active employees HEALTH BENEFITS BLUE SHIELD HMO BLUE SHIELD PPO BLUE SHIELD HDPPO ($3000) KAISER HMO

HEALTH BENEFITS · BLUE SHIELD HMO · BLUE SHIELD PPO · BLUE SHIELD HDPPO ($3000) · KAISER HMO SUPPLEMENTAL BENEFITS · PRESCRIPTION DRUGS · VISION CO...
Author: Logan Newton
0 downloads 1 Views 1016KB Size
HEALTH BENEFITS

· BLUE SHIELD HMO · BLUE SHIELD PPO · BLUE SHIELD HDPPO ($3000) · KAISER HMO

SUPPLEMENTAL BENEFITS

· PRESCRIPTION DRUGS · VISION COVERAGE · DENTAL PLANS · MENTAL HEALTH

active employees COUNTY OF FRESNO · PERSONNEL SERVICES · EMPLOYEE BENEFITS

Open Enrollment 2009 Open Enrollment Office located at: 2220 Tulare Street, 14th Floor, Fresno, CA 93721 Phone: (559) 488-3069

O P E N E N R O L L M E N T 2 0 0 9 S T A R T S O C T O B E R 2 0

DATE:

October 13, 2008

TO:

All Fresno County Employees

FROM:

Ralph Jimenez, Director of Personnel Services__________________________

SUBJECT:

HEALTH PLAN OPEN ENROLLMENT ANNOUNCEMENT

Open Enrollment for Plan Year 2009 is scheduled to begin Monday, October 20, 2008 and will continue through Friday, November 14, 2008. Open Enrollment is the one time during the year that you may change from one health plan to another and add or delete eligible dependents to your coverage without a qualifying event. As of the date of this letter, the County contribution to Health Premiums was still being negotiated. When the County contribution negotiations are finalized and approved by the Board of Supervisors, comparison charts with the employee contribution rates will be e-mailed to all employees, available at the Information Fairs / Open Enrollment Meetings (see enclosed calendar) and on the Personnel Services web site.

-

IMPORTANT DATES TO REMEMBER Open Enrollment 2009 Information Fairs (see enclosed calendar for dates/locations)

-

October 20, 2008 – First day to make changes

-

October 23, 2008 – 2009 Health & Wellness Fair

-

November 14, 2008 by 5:00 pm – Last day to make changes (Forms must be received at Employee Benefits Office)

-

December 15, 2008 – Changes take effect

PLANS FOR 2009 The County is offering: Health Plans •

Blue Shield – HMO



Blue Shield – PPO



Blue Shield – HDPPO (new)



Kaiser – HMO1

Dental Plans •

Delta Dental DPPO (Replacing Blue Cross DPPO)



DeltaCare Dental DHMO (Replacing United Concordia DHMO)

Vision, Mental Health and Prescription Coverage for non-Kaiser Employees

1



Medical Eye Services (MES) (Replacing Safeguard Vision)



Avante Mental Health



Express Scripts Prescription

Kaiser coverage includes prescription, mental health and vision under one plan.

WHAT’S DIFFERENT THIS YEAR

O P E N E N R O L L M E N T

The County of Fresno is now offering a new plan, which is the Blue Shield High Deductible PPO (HDPPO). Please read the “2009 Changes You Should Know About” or attend one of the Health Fairs for more information.



Delta Dental (DPPO) has replaced Anthem Blue Cross Dental DPPO, and DeltaCare Dental (DHMO) has replaced United Concordia Dental DHMO.



Medical Eye Services (MES) has replaced SafeGuard as the new vision provider for all Blue Shield plans.

WHAT DO I NEED TO DO IF . . .?

I HAVE QUESTIONS?

2 0 0 9

I DON’T HAVE ANY CHANGES? I WANT TO CHANGE HEALTH/DENTAL PLANS?

C L O S E S N O V E M B E R 1 4



I WANT TO ADD OR DELETE DEPENDENTS?

First, check out the enclosed “Frequently Asked Questions” sheet. If your question isn’t there, contact the Open Enrollment 2009 Office at (559) 488-3069, visit the Open Enrollment web site at http://www.co.fresno.ca.us and select “Personnel Services” under menu, click on “Employee Benefits”, then click on “Open Enrollment”, or attend an Information Fair. DON’T DO A THING! All of your updated materials will be mailed to you at home. However, please be sure you are familiar with this year’s changes. Complete, sign and submit forms no later than 5:00 p.m. on November 14th. Call (559) 488-3069 for details, or attend an Information Fair / Open Enrollment Meeting. Complete, sign and submit forms no later than 5:00 p.m. on November 14th. Call (559) 488-3069 for details, or attend an Information Fair / Open Enrollment Meeting.

TIPS ON “OPEN ENROLLING” FOR 2009 - Attend one of the Information Fairs (see enclosed calendar). Information Fairs / Open Enrollment Meetings are great opportunities to get your questions answered and to talk to others about their coverage and experiences. There will be a Health & Wellness Fair on October 23, 2008. - Review your current health and dental ID cards to know which health and dental options you and your dependents are currently enrolled. This will help you make the best choice when reviewing the plan options for the 2009 plan year. - Seriously consider a FLEX Spending Account to pay for deductibles, co-pays and other medical expenses (not covered by your plan) with pre-tax earnings. It can literally save you hundreds of dollars a year on costs you are going to pay anyway. - Read the enclosed Benefits Comparison Charts to see which plan appears to best meet your needs. Look at the premiums last, instead of first. - Don’t wait until the last minute to submit your paperwork. The Open Enrollment Office is located at 2220 Tulare Street, 14th Floor, in the Fresno County Plaza. Phone: (559) 488-3069.

RJ:PN Enclosures

Blue Shield High Deductible PPO (HDPPO) Overview The Blue Shield HDPPO is a new plan being offered by the County of Fresno. Please read Blue Shield’s plan summary matrix for more detailed information (see enclosed information, visit the County’s website, or attend one of the Health Fairs). This plan has a $3,000 calendar-year deductible for an individual and a $6,000 calendar-year deductible for family. For preferred provider coverage, members must first meet their deductible before benefits are paid at 100%. A deductible is the amount you will have to pay before the plan will pay any claims. The annual deductible is satisfied by covered services received from both preferred and nonpreferred providers. If members receive services from non-preferred providers, they must pay the deductible, plus the additional out-of-pocket maximum (for a total of $5,000 individual / $10,000 family) before Blue Shield covers 100% of the covered services. Note that certain preventive care (i.e. - annual physical exam, mammogram, Pap test screening etc…) is not subject to the plan’s calendar-year deductible and is provided at no charge if services are from a Network Provider. •

Preferred Providers vs. Non-Preferred Providers By utilizing a Blue Shield HDPPO Preferred Provider (in the PPO network), participants will be subject to the $3,000 individual/$6,000 family deductible. When the deductible is met, there will not be any additional out-of-pocket expenses for covered services. By using a Non-Preferred Provider (not in the HDPPO network), participants will be subject to a $5,000 individual/ $10,000 family deductible. When the deductible is met, there will not be any additional out-of-pocket expenses for covered services.



