Take time f or your annual  benefits checkup 2013 Health Benefits Open Enrollment For RETIREES October 29, 8am–November 20, 5pm

Time for your benefits checkup

Open Enrollment is a good time to review your UC-sponsored benefits. It’s the one time during the year when you can change medical plans, add eligible family members and enroll in other plans that aren’t always open for enrollment. This year you may want to: • Check out the plan changes for 2013. Copayments for some services and prescription drugs are going up and many women’s services will now be available at no cost for non-Medicare plans. • Review UC’s medical plans to be sure you’re in the best one for you. Check out our comparison chart on pages 8 and 9 and use our online Medical Plan Chooser (uc.chooser.pbgh.org) to compare plans.

YOUR OPEN ENROLLMENT “TO DO” LIST ……

Go online to atyourservice.ucop.edu and sign in to your account. You can view your current health and welfare plan enrollments with 2013 premiums by selecting “Open Enrollment.” If you have reviewed your current plans and are satisfied, no action is required.

…… If you want to change your primary care physician and you will not be changing your medical plan, call your plan to request the change. ……

If you want to make any changes, select “Open Enrollment.” Use the options in the left column to navigate through your Open Enrollment choices. Don’t remember your password? See page 7 for information on how to retrieve your password.

……

After you sign in, you can enroll or de-enroll your dependents by selecting “Family Members” from the menu on the left. This will ensure that any plan changes you make will be effective for all of your family members.

Atyourservice.ucop.edu

……

When you are finished, select “Review & Confirm” to see all of the changes you’ve made. If you want to make additional changes, use the links in the left column. If you decide you don’t want the changes shown, simply sign off or return to the main menu.

Go online to the At Your Service website (atyourservice.ucop. edu) and select the Open Enrollment 2013 icon for all the details. On the Open Enrollment website you can:

…… If you are satisfied with the changes, select “Confirm.” You must confirm your changes­—and get a confirmation number—in order to process your transactions.

• Read about plan changes, plan rates and other important information.

…… Print a copy of your elections for your records by selecting the print-friendly option on the confirmation page.

• Consider enrolling in the ARAG Legal plan, which is open for enrollment this year. • Use the Open Enrollment period to review your beneficiaries and update their information. It’s easy to do online. See page 6 for more information. • Review your Retirement Savings Program accounts to be sure you’re happy with your investments. See page 6 for more information.

OPEN ENROLLMENT IS ONLINE:

• Use the Medical Plan Chooser to help you find the medical plan best suited to you and your family. • Find contact information and website links for plan carriers, including links to the medical plans’ physician directories.

……

Review your confirmation statement carefully to ensure that your benefit elections were recorded correctly. You can sign in again, make corrections, then review and confirm again.

• Sign in to your personal account to make Open Enrollment changes.

…… Medicare members who change medical plans must complete additional paperwork and submit it by Dec. 7, 2012. See page 5 for details.

IF YOU DON’T HAVE ACCESS TO A COMPUTER

Any changes you make during Open Enrollment will be effective Jan. 1, 2013.

If you need additional information or a form to complete your benefits changes during Open Enrollment, contact the UC Customer Service Center: 800-888-8267.

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2013 Health Benefits Open Enrollment for Retirees

Overview of 2013 plan changes

Below is a summary of changes for 2013. Details of these changes are available on the Open Enrollment website (atyourservice. ucop.edu/open_enrollment). For complete information about the benefits for each plan, see the evidence of coverage booklet or

summary plan description, also available on the Open Enrollment website. You may also request paper copies by calling the plan carriers directly.

PLAN CHANGES All UC non-Medicare medical plans For Anthem PPO, PLUS, Lumenos PPO with HRA, and Core plans, these enhancements are applicable for in-network benefits only.

The following women’s preventive health services will be available at no cost under all UC medical plans: • Well-woman visits

• FDA-approved contraception methods and counseling

• Screening for gestational diabetes

• Breastfeeding support, supplies and counseling

• HPV testing

• Screening and counseling for interpersonal and domestic violence

• Sexually transmitted infections and HIV counseling

Anthem Blue Cross PLUS, Anthem Blue Cross PPO (non-Medicare)

• The benefit for outpatient surgery at out-ofnetwork ambulatory surgical centers is limited to $350 and requires prior authorization.

• Some copayments are increasing. See page 4.

Anthem Blue Cross PLUS, Anthem Blue Cross PPO, (Medicare)

• The benefit for outpatient surgery at out-ofnetwork ambulatory surgical centers is limited to $350 and requires prior authorization. Prescription drugs: brand name from $25 to $30; non-formulary from $40 to $45

• Some copayments are increasing. See page 4.

Anthem Lumenos PPO with HRA

The benefit for outpatient surgery at out-of-network ambulatory surgical centers is limited to $350 and requires prior authorization.

Core (Medicare and non-Medicare)

• The benefit for outpatient surgery at out-ofnetwork ambulatory surgical centers is limited to $350 and requires prior authorization.

• Medicare prescription drug out-of-pocket maximum is increasing from $1,000 to $4,750.

Health Net HMO Health Net Blue & Gold HMO Health Net Seniority Plus

• Some copayments are increasing. See page 4

• The Blue & Gold network is changing. Check the Health Net doctor directory to see if your doctor or medical group has joined or left the network.

Health Net non-Medicare EPO and Medicare COB

Eliminated for 2013. Enrollees must select a new plan or you will be enrolled in Anthem Lumenos PPO with HRA (EPO members) or Anthem Blue Cross PLUS (Medicare COB).

High Option Supplement to Medicare

The benefit for outpatient surgery at out-of-network ambulatory surgical centers is limited to $350 and requires prior authorization.

