GIC Benefit Decision Guide - City of Somerville

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GIC Benefit Decision Guide - City of Somerville

2013-2014GIC BenefItDeCIsIonGuIDeFOR COMMONWEALTH OF MASSACHUSETTSMunICIpalEMPLOYEES, RETIREES & SURVIVORSBenefits and Rates Effective July 1, 2013HEALTH CARE IS CHANGING –Evaluate Your Options Carefully!


NEW HIRE AND ANNUAL ENROLLMENT OVERVIEWAnnual enrollment gives you the opportunityto review your benefit options and enroll in ahealth plan or make changes if you desire.If you are a current municipal enrollee and want to keepthe same GIC health plan, you do not need to fill out anypaperwork. Your coverage will continue automatically.NEW EMPLOYEESWithin 10 Calendar Days of HireGIC benefits begin on the first dayof the month following 60 days ortwo full calendar months,whichever comes first.EMPLOYEES, GIC RETIRED MUNICIPALTEACHERS (RMTs) CONVERTINGTO MUNICIPAL COVERAGE andNON-MEDICARE RETIREES/SURVIVORSDuring Annual EnrollmentApril 10-May 8, 2013for changes effective July 1, 2013MEDICARE RETIREES/SURVIVORSand RETIRED MUNICIPALTEACHERS (RMTs) CONVERTING TOMUNICIPAL COVERAGE●●You may enroll in one ofthese health plans:●●●●●●●●●●●Fallon Community Health Plan Direct CareFallon Community Health Plan Select CareHarvard Pilgrim Independence PlanHarvard Pilgrim Primary Choice PlanHealth New EnglandNHP Care (Neighborhood Health Plan)Tufts Health Plan NavigatorTufts Health Plan SpiritUniCare State Indemnity Plan/BasicUniCare State Indemnity Plan/Community ChoiceUniCare State Indemnity Plan/PLUSBy submitting within 10 daysof employment…GIC enrollment forms; andRequired documentation forfamily coverage (if applicable) asoutlined in the Forms section ofour website to the GIC Coordinatorin your benefits officeNOTE: Current employees who lose healthinsurance coverage elsewhere may enroll inGIC health coverage during the year withproof of involuntary loss of coverage. Seeyour municipality’s GIC Coordinator for details.Once you choose a health plan,you cannot change plans until thenext annual enrollment, even if yourdoctor or hospital leaves the healthplan, unless you move out of theplan’s service area or become eligiblefor Medicare (in which case youmust switch plans).Indicates this is a GIC LimitedNetwork Plan.You may enroll in or change yourselection of one of these health plans:You may enroll in...Retiree Dental Plan*By submitting by May 8…New GIC Enrollees, including GICRMTs converting to municipalcoverage, and Active Employees:GIC enrollment forms and, if notalready enrolled in a GIC plan or anRMT, required documentation asoutlined on the Forms section of ourwebsite to the GIC Coordinator inyour benefits officeExisting Municipal Retirees/Survivors: Medicare or Non-Medicare enrollment/change formor written request to the GIC askingfor the changeRetiree Dental Form to the GICCoordinator in your benefits office2●●●●●●You may change your selection ofone of these health plans:Fallon Senior PlanHarvard Pilgrim MedicareEnhanceHealth New England MedPlusTufts Health Plan MedicareComplementTufts Health Plan MedicarePreferredUniCare State Indemnity Plan/Medicare Extension (OME)You may enroll in...Retiree Dental Plan*By submitting by May 8…New Municipal Retirees/Survivorsand GIC RMTs converting tomunicipal coverage: GIC MunicipalityEnrollment Forms and, if notan RMT, required documentation asoutlined on the Forms section of ourwebsite to the GIC Coordinator inyour benefits officeExisting Municipal Retirees/Survivors: Medicare or Non-Medicare enrollment/change formor written request to the GIC askingfor the changeRetiree Dental Form to the GICCoordinator in your benefits office* See page 32 for eligibility details.• Enrollment and application forms are available on our websitewww.mass.gov/gic/forms – and through the GIC Coordinator in your benefits office.• Current Retirees/Survivors: for written requests to make a health plan change,include your name, address and GIC identification number.