Prescriptions The Blue Shield HDPPO prescription drug coverage is through Blue Shield, NOT Express Scripts. Your prescriptions will count toward your deductible. While Blue Shield has discounts toward prescriptions, you may have to pay full price for the drugs if your deductible has not been met. Once you meet your deductible, Blue Shield will cover qualified prescriptions at 100%.



Mental Health Benefits The Blue Shield HDPPO mental health benefits are through Blue Shield, NOT Avante. Any mental health services will count toward your deductible. Once the deductible is met, covered services will be covered at 100% (if utilizing Preferred Providers).



Health Savings Accounts (HSA) Participants in the Blue Shield High Deductible PPO ($3,000/$6,000) plan may be able to contribute to a “Health Savings Account” (HSA). HSAs are a tax-favored savings account combined with a qualifying high-deductible health insurance plan. HSAs allow you to legally avoid federal income tax by contributing up to $2,900 for singles or $5,800 for families, into your HSA account. HSAs are not coordinated through the County of Fresno but may be set up through many local banks or financial institutions. For more information on HSAs, please attend an Information Fair / Open Enrollment Meeting or check with your local bank. IMPORTANT (please read this): 1. If enrolled in the Blue Shield HDPPO, you must meet your deductible ($3,000 or $6,000) before the plan will pay any medical or prescription claims. 2. When utilizing Preferred Providers, there is NO additional out-of-pocket once the deductible is met. When utilizing Non-Preferred Providers, there is an additional out-of-pocket expense, to a maximum of $5,000 individual / $10,000 family.

Delta Dental DPPO Overview Delta Dental has replaced Blue Cross Dental (DPPO) as the new dental PPO provider. Delta Dental offers benefits that are essentially the same as Blue Cross (please read the plan summary for detailed information). However, there are some enhancements including coverage for posterior composite fillings, dental implants, and an extra cleaning during pregnancy. Also, preventive services are not subject to the annual maximum. Delta Dental also offers an expanded PPO network (see the Delta Dental PPO listing). If you are currently enrolled in Blue Cross Dental (DPPO), you will be automatically enrolled into Delta Dental (DPPO). New cards will be mailed mid-December. If you or a dependent are currently receiving Orthodontic treatment, you are encouraged to call Delta Dental at (800) 765-6003.

DeltaCare DHMO Overview DeltaCare Dental (DHMO) has replaced United Concordia Dental (DHMO) as the new dental HMO provider. DeltaCare offers benefits that are essentially the same as United Concordia (please read the plan summary for detailed information). However, there are some enhancements including teeth bleaching and an expanded DHMO network (see the DeltaCare DHMO listing). If you are currently enrolled in the United Concordia Dental (DHMO), you will be automatically enrolled into DeltaCare Dental (DHMO). New cards will be mailed midDecember. Also, you may be assigned to a new Primary Care Dentist if your previous dental HMO provider is unavailable. If you or a dependent are currently receiving Orthodontic treatment, you are encouraged to call DeltaCare at (800) 422-4234.

Medical Eye Services (MES) Overview If you are covered under a Blue Shield medical plan, (HMO, PPO, or HDPPO), Medical Eye Services (MES) has replaced SafeGuard vision. The benefits are essentially the same with an expanded provider network. If you are currently enrolled in the SafeGuard Vision plan, you will automatically be enrolled into MES.

There will be a Health & Wellness Fair on Thursday, October 23, 2008 from 7:30am – 4:00pm (County Plaza Building Ballroom).

County Plaza Building 2220 Tulare Street, 14th Floor Fresno, CA 93721 (559) 488-3069

This is your opportunity to obtain information from several different vendors all at one location. Plus, you will have a chance to experience free health and wellness checks on-site. There will be great presenters, raffle prizes and more. Don’t miss this event!

Active Employees and COBRA Participants 2009 Health Open Enrollment Frequently Asked Questions 1)

What do I need to do if I decide not to change health or dental plans or make any dependent changes? Answer: Nothing. If you elect not to change health/dental plans and/or add or drop dependents from your coverage, no paper work is required. Those currently enrolled in Blue Cross Dental (DPPO) will be automatically enrolled into the Delta Dental DPPO. Those currently enrolled in the United Concordia Dental (DHMO) will automatically be enrolled in the DeltaCare DHMO. However, a new DHMO dental provider may be assigned if the previous dental provider is not available.

2)

What do I need to do if I decide to change health and/or dental plans? Answer: If you wish to change options for any reason, you must complete an enrollment form during Open Enrollment. You will not be able to change from your selected option until the next Open Enrollment period. If you have further questions, please contact the Open Enrollment Office at (559) 488-3069.

3)

How is the new Blue Shield High Deductible PPO (HDPPO) different from the Blue Shield PPO plan? Answer: Subscribers of the High Deductible plan must meet a $3,000 deductible for one individual, and a $6,000 deductible for family coverage. A deductible is the amount that must be paid, by the subscriber, before the plan will pay any claims. The HDPPO plan is also Health Savings Account (HSA) qualified. Please see enclosed “2009 Changes You Need to Know About” for further information.

4)

The Blue Shield HDPPO Plan is Health Savings Account (HSA) qualified. What is an HSA? Answer: HSA stands for Health Savings Account. HSAs allow you to make tax deductible deposits and withdraw the funds to pay for qualified medical expenses tax free. If you enroll in the Blue Shield HDPPO Plan and have no other first dollar medical coverage (e.g. low or no deductible medical coverage), you may be eligible to open an HSA account. We strongly encourage you to attend one of the Open Enrollment meetings to get a better understanding of how this works.

5)

Can I go to any Bank or Financial Institution to open an HSA account? Answer: No, only a bank or financial institution that has taken the appropriate steps can provide HSA qualified accounts. Check with your local financial institution or attend one of the Open Enrollment meetings for more information.

6)

How do I enroll into the new Blue Shield High Deductible PPO (HDPPO) plan? Answer: Complete an Open Enrollment form and the Blue Shield HDPPO supplemental form. The forms must be received in the Open Enrollment Office by Friday, November 14, 2008 at 5:00 pm.

7)

What are the changes to the vision plan? Answer: For all Blue Shield plans, the new vision carrier is Medical Eye Services (MES). Those currently enrolled in SafeGuard will be automatically enrolled into the MES plan. The benefits are essentially the same, but there are some enhancements. Attend one of the Open Enrollment fairs or go to the Open Enrollment website for further information.

FREQUENTLY ASKED QUESTIONS CONTINUED 8)

What information do I need to properly enroll eligible dependents? Answer: Depending on the category of dependent, you will need to provide the following for each eligible dependent: • Name • Relationship to employee • Date of birth • Gender • Social security number • Marriage certificate • Domestic Partner Registration • Birth certificate or adoption paperwork • Full-time student status (ages 19-25) • Designation of a primary care physician and/or dentist, if enrolled in the Blue Shield HMO or DeltaCare Dental DHMO. (If there is no designation, an HMO or DHMO provider will be assigned by the plan.)