Kaiser Permanente/Kaiser Senior Advantage

Some copayments are increasing. See page 4.

Western Health Advantage

Some copayments are increasing. See page 4.

Optum (formerly United Behavioral Health)

Some copayments are increasing. See page 4.

DeltaCare USA

• Federally mandated screenings, such as for children entering kindergarten, are offered at no cost

ARAG Legal

This plan is open for enrollment.

Chartis AD&D

Plan name is changing to AIG Benefit Solutions.

• Copay for smoking cessation drug is $0.

• Prescription drug out-of-pocket maximum is increasing from $4,700 to $4,750.

• Medicare prescription drug copays are increasing. See page 4.

• Preventive resin restoration for permanent teeth of children to age 15 offered at no cost.

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Important changes for 2013

Copayments are increasing for medical plans For many of UC’s medical plans, you pay a small copayment when you visit your doctor, have outpatient surgery or use an emergency room or urgent care center. In 2013, copayments for those services and for brand-name and non-formulary drugs are increasing. This is the first increase in copayments since 2006. Generic prescription drug copayments remain at $5 ($10 for Anthem plans), and preventive care visits continue to be offered with no copayment. For Health Net Blue & Gold HMO, Health Net HMO, Health Net Seniority Plus, Kaiser Permanente, Kaiser Senior Advantage and Western Health Advantage, copayments are increasing as follows: • Office visits—including behavioral health visits—and urgent care: $20; for non-Medicare plans the first three Optum (formerly United Behavioral Health) visits continue to be covered without a member copayment. • Outpatient surgery at hospital ambulatory surgery centers: $100 • Emergency room visits, including behavioral health: $75 (Health Net Seniority Plus and Kaiser Senior Advantage are increasing to $65) • Prescription drugs: brand name $25; non-formulary $40 For Anthem Blue Cross PLUS Medicare and non-Medicare plans, copayments are increasing as follows: • Office visits—including behavioral health visits covered by Optum— and urgent care: $25; the first three behavioral health visits continue to be covered without a member copayment. • In-network outpatient surgery: $100 • Emergency room visits: $100 • Prescription drugs: brand name $30; non-formulary $45 For Anthem Blue Cross PPO (Medicare and non-Medicare), High Option Supplement to Medicare and Core Medicare, the copayments for prescription drugs are increasing to $30 for brand names and to $45 for non-formulary.

UC GRADUALLY REDUCING CONTRIBUTIONS TO MEDICAL PREMIUMS UC continues to gradually reduce the overall level of contributions to retiree medical plan premiums to a floor of 70 percent, as approved by the Regents in December 2010. For 2013, that means UC will contribute, on average, 80 percent of the cost of retiree medical insurance premiums, down from 83 percent in 2012. Even with the reduction, UC will spend roughly $242 million on retiree health benefits in 2013. UC has increased the maximum Medicare Part B reimbursement to $99.90 per person. Retirees enrolled in Medicare plans receive some or all of this amount only when the UC contribution is greater than the plan premium. Retirees aged 65 and older who are not eligible for Medicare through UC, their spouse or their own employment have a different rate tied to premiums for employees. See pages 10 and 11 for more information about 2013 premium costs.

StayWell Incentive Program The StayWell program is UC’s wellness initiative for employees and retirees and their adult family members enrolled in most UC-sponsored medical plans. In 2013, it will be easier than ever to earn your $100 incentive! Participants are eligible for an incentive award if they complete the Health Assessment by June 15, 2013 and complete follow-up activities worth 50 points. You can earn your points by attending certain campus-sponsored wellness events such as brown bags or walking programs. Or, take advantage of StayWell wellness coaching and online programs. To qualify for the incentive, you can complete the health assessment and activities in any order, but you must complete the health assessment by June 15, 2013, and the additional activities by Dec. 15, 2013. The incentive award for retirees is a $100 gift certificate and for spouses/domestic partners, it is a $50 gift certificate. The StayWell program is available to those enrolled on Jan. 1, 2013 in UC medical plans except Kaiser, which provides similar wellness resources via its HealthWorks program.

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UC now requires all retirees who enroll new family members in their medical, dental and/or vision insurance plans to provide documents to verify their family members’ eligibility for coverage. If you add a family member to your coverage during Open Enrollment, in early 2013 you will receive a packet of materials to complete the verification process. You must respond by the deadline shown on the letter or risk de-enrollment of your newly enrolled family members from UC benefits. No documentation is required for family members whose eligibility was verified previously in 2012. UC has hired Secova, Inc. to administer the project. More information about the verification process is available online at atyourservice.ucop.edu/family-member-verification/.

SAME PLANS, NEW NAMES Two of UC’s benefits plans are changing their names: United Behavioral Health is now Optum, and Chartis (accidental death & dismemberment) is now AIG Benefit Solutions.

Anthem Blue Cross PPO Medicare Plan without Prescription Drugs UC has integrated Medicare prescription drug plans into each of the Medicare-coordinated medical plans, except for this plan. Because Medicare allows enrollment in only one Part D plan, you may enroll in this plan if: • You have group Medicare-coordinated health insurance that covers prescription drugs through another employer or individual retiree plan, including TRICARE for Life. • All covered members are enrolled in Medicare, and • You provide documentation of enrollment in another group health insurance plan with creditable Part D coverage. For enrollment information, contact the UC Customer Service Center or your local Health Care Facilitator (see page 12).

Transitioning from one plan to another If you want to change your medical plan during Open Enrollment and you or a family member is scheduled for surgery/other medical procedure or continuing treatment in late 2012, call the new plan to make sure it offers your current providers, and ask how they will oversee the transition of your care.

