Download Arizona State Retirement System Plan Benefit Information for

Arizona State Retirement System Plan Benefit
Information for Medicare Eligible Members
Benefits Effective January 1, 2012
UHAZ12HM3349753_000
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Summary of the UnitedHealthcare® plans available to
retirees of the Arizona State Retirement System (ASRS)
The following plan options are being offered for 2012:
UnitedHealthcare® Group Medicare Advantage (HMO)
Each covered individual must choose a primary care physician (PCP) from the HMO’s network of providers.
Keep in mind, providers in the network may change at any time.
• W hen a covered individual needs health care, he or she must visit their PCP. The PCP will either provide care
or refer the individual to a specialist in the HMO network.
• If care is received from the PCP or a referred network physician, you generally make a copay. If care is received
from a non‑network provider, you’ll have to pay the full cost. If your PCP refers you to a specialist or other
physician, it’s important that you always check first to be sure the physician is a network provider.
This Medicare Advantage Plan includes a Medicare Part D drug benefit. You automatically receive prescription
drug coverage when you enroll in this plan.
UnitedHealthcare® RxSupplement™
This plan provides supplemental prescription drug coverage while in the coverage gap. With this plan, your
coverage remains the same. You will continue to pay the same copayment or coinsurance while in the coverage
gap as you did before you entered the coverage gap. Enrollment in the supplement plan is automatically
included as part of your coverage when you enroll in the UnitedHealthcare Group Medicare Advantage (HMO)
plan.
UnitedHealthcare® Senior Supplement Plan
• The UnitedHealthcare Senior Supplement Plan is an indemnity health care plan that supplements Medicare
coverage.
• This plan is designed to help pay for some or all the out‑of‑pocket costs that Medicare doesn’t fully cover.
• In general, the plan covers services that are allowed or covered by Medicare including:
‑ Medicare deductibles for inpatient hospital stays
‑ Medicare Part B deductible
‑ Most copays and coinsurances
• However, enrollment in the plan does offer some additional programs not covered by Medicare such as:
‑ A fitness program
‑ Resources to help make caring for a spouse or family member easier
‑ Access to a nurseline
• Other features of the plan include:
‑ The ability to receive care from any health care provider who participates in Medicare and is eligible to
receive payment from Medicare.
‑ No requirement to choose a primary care physician or to obtain a referral to see a specialist.
You are automatically enrolled in the prescription drug plan with UnitedHealthcare® MedicareRx when you
enroll in the UnitedHealthcare Senior Supplement plan.
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UnitedHealthcare® MedicareRx for Groups (PDP)
This Medicare Part D plan provides coverage for your prescription drugs.
• A broad formulary that covers 100% of Medicare‑eligible drugs.
• A national network of over 65,000 pharmacies.
These plans are part of the Medicare program, with all the rights and protections under Original Medicare —
but they have been customized by ASRS to provide you with additional benefits. Please review the following
pages for plan details.
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UnitedHealthcare® Group Medicare Advantage (HMO)
Medical Benefits
Your In‑Network Cost (unless otherwise noted)
Annual out‑of‑pocket maximum
Your plan has an annual out‑of‑pocket maximum of $6,700
each plan year.
Doctor Office Visits
Primary care physician
$15 copay
Specialist
$30 copay
Preventive Care
Annual physical
$0 copay
Prostate cancer screening
$0 copay
Breast cancer screening
$0 copay
Immunizations
$0 copay
Inpatient Care
Inpatient hospital care
$100 copay per admission
Skilled Nursing Facility (SNF) care
$0 copay, up to 100 days
Home Health Care
$0 copay
Hospice
$0 copay
Outpatient Services
Outpatient mental health care ‑
individual therapy session
$30 copay
Outpatient mental health care ‑
group therapy session
$15 copay
Radiation therapy
$0 copay
Outpatient surgery and
hospital services
$100 copay
Outpatient rehabilitation services
$15 copay
Durable medical equipment (DME)
$0 copay
Part B Drugs
$0 copay
Lab Services
Laboratory tests
$0 copay
X‑rays
$0 copay
Diagnostic radiology services
$50 copay
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Medical Benefits
Your In‑Network Cost (unless otherwise noted)
Emergency Services
Ambulance services
$25 copay
Emergency care
(waived if admitted to the hospital)
$50 copay
Urgently needed care
(waived if admitted to the hospital)
$15 copay
Medicare‑Covered Physician Services
Chiropractic services
(routine chiropractic care
not covered)
$15 copay
Podiatry services
$30 copay
Eye exam
$30 copay
Hearing exam
$30 copay
Additional Benefits and Programs Not Covered Under Medicare
Hearing Services
Routine hearing exams
(1 exam every 12 months)
Hearing aids (every 36 months)
$0 copay
Up to $500
Vision Services
Routine eye exam (refraction)
(1 exam every 12 months)
Routine eyewear or contact lenses
SilverSneakers® Fitness program
NurseLineSM Services
UnitedHealth Passport® Program
Solutions for Caregivers*
$20 copay
Up to $130 eyewear allowance every 12 months.