9)

My child is over 18 but is a full-time student. Where do I send the information? Answer: 1.) If you are adding a dependent child during Open Enrollment, or during the year due to a qualifying event, you must submit a completed student status form with your enrollment form (student status forms are available on the Employee Benefits website, at the Open Enrollment office and at health fairs). 2.) The health plans periodically request you submit proof of full-time student status. When this occurs, you must submit the student status form directly to the health plan by their required date. If the plans do not receive the information, the dependent will be ineligible to receive benefits, and will be dropped from your plan. You may not be able to reenroll them until the next Open Enrollment period or if a qualifying event occurs. NOTE: This applies to dependent children ages 19-25.

10)

When do the health plan changes take effect? Answer: Any changes made during Open Enrollment are effective December 15, 2008 for active employees and January 1, 2009 for COBRA participants.

11)

When will I see the biweekly deductions for health coverage and the flexible spending account come out of my payroll check? Answer: If applicable, you will see the deductions on your first pay check in January (January 9, 2009). COBRA participants will be billed directly on a monthly basis from the County of Fresno’s Third Party Administrator (BMTI).

12)

Can I change to another health or dental plan after the Open Enrollment period ends? Answer: No. If forms are not received in the Open Enrollment Office by Friday, November 14, 2008 at 5:00 pm, you will not be able to make changes until the next Open Enrollment period.

13)

Can I add or delete dependents after the Open Enrollment period ends? Answer: No, unless you experience a qualifying event (e.g. marriage, birth or adoption of a child, spouse’s loss of other health insurance, child’s change in student status). Documentation of qualifying event must be provided to the Benefits office within 30 days of the qualifying event.

Are Your Dependents Eligible? (Please Read This If You Have Dependents Enrolled in the County Health Plan) During the Open Enrollment period, please take the time to review your currently enrolled dependents and follow the eligibility guidelines below when adding dependents for Plan Year 2009.

IMPORTANT If you currently have any dependent(s) covered on the County’s Health Program that do not fall within the eligibility guidelines below, you will need to submit an enrollment change form deleting them from coverage during Open Enrollment 2009 (October 20 – November 14, 2008). Forms may be submitted to the Open Enrollment Office at Stop Mail “HMO”, 2220 Tulare Street, 14th Floor – Fresno County Plaza, or at any of the scheduled Information Fairs (see enclosed calendar). Beginning in the spring of 2009, the County of Fresno will be conducting an audit of employees’ dependents enrolled in the County’s Group Health Plan to verify eligibility. Eligibility is defined by Fresno County Management Directive 250 and is included in the County’s Agreements with participating health plans. If you have dependents enrolled in the plan that are found to be ineligible, you may be liable for the County’s contribution toward dependents and any claims incurred during the period of ineligibility. The following information is provided as a guideline to help you determine which dependents are eligible to be enrolled on your health plan under the Fresno County Group Health Plan Program. Eligible Dependents: •

Legal Spouse



Registered Domestic Partner



Children* up to age 19 (or up to age 26 with documented full-time student status)

*Includes an employee’s children, legally adopted children and stepchildren; children must be unmarried, reside in the employee’s household (unless otherwise court ordered or child is a full-time student), and depend upon the employee for financial support. Ineligible Dependents/Miscellaneous Requirements: •

Other County employees eligible to enroll in the County’s Group Health Plan are not eligible dependents



“Common-law” relationships do not qualify

If you have questions about the eligibility of currently enrolled dependents or those you are considering enrolling during Open Enrollment 2009, we strongly encourage you to contact the Open Enrollment Office at 488-3069 or stop by our office at 2220 Tulare Street, 14th Floor – Fresno County Plaza.

(All forms are available at Health Fairs, the Open Enrollment Office and on the County’s website)

Adding Dependents •

Employee Group Health & Life Insurance/Change Form (see sample below)



Dependent Back-up Documentation o

Marriage Certificate / Certificate of Registered Domestic Partnership

o

Birth Certificate / Proof of Student Status (19 through 25 years old)

Deleting Dependents •

Employee Group Health & Life Insurance/Change Form (see sample below)

Changing Health or Dental Plans •

Employee Group Health & Life Insurance/Change Form (see sample below) o

If enrolling in the Blue Shield HMO, please complete information on the form selecting a Primary Care Physician for you and your dependents.

o

If enrolling in the DeltaCare DHMO, please complete information on the form selecting a Dentist for you and your dependents.

Changing Health or Dental Plans (Blue Shield HDPPO) •

Employee Group Health & Life Insurance/Change Form (see sample below)



Blue Shield HDPPO Disclosure and Understanding Form

Sample Employee Group Health Insurance Enrollment/Change Form

ACTIVE EMPLOYEES

FRESNO COUNTY HEALTH AND FLEX PLAN OPEN ENROLLMENT INFORMATION FAIR SCHEDULE MON

20

TUES

27

21

28

ITSD TAHOE ROOM 2048 Fine Ave. 10:00am – 1:00pm

DBH PATHS TRAINING ROOM 10:00am – 1:00pm

3

4

OCTOBER / NOVEMBER 2008 WED

22

29

THURS

23

FRI

24

COUNTY PLAZA BALLROOM 7:30am – 4:00pm

REEDLEY REGIONAL CENTER 2:00pm – 4:00pm

Health and Wellness Fair

Workforce Connection Large Training Room

30

31

FIREBAUGH COURT 10:00am – 11:30am COALINGA REGIONAL CENTER 1:30pm – 3:00pm

COUNTY PLAZA LOBBY 7:30am – 10:30am

5

HERITAGE CENTER COURTYARD OR ROOM 66 (In case of rain) 1:30pm - 4:00pm

6

SANGER LIBRARY 10:00am – 11:30am SELMA REGIONAL CENTER 2:30pm – 4:00pm

Large Bank Building Conference Room

7

HEALTH DEPARTMENT BRIX BUILDING ROOM 120 10:00am – 12:00pm SENIOR RESOURCE CENTER SIERRA ROOM 2:00pm – 4:00pm Located on the 2nd floor of the old Sierra Community Hospital Blackstone & Dakota

Old Valley Children’s Hospital

10

11 HOLIDAY

12

13

14 OPEN ENROLLMENT CLOSES 5:00 PM

medical plans FRESNO COUNTY HEALTH CARE BENEFITS COMPARISON - ACTIVE EMPLOYEES As of the date of publication of this comparison chart, negotiations were not complete for the County contribution toward biweekly health plan premiums. Therefore, 2008 contribution rates of up to $208.06 per pay period and an additional $95.00 per pay period for employee plus children or spouse OR $100 for employee plus family are included on the chart for comparison purposes only. Upon completion of negotiations and Board approval, the 2009 County contribution rates will be made available. Employees who select a health plan with a premium less than the County contribution will not receive the excess contribution. Please note the employee costs listed on this chart do not apply to part-time or Court employees. Court employees may contact the Court Personnel Office for the current Court contribution rates. The following information summarizes certain key features of the health plans. It is provided for your convenience in comparing plans only. In all cases, official documents legally govern each plan’s operations and benefits. Employees must meet all the eligibility requirements of the selected plan regarding service area limitations. All benefits are covered as stated only so long as plan requirements for prior authorization, primary care physician referrals and/or bona fide emergency or medical necessity are met. All benefits with a notation, “limit _days,” indicate the maximum covered per calendar year.