If You or a Family Member Become Eligible for Medicare in 2013 If you or any eligible family member expect to enroll in Medicare during 2013, consider whether the Medicare version of your medical plan offers the benefits you want. If not, Open Enrollment is the time to change plans. You will not be allowed to change plans later simply because you have become eligible for Medicare unless your plan does not have a Medicare component or the Medicare version of your plan is not available in your zip code. Medicare plan service areas may differ from non-Medicare plan service areas. The Medicare version of your medical plan may have different benefits, medical groups, specialists and behavioral health providers. To receive benefits under a UC-sponsored Medicare plan, you must use a provider who accepts Medicare. If your doctor does not take Medicare patients or will only render services under a “private contract” directly with you, neither Medicare nor your UC-sponsored medical plan will cover the services. Call the plan directly or visit its website for more information and talk to your doctor to be sure he/she accepts Medicare. For Medicare information, read the UC Medicare Factsheet, available on the At Your Service website under “Forms and Publications.”

Required Medicare Forms If you are enrolled in Medicare and change your UC medical plan, you must fill out a form to assign your Medicare coverage (Parts A, B and/or D) to the new plan. UC will send forms to you along with a confirmation of your Open Enrollment change. You must submit the white copy of the form for each Medicare member to your medical plan by Dec. 7, 2012, for your election to be complete. For UC’s Medicare Advantage plans—Health Net Seniority Plus and Kaiser Senior Advantage—you must submit a Medicare Advantage Universal Enrollment/Election Form (UBEN 127) to the address of the new plan printed on the instruction sheet (in addition to sending a copy to UC and completing your UC Open Enrollment transaction). If you are a new enrollee into the Medicare version of Anthem Blue Cross PLUS, Anthem Blue Cross PPO, Core or High Option Supplement to Medicare, you must submit an Anthem Blue Cross Part D Enrollment Form for each Medicare member. This form will automatically de-enroll you from any previous Medicare Advantage Plan. You must submit the form to UC by Dec. 7, 2012. Failure to return these forms will prevent your enrollment into your new Medicare plan. 5

2013 Health Benefits Open Enrollment for Retirees

Family Member Eligibility Verification

Things to consider

Be sure your doctor is in your plan

Suspension of Coverage for Medical and Dental

Doctors in a medical plan can change throughout the year. Check the medical plan’s website or call the medical plan directly to find out if the doctor you are currently using or would like to use is a listed provider. If you want to sign up to use a new doctor, confirm that he or she is currently accepting new patients.

If you have other group or individual medical and/or dental coverage, you may suspend your UC-sponsored coverage and re-enroll during a future Open Enrollment or within 31 days of the loss of the other coverage. (Call the UC Customer Service Center or local Health Care Facilitator for more details.)

Plans may have different drug formularies

Are Your Beneficiaries Up-to-Date?

You should review the plan formularies and compare the outof-pocket costs for the various plans, keeping in mind any medications you or your family take. The categories “generic formulary,” “brand formulary” and “non-formulary” are important because the costs for a specific medication may vary considerably under different medical plans, depending on its formulary category.

Open Enrollment is a good time to review all of your benefits, including whether your beneficiary designations are up to date. Your beneficiary is the person to whom benefits are payable in the event of your death. It is important to name your beneficiaries to ensure that any benefits payable at your death are left to the survivors you intend.

Additionally, for all plans except Kaiser, participating UC Medical Center pharmacies will fill maintenance prescription drugs for up to a 90-day supply at the same cost as that available through each plan’s mail-order vendor. Call the medical plan for information on coverage for specific medications.

No Duplicate Coverage You may only have UC-sponsored coverage in one category: as an employee, as a retiree, or as an eligible family member. If you and your spouse or domestic partner are both UC employees or retirees, only one of you may cover your eligible family members. If a duplicate enrollment occurs, UC will cancel the later enrollment. UC reserves the right to collect repayment for any duplicate premium payments and/or Part B reimbursement.

If You Change or Cancel Coverage When you and/or your eligible family members cancel or change UC-sponsored medical coverage, you will receive a HIPAA Certificate of Creditable Coverage from your former plan. If you transfer from one UC plan to another, you do not need to provide the certificate. However, a non-UC insurance carrier may need this HIPAA certificate if the plan/policy would otherwise exclude coverage or impose a waiting period for certain pre-existing medical conditions. Contact your medical plan if you need a certificate and did not receive one. 6

If you’ll be signing in to make Open Enrollment changes, why not take a few minutes to make sure that your UC Retirement Plan beneficiaries and their contact information are up to date? After signing in to your personal account on At Your Service, select “My Beneficiaries.” To name or change beneficiaries for your Retirement Savings Program plans—Defined Contribution, 403(b) and/or 457(b)— log in to ucfocusonyourfuture.com. Then select “My Account” and then “Update Beneficiaries.” You may name the same or different beneficiaries for your various benefits. You also may name more than one beneficiary for a single benefit and specify the percentage that each beneficiary is to receive. Keep in mind that if you are married, your spouse may have a legal interest in benefits payable at your death. A beneficiary designation may be subject to challenge if it will result in your spouse receiving less than his or her share of that portion of the benefit that is considered community property.

Are You Satisfied with Your Retirement Savings? Are you happy with the way your retirement savings are invested? You can view your retirement savings accounts and make changes to your investment funds at ucfocusonyourfuture.com. You also can learn more about managing your money in retirement and UC’s Retirement Savings Program on the UC Focus on Your Future website (ucfocusonyourfuture.com). It has information targeted to your needs. You can also view descriptions and a calendar of financial education classes that UC offers at no cost to you.

