This applies to Kaiser and in-network services under 50

This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. PacificSource Health Plans 1 Providence Health Plan In-plan Out-of-plan In-plan Out-of-plan Refer to page 31 Refer to page 31 Plan physicians and hospitals Any licensed physician or facility Plan physicians and hospitals Any licensed physician or facility MEMBER pays: MEMBER pays: $500 per individual; $1,500 per family $2,000 + deductible per individual; $6,000 + deductible per family $1,000 per individual; $3,000 per family $6,000 + deductible per individual; $18,000 + deductible per family $500 per individual; $1,500 per family (3 or more) $2,000 + deductible per individual; $6,000 + deductible per family (3 or more) $6,000 + deductible per individual; $18,000 + deductible per family (3 or more) $20 copay, no deductible 5 $20 copay, no deductible 20%, no deductible $200 copay, then 20% 4 $20 copay, no deductible $20 copay, no deductible 9 20%, no deductible $200 copay, then 20% 4 40%, no deductible 9 $20 copay, no deductible $20 copay, no deductible $200 copay, then 20% 6 $20 copay, no deductible 7 8 9 40%, no deductible 40%, no deductible $200 copay, then 20% 6 40%, no deductible 7 8 9 40%, no deductible 40%, no deductible $20 copy, no deductible 11 $25 copay, no deductible 13 Not covered Not covered 13 Not covered Not covered $25 copay 14 Discounts available, contact Providence Health Not covered Discounts available, contact Providence Health Moda Health, PacificSource, and Providence. 11. Prostate cancer screening lab work is subject to the lab benefit. 12. Chiropractic and acupuncture office visits are limited to 12 combined visits per calendar year. Naturopathic benefit is available through select providers listed at CHPActiveandHealthy.com. $25 copay per naturopath visit; no visit limitations. No massage therapy coverage. 13. Chiropractic and acupuncture office visits are limited to 12 combined visits per calendar year. Coverage for naturopaths is included, no visit limitations. No massage therapy coverage. 14. Chiropractic and acupuncture office visits are limited to 12 combined visits per calendar year. Coverage for naturopaths is included, no visit limitations. No massage therapy coverage. Contact Providence Customer Service for a list of contracted providers. 15. Under Moda Health, at retail, brand drugs are covered up to a 31 day supply and generic drugs up to a 93 day supply. 51

2015 Select Value non-medicare benefit comparison In-plan Moda Health Plan Out-of-plan Kaiser Permanente Service area Refer to page 30 Refer to page 30 Eligible providers Preferred physicians and providers MEMBER pays: Any licensed physician or facility Kaiser Permanente and the Portland Clinic physicians and hospitals MEMBER pays: Calendar year deductible Calendar year medical out-of-pocket maximum $2,000 + deductible per individual $1,000 per individual $6,000 + deductible per individual $1,000 per individual; $3,000 per family $3,000 + deductible per individual; $9,000 + deductible per family Inpatient care Inpatient hospital care Skilled nursing facility 30% after deductible 30% after deductible 2 Outpatient care Physician office visits Specialist office visits Outpatient surgery Ambulance Emergency services Urgent care DME Lab test Diagnostic procedures Physical therapy $20 copay, no deductible $20 copay, no deductible $200 copay, then 20% 4 $20 copay, no deductible 9 $200 copay, then 20% 4 9 $25 copay, no deductible $35 copay, no deductible 30% after deductible 30% after deductible 30% after deductible $25 copay, no deductible 30% after deductible 30% after deductible 30% after deductible $35 copay after deductible 3 Preventive care Preventive physical exam 10 Women s preventive Prostate cancer screening Immunizations $20 copay, no deductible Other services Alternative care Vision routine eye exam Vision hardware $25 copay, no deductible 13 Discounts available, contact Moda Health 13 Discounts available, contact Moda Health $25 copay, no deductible 12 $25 copay, no deductible Not covered Prescription drugs 15 Retail Brand and generic Rx out-of-pocket maximum Refer to pages 40-42 40% of charge up to a $150 max per prescription for a 30-day supply, no deductible $4,700 out-of-pocket max per member per calendar year, no deductible 1. Must select a Primary Care Physician (PCP). 2. Covered in Full in a Medicare certified facility for up to 100 days per calendar year. 3. Limited to 20 visits per calendar year. 4. ER copay waived if admitted. Coinsurance is still required. 5. Prenatal, delivery & postnatal physician services require a $200 copay, deductible does not apply. 6. If admitted to the hospital, copayment is not applied; all services are subject to inpatient benefits. 7. Urgent/ Immediate Care ancillary charges billed separately will be subject to the applicable cost share. The deductible will apply to diagnostics (lab, x-rays, etc) received during the visit. 8. Deductible does not apply to diabetic supplies. 9. Limited to 30 visits per calendar year; this 30 visit limitation encompasses all therapy modalities combined. 10. Preventive services will be covered in accordance with ACA guidelines. This applies to Kaiser and in-network 52