rates PLAN YEAR 12/15/08 to 12/13/09

medical prescription vision mental health dental plans Employee Only Employee + Child(ren) Employee + Spouse Employee + Family

medical prescription vision mental health dental plans Employee Only Employee + Child(ren) Employee + Spouse Employee + Family

Active - 2009

bi-weekly premiums PLAN 1

PLAN 2

BLUE SHIELD HMO Express Scripts RX MES Vision Avante Mental Health

BLUE SHIELD PPO Express Scripts RX MES Vision Avante Mental Health

Delta Dental DPPO TOTAL PREMIUM EMPLOYEE COST $230.55 $35.66 $359.10 $69.21 $406.82 $116.93 $536.07 $241.18

or

DeltaCare Dental DHMO TOTAL PREMIUM EMPLOYEE COST $221.98 $27.09 $352.99 $63.10 $397.52 $107.63 $528.15 $233.26

Delta Dental DPPO TOTAL PREMIUM EMPLOYEE COST $316.04 $107.98 $589.88 $286.82 $651.53 $348.47 $897.04 $588.98

or

DeltaCare Dental DHMO TOTAL PREMIUM EMPLOYEE COST $307.47 $99.41 $583.77 $280.71 $642.23 $339.17 $889.12 $581.06

PLAN 3

PLAN 4

BLUE SHIELD HDPPO Blue Shield RX MES Vision Blue Shield Mental Health Delta DeltaCare or Dental DPPO Dental DHMO TOTAL PREMIUM EMPLOYEE COST TOTAL PREMIUM EMPLOYEE COST $184.18 $175.61 $338.63 $48.74 $332.52 $42.63 $374.16 $84.27 $364.86 $74.97 $513.64 $218.75 $505.72 $210.83

KAISER HMO Kaiser RX Kaiser Vision Kaiser Mental Health Delta Dental DPPO TOTAL PREMIUM EMPLOYEE COST $297.21 $89.15 $452.70 $149.64 $539.82 $236.76 $692.70 $384.64

or

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

DeltaCare Dental DHMO TOTAL PREMIUM EMPLOYEE COST $288.64 $80.58 $446.59 $143.53 $530.52 $227.46 $684.78 $376.72

medical plans ACTIVE EMPLOYEES

bi-weekly premiums

benefits PLAN YEAR 12/15/08 to 12/13/09

Employee Only Employee + Child(ren) Employee + Spouse Employee + Family

OTHER BENEFITS Employees and dependents must live or work ROUTINE HOME CARE AND within a Blue Shield service area and receive INPATIENT RESPITE CARE care from Plan providers. Employees and dependents must select a primary care physician. HOME HEALTH CARE HOME HOSPICE CARE Each family member may select a different primary care physician. DURABLE MEDICAL EQUIPMENT $15 per visit. PROSTHETIC MEDICAL No charge for inpatient care. DEVICES $15 per visit (as medically necessary).

PREVENTIVE SERVICES ROUTINE PHYSICALS Pediatric & Adult/ LABORATORY/ IMMUNIZATIONS/ WELL BABY CARE (Newborn to 2)/ ANNUAL BREAST & PELVIC

$0 per visit.

HOSPITAL SERVICES

Area Hospitals including Community Medical Center of Fresno, Clovis Community Hospital, Children’s Hospital Central California. (Not all Valley hospitals listed. Please visit the Blue Shield website for a complete listing.)

EMERGENCY SERVICES (When medically necessary)

AMBULANCE EMERGENCY ROOM Accident or Illness INPATIENT SERVICES Inpatient Services, Semiprivate Room, ICU OUTPATIENT SERVICES SURGERY/X-RAY/LAB TESTS SKILLED NURSING FACILITY FREESTANDING SNF/HOSPITAL SNF UNIT

MATERNITY HOSPITAL/PHYSICIAN INHOSPITAL/NEWBORN NURSERY CARE PRENATAL CARE FAMILY PLANNING STERILIZATIONS ABORTION Therapeutic Elective

INFERTILITY SERVICES Worldwide coverage: Services which are Diagnosis for Infertility immediately required to treat a sudden, serious and unexpected illness or injury, including Treatment of Infertility services to alleviate severe pain associated with a sudden, serious and unexpected illness or injury. Member must notify PCP within 48 hours. No charge when medically necessary. PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY/ $100 per visit, waived if admitted. REHABILITATIVE SERVICES Outpatient Services No charge. Authorization by a Plan physician required for all non-emergency admissions. ALLERGY TESTING/ TREATMENT No charge.

No charge. “Limit 100 days” per calendar year.

$35.66 $69.21 $116.93 $241.18

or

$221.98 $352.99 $397.52 $528.15

$27.09 $63.10 $107.63 $233.26

$15 per visit – “limit of 100 visits” per calendar year. Routine Home Care and Inpatient Respite Care – no charge. 24-hour continuous Home Care and General Inpatient Care – no charge. No charge. $2,000 maximum (includes hearing aid benefit of $1,000 every 36 months for one or both ears). No charge.

No charge. $15 for initial visit. $15 copay per visit – no charge for family planning counseling. Provided with copay of $15 for males, $15 for females. $100 copay. $100 copay. $15 office copay applies, including treatment, testing, medical advice, and instruction. Injectables for infertility, in vitro fertilization, ovum transplant, G.I.F.T., Z.I.F.T. or any other reproductive technology is not covered. $15 copay. Covered when medically necessary as approved by medical director.

$0 copay included in office visit. Serum included in office visit. Allergy serum purchased separately for treatment is 50% of allowed charges.

HEARING TEST HEARING AID

No charge (for children under 18), for screening. Refer to Durable Medical Equipment.

INITIAL EVALUATION SPEECH & HEARING DISORDERS

$15 copay. $15 copay.

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

PHYSICIAN SERVICES OFFICE VISITS HOSPITAL CARE HOME VISITS

$230.55 $359.10 $406.82 $536.07

DeltaCare Dental DHMO TOTAL PREMIUM EMPLOYEE COST

Active - 2009

PHYSICIAN SELECTION (SERVICE AREAS ARE DEFINED IN EACH PLAN’S BENEFIT SUMMARY)

PLAN 1 Delta Dental DPPO TOTAL PREMIUM EMPLOYEE COST

medical plans ACTIVE EMPLOYEES

continued PLAN 1

ACUPUNCTURE

No charge by primary care physician. $15 copay VISION BENEFITS for Diabetes self-management training and Copayments education. Examinations $10 per visit, “limit 40 visits” per year. Services must be rendered by American Specialty Health plans contracted providers. Eyeglass Lenses Not covered.

ANNUAL COPAYMENT LIMIT

$1,000 per person or $2,000 per family per calendar year.

CLAIM FORMS

None in service area, may be required for out-of-area emergency service.

COORDINATION OF BENEFITS

Required.