2013 Health Benefits Open Enrollment for Retirees

Navigating online tools

How to find your 2013 medical plan premiums

How to retrieve your password

If you receive the full UC contribution to medical plan premiums, you can find the 2013 rates on pages 10 and 11. You are eligible for the full contribution if you retired with 20 or more years of service or began working before 1990 and did not have a break in service before retiring.

You can view your current health and welfare plan enrollments and make changes during Open Enrollment online via At Your Service. You’ll need to sign in to your account using your username and password.

If you are subject to graduated eligibility for retiree medical insurance and receive less than 100 percent of the UC contribution, you can find your 2013 premium in one of the following ways: Sign in to your personal account on At Your Service (atyourservice.ucop.edu) and follow these simple steps: • Beginning Oct. 29, choose “Open Enrollment” on the main menu under “Health & Welfare.” Your current medical plan with the 2013 premium will be displayed. • If you want to see the premiums for other medical plans, select “Medical Plans” in the left-hand column. The plans for which you are eligible and their premiums will be displayed.

If you have forgotten your password, select “Sign in to my accounts” on the front page of At Your Service (atyourservice. ucop.edu). Then select “Forgot your Password?” and enter your Username or SSN. You can have a temporary password sent to your email address on file, or gain access by answering the At Your Service Online (AYSO) Challenge Questions. If you do not have a current email on file with UC or if you have never set up a personal account on At Your Service, call UC Customer Service (800-888-8267) and they will help you set up an account or reset your password. You may want to bookmark the At Your Service website so you can reach it easily to check your benefits in the future.

If you need help with your password, see “How to retrieve your password” at right for more information. Use the Medical Plan Chooser (uc.chooser.pbgh.org) by following these simple steps: • Review and accept the terms and conditions and select “Begin Now.” • Then complete section 1 “Medical Plan Coverage.” You will be asked to enter your years of service/graduated eligibility. If you aren’t sure of your years of service/graduate eligibility percentage, check your address label on this booklet. The percent contribution is printed above your name. Enter this percentage. • Scroll to the bottom of the page and select “Start Comparing Plans.” The premiums for the plans for which you are eligible will be displayed. If you don’t have access to the Internet: Call UC Customer Service at 800-888-8267 and select option 6 to speak with an Open Enrollment Customer Service Representative. The representative can tell you the 2013 premium for your current plan or you can request that a printed version of the premiums for the plans for which you are eligible be mailed or faxed to you. If you want the printed version mailed to you, you must call by Nov. 8, 2012 to be sure it arrives before Open Enrollment ends.

7

Choosing the right medical plan for you and your family

UC offers you the choice of several excellent medical plans, all with the same comprehensive coverage including free preventive care, prescription drug coverage and much more.

UC Medicare Medical Plans

Your Monthly Premium

Anthem Blue Cross PLUS Use a PLUS network doctor for highest benefits; however, out-ofnetwork benefits are available when you use any Medicare doctor

$

Anthem Blue Cross PPO May use any Medicare doctor without referral from primary care physician

$0

Anthem Blue Cross PPO without Prescription Drugs May use any Medicare doctor without referral from primary care physician

$0

Core May use any Medicare doctor without referral from primary care physician

$0

Health Net Seniority Plus Must use network providers, except in emergencies

$0

High Option Supplement to Medicare May use any Medicare doctor without referral from primary care physician

$

Kaiser Permanente Senior Advantage Must use network providers, except in emergencies

$0

This chart provides a general overview of key features of UC’s medical plans to help you make the choice that is right for you and your family.

Your Cost for Services

Best Fit for People Who:

$

• Want fixed copay for in-network services

For in-network, Medicare & Plan pay most costs except for copays. For out-of-network, annual deductible applies and Plan pays nothing more after Medicare pays

• Are willing to pay higher cost per service for access to out-of-network Medicare providers

$

• Are willing to pay variable cost per service for provider choice

After Medicare pays deductible applies; then Plan pays 80% of the balance. You pay remainder

$ After Medicare pays, Plan pays 80% of the balance. You pay remainder (Prescription drugs not covered)

$$ After Medicare pays, you pay remainder until you reach maximum out-of-pocket cost

• Accept primary care physician model for in-network care

• Want direct access to Medicare providers without need for referrals • Have Medicare Part D prescription drug coverage through another employer’s retiree plan • Want direct access to Medicare providers without need for referrals • Are willing to pay variable out-of-pocket costs for lower monthly premium • Want direct access to Medicare providers without need for referrals

$

• Want lower cost per service

No deductible; you pay a copay for office visits and hospital stays; most other services have no charge

• Are comfortable with HMO model: primary care physician manages care; no out-ofnetwork coverage

$

• Are willing to pay higher premiums for nearly 100% coverage

After Medicare pays, Plan pays 100% of the balance

• Want direct access to all Medicare providers without need for referrals

$

• Want lower premiums and cost per service

No deductible; you pay a copay for office visits, prescriptions and hospital stays; most other services have no charge

• Are comfortable with getting medical care only within the Kaiser system

$ lowest costs in relation to all plans $$ mid-range of costs in relation to all plans $$$ highest costs in relation to all plans

8

Anthem Blue Cross PLUS Use a PLUS network doctor for highest benefits; however, out-of network benefits are available

Anthem Blue Cross PPO May use any doctor without referral from primary care physician; in-network providers cost less

Your Monthly Premium $$$

$$ Copay for in-network services; annual deductible for out-of-network services only and fewer out-of-pocket expenses for in-network services

$$$

$$$ Annual deductible and higher out-of-pocket expenses; separate in-network and out-of-network deductibles

Anthem Lumenos PPO with HRA* May use any doctor without referral from primary care physician; innetwork providers cost less. Health Reimbursement Account covers part of annual deductible before PPO benefits apply.