Up to $105 contact lens allowance in lieu of eyewear allowance
every 12 months
Membership in a senior fitness program at no additional cost to you
Health and well‑being programs provided through OptumHealthSM
Your health care coverage travels with you
Provides support for caregivers
*The product and services described above is neither offered nor guaranteed under our contract with
the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes
regarding these products and services may be subject to the UnitedHealthcare Group Medicare Advantage
grievance process.
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Prescription Drugs
Your Cost
Network Pharmacy (for up to a 31‑day supply)
Tier 1 ‑ Preferred Generic
$20 copay
Tier 2 ‑ Preferred Brand
$40 copay
Tier 3 ‑ Non‑preferred
$40 copay
Tier 4 ‑ Specialty Drug
$40 copay
Coverage in the Gap
Yes
Mail Service Pharmacy (up to a 90‑day supply)
Tier 1 ‑ Preferred Generic
$40 copay
Tier 2 ‑ Preferred Brand
$80 copay
Tier 3 ‑ Non‑preferred
$80 copay
Tier 4 ‑ Specialty Drug
$80 copay
Coverage in the gap
Catastrophic coverage stage (after
you have paid $4,700 out‑of‑pocket)
Yes
The greater of $2.60 copay for generic,
$6.50 copay for brand‑name, or 5% coinsurance
Bonus drugs included.
Doctor and Hospital Choice
In most cases, you must go to network doctors, specialists and hospitals in order to have services covered by the
UnitedHealthcare Group Medicare Advantage (HMO) plan. You must select a Primary Care Physician (PCP) and get a
referral to see network specialists. You need prior authorization to go to non‑network doctors, specialists or hospitals.
Emergency and urgently needed services never require prior authorization.
Physician Services, including doctor office visits
Covered services include:
• Office visits, including medical and surgical care in a physician’s office or certified ambulatory surgical center
• Consultation, diagnosis, and treatment by a specialist
• Hearing and balance exams, if your doctor orders it to see if you need medical treatment
• Telehealth office visits including consultation, diagnosis and treatment by a specialist
• Second opinion by another network provider prior to surgery
• Outpatient hospital services
• Non‑routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of
the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or
services that would be covered when provided by a doctor)
Choose Your Primary Care Physician
There are three ways to select a Primary Care Physician within our network: geographically, if you’re looking for a
Primary Care Physician (PCP) in a convenient area; hospital preference, if you would like to use a specific hospital; or
physician preference, if you have a specific physician you prefer to use. Your PCP may be a family practitioner, general
practitioner or an internist.
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UnitedHealthcare® Senior Supplement Plan
Medical Benefits
Your In‑Network Cost (unless otherwise noted)
Annual out‑of‑pocket maximum
$6,700 per calendar year
Covered Service
Medicare Pays
UnitedHealthcare
Pays
You Pay
Inpatient Care
Inpatient hospital Deductible
(Applies to inpatient hospital
and inpatient mental health
benefits only)
$150 per
covered person
Semi‑private room and board,
general nursing and miscellaneous
services and supplies
Part A Hospital — first 60 days
All but $1,132
$1,132
(Part A Deductible)
$0
Part A Hospital — 61–90 days
All but $283 per day
$283 per day
$0
Part A Hospital — day 91 and after:
While using 60 lifetime reserve days
All but $566 per day
$566 per day
$0
After 60 lifetime reserve days
are used
• 365 lifetime additional days
$0
100% of Medicare
Eligible Expenses
$0
Beyond 365 lifetime additional days
$0
$0
All costs
$0
100%
$0
100%
Not covered
$0
Blood
Blood — First 3 pints Medicare
Parts A or B
Additional amounts under
Medicare Part A
Skilled Nursing Facility Care
You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entering the
Medicare approved facility within 30 days of leaving the hospital.