MENTAL HEALTH SERVICES INPATIENT

Benefits provided by Avante Behavioral Health. Unlimited Inpatient days per year, plan pays 100%. Parity diagnosis (severe mental illness) unlimited days, plan pays 100%. 20 visits per year (combined with chemical dependency visits). $25 copay per visit. Parity diagnosis (severe mental illness) unlimited visits, $15 copay per visit.

CHIROPRACTIC CARE

OUTPATIENT

PRESCRIPTION DRUGS ADMINISTERED IN HOSPITAL OR DR. OFFICE OUTPATIENT PRESCRIPTIONS

DENTAL RX RX CONTRACEPTIVES

No charge. Prescription drugs provided by Express Scripts at the following copay levels: $10 copay (Generic); $20 copay (Preferred); $35 copay (Non-preferred) 30-day supply when member utilizes a Participating Pharmacy. Mail order 90-day supply for 2 copay. If prescribed by plan physician (not dentist), same benefit level as “Outpatient Prescriptions”. Same as Outpatient Rx. Contraceptive diaphragms are limited to one per year and are subject to the brand name copay.

Eyeglass Frames

Elective Contact Lenses Medically Necessary Contact Lenses Laser Eye Surgery Lens customization/ additional benefits

Benefits provided by Medical Eye Services. $5.00 per covered person annually. Every 12 Months. In Network: Complete eye exam 100%. Out of Network: Maximum payable of $40. Every 12 Months. In Network: Covers standard lenses at 100%. Progessive lenses and polycarbonate lens coverage up to $89.50. Additional allowances applied to some lens upgrades. Out of Network: Payable based on reimbursement benefit schedule. Every 24 Months. In Network: Allowance $150 + 20% discount of the amount over $150 on higher priced frames at participating discount provider locations. Out of Network: Maximum reimbursement of $75. Every 12 Months in lieu of eyeglasses. In Network: $130 maximum. Out of Network: $130 maximum. Every 12 Months. In Network: Paid in full. Out of Network: $250 maximum. Must be pre-authorized by MES Vision. 15% discount through TLC Vision network: www.tlcvision.com. Members responsible for optional upgrades such as lens tints and coatings. Some discounts may apply.

Active - 2009

HEALTH EDUCATION

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

See Rate Chart for Current Pricing See Supplemental Chart for Additional Benefits

benefits PLAN YEAR 12/15/08 to 12/13/09

benefits PLAN YEAR 12/15/08 to 12/13/09

Employee Only Employee + Child(ren) Employee + Spouse Employee + Family

PHYSICIAN SELECTION (SERVICE AREAS ARE DEFINED IN EACH PLAN’S BENEFIT SUMMARY) PHYSICIAN SERVICES OFFICE VISITS HOSPITAL CARE HOME VISITS

PREVENTIVE SERVICES ROUTINE PHYSICALS Pediatric & Adult LABORATORY/ IMMUNIZATIONS WELL BABY CARE (Newborn to 2) ANNUAL BREAST & PELVIC HOSPITAL SERVICES

EMERGENCY SERVICES (When medically necessary)

AMBULANCE EMERGENCY ROOM Accident or Illness INPATIENT SERVICES Inpatient Services/ Semiprivate Room, ICU

$250 per individual/$500 per family. Preferred/Non-preferred.

Members can access care from either Preferred Providers or Non-preferred Providers. If a member uses a Non-preferred Provider they are responsible for the full billed amount. BSC only pays 50% up to the allowed amount.

Delta Dental DPPO TOTAL PREMIUM EMPLOYEE COST $316.04 $589.88 $651.53 $897.04

OUTPATIENT SERVICES SURGERY/X-RAY/LAB TESTS

$20 per visit (deductible waived)/Non-preferred Provider 50% after deductible. SKILLED NURSING FACILITY No charge/Non-preferred Provider 50% after FREESTANDING SNF deductible. HOSPITAL SNF UNIT $20 per visit (deductible waived for routine physical exam)/Non-preferred Provider 50% after deductible. OTHER BENEFITS ROUTINE HOME CARE AND INPATIENT RESPITE $20 per visit (deductible waived for routine CARE/HOME HEALTH physical exam). Non-preferred Provider 50% CARE/HOME HOSPICE CARE after deductible. No charge/Non-preferred Provider 50% after deductible. $20 per visit (deductible waived for routine physical exam)/Non-preferred Provider 50% after deductible. No charge/Non-preferred 50%. Area Hospitals including Saint Agnes, Community Medical Center of Fresno, Clovis Community Hospital, Children’s Hospital Central California. (Not all Valley hospitals listed. Please visit the Blue Shield website for a complete listing.)

or

$307.47 $583.77 $642.23 $889.12

$99.41 $280.71 $339.17 $581.06

No charge/Non-preferred Provider 50% after deductible. The maximum allowed charges for Non-preferred Outpatient hospital or Ambulatory Surgery Center services is $350 per day, member is responsible for 50% of this $350 per day, plus all charges in excess of $350.

No charge/No charge with prior authorization. No charge/Non-preferred Provider 50% after deductible. 100 day maximum. No charge – Limited to 100 visits per calendar year.

DURABLE MEDICAL EQUIPMENT PROSTHETIC MEDICAL DEVICES

No charge/Non-preferred Provider 50% after deductible plan payment up to $2,000. No charge/Non-preferred Provider 50% after deductible; no calendar year limit.

MATERNITY

The maximum allowed charges for Non-preferred inpatient hospital services is $600 per day, member is responsible for 50% of this 600 per day, plus all charges in excess of $600. No charge/Non-preferred Provider 50% after deductible.

HOSPITAL/PHYSICIAN INHOSPITAL/NEWBORN NURSERY CARE PRENATAL CARE

Worldwide coverage: Emergency service for sudden, serious, and unexpected acute illness, injury, or condition which the member FAMILY PLANNING/ reasonably believes could permanently endanger STERILIZATIONS/ health if medical treatment is not received ABORTION immediately. Therapeutic/Elective No charge. INFERTILITY SERVICES Diagnosis for Infertility $100 per visit, waived if admitted to hospital. Treatment of Infertility No charge/Non-preferred Provider 50% after deductible. The maximum allowed charges for Non-preferred Inpatient hospital services is $600 per day, member is responsible for 50% of this $600 per day, plus all charges in excess of $600.

$107.98 $286.82 $348.47 $588.98

PLAN 2

DeltaCare Dental DHMO TOTAL PREMIUM EMPLOYEE COST

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY/ REHABILITATIVE SERVICES Outpatient Services

$20 per visit/Non-preferred Provider 50% after deductible. No charge/Non-preferred Provider 50% after deductible.

Not covered. Not covered. No charge/Non-preferred Provider 50% after deductible, subject to medical necessity.

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

bi-weekly premiums

Active - 2009

medical plans ACTIVE EMPLOYEES

medical plans ACTIVE EMPLOYEES

continued PLAN 2 See Rate Chart for Current Pricing See Supplemental Chart for Additional Benefits

No charge/Non-preferred Provider 50% after deductible.

HEARING TEST

Routine hearing tests are not covered (medically necessary hearing tests are covered). No charge. Up to $1,000 per calendar year. Vision screening covered as part of preventive care benefit according to age schedule.