$

Core May use any doctor without referral from primary care physician; in-network providers cost less

$0

Health Net Blue & Gold HMO Must use network providers, except in emergencies

$$

Health Net HMO Must use network providers, except in emergencies

Your Cost for Services

$$$

Kaiser Permanente–CA Must use network providers, except in emergencies

$

Western Health Advantage Must use network providers, except in emergencies

$

2013 Health Benefits Open Enrollment for Retirees

UC NON-Medicare Medical Plans

Best Fit for People Who: • Want no deductible, fixed copay for in-network services • Are willing to pay higher premium for access to out-of-network providers • Accept primary care physician model for in-network care • Want direct access to all providers without need for referrals • Want access to in and out-of-network providers • Are willing to pay higher premiums and cost per service for provider choice

$$$

• Want lower premium and broad access to providers

You pay nothing until Health Reimbursement Account is used up; then you have out-of-pocket costs until deductible is met. You pay a coinsurance thereafter

• Are willing to take an active role in managing care and costs

$$$+

• Want no monthly premium

Except for certain preventive care, you pay the full cost until you reach the $3,000 deductible, then 20%

• Want protection for catastrophic care only

$

• Want lower premiums and cost per service

No deductible; you pay a copay for office visits and hospital stays; most other services have no charge

• Are comfortable with HMO model; primary care physician manages care; no out-of-network coverage

$

• Accept higher premium to get wider provider choice

No deductible; you pay a copay for office visits and hospital stays; most other services have no charge

• Want lower cost per service

$

• Want lower premiums and cost per service

No deductible; you pay a copay for office visits and hospital stays; most other services have no charge

• Are comfortable with getting medical care only within the Kaiser system

$

• Want lower premiums and cost per service

No deductible; you pay a copay for office visits and hospital stays; most other services have no charge

• Are comfortable with HMO model: primary care physician manages care; no out-of-network coverage

• Are able to risk incurring greater out-of-pocket costs • Want worldwide coverage for a reasonable premium

• Want direct access to all providers without need for referrals

• Are content with the selection of community providers

• Are comfortable with HMO model: primary care physician manages care; no out-of-network coverage

*Not open for new retiree enrollments

9

Your medical plan costs

The monthly costs for medical coverage below apply to retirees eligible for 100 percent of the UC/employer contribution toward the premium for each plan. If you are subject to graduated eligibility and, therefore, not eligible for the maximum UC/

Self in Medicare

Medicare Plans Anthem Blue Cross PLUS

Anthem Blue Cross PPO

Anthem Blue Cross PPO without Prescription Drugs Core

+A or +C Both in Medicare

employer contribution, your costs may be higher than those listed below. For more information about how to view your 2013 premiums, see page 7. Your plan cost appears as a deduction on your benefit check stub or direct deposit statement.

+F All in Medicare

+A 1 Adult in Medicare

+C Adult in Medicare

+F 1 Adult in Medicare

+F 2 Adults in Medicare

0.00

0.00

0.00

235.50

134.22

378.10

139.22

6.49

12.98

19.47

0.00

0.00

0.00

0.00

0.00

0.00

0.00

235.80

125.13

403.47

130.13

40.65

81.30

121.95

0.00

0.00

0.00

0.00

0.00

0.00

0.00

N/A

N/A

N/A

N/A

99.90

199.80

299.70

N/A

N/A

N/A

N/A

0.00

0.00

0.00

0.00

0.00

0.00

0.00

99.90

199.80

299.70

99.90

99.90

99.90

199.80

Health Net Blue & Gold/ Seniority Plus (non-Medicare & Medicare members)

N/A

N/A

N/A

173.66

87.44

276.13

92.44

N/A

N/A

N/A

0.00

0.00

0.00

0.00

Health Net Seniority Plus HMO

0.00

0.00

0.00

264.98

153.86

433.87

158.86

13.14

26.28

39.42

0.00

0.00

0.00

0.00

41.44

82.88

124.32

N/A

N/A

N/A

N/A

0.00

0.00

0.00

N/A

N/A

N/A

N/A

High Option Supplement to Medicare Kaiser Permanente– California

0.00

0.00

0.00

0.00

0.00

17.08

0.00

99.90

199.80

299.70

28.94

77.21

0.00

199.80

Kaiser Umbrella (closed to new members)

0.00

0.00

0.00

231.46

111.55

423.76

116.55

78.85

157.70

236.55

0.00

0.00

0.00

0.00

S: Self

+C: Self Plus Child(ren)

+A: Self Plus Adult

Dental Plan Costs

Plan Cost Key 0.00 99.90

Your Premium

Medicare Part B Reimbursement

Medicare Part B reimbursement may apply if your premium cost is $0.00. Part B reimbursement is based on a Medicare Part B premium of $99.90 per person. Reimbursements vary.

10

+F: Self Plus Adult and Child(ren)

UC continues to pay the full cost of dental coverage provided you are eligible for 100 percent of the UC/employer contribution. VISION PLAN The Vision Service Plan is not open for enrollment this year. Plan benefits and premiums are unchanged.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.