ANNUAL ENROLLMENT NEWSGIC Chooses Health Plans for FY14 – FY19Procurement Emphasizes Improving the Way WeGet and Pay for Health Care ServicesAll GIC health plan contracts come to an end on June 30, 2013,so the agency went out to bid last fall to select plans for the newfive-year contract period. The procurement incorporated the basicelements of Chapter 224, the state’s new Health Care PaymentReform law, as well as the federal Affordable Care Act. Bothlaws emphasize coordinated care, price transparency, and newways of paying providers – shifting from fee for service to someform of global payment. The new laws also emphasize primarycare as the focal point for achieving better patient care, betterpopulation health, and lower per capita costs. The GIC used itsprocurement to require plans to work with providers to establishintegrated systems of care, and offered financial incentives forachieving budget targets and adopting the new paymentsystems, or penalties for not achieving these benchmarks.What does this mean to members?● You are encouraged to designate a Primary Care Provider (PCP)with your health plan;● You can now choose a nurse practitioner or physician assistantas your PCP;● You should get more coordinated, integrated care;● You have incentives to use quality, lower-cost providers; and● Your premiums should stabilize or even go down over the nextfew years.Health Plan Options Remain the Same, NoMajor Benefit Changes, and Excellent RatesAfter a rigorous procurement, the Commission awarded newcontracts to all of the GIC’s incumbent vendors and their currentplan offerings:● Fallon Direct Care, Select Care, and Senior Plan● Harvard Pilgrim Independence, Primary Choice and MedicareEnhance Plans● Health New England HMO and MedPlus● Neighborhood Health Plan – NHP Care● Tufts Health Plan Navigator, Spirit, Medicare Complement, andMedicare Preferred● UniCare State Indemnity Plan/Basic, Community Choice,Medicare Extension (OME), and PLUSThe GIC’s aggressive approach to bending the cost curvebenefits both members and Commonwealth taxpayers. Notonly were we able to avoid cutting benefits, we were alsoable to add required new state- and federal-mandated benefits,and some modest benefit enhancements, while also achievingan overall 3.5% premium increase for FY14. This comparesextremely favorably to other employer trends, which according toMercer’s fall National Survey of Employer-Sponsored HealthPlans, will increase by an average of 7.4% in 2013 if they do notcut benefits.Clinical Performance Improvement (CPI)Initiative Continues – Select & SaveBe sure to consider physician and hospital tiers when choosing aprovider. Employees and Non-Medicare Retirees/Survivorspay the lowest copay for Tier 1 doctors and hospitals. The GIC’sClinical Performance Improvement (CPI) initiative gives you anincentive to use doctors with higher quality and/or costefficiencyscores. Millions of physician claims are analyzed fordifferences in how physicians perform on nationally recognizedmeasures of quality and/or cost efficiency. You pay the lowestcopay for the highest-performing doctors:★ ★ ★ Tier 1 (excellent)★ ★ Tier 2 (good)★ Tier 3 (standard)Physicians for whom there is not enough data and non-tieredspecialists are assigned a plan’s Tier 2 copay.During annual enrollment, checkyour doctor’s and hospital’s tier, as they canchange each July 1 with new data.Does Your Current Health Plan Still MeetYour Needs?During Annual Enrollment, employees and Non-Medicareretirees/survivors may wish to consider a limited network plan,which offers the same great benefits as wider network plans, butsaves you money because there are fewer doctors and hospitalsin the network. See page 8 for additional details.If you want to keep your current GIC healthplan, you do not need to fill out any paperwork.Your coverage will continue automatically.5


CHOOSE THE BEST HEALTH PLAN FOR YOU AND YOUR FAMILYSTEP 1:IDENTIFY which plan(s) you are eligible to join:● Determine if you are eligible for Medicare (see page 11).●●Where you live determines which plan(s) you may enroll in.See the map on page 9 for Employee/Non-Medicare planlocations and page 12 for Medicare plan locations.See each health plan page for eligibility details(see pages 15-31).Do YourHomework DuringAnnual Enrollment—Even If YouWant to Stayin the SameHealth PlanSTEP 2:For the plans you are eligible to join and are interested in….● REVIEW their benefit summaries (see pages 15-31).● WEIGH features that are important to you, such as out-of-network benefits, prescriptiondrug coverage and mental health benefits.● REVIEW their monthly rates (see separate rate chart).● CONSIDER enrolling in a limited network plan if you are an employee or Non-Medicareretiree/survivor – you will save money on your monthly premium (see page 8).● CONTACT the plan to find out about benefits that are not described in this guide.STEP 3:Find out if your doctors and hospitals are in the plan’s network. Call the plan or go to theplan’s website and search for your doctors and hospitals. Be sure to specify the health plan’s fullname, such as “Harvard Pilgrim Primary Choice Plan” or “Harvard Pilgrim Independence Plan,” notjust “Harvard Pilgrim.”Keep in mind that if your doctor or hospital leaves your health plan’snetwork during the year, you must stay in the plan until the next annualenrollment. The health plan will help you find another provider.STEP 4:Check on copay tier assignments that affect what you pay when you get physician or hospitalservices. (Copay tiers do not apply to the GIC Medicare plans.)Physician and hospital copay tiers can change each July 1 for GICEmployee and Non-Medicare Retiree/Survivor plans. During annualenrollment, check to see if your doctor’s or hospital’s tier has changed.THREE GREAT RESOURCES1 The plan’s website: Get additional benefit details, information about network physicians, tools tomake health care decisions and more. See page 35 for website addresses.2 The health plan’s customer service line: A representative can help you. See page 35 for phonenumbers.3 A GIC Health Fair: Talk with plan representatives and get personalized information and answers toyour questions. See page 34 for the health fair schedule.7