HEARING AID EYE EXAM (UNDER 18) SPEECH & HEARING DISORDERS/INITIAL EVALUATION

$20 per visit (deductible waived)/Non-preferred Provider 50% after deductible.

HEALTH EDUCATION

$20 per visit (deductible waived)/Non-preferred Provider 50% after deductible.

CHIROPRACTIC CARE

20 visits per calendar year. No charge/ Non-preferred Provider 50% after deductible. 20 visits per calendar year. $25 per visit.

ACUPUNCTURE ANNUAL COPAYMENT LIMIT

$3,000 per individual/$6,000 per family. Preferred Providers. $10,000 per individual/$20,000 per family. Non-preferred Provider.

CLAIM FORMS

Required.

COORDINATION OF BENEFITS

Required.

MENTAL HEALTH SERVICES INPATIENT

Benefits provided by Avante Behavioral Health. Unlimited Inpatient days per year. Plan payment limited to $350 per day. Parity diagnosis (severe mental illness) unlimited days, plan pays 100%. Unlimited visits per year with Plan payment limited to $25 per visit. Parity diagnosis (severe mental illness) unlimited visits with patient copay of $20 per visit.

OUTPATIENT

PRESCRIPTION DRUGS ADMINISTERED IN HOSPITAL OR DR. OFFICE OUTPATIENT PRESCRIPTIONS

DENTAL RX RX CONTRACEPTIVES

VISION BENEFITS Copayments Examinations Eyeglass Lenses

Eyeglass Frames

Elective Contact Lenses Medically Necessary Contact Lenses Laser Eye Surgery Lens customization/ additional benefits

No charge. Prescription drugs provided by Express Scripts at the following copay levels: $10 copay (Generic); $20 copay (Preferred); $35 copay (Non-preferred) 30-day supply when member utilizes a Participating Pharmacy. Mail order 90-day supply for 2 copays. Same as Outpatient. Same as Outpatient Rx. Contraceptive diaphragms are limited to one per year and are subject to the brand name copay. Benefits provided by Medical Eye Services. $5.00 per covered person annually. Every 12 Months. In Network: Complete eye exam 100%. Out of Network: Maximum payable of $40. Every 12 Months. In Network: Covers standard lenses at 100%. Progessive lenses and polycarbonate lens coverage up to $89.50. Additional allowances applied to some lens upgrades. Out of Network: Payable based on reimbursement benefit schedule. Every 24 Months. In Network: Allowance $150 + 20% discount of the amount over $150 on higher priced frames at participating discount provider locations. Out of Network: Maximum reimbursement of $75. Every 12 Months in lieu of eyeglasses. In Network: $130 maximum. Out of Network: $130 maximum. Every 12 Months. In Network: Paid in full. Out of Network: $250 maximum. Must be pre-authorized by MES Vision. 15% discount through TLC Vision network: www.tlcvision.com. Members responsible for optional upgrades such as lens tints and coatings. Some discounts may apply.

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

ALLERGY TESTING/ TREATMENT

$250 per individual/$500 per family. Preferred/Non-preferred.

Active - 2009

benefits PLAN YEAR 12/15/08 to 12/13/09

Calendar-year Deductible: Individual $3,000/Family $6,000

Employee Only Employee + Child(ren) Employee + Spouse Employee + Family

benefits PLAN YEAR 12/15/08 to 12/13/09 PROVIDERS PHYSICIAN SELECTION (SERVICE AREAS ARE DEFINED IN EACH PLAN’S BENEFIT SUMMARY)

PHYSICIAN SERVICES OFFICE VISITS/HOSPITAL CARE/HOME VISITS PREVENTIVE SERVICES ROUTINE PHYSICALS Pediatric & Adult/ Laboratory IMMUNIZATIONS ANNUAL BREAST & PELVIC HOSPITAL SERVICES

EMERGENCY SERVICES (When medically necessary) AMBULANCE EMERGENCY ROOM Accident or Illness INPATIENT SERVICES Semiprivate Room, ICU/ Bariatric Surgery (Preauthorization Required) OUTPATIENT SERVICES SURGERY/X-RAY/ LAB TESTS SKILLED NURSING FACILITY Freestanding SNF Hospital SNF Unit

Preferred

Delta Dental DPPO TOTAL PREMIUM EMPLOYEE COST

Non-Preferred

Covered out-of-state services (Benefits provided through the BlueCard® Program) Benefits provided through the BlueCard® Program, for out-of-state emergency and non-emergency care, are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider. No charge after deductible. 50%

$184.18 $338.63 $374.16 $513.64

PROVIDERS OTHER BENEFITS ROUTINE HOME CARE AND INPATIENT RESPITE CARE HOME HEALTH CARE/ HOME HOSPICE CARE

$48.74 $84.27 $218.75

Preferred

PLAN 3

DeltaCare Dental DHMO TOTAL PREMIUM EMPLOYEE COST

or

$175.61 $332.52 $364.86 $505.72

$42.63 $74.97 $210.83

Non-Preferred

(Up to 100 combined prior authorization visit max per calendar year.) No charge after deductible. with prior authorization No charge. with prior authorization

DURABLE MEDICAL No charge after deductible. 50% after deductible. EQUIPMENT (Plan payment up to $2,000 maximum per PROSTHETIC MEDICAL calendar year.) Preventive care (not subject to the calendar year DEVICES deductible; age 3 and older). MATERNITY No charge after deductible. 50% after deductible. No charge. Not covered. HOSPITAL/PHYSICIAN INHOSPITAL/NEWBORN No charge. Not covered. NURSERY CARE/ PRENATAL CARE No charge. Not covered. FAMILY PLANNING/ No charge after deductible. Not covered. No charge. Not covered. STERILIZATIONS/ Area Hospitals including Saint Agnes, Community ABORTION Therapeutic/Elective Medical Center of Fresno, Clovis Community Hospital, Children’s Hospital Central California. INFERTILITY SERVICES (Not all Valley hospitals listed. Please visit the Diagnosis for Infertility Not covered. Blue Shield website for a complete listing.) Treatment of Infertility Not covered. Emergency health coverage. No charge after deductible. 50% after deductible. PHYSICAL, No charge after deductible. OCCUPATIONAL No charge after deductible. AND SPEECH THERAPY No charge after deductible. 50% after deductible. REHABILITATIVE No charge after deductible. SERVICES Outpatient Services No charge after deductible. 50% after deductible. ALLERGY TESTING No charge after deductible. 50% after deductible. AND TREATMENT No charge after deductible. 50% after deductible.

HEARING TEST HEARING AID No charge after deductible. 50% after deductible.

No charge after deductible. with prior authorization No charge after deductible. 50% after deductible.

HEALTH EDUCATION

DIABETES CARE

No charge.

Not covered. Not covered.

Self-management training and education (if billed by your provider, you will also be responsible for the office visit copay). No charge after deductible. 50% after deductible. Equipment, devices and supplies No charge after deductible. 50% after deductible.