S

+C

+A

+F

Anthem Blue Cross PLUS

178.26

320.87

422.15

564.75

Anthem Blue Cross PPO

209.59

377.27

487.94

655.61

Anthem Lumenos PPO w/ HRA (closed to new retiree enrollment)

66.85

120.33

147.07

200.56

Core

0.00

0.00

0.00

0.00

Health Net Blue & Gold HMO

128.09

230.57

316.79

419.26

Health Net HMO

211.11

380.01

491.13

660.02

Kaiser Permanente–California

66.85

120.33

168.60

214.62

Kaiser Umbrella (closed to new members)

240.37

432.67

552.58

744.88

Western Health Advantage (WHA)

77.65

139.78

210.87

272.98

Non-Medicare Plans Age 65 and over, NOT Medicare eligible

S

+C

+A

+F

Anthem Blue Cross PLUS

111.48

200.66

288.91

378.08

Anthem Blue Cross PPO

142.81

257.06

354.70

468.94

Anthem Lumenos PPO w/ HRA (closed to new retiree enrollment)

45.72

82.30

102.61

139.18

Core

0.00

0.00

0.00

0.00

Health Net Blue & Gold HMO

61.31

110.36

183.55

232.59

Health Net HMO

144.33

259.80

357.89

473.35

Kaiser Permanente–California

45.72

82.30

102.61

139.18

Kaiser Umbrella (closed to new members)

173.59

312.46

419.34

558.21

Western Health Advantage (WHA)

45.72

82.30

102.61

139.18

Legal Plan MONTHLY Costs

AD&D Plan ANNUAL Costs

Self

$10.02

Coverage Amount

Self

Self+Spouse/Domestic Partner

Self+Children

$13.78

$10,000

$15.00

$20.00

Self+Adult

$13.78

$25,000

$37.50

$50.00

Self+Family

$15.03

$50,000

$75.00

$100.00

$250,000*

$375.00

$500.00

The monthly cost is not increasing.

2013 Health Benefits Open Enrollment for Retirees

Non-Medicare Plans

The annual cost is not increasing. *Available only if coverage as employee exceeded $250,000

11

If you need assistance

If you do not have internet access and need help making plan changes during Open Enrollment, contact the UC Customer Service Center (1-800-888-8267, Monday-Friday, 8:30 a.m.–4:30 p.m., PT). UC Customer Service for Hearing Impaired If you are hearing or speech impaired, call the California Relay Service and provide the UC Customer Service Center telephone number to receive assistance.

Plan Contact Information Call the plan directly if you need coverage information for a specific condition, prescription medication, service area, or plan provider. Medical Plan Carriers Anthem Blue Cross PLUS and Anthem Blue Cross PPO: 888-209-7975 anthem.com/ca/uc

Western Health Advantage: 888-563-2252 westernhealth.com/ members/ucd_active.cfm

Outside California: 1-800-688-4889 (text telephone) 1-800-947-8642 (voice)

Anthem Lumenos PPO with HRA: 888-209-7975 anthem.com/ca/uc

Health Care Facilitators

CORE: 888-209-7975 anthem.com/ca/uc

Behavioral Health Plan Optum: 888-440-8225 liveandworkwell.com (access code: 11280) 800-842-9489 (tdd)

Inside California: 1-800-735-2929 (text telephone) 1-800-735-2922 (voice)

Health Care Facilitators help retirees and their eligible family members to better understand and obtain services and benefits from UC-sponsored health plans and to resolve issues with doctors, medical groups, or medical carriers. There is no fee for their services, and the consultations are private and confidential.

High Option Supplement to Medicare: 888-209-7975 anthem.com/ca/uc

The Health Care Facilitators are located in the Benefits Offices at UC campuses, medical centers and laboratories.

Health Net HMO Health Net Blue & Gold HMO: 800-539-4072 healthnet.com/uc

DeltaCare® USA: 800-422-4234 deltadentalca.org/uc

Health Net/ Seniority Plus: 800-539-4072 healthnet.com/uc

ARAG Legal: 800-828-1395 members.araggroup.com/ ucop

Kaiser Permanente– California: 800-464-4000 my.kp.org/ca/ universityofcalifornia

AIG Benefit Solutions: 800-772-7863 chartisinsurance.com

Berkeley: Sharon Johnson 510-643-7547

Riverside: Mary Johnson 951-827-1425

Davis: Guerren Solbach 530-752-4264

Santa Barbara: Laura Morgan 805-893-4201

Irvine: Glenn Rodriguez 949-824-9065

Santa Cruz: Frank Trueba 831-459-3573

Los Angeles: Bridget Sheehan-Watanabe 310-794-3057

San Diego: Debra Wells 858-822-2197

Merced: Tina Machado 209-228-2348

San Francisco Susan Forstat 415-514-3324

Office of the President 510-987-0900

Lawrence Berkeley National Laboratory: Loida Bartolome-Mingao 510-486-6997

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Kaiser Permanente– Senior Advantage: 800-443-0815 my.kp.org/ca/ universityofcalifornia Kaiser Permanente Umbrella: Check your Kaiser card for member services phone number kp.org

Other Carriers Delta Dental PPO: 800-777-5854 deltadentalca.org/uc

Vision Service Plan: 866-240-8344 vsp.com/go.ucretirees StayWell: 800-721-2693 uclivingwell.ucop.edu

SUMMARIES OF BENEFITS AND COVERAGE ARE ONLINE Choosing a medical plan is an important decision, and UC offers a range of plans and coverage options. To help you make an informed choice, each of the medical plans makes available a Summary of Benefits and Coverage (SBC), which provides important information about that plan’s coverage in a standard format so that you can easily compare plans. The SBCs for UC’s non-Medicare plans—including information for behavioral health services from Optum (formerly United Behavioral Health)—are available online at atyourservice.ucop. edu/open_enrollment and on each plan’s website. Paper copies are also available, free of charge, by calling the plans (see page 12 for phone numbers).