CALENDAR YEAR DEDUCTIBLE QUESTIONS AND ANSWERSAll GIC Employee and Non-Medicare retiree/survivorhealth plans include a calendar year deductible. The in-networkdeductible is $250 per member to a maximum of $750 per family.This is a fixed dollar amount you must pay before your healthplan begins paying benefits for you or your covered dependent(s).These deductible amounts are less than half of those charged bythe majority of employers.Deductible Questions and AnswersQAQAWhat is a deductible?This is a fixed dollar amount you must pay each calendaryear before your health plan begins paying benefits for youor your covered dependent(s). This is a separate charge fromany copays.How much is the in-network calendar year deductible?The in-network deductible is $250 per member, up to amaximum of $750 per family.Here is how it works for each coverage level:● Individual: The individual has a $250 deductible beforebenefits begin.● Two-person family: Each person must satisfy a $250deductible.● Three- or more person family: The maximum eachperson must satisfy is $250 until the family as a wholereaches the $750 maximum.If you are in a PPO-type plan, the out-of-network deductibleis $400 per member, up to a maximum of $800 per family;this is a separate charge from the in-network deductible.QAIf I change health plans, am I subject toanother deductible?Although GIC health benefits are effective eachJuly, the deductible is a calendar year cost.You will not be subject to a new deductible if:You stay with the same health plan carrier butswitch to one of its other options.You will be subject to a new deductible if:You choose a new GIC health plan carrier.QAQAWhich health care services are subject to thedeductible?The lists below summarize expenses that generally areor are not subject to the annual deductible. These are notexhaustive lists. You should check with your health plan fordetails. Also, as with all benefits, variations in theseguidelines below may occur, depending uponindividual patient circumstances and a plan’sschedule of benefits.Examples of in-network expenses generally exempt fromthe deductible:● Prescription drug benefits● Outpatient mental health/substance abuse benefits● Office visits (primary care physician, specialist, retailclinics, preventive care, maternity and well baby care,routine eye exam, occupational therapy, physical therapy,chiropractic care and speech therapy)● Medically necessary child and adult immunizations● Wigs (medically necessary)● Hearing Aids● Mammograms● Pap smears● EKGs● ColonoscopiesExamples of in-network expenses generally subject tothe deductible:● Emergency room visits● Inpatient hospitalization● Surgery● Laboratory and blood tests● X-rays and radiology (including high-tech imaging such asMRI, PET and CT scans)● Durable medical equipmentHow will I know how much I need to pay out ofpocket?When you visit a doctor or hospital, the provider will ask youfor your copay upfront. After you receive services, your healthplan may provide you with an Explanation of Benefits, or youcan call your plan to find out which portion of the costs youwill be responsible for. The provider will then bill you for anybalance owed.10