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

bi-weekly premiums

Active - 2009

medical plans ACTIVE EMPLOYEES

medical plans ACTIVE EMPLOYEES

continued PLAN 3

See Rate Chart for Current Pricing See Supplemental Charts for Additional Benefits

PROVIDERS CHIROPRACTIC CARE ACUPUNCTURE ANNUAL COPAYMENT LIMIT CLAIM FORMS COORDINATION OF BENEFITS MENTAL HEALTH SERVICES INPATIENT OUTPATIENT

PRESCRIPTION DRUGS ADMINISTERED IN HOSPITAL OR DR. OFFICE/OUTPATIENT PRESCRIPTIONS/ DENTAL RX

Preferred

Non-Preferred

Chiropractic services provided by a chiropractor (up to 20 visits per calendar year). No charge after deductible. 50% after deductible. Not covered. Not covered. Individual Coverage $3,000

Family Coverage $6,000

Providers bill.

VISION BENEFITS Copayments Examinations Eyeglass Lenses

Required.

Required. Benefits provided by Blue Shield. No charge after deductible. 50% after deductible. Parity Diagnosis (Severe Mental Illness) No charge after deductible. 50% after deductible. Non-severe Mental Health (Up to 20 visits per calendar year, combined with Outpatient chemical dependency.) No charge. Not covered. Benefits provided by Blue Shield. (Subject to deductible) Retail pharmacy mail service (claim form needed). No charge after deductible.

Eyeglass Frames

Elective Contact Lenses Medically Necessary Contact Lenses Laser Eye Surgery Lens customization/ additional benefits

Benefits provided by Medical Eye Services. $5.00 per covered person annually. Every 12 Months. In Network: Complete eye exam 100%. Out of Network: Maximum payable of $40. Every 12 Months. In Network: Covers standard lenses at 100%. Progessive lenses and polycarbonate lens coverage up to $89.50. Additional allowances applied to some lens upgrades. Out of Network: Payable based on reimbursement benefit schedule. Every 24 Months. In Network: Allowance $150 + 20% discount of the amount over $150 on higher priced frames at participating discount provider locations. Out of Network: Maximum reimbursement of $75. Every 12 Months in lieu of eyeglasses. In Network: $130 maximum. Out of Network: $130 maximum. Every 12 Months. In Network: Paid in full. Out of Network: $250 maximum. Must be pre-authorized by MES Vision. 15% discount through TLC Vision network: www.tlcvision.com. Members responsible for optional upgrades such as lens tints and coatings. Some discounts may apply.

Active - 2009

benefits PLAN YEAR 12/15/08 to 12/13/09

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

Calendar-year Out-of-pocket Maximum Preferred Provider: $3,000 Individual/$6,000 Family Non-preferred Provider: $5,000 Individual/$10,000 Family

medical plans ACTIVE EMPLOYEES

bi-weekly premiums

benefits PLAN YEAR 12/15/08 to 12/13/09

Employee Only Employee + Child(ren) Employee + Spouse Employee + Family

$15 per provider visit. No charge for Inpatient care. No charge. $15 per visit. No charge. $5 per visit. $15 per visit.

HOSPITAL SERVICES

Services available at Kaiser Permanente facilities.

EMERGENCY SERVICES (When medically necessary)

Worldwide coverage: Emergency service received within the service area from providers not contracting with health plan are limited to emergencies which might result in death, serious disability or significant jeopardy to the member’s condition. Emergency services are provided outside the service area for members becoming ill or injured while outside the service area. Ambulance: $50 per trip.

AMBULANCE EMERGENCY ROOM Accident or Illness

$100 per visit, waived if admitted.

INPATIENT SERVICES Inpatient Services, Semiprivate Room, ICU

No charge at participating hospitals. Referral by a Plan physician required for all non-emergency hospital services.

OUTPATIENT SERVICES SURGERY X-RAY/LAB TESTS

$15 per procedure. No charge.

SKILLED NURSING FACILITY FREESTANDING SNF HOSPITAL SNF UNIT

No charge. “Limit 100 days” per benefit period.

$89.15 $149.64 $236.76 $384.64

or

$288.64 $446.59 $530.52 $684.78

$80.58 $143.53 $227.46 $376.72

OTHER BENEFITS No charge if prescribed by a Plan physician. ROUTINE HOME CARE AND Paid in full up to 180 days per lifetime. INPATIENT RESPITE CARE HOME HEALTH CARE/HOME HOSPICE CARE DURABLE MEDICAL EQUIPMENT PROSTHETIC MEDICAL DEVICES MATERNITY HOSPITAL/PHYSICIAN INHOSPITAL/NEWBORN NURSERY CARE PRENATAL CARE FAMILY PLANNING/ STERILIZATIONS ABORTION Therapeutic/Elective INFERTILITY SERVICES Diagnosis for Infertility Treatment of Infertility

20% coinsurance. 20% coinsurance.

No charge. $5 per visit. $15 per visit. $15 per visit.

Office visits: $15 per visit. Outpatient surgery: $15 per procedure. Outpatient lab tests and special procedures: No charge. Hospital inpatient care: No charge.

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY REHABILITATIVE SERVICES Outpatient Services

$15 per visit. Occupational and speech therapy.

ALLERGY TESTING TREATMENT

$15 per visit. $3 per injection.

HEARING TEST HEARING AID

$15 per visit. Hearing aid(s) benefit of $1,000 allowance per device, one device per ear, two devices every 36 months.

SPEECH & HEARING DISORDERS/INITIAL EVALUATION

$15 per visit.

HEALTH EDUCATION

Most classes relating to specific medical conditions are $15 per visit. Classes relating to general health are provided at a reasonable rate.

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

PHYSICIAN SERVICES OFFICE VISITS HOSPITAL CARE HOME VISITS PREVENTIVE SERVICES ROUTINE PHYSICALS Pediatric & Adult/Laboratory/ Immunizations WELL BABY CARE (Newborn to 2) ANNUAL BREAST & PELVIC

Primary care and specialty physician services must be obtained at Kaiser Permanente medical offices by teams of physicians affiliated with the Plan. You are encouraged to choose a personal physician from the staff for you and your family members. Referral to community specialists may be provided when Specialty care services are unavailable at Kaiser Permanente facilities.

$297.21 $452.70 $539.82 $692.70

DeltaCare Dental DHMO TOTAL PREMIUM EMPLOYEE COST

Active - 2009

PHYSICIAN SELECTION (SERVICE AREAS ARE DEFINED IN EACH PLAN’S BENEFIT SUMMARY)

PLAN 4 Delta Dental DPPO TOTAL PREMIUM EMPLOYEE COST

CHIROPRACTIC CARE ACUPUNCTURE

$10 copay, “limit 30 visits” per calendar year. Services must be rendered by an American Specialty Health Plan Provider. Not covered.

ANNUAL COPAYMENT LIMIT

$1,500 for one member. $3,000 for the Subscriber and all his or her dependents.

CLAIM FORMS

May be required for out-of-area emergency service.

COORDINATION OF BENEFITS

None.

MENTAL HEALTH SERVICES INPATIENT

Benefits provided by Kaiser Permanente.