The Women’s Health and Cancer Rights Act Annual Notification of Rights The Women’s Health and Cancer Rights Act of 1998 (Women’s Health Act) requires group medical plans such as those offered by UC that provide coverage for mastectomies to also provide certain related benefits or services. Under a UC-sponsored medical plan, a plan member (employee, retiree, or eligible family member) who receives a mastectomy and elects breast reconstruction in connection with the mastectomy must receive coverage for the following: reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; and prostheses and treatment of physical complications of the mastectomy, including lymphedema. Coverage will be provided in a manner determined in consultation with the patient’s physician and is subject to the same deductibles, coinsurance, and copayments that apply to other medical or surgical benefits covered under the plan. If you have questions, please contact your medical plan carrier or refer to your carrier‘s plan booklet for specific coverage.

Other notices online Under HIPAA (Health Insurance Portability and Accountability Act of 1996), you may have additional opportunities outside of Open Enrollment to enroll in a UC-sponsored medical plan—for instance, if you have lost eligibility for coverage in another plan. However, certain conditions apply. See the full HIPAA notice on the Open Enrollment website (atyourservice.ucop.edu).

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact your state Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your state Medicaid (Medi-Cal in California) or CHIP office or visit www.insurekidsnow.gov or dial 1-877-KIDS-NOW to find out how to apply. If you qualify, you can ask the state if it has a program that might help you pay the premiums for a UC-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, and that you are eligible under UC’s plan, UC will permit you to enroll in UC’s plan, if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you live in California, you can contact the California Department of Health Care Services for further information on eligibility at: Website: http://www.dhcs.ca.gov/services/ Pages/TPLRD_CAU_cont.aspx
Email: [email protected] If you live outside of California, please visit the UC Open Enrollment website (atyourservice.ucop.edu/open_enrollment/docs/chipra.pdf) for a list of states that currently provide premium assistance. The list is effective as of July 31, 2012, and includes contact information for each state listed. To see if any more states have added a premium assistance program since July 31, 2012, or for more information on special enrollment rights, you can contact: U.S. Department of Health and Human Services
 Centers for Medicare & Medicaid Services
 www.cms.hhs.gov
 1-877-267-2323, Ext. 61565

The Creditable Coverage notice pertaining to Medicare Part D prescription drug coverage is also available online. 13

2013 Health Benefits Open Enrollment for Retirees

Important notices

Terms and Conditions

Your Social Security number is required for purposes of benefit plan administration, for financial reporting, to verify your identity, or for legally required reporting purposes, all in compliance with federal and state laws. As a participant in UC-sponsored plans, you are subject to the following terms and conditions: 1. With the exception of benefits provided by Optum Health, UCsponsored medical plans require resolution of disputes through arbitration. With regard to each plan, IT IS UNDERSTOOD THAT ANY DISPUTE AS TO MEDICAL MALPRACTICE, THAT IS AS TO WHETHER ANY MEDICAL SERVICES RENDERED UNDER THE CONTRACT WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPETENTLY RENDERED, WILL BE DETERMINED BY SUBMISSION TO ARBITRATION AS PROVIDED BY CALIFORNIA LAW, AND NOT BY A LAWSUIT OR RESORT TO COURT PROCESS EXCEPT AS CALIFORNIA LAW PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. BOTH PARTIES TO THE CONTRACT, BY ENTERING INTO IT, ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF ARBITRATION. For more information about each plan’s arbitration provision, please see the appropriate plan booklet or call the plan. 2. UC and UC health plan vendors comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other federal/state regulations related to the privacy of personal health information. To fulfill their contracted responsibilities and services, health plans and associated service vendors may share UC member health information between and among each other within the limits established by HIPAA and federal/state regulations for purposes of health care operations, payment, and treatment. A member’s requested restriction on the sharing of specified protected health information for health care operations, payment and treatment will be honored as required by HIPAA. 3. By making an election with your written or electronic signature, you are authorizing the University to take deductions from your earnings (employees)/monthly Retirement Plan income (retirees) to cover your contributions toward the monthly costs, if any, for the plans you have chosen for yourself and your eligible family members. You are also authorizing UC to transmit your enrollment demographic data to the plans in which you are enrolled. 4. You are subject to all terms and conditions of the UC-sponsored plans in which you are enrolled as stated in the plan booklets and the University of California Group Insurance Regulations. 5. By enrolling individuals as your family members, you are certifying that those individuals are eligible for coverage based on the definitions and rules specified in the University of California Group Insurance Regulations and described in UC publications, “Group Insurance Eligibility Factsheet for Employees and Eligible Family Members” and “Group Insurance Eligibility Factsheet for Retirees and Eligible Family Members”. You are also certifying, under penalty of perjury, that all the information you provide regarding the individuals you enroll is true to the best of your knowledge.

14

6. If you enroll individuals as your family members you must provide, upon request, documentation verifying that those individuals are eligible for coverage. The carrier may also require documentation verifying eligibility. Verification documentation includes but is not limited to marriage or birth certificates, domestic partner verification, adoption papers, tax records, and the like.. 7. If your enrolled family member loses eligibility for UC-sponsored coverage (for example, because of divorce or loss of eligible child status), you must notify UC by de-enrolling that individual. If you wish to make a permitted change in your health or flexible spending account coverage, you must notify UC within 31 days of the eligibility loss event, although for purposes of COBRA eligibility, notice may be provided to UC within 60 days of the family member’s loss of coverage, However, regardless of the timing of notice to UC, coverage for the ineligible family member will end on the last day of the month in which the eligibility loss event occurs (subject to any continued coverage option available and elected.) 8. Making false statements about satisfying eligibility criteria, failing to timely notify the University of a family member’s loss of eligibility, or failing to provide verification documentation when requested may lead to de-enrollment of the affected family members. In addition, employees/retirees may be subject to disciplinary action and de-enrollment from health benefits for a period of up to 12 months and may be responsible for any UC-paid premiums due to enrollment of ineligible individuals. 9. Under current state and federal tax laws, the value of the contribution UC makes toward the cost of health coverage provided to certain family members who are not your “dependents” under state and federal tax rules may be considered imputed income that will be subject to income taxes, FICA (Social Security and Medicare), and any other required payroll taxes. 10. If you specifically ask UC representatives to intercede on your behalf with your insurance plan, University representatives will request the minimum necessary protected health information required to assist you with your problem. If more protected health information is needed to solve your problem, in compliance with state laws and federal privacy laws, including HIPAA (Health Insurance Portability and Accountability Act of 1996), you may be required to sign an authorization allowing UC to provide the insurance plan with relevant protected health information or authorizing the insurance plan to release such information to the University representative. 11. Actions you take during Open Enrollment will be effective the following January 1, unless otherwise stated—provided all electronic and form transactions have been completed properly and submitted timely.