This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. PacificSource Health Plans 1 Providence Health Plan In-plan Out-of-plan In-plan Out-of-plan Refer to page 31 Refer to page 31 Plan physicians and hospitals Any licensed physician or facility Plan physicians and hospitals Any licensed physician or facility MEMBER pays: MEMBER pays: $1,000 per individual; $3,000 per family $2,000 + deductible per individual; $6,000 + deductible per family $1,000 per individual; $3,000 per family $6,000 + deductible per individual; $18,000 + deductible per family $1,000 per individual; $3,000 per family (3 or more) $2,000 + deductible per individual; $6,000 + deductible per family ( 3 or more) $6,000 + deductible per individual; $18,000 + deductible per family (3 or more) $25 copay, no deductible 5 $25 copay, no deductible 20%, no deductible $200 copay, then 20% 4 $25 copay, no deductible $25 copay, no deductible 9 20%, no deductible $200 copay, then 20% 4 40%, no deductible 9 $20 copay, no deductible $20 copay, no deductible $200 copay, then 20% 6 $20 copay, no deductible 7 8 9 40%, no deductible 40%, no deductible $200 copay, then 20% 6 40%, no deductible 7 8 9 40%, no deductible 40%, no deductible $20 copay, no deductible 11 $25 copay, no deductible 13 Not covered Not covered 13 Not covered Not covered $25 copay, no deductible 14 Discounts available, contact Providence Health Not covered Discounts available, contact Providence Health services under Moda Health, PacificSource, and Providence. 11. Prostate cancer screening lab work is subject to the lab benefit. 12. Chiropractic and acupuncture office visits are limited to 12 combined visits per calendar year. Naturopathic benefit is available through select providers listed at www.chpactiveandhealthy.com. $25 copay per naturopath visit; no visit limitations. No massage therapy coverage. 13. Chiropractic and acupuncture office visits are limited to 12 combined visits per calendar year. Coverage for naturopaths is included, no visit limitations. No massage therapy coverage. 14. Chiropractic and acupuncture office visits are limited to 12 combined visits per calendar year. Coverage for naturopaths is included, no visit limitations. No massage therapy coverage. Contact Providence Customer Service for a list of contracted providers. 15. Under Moda Health, at retail, brand drugs are covered up to a 31 day supply and generic drugs up to a 93 day supply. 53

2015 dental benefit comparison ODS 1 Kaiser Permanente 54 Medical plan enrollment Providers PacificSource, Kaiser Permanente, Moda Health, Providence Health Plan Any licensed dentist, hygienist and certified denturist working within the scope of their license Kaiser Permanente, Moda Health, Providence Health Plan Kaiser Permanente Dental Associates Calendar year deductible $25 per individual None Calendar year benefit maximum (plan pays) Preventive Care Exams Cleanings Diagnostic Basic Services Restorative Oral surgery (extractions) Endodontic/periodontic Major Services Crowns Cast restorations Dentures/bridge work Implants $1,500 per individual 2 $1,500 per individual 2 MEMBER pays: Available twice in a calendar year 2 2 2,3 4 4 4 50% after deductible 4 50% after deductible 4 50% after deductible 4 50% after deductible 4 MEMBER pays: Limit of two cleanings per year $10 copay per visit 2 $10 copay per visit 2 $10 copay per visit 2 $10 copay, then 20% $10 copay, then 20% $10 copay, then 20% $10 copay, then 50% $10 copay, then 50% $10 copay, then 50% Not covered Orthodontic services Not covered Not covered Out-of-area coverage Exclusions and limitations Rates Retiree only Retiree and family Worldwide for emergency services only Some services are limited or not covered at all, including congenital or developmental malformations, cosmetic services and experimental procedures. Also, there may be limitations for procedures for which you might receive payment from other insurance or government programs. $63.38 $126.57 Kaiser Permanente allows a benefit of up to $100 of reimbursement on an approved out-of-area emergency claim Certain services are limited or not covered at all. Some exclusions include congenital or developmental malformations, dental implants, cosmetic services and experimental procedures. Also, there may be limitations for procedures for which you might receive payment from other insurance or government programs. $ 58.26 $116.40