Days 1 – 20
Days 21 – 100
Days 101 and after
All approved amounts
$0
$0
All but $141.50
per day
All but $141.50
per day
$0
$0
$0
All costs
(These Medicare amounts listed are for 2011 and may change for 2012.)
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Medicare Pays
UnitedHealthcare
Pays
You Pay
All but very limited
coinsurance for
outpatient drugs and
inpatient respite care
100%
$0
All approved amounts
Balance
$0
Covered Service
Hospice Care
Available as long as your doctor
certifies you are terminally ill and
you elect to receive these services.
Home Health Care
Skilled Care Services and
Medical Supplies
Outpatient Services
Emergency Care
(waived if admitted to the hospital)
$50
Urgently Needed Services
$25
Durable Medical Equipment
First $162 of Medicare
Approved Amounts
$0
$162
(Part B Deductible)*
$0
Remainder of Medicare
Approved Amounts
80% of
approved amounts
20% of
approved amounts
$0
Medical Services
Includes services such as Physician services, inpatient and outpatient medical and surgical services and
supplies, physical and speech therapy and diagnostic tests.
First $162 of Medicare
Approved Amounts
$0
$162
(Part B Deductible)*
$0
Remainder of Medicare
Approved Amounts
Generally 80%
Generally 20%
$0
Physician Office Visits
Generally 80%
100% Coinsurance
less $15
$15
Outpatient Hospital Services
Outpatient Mental Illness
• For most outpatient mental
illness services
Part B Excess Charges
(above Medicare Approved Amounts)
$50
55%
45%
$0
$0
$0
All costs
* Once you have been billed $162 of Medicare Approved Amounts for covered services (which are noted with an
asterisk), your Part B Deductible will have been met for the calendar year.
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Medicare Pays
UnitedHealthcare
Pays
You Pay
First $250 each calendar year
$0
$250
$250
Remainder of charges
$0
80% up to a lifetime
maximum benefit of
$50,000
20% and all amounts
over the $50,000
lifetime maximum
Covered Service
Foreign Travel
Medically Necessary Emergency
Care services beginning during the
first 6 months of each trip outside
the United States
(These Medicare amounts listed are for 2011 and may change for 2012.)
Supplemental Routine Vision Benefit
Limited to 1 Time
Every 12 Months
Your In‑Network Costs
Your Out‑of‑Network Costs
$20
$20
Routine Eye Refraction (examination)
$0 after deductible satisfied
Charges in excess of $80
Eyeglass Lenses
(Standard single, bifocal and trifocal)
$0 covered in full
Deductible
Eyeglass Frames
Charges in excess of $130
retail allowance
Contact Lenses
(in lieu of eyeglasses)
Charges in excess of $105
retail allowance
Charges in excess of
$100 for lenses, frames,
or contacts combined
Please contact our vision provider OptumHealth Vision at 1‑800‑638‑3120 to find a participating vision provider or visit
the website at www.myoptumhealthvision.com.
This Supplemental Routine Vision Benefit is available with the UnitedHealthcare Senior Supplement insurance plan.
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UnitedHealthcare Senior Supplement Part B
Prescription Drugs
Medicare Part B Prescription Drugs — Covered under the Medical Benefit
Includes coverage for immunizing agents, biological sera, blood or blood plasma, or drugs (except insulin)
prescribed for intravenous or intramuscular use or administration when authorized by your doctor and in
accordance with Medicare guidelines.
Medicare Part B‑Covered Immunosuppressive Drugs
Covered according to Medicare guidelines. (Following a Medicare‑approved organ transplant in accordance
with Medicare guidelines.)
Medicare Part B‑Covered Oral Chemotherapy Drugs Including Anti‑nausea Drugs
Covered according to Medicare guidelines.
Medicare Part B‑Covered Inhalation Solutions
Covered according to Medicare guidelines.