If you are declining enrollment for yourself or your eligible family members because of other medical insurance or group medical plan coverage, you may be able to enroll yourself and your eligible family members* in a UC-sponsored medical plan if you or your family members lose eligibility for that other coverage (or if the employer stops contributing toward the other coverage for you or your family members.) You must request enrollment within 31 days after you or your family member’s other medical coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a newly eligible family member as a result of a marriage or domestic partnership, birth, adoption, or placement for adoption, you may be eligible to enroll your newly eligible family member. If you are an employee, you may be eligible to enroll yourself and your eligible family member(s). You must request enrollment within 31 days after the marriage or partnership, birth, adoption, or placement for adoption. If you decline enrollment for yourself or for an eligible family member because of coverage under Medicaid (in California, Medi-Cal) or under a state children’s health insurance program (CHIP), you may be able to enroll yourself and your eligible family members in a UC-sponsored plan if you or your family members lose eligibility for that coverage. You must request enrollment within 60 days after your coverage or your family members’ coverage ends under Medicaid or CHIP. Also, if you are eligible for health coverage from UC but cannot afford the premiums, some states have premium assistance programs that can help pay for coverage. For details, see the Notice provided in UC’s Open Enrollment booklet or call your Benefits Office. You may also contact the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services at www.cms.gov or 1-877-267-2323, ext. 61565. IF YOU DO NOT ENROLL YOURSELF AND/OR YOUR FAMILY MEMBER(S) IN MEDICAL COVERAGE WITHIN THE 31 DAYS WHEN FIRST ELIGIBLE, WITHIN THE SPECIAL ENROLLMENT PERIOD DESCRIBED ABOVE OR WITHIN AN OPEN ENROLLMENT PERIOD, YOU MAY BE ELIGIBLE TO ENROLL AT A LATER DATE. However, even if eligible, each member will need to complete a waiting period of 90 consecutive calendar days before medical coverage becomes effective and your premiums may need to be paid on an after-tax basis, or you/ they can enroll during the next Open Enrollment Period.

* TO BE ELIGIBLE FOR PLAN MEMBERSHIP, YOU AND YOUR FAMILY MEMBERS MUST MEET ALL UC EMPLOYEE OR RETIREE ENROLLMENT AND ELIGIBILITY REQUIREMENTS. AS A CONDITION OF COVERAGE, ALL PLAN MEMBERS ARE SUBJECT TO ELIGIBILITY VERIFICATION BY THE UNIVERSITY AND/OR INSURANCE CARRIERS, AS DESCRIBED ABOVE IN THE PARTICIPATION TERMS AND CONDITIONS. By authority of The Regents, University of California Human Resources, located in Oakland, administers all benefit plans in accordance with applicable plan documents and regulations, custodial agreements, University of California Group Insurance Regulations, group insurance contracts, and state and federal laws. No person is authorized to provide benefits information not contained in these source documents, and information not contained in these source documents cannot be relied upon as having been authorized by The Regents. Source documents are available for inspection upon request (1-800-888-8267). What is written here does not constitute a guarantee of plan coverage or benefits--particular rules and eligibility requirements must be met before benefits can be received. The University of California intends to continue the benefits described here indefinitely; however, the benefits of all employees, retirees, and plan beneficiaries are subject to change or termination at the time of contract renewal or at any other time by the University or other governing authorities. The University also reserves the right to determine new premiums, employer contributions and monthly costs at any time. Health and welfare benefits are not accrued or vested benefit entitlements. UC’s contribution toward the monthly cost of the coverage is determined by UC and may change or stop altogether, and may be affected by the state of California’s annual budget appropriation. If you belong to an exclusively represented bargaining unit, some of your benefits may differ from the ones described here. For more information, employees should contact your Human Resources Office and retirees should call UC Customer Service (1-800-888-8267). In conformance with applicable law and University policy, the University is an affirmative action/equal opportunity employer. Please send inquiries regarding the University’s affirmative action and equal opportunity policies for staff to Systemwide AA/EEO Policy Coordinator, University of California, Office of the President, 1111 Franklin Street, 5th Floor, Oakland, CA 94607, and for faculty to the Office of Academic Personnel, University of California Office of the President, 1111 Franklin Street, Oakland, CA 94607.

To request special enrollment or obtain more information, employees should contact your local Benefits Office and retirees should call UC Customer Service (1-800-888-8267). Note: If you are enrolled in a UC medical plan, you may be able to change medical plans if:

• you acquire a newly eligible family member; or • your eligible family member loses other coverage. In either case, you must request enrollment within 31 days of the occurrence.

15

2013 Health Benefits Open Enrollment for Retirees

HIPAA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996) NOTIFICATION FOR MEDICAL PROGRAM ELIGIBILITY

University of California Human Resources P.O. Box 24570 Oakland, CA 94623-1570

2013 Health Benefits OPEN ENROLLMENT for RETIREES

2050-RET 10/12 43M

Presorted First Class Mail US Postage Paid University of California