This is a summary of benefits only, for general comparison. Any errors or omissions are purely unintentional. Should any discrepancies be found between this guide and the plan document, the information in the plan document shall prevail. 1. A higher level of benefits is paid to providers who participate in the ODS Premier Dental Network. Under the Delta Dental Plan of Oregon, members who live or travel outside Oregon have access to more than 148,000 dental professionals nationwide through the Delta Dental Network. Services provided by licensed dentist and certified denturists not participating with ODS or Delta Dental are paid at the out-of-network level. 2. Charges for preventive services do not apply to the calendar year benefit maximum. 3. Some limitations may apply. 4. 12-month waiting period for basic and major services following enrollment unless member has had continuous employer-sponsored dental coverage for the previous 12 months. 55

Definitions Benefit period The way Medicare measures your use of hospital and skilled nursing facility (SNF) services. A benefit period begins the day you go to a hospital or SNF. The benefit period ends when you haven t received any hospital (or skilled care) for 60 days in a row. Care management Sometimes also called case management or disease state management, these services help ensure the best possible care and coordination of care for people who have either chronic or catastrophic conditions. Coinsurance Other than the deductible, coinsurance, which is usually expressed as a percentage, is the portion of cost that the member will pay for healthcare services. Community plans Commercial Medicare plans offered to the general public. Copayment A fixed amount that the member pays at the time of service. Generally the copayment is the only cost the member will have for a particular service. Deductible Generally applied on a calendar-year basis, the deductible is the amount of money each year that members pay out of their own pocket before the benefit plan begins to pay. Usually expressed as a per-person amount. Durable medical equipment (DME) Medicare-approved, medically necessary durable medical equipment is reusable medical equipment such as walkers, wheelchairs, hospital beds, etc. Employer-sponsored health plan A plan sponsored by an employer, or by an employer in partnership with a union, that provides medical care to two or more employees. Essential benefit plan maximum The maximum amount that the plan will pay out in a calendar year for essential benefits as noted under the Patient Protection and Affordable Care Act (PPACA). Fee for service (FFS or private FFS) Another form of reimbursement to physicians. Under this scenario, a physician is not paid until he or she submits a bill for a service rendered. Essentially, this is the opposite of capitation. Health Maintenance Organization (HMO) Covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO s guidelines and restrictions. Most HMOs require members to select a primary care physician (PCP). Except for a medical emergency, patients need a referral from the PCP in order to see a specialist or other doctor. Limiting charge See Medicare limiting charge. 56

Maintenance drug A drug that is appropriate for chronic use as prescribed and is supported by evidence that it is safe and effective when used for a chronic condition. For example, certain drugs for high blood pressure or diabetes are considered maintenance drugs. Maximum allowable cost See Usual and customary. Maximum out-of-pocket This is the maximum amount of money that a member is responsible for paying in any one calendar year, when a member uses only PPO or participating providers (depending on the contract). Medicare-approved amount In the original Medicare Supplement plan, this is the Medicare payment amount for an item or service. This is the amount a doctor or supplier is paid by Medicare, your supplement and/or you for a service or supply. It may be less than the actual amount charged by the doctor or supplier. Medicare limiting charge Doctors and providers who do not accept assignment may charge you more than the Medicare-approved amount. The limit on the amount over the Medicare-approved amount these providers can charge is 15 percent. The limiting charge applies only to certain services and doesn t apply to supplies and equipment. In addition, you may have to pay the entire charge at the time of service. Medicare Part A Hospital insurance that covers hospital stays, skilled nursing facility care and hospice. Medicare Part B Medical insurance that covers doctors services and outpatient hospital care. Medicare Part D Medicare prescription drug plan. Medicare participating provider A provider who accepts Medicare patients; this provider may or may not accept Medicare assignment. Medigap Medicare Supplement insurance that conforms to one of the 10 Medicare-approved plans. Medsupp Medicare Supplement insurance. Nonpar Nonparticipating provider. Participating provider Providers that are contracted to provide services for specific fees. The fees may or may not be discounted, but the providers are bound to not charge the member for anything above the contracted fee even if they would generally charge someone with other coverage more. This is often referred to as hold harmless because the member is held harmless for charges over the contracted fee. 57