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Outpatient Prescription Drugs Through
UnitedHealthcare® MedicareRx for Groups (PDP)
Medicare Benefits
Outpatient
Benefits
Prescription
Drugs
You pay:
100%
for most
prescription
drugs, unless
you enroll in
the Medicare
Part D
Prescription
Drug Program
UnitedHealthcare MedicareRx for Groups (PDP)
When total
When true
drug costs out‑of‑pocket
are:
costs are:
You pay:
Retail Pharmacy
$10 copay for a one‑month (31‑day) supply of
Tier 1 drugs.
$30 copay for a three‑month (90‑day) supply of
Tier 1 drugs.
$35 copay for a one‑month (31‑day) supply of
Tier 2, Tier 3 or Specialty Tier drugs.
$105 copay for a three‑month (90‑day) supply of
Tier 2, Tier 3 or Specialty Tier drugs.
Between
$0–$2,930
Long‑Term Care Pharmacy
$10 copay for a one‑month (31‑day) supply of
Tier 1 drugs.
$35 copay for a one‑month (31‑day) supply of
Tier 2, Tier 3 or Specialty Tier drugs.
Mail Service Pharmacy
$20 copay for a three‑month (90‑day) supply of
Tier 1 drugs you get through mail service.
$70 copay for a three‑month (90‑day) supply of
Tier 2, Tier 3 or Specialty Tier drugs you get
through mail service.
Greater than
$2,930
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Less than
$4,700
You pay 86% of the cost of generic drugs and
about 50% of the cost of most brand‑name
drugs, until your True Out‑of‑Pocket costs reach
$4,700
Greater than
$4,700
$2.60 for generics (including brand drugs
treated as generic) and $6.50 for all other
drugs, or 5% coinsurance, whichever is greater
Additional
Programs
Your Additional
Benefits
and Services
Programs.
Both
the UnitedHealthcare
Medicare
Advantage
Your plan
provides the sameGroup
coverage
as Medicare
Parts (HMO)
A and B,
and
the
Senior
Supplement
plan
provide
additional
programs
plus many additional benefits and programs that contribute
toand
your
services
that
contribute
to
your
health
and
wellness.
They
include:
health and wellness. They may include:
NurseLine Services
SM
Speak with a registered nurse, 24 hours a day, 7 days a week.
• Discuss your health and diet.
• Review or discuss your medications.
• Receive information about illnesses and injuries.
• Get tips on working with your doctor.
SilverSneakers® Fitness Program
Stay physically fit and active with the SilverSneakers Fitness Program. This fitness program is available
to you at no additional cost.
With the SilverSneakers Fitness Program you’ll receive:
• A basic fitness center membership at more than 11,000 participating locations.
• Access to all amenities, programs and services that are standard with a basic fitness center membership.
• Nationwide access to any participating fitness location (find locations at www.silversneakers.com).
• Many women-only locations, including Curves,® are available nationwide.
If the nearest participating location is 15 miles or more away from your home, you can register for
the SilverSneakers® Steps program. This is a personalized program that provides tools such as resistance
bands, exercise DVDs and “how-to” material to help you measure, track and increase your daily activity.
The products and services described below are neither offered nor guaranteed under our contract with the
Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding
these products and services may be subject to the UnitedHealthcare grievance process.
Solutions for Caregivers
Providing care for a loved one can be demanding and overwhelming. This plan gives you access to
Solutions for Caregivers – a program that supports you, your family and your loved ones.
Services provided by Solutions for Caregivers include:
• On-site assessment and development of a personalized care plan for you or your loved one.
• Unlimited phone access to a Care Specialist who can provide counsel on individual, medical, financial,
safety, emotional and social needs.
• Connections with professionals, including home health aides, nurses, lawyers and financial advisors.
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The UnitedHealth Passport® program.
The UnitedHealth Passport® program offers coverage for members who travel or live away from home up to
nine consecutive months during the year. Whether you plan a scenic road trip or extended stay, when you travel
within the UnitedHealth Passport service area, you will have health care coverage in the event you need it.
This program is included with your plan. You pay no additional charge for health care coverage when you
travel within the UnitedHealth Passport service area. You simply pay the same copay or coinsurance as you
would at home.