OUTPATIENT

PRESCRIPTION DRUGS ADMINISTERED IN HOSPITAL OR DR. OFFICE OUTPATIENT PRESCRIPTIONS DENTAL RX RX CONTRACEPTIVES VISION BENEFITS COPAYMENTS EYEGLASS LENSES/EYEGLASS FRAMES/CONTACT LENSES LENS CUSTOMIZATION/ ADDITIONAL BENEFITS

“Limited to 45 days” per calendar year at no charge (up to 190 days in a lifetime). Referral by a Plan physician required for all non-emergency admissions. Up to 20 visits per calendar year per member at $15 for an individual visit and $5 for a group visit. No visit limitation on parity diagnosis. Benefits provided by Kaiser Permanente. No charge. $10 copay (Generic); $20 copay (Brand), per 30-day supply. Mail orders: 100-day supply for two copays. Same as Outpatient. Same as Outpatient. Benefits provided by Kaiser Permanente. $15 per visit. $175 allowance toward the purchase of covered lenses, frames and/or cosmetic contact lenses, every 24 months. Tinting, scratch coating, photo chromic lenses etc. Members responsible for non-basic lens options. 25% discount on second pair if purchased within one year.

See Rate Chart for Current Pricing See Supplemental Chart for Additional Benefits

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

benefits PLAN YEAR 12/15/08 to 12/13/09

continued PLAN 4

Active - 2009

medical plans ACTIVE EMPLOYEES

dental ACTIVE EMPLOYEES

SUPPLEMENTAL Delta Dental DPPO Plan

benefits

Preferred Provider Dentist

DeltaCare DHMO Plan

Non-preferred Provider Dentist

SUMMARY

Plan will pay a portion of the bill after deductible is met. The Plan’s portion for covered basic and preventive services is 100% of the covered dental expense. All covered major services and some basic services are paid at 50% of the covered dental expense. Dental implants and composite fillings may be covered.

Members receive benefits from one of the participating dentists in the network. The plan covers most preventive diagnostic, restorative and other basic procedures at NO CHARGE. Major procedures may require fixed copays.

DENTIST SELECTION

All covered persons may select a dentist without restriction. If a participating dentist is selected, the member may have a reduction in out-of-pocket costs.

Members must select a dentist from the list of Plan approved dentists.

DEDUCTIBLE

Basic and Major Services: $50 per person, $150 per family per calendar year. No deductible for Preventive, Diagnostic and Orthodontic services. The deductible is waived for PPO Providers only.

No deductible.

MAXIMUM BENEFITS Predetermination of Benefits

$2,500 per person per year.

No annual maximum.

EMERGENCY SERVICES

Covered the same as routine services.

Reimbursement to a maximum of $100 per incident.

CLAIM FORMS

Participating dentists will submit claim forms for you.

No claim forms are necessary except for out-of the-area emergencies.

COORDINATION OF BENEFITS

The plan will coordinate with other coverages if the person is qualified in more than one plan.

The plan will coordinate with other coverages if the person is qualified in more than one plan for specialty claims only.

SERVICE AREA

No service limitations in California.

No service limitations in California.

BENEFIT PROVISIONS BASIC/PREVENTIVE SERVICES Diagnostic Services Examinations, X-rays, Check-ups

0% *(Deductible Waived) 10% * Extra visit for pregnancy.

Preventive Services/Cleanings & Fluoride Treatment

0% *(Deductible Waived) 10% * Extra visit for pregnancy.

Active - 2009

No charge (except for resin/composite fillings on posterior teeth; the copays for these procedures range from $85-$140). The no charge is for amalgam for all teeth and resin/composite for anterior teeth. No charge.

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

dental ACTIVE EMPLOYEES

continued SUPPLEMENTAL Delta Dental DPPO Plan

benefits

Preferred Provider Dentist

DeltaCare DHMO Plan

Non-preferred Provider Dentist

Restorative Services/Fillings, Pulp Capping

10%

10%

Members receive benefits from one of the participating dentists in the network. The plan covers most preventive diagnostic, restorative and other basic procedures at NO CHARGE.

OTHER SERVICES - Endodontics (minor)/Treatment of Gums (minor)/Teeth Bleaching (DHMO Only)

50%

50%

No charge, except for teeth bleaching at $125 copay.

MAJOR SERVICES - Oral Surgery Impactions/Root Canals/ Apicoectomy/Periodontal Surgery/Crowns/Bridges/ Dentures/Other Prosthetics/ Simple Extractions/Implants (DPPO Only)

50%

50%

Most services do not require a copay. Copay may be required for an upgrade from a base metal to a precious metal.

OTHER BENEFITS - Orthodontia (Teeth Straightening - Adults and Children)

Adult member (age 20 and over) $1,880 copay per case. Child member (through age 19) $1,660 copay per case.

Adult member (age 20 and over) $2,000 copay per case. Child member (through age 19) $1,500 copay per case.

One case per lifetime. Maximum of 24 months of active orthodontic treatment. * Prior Blue Cross PPO orthodontic copay will credit toward this plan.

$265 copay for orthodontic records and $240 copay for retention.

EXCLUSIONS/LIMITATIONS

More than one cleaning every six months (exception for pregnancy); Lost/stolen appliances; Cosmetic dentistry; Charges in excess of customary for Nonparticipating dentists; Hospital expenses; Prescription drugs; Replacement of prosthetics within 5 years of placement; Unnecessary/Experimental procedures; Treatment to alter vertical dimension; TMJ treatment; Other exclusions/limitations as provided in policy.

Lost/stolen appliances; Cosmetic dentistry (except those noted within the schedule of benefits); Hospital expenses; Replacement of repairable dentures; Orthognatic surgery; Implants; Experimental/unnecessary procedures; Treatment to alter vertical dimension; TMJ treatment; Other exclusions/limitations as provided in policy.

Active - 2009

This chart is only a summary of benefits. Please see the Evidence of Coverage, the Disclosure Form and the Group Health Services Contract for the exact terms and conditions of coverage.

Important Notice from the County of Fresno About Your Prescription Drug Coverage and Medicare This Notice applies to County Employees Enrolled in the Blue Shield HMO or PPO Plan w/ Prescription Coverage through Express Scripts, Inc. Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the County of Fresno and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. The County of Fresno has determined that the prescription drug coverage offered by the County of Fresno is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays, and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

______________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15th through December 31st. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current County of Fresno coverage will be affected. You will not continue to be covered at the same level of benefits you have today. If you decide to join a Medicare drug plan and drop your current County of Fresno coverage, be aware that you and your dependents will not be able to get this coverage back.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with the County of Fresno and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. CMS Form 10182-CC Updated June 15, 2008

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact the person listed below for further information NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the County of Fresno changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: • Visit www.medicare.gov. •

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.



Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: Name of Entity/Sender: Contact--Position/Office:

October 13, 2008 County of Fresno Paul Nerland Personnel Services Manager Personnel Services Department Employee Benefits Division

Address: Phone Number:

2220 Tulare Street, Suite 1400, Fresno, CA 93721 559-488-3069

CMS Form 10182-CC Updated June 15, 2008

Suggest Documents