Definitions (continued) Point-Of-Service (POS) plan A type of benefit design that requires members to choose a primary care physician to receive in-network benefits. This type of plan also offers lower benefits (or the same benefits, depending on the contract) to members who receive benefits out-of-network. PPO provider Preferred Provider Organization (PPO) relates to a panel of doctors. Similar to participating providers, PPO providers sign contracts and cannot charge members more than the contracted fee. These providers agree to discount their charges. Preferred Provider Organization (PPO) plan A type of benefit design that includes different levels of benefits depending on whether or not services are received from a preferred provider. These plans have specific service areas where preferred providers are available, although they usually cover wider geographic regions than managed care plans. Retirement Health Insurance Account (RHIA) A monthly subsidy that PERS contributes toward the cost of a retiree s health insurance premiums. A retiree must be enrolled in Medicare Parts A and B and have eight or more years of creditable service with a PERS employer. See page 19 for further explanation. Usual and customary/maximum allowable cost These are two very similar concepts. Both limit the amount a carrier will pay for a specific service. These designations are generally used in the absence of participating or preferred contracts. In the case of most carriers, a national data clearinghouse is used. The clearinghouse collects fee data by ZIP code and procedure and then publishes the information. Fees are usually updated every six months. Retiree Health Insurance Premium Account (RHIPA) A monthly subsidy that PERS contributes toward the cost of a non-medicare state of Oregon retiree s health insurance premium. A retiree must have eight or more years of creditable service with a PERS employer and must have retired directly from a state agency. City, county and district employers, including schools, are not considered state agencies. See page 19 for further explanation. 58

Acronyms and abbreviations CMS Centers for Medicare and Medicaid Services COB coordination of benefits COBRA Consolidated Omnibus Budget Reconciliation Act (federal act) DME durable medical equipment DUR drug utilization review DXL diagnostic X-ray and lab E&I experimental and investigational EDI electronic data interchange EFT electronic funds transfer EOB explanation of benefits ESRD end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant) FFS fee for service HCFA Health Care Financing Administration (now CMS, a federal agency) HIPAA Health Insurance Portability and Accountability Act (federal act and state law) HMO Health Maintenance Organization IRMAA Income Related Monthly Adjustment Amount LTC long-term care MA Medicare Advantage MSP Medicare secondary payer OOA out-of-area OOP out-of-pocket OV office visit PCP primary care physician (provider) PDL preferred drug list PDP prescription drug plan PHI protected health information PHIP PERS Health Insurance Program POS Point-of-Service PPACA Patient Protection and Affordable Care Act (health care reform) PPO preferred provider organization Rx prescription drug SHIBA Senior Health Insurance Benefits Assistance Program (a state of Oregon agency) SNF skilled nursing facility U&C, R&C, UCR usual and customary; reasonable and customary; usual, customary and reasonable UR utilization review WHCRA Women s Health and Cancer Rights Act YTD year-to-date 59

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Contact Information PERS Health Insurance Program (PHIP) www.pershealth.com In Portland: 503-224-7377 Toll-free: 800-768-7377 Fax: 503-765-3452 or 888-393-2943 Mailing address: P.O. Box 40187, Portland, OR 97240 PERS Pension Office (Pension questions only) www.oregon.gov/pers In Portland: 503-598-7377 Toll-free: 888-320-7377 Mailing address: P.O. Box 23700, Tigard, OR 97281-3700 PHIP Long-Term Care Insurance (Unum Life Insurance Company of America) http://w3.unum.com/enroll/pers Toll-free: 800-227-4165 Moda Health www.modahealth.com/pers Medical questions: (Medicare supplement and non-medicare PPO) In Portland: 503-243-3880 Toll-free: 800-962-1533 PERS Moda Health PPORX (PPO) (Medicare): www.modahealth.com/medicare In Portland: 503-265-4761 Toll-free: 877-299-9061 Teletypewriter (TTY): 711 ODS dental questions: In Portland: 503-243-4494 Toll-free: 800-452-1058 PHIP Pharmacy Program (PacificSource, Moda Health and Providence members only) In Portland: 503-265-4709 Toll-free: 888-786-7509 Kaiser Permanente www.kp.org In Portland: 503-813-2000 Toll-free: 800-813-2000 Teletypewriter (TTY): 800-735-2900 Medicare members: 877-221-8221 Mail-order pharmacy: In Portland: 503-778-2678 Toll-free: 800-548-9809 Pacificsource Health Plans Non-Medicare plans: www.pacificsource.com In Oregon: 541-686-1242 Toll-free: 800-624-6052 Medicare plans: www.medicare.pacificsource.com In Oregon: 541-385-5315 Toll-free: 888-863-3637 Teletypewriter (TTY): 800-735-2900 Providence Health Plan www.providencehealthplan.com/phip Prospective members: In Portland: 503-574-5551 Toll-free: 800-457-6064 Enrolled Medicare members: In Portland: 503-574-8000 Toll-free: 800-603-2340 Enrolled non-medicare members: In Portland: 503-574-7500 Toll-free: 800-878-4445 Teletypewriter (TTY): 711 Social Security Administration www.ssa.gov Toll-free: 800-772-1213 Medicare (Centers for Medicare and Medicaid Services) www.medicare.gov Toll-free: 800-Medicare (800-633-4227) Other websites noted within http://arcweb.sos.state.or.us/ banners/rules.htm 903180 (7/13)