Enrolling in Your Selected Plan(s)
Health Plan Premium
In most cases, ASRS is responsible for making payment of any applicable Health Plan Premium directly to
us on behalf of its enrolled Plan Members and their eligible dependent(s). ASRS determines the amount of
any retiree subscriber contribution toward Health Plan Premiums. Some Plan Sponsors, however, have made
arrangements with us to bill you, the Member, directly for Health Plan Premiums. If this is the case, your
monthly Health Plan Premium is due on the first day of each month for the prior month’s coverage. Refer to the
ASRS Enrollment Guide for your Monthly Health Plan Premium amount.
Complete the Enrollment Form
Having determined the plan or plans that meet your needs, you are now ready to complete the ASRS enrollment
form(s). These forms are available in this enrollment kit or from ASRS. Keep in mind it is important to press
firmly with your pen when completing the enrollment form. We need to be able to read all copies.
Return the Enrollment Form
Now mail the completed form to the address listed below.
Arizona State Retirement System ASRS/PSPRS
Attn: Health Insurance
P.O. Box 33910
Phoenix, AZ 85067
Public Safety Personnel Retirement System
Attn: Health Insurance
3010 E. Camelback Rd., Suite 200
Phoenix, AZ 85016
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Questions?
Call Customer Service toll‑free:
UnitedHealthcare Group Medicare Advantage (HMO)
1‑877‑714‑0178, TTY 711
8 a.m. – 8 p.m. local time, 7 days a week
UnitedHealthcare Senior Supplement Insurance Plan
1‑866‑480‑1087, TTY 711
8 a.m. – 8 p.m. local time, 7 days a week
UnitedHealthcare MedicareRx for Groups (PDP)
1‑888‑556‑6648, TTY 711
8 a.m. – 8 p.m. local time, 7 days a week
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UnitedHealthcare Senior Supplement is not a Medicare Supplement plan. This is an employer group retiree
plan and may provide coverage that is different from a Medicare Supplement plan.
UnitedHealthcare Senior Supplement and Senior Security group retiree plans are underwritten by
UnitedHealthcare Insurance Company, a private insurance company not connected with or endorsed by the
U.S. Government or the federal Medicare program. Senior Supplement and Senior Security plans may not be
available in all states. UnitedHealthcare is part of the UnitedHealth Group family of companies.
UnitedHealthcare® Medicare Advantage plans are insured through UnitedHealthcare Insurance Company
and its affiliated companies, a Medicare Advantage organization with a Medicare contract. Members may
enroll in the plan only during specific times of the year. Contact UnitedHealthcare for more information. You
must have both Medicare Parts A and B to enroll in the plan. Retiree plan prospects must meet the
eligibility requirements to enroll for group coverage. The benefit information provided herein is a brief
summary, not a comprehensive description of benefits. For more information contact the plan. You must
continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third
party. Limitations, copayments, and restrictions may apply. HMO members must use plan providers
except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain
routine care from out-of-network providers neither Medicare nor UnitedHealthcare® Medicare
Advantage plans will be responsible for the costs.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify
for Extra Help, call: 1‑800‑MEDICARE (1‑800‑633‑4227). TTY users should call 1‑877‑486‑2048,
24 hours a day/7 days a week; the Social Security Office at 1‑800‑772‑1213 between 7 a.m. and 7 p.m.,
Monday through Friday. TTY users should call 1‑800‑325‑0778; or your Medicaid Office. You must use
contracted network pharmacies to access your Part D prescription drug benefit except under non‑routine
circumstances, in which case quantity limitations and restrictions may apply.
OptumHealth` is a health and well‑being company that provides information and support as part of your
health plan. NurseLine` nurses cannot diagnose problems or recommend specific treatment and are not a
substitute for your doctor’s care. NurseLine services are not an insurance program and may be discontinued
at any time.
Solutions for Caregivers assists in coordinating community and in‑home resources. The final decision about
your care arrangements must be made by you. In addition, the quality of a particular provider must be solely
determined and monitored by you. Information provided to you about a particular provider does not imply
and is in no way an endorsement of that particular provider by Solutions for Caregivers. The information on
and the selection of a particular provider has been supplied by the provider and is subject to change without
written consent of Solutions for Caregivers.
SilverSneakers® is a registered mark of Healthways, Inc. Consult a health care professional before beginning
any exercise program.
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