PRESCRIPTION DRUG BENEFITSDrug CopaymentsAll GIC health plans provide benefits for prescription drugs usinga three-tier copayment structure in which your copayments vary,depending on the drug dispensed. The following descriptions willhelp you understand your prescription drug copayment levels.Contact the plans you are considering with questions about yourspecific medications.Tier 1: You pay the lowest copayment. This tier is primarily madeup of generic drugs, although some brand name drugs may beincluded. Generic drugs have the same active ingredients in thesame strength as their brand name counterparts. Brand namedrugs are almost always significantly more expensive.Tier 2: You pay the mid-level copayment. This tier is primarilymade up of brand name drugs, selected based on reviews of therelative safety, effectiveness and cost of the many brand namedrugs on the market. Some generics may also be included.Tier 3: You pay the highest copayment. This tier is primarilymade up of brand name drugs not included in Tiers 1 or 2.Generic or brand name alternatives for Tier 3 drugs may beavailable in Tiers 1 or 2.Tip for Reducing YourPrescription Drug CostsUse Mail Order: Are you taking prescription drugs for along-term condition, such as asthma, high blood pressure,allergies, or high cholesterol? Switch your prescriptionfrom a retail pharmacy to mail order. It can save youmoney – up to one copay every three months. See pages15-31 for copay details. Once you begin mail order, youcan conveniently order refills by phone or online. Contactyour plan for details.Prescription Drug ProgramsSome GIC plans, including the UniCare State Indemnity Plans’prescription drug program managed by CVS Caremark, have thefollowing programs to encourage the use of safe, effective andless costly prescription drugs. Contact the plans you areconsidering to find out details about these programs:● Mandatory Generics – When filling a prescription for abrand name drug for which there is a generic equivalent, youwill be responsible for the cost difference between the brandname drug and the generic, plus the generic copay.●●Maintenance Drug Pharmacy Selection – If you receive30-day supplies of your maintenance drugs at a retailpharmacy, you must call your prescription drug plan to tellthem whether or not you wish to change to 90-day suppliesthrough either mail order or certain retail pharmacies.Specialty Drug Pharmacies – If you are prescribed specialtydrugs—such as injectable drugs for conditions such asHepatitis C, rheumatoid arthritis, infertility, and multiplesclerosis—you’ll need to use a specialized pharmacy whichcan provide you with 24-hour clinical support, education andside effect management. Medications are delivered to yourhome or to your doctor’s office.Medicare Part D Prescription DrugReminders and WarningsFor most GIC Medicare enrollees, the drug coverage youcurrently have through your GIC health plan is a bettervalue than the federal Medicare Part D drug plans beingoffered. Therefore, most individuals should not enroll in afederal Medicare drug plan.●●●A “Notice of Creditable Coverage” is in your planhandbook. It provides proof that you have comparable orbetter coverage than Medicare Part D. If you should laterenroll in a Medicare drug plan because of changedcircumstances, you must show the Notice of CreditableCoverage to the Social Security Administration to avoidpaying a penalty. Keep this notice with your importantpapers.If you have limited income and assets, the SocialSecurity Administration offers help paying for Medicareprescription drug coverage; this may be the one instancewhere signing up for a Medicare Part D plan may workfor you. Help is available online at www.ssa.gov or byphone at 1.800.772.1213.If you are a member of one of our Medicare Advantageplans (Fallon Senior Plan and Tufts Health Plan MedicarePreferred), your plan automatically includes MedicarePart D coverage. If you enroll in another Medicare Part Ddrug plan, the Centers for Medicare & MedicaidServices will automatically dis-enroll you from yourGIC Medicare Advantage health plan, which meansyou will no longer have a Medicare plan throughthe GIC.●Step Therapy – This program requires enrollees to tryeffective, less costly drugs before more expensive alternativeswill be covered.14


EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH PLANSFALLON COMMUNITY HEALTH PLANDIRECT CAREHMOFallon Community Health Plan Direct Care is an HMO thatprovides coverage through the plan’s network of doctors,hospitals and other providers. Members must select a PrimaryCare Provider (PCP) to manage their care, including referrals tospecialists. The plan offers a selective network based in ageographically concentrated area.Contact the plan to see if your doctors and hospitals arein the network. There are no out-of-network benefits,with the exception of emergency care.Calendar Year Deductible$250 per individual up to a maximum of $750 per family.See page 10 for details.Who is Eligible?Employees, Retirees, Survivors, and their eligible dependentswithout Medicare are eligible.Where You Live Determines Which PlanYou May Enroll In:Fallon Community Health Plan Direct Care is available in thefollowing Massachusetts counties:Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk,WorcesterFallon Community Health Plan Direct Care is available only incertain parts of the following Massachusetts counties; contactthe plan to find out if you live in the service area:Hampden, HampshireMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationCopays Effective July 1, 2013Primary Care Provider Office Visit:$15 per visitPreventive Services:Most covered at 100% – no copaySpecialist Physician Office Visit:$25 per visitOutpatient Mental Health and SubstanceAbuse Care:$15 per visitRetail Clinic:$15 per visitInpatient Hospital Care – Medical(Maximum one copay per person per calendar year quarter;waived if readmitted within 30 days in the same calendar year):$200 per admissionOutpatient Surgery(Maximum four copays per person per calendar year):$110 per occurrenceHigh-Tech Imaging (e.g., MRI, PET and CT scans)(Maximum one copay per day):$100 per scanEmergency Room:$100 per visit (waived if admitted)YOUR RESPONSIBILITYDo your doctors andhospitals participate inFallon Direct?Contact the plan.Contact the plan for additional information on participatingproviders and benefits.Fallon Community Health Plan1.866.344.4442 | www.fchp.org/gicPrescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11015


EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH PLANSFALLON COMMUNITY HEALTH PLAN SELECT CAREHMOFallon Community Health Plan Select Care is an HMO thatprovides coverage through the plan’s network of doctors,hospitals, and other providers. Members must select a PrimaryCare Provider (PCP) to manage their care, including referrals tospecialists.Contact the plan to see if your doctors and hospitals arein the network. There are no out-of-network benefits, withthe exception of emergency care.Members pay lower copays when they see Tier 1 or Tier 2specialists. Contact the plan to see how your provider is rated.Effective July 1, 2013, the plan will tier hospitals based onquality and/or cost; members pay a lower inpatient hospitalcopay when they use Tier 1 or Tier 2 hospitals. Contact the planto find out which tier your hospital is in.Calendar Year Deductible$250 per individual up to a maximum of $750 per family.See page 10 for details.Who is Eligible?Employees, Retirees, Survivors, and their eligible dependentswithout Medicare are eligible.Where You Live Determines Which PlanYou May Enroll In:Fallon Community Health Plan Select Care is available in thefollowing Massachusetts counties:Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire,Middlesex, Norfolk, Plymouth, Suffolk, WorcesterFallon Community Health Plan Select Care is available only incertain parts of the following state; contact the plan to find outif you live in the service area:New HampshireMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationCopays Effective July 1, 2013Primary Care Provider Office Visit: $20 per visitPreventive Services: Most covered at 100% – no copaySpecialist Office Visit:Fallon Community Health Plan tiers the following specialistsbased on quality and/or cost efficiency: Allergists/Immunologists,Cardiologists, Endocrinologists, Gastroenterologists,Hematologists/Oncologists, Nephrologists, Neurologists,Obstetrician/Gynecologists, Orthopedists, Otolaryngologists (ENTs),Podiatrists, Pulmonologists, Rheumatologists, and Urologists.★★★ Tier 1 (excellent): $25 per visit★★ Tier 2 (good): $35 per visit★ Tier 3 (standard): $45 per visitRetail Clinic: $20 per visitOutpatient Mental Health and SubstanceAbuse Care: $20 per visitYOUR RESPONSIBILITYDo your doctors andhospitals participate inFallon Select?Contact the plan.Contact the plan for additional information on participatingproviders and benefits.Fallon Community Health Plan1.866.344.4442 | www.fchp.org/gicInpatient Hospital Care – Medical(Maximum one copay per person per calendar year quarter;waived if readmitted within 30 days in the same calendar year)Tier 1: $250 per admissionTier 2: $500 per admissionTier 3: $750 per admissionOutpatient Surgery(Maximum four copays per person per calendar year):$125 per occurrenceHigh-Tech Imaging (e.g., MRI, PET and CT scans)(Maximum one copay per day):$100 per scanEmergency Room: $100 per visit (waived if admitted)Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11016


EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH PLANSHARVARD PILGRIM INDEPENDENCE PLANPPOThe Harvard Pilgrim Independence Plan, administered byHarvard Pilgrim Health Care, is a PPO plan that offers coveragethrough network doctors, hospitals, and other health careproviders with a copay. Or you may seek care from an out-ofnetworkprovider for 80% coverage of reasonable and customarycharges. The plan encourages but does not require members toselect a Primary Care Provider (PCP). Members pay lower officevisit copays when they see Tier 1 or Tier 2 specialists. Contactthe plan to see if your provider is in the network and how he/sheis rated.The plan also tiers hospitals based on quality and/or cost;members pay a lower inpatient hospital copay when they useTier 1 or Tier 2 hospitals. Contact the plan to see which tier yourhospital is in.Calendar Year Deductible$250 per individual up to a maximum of $750 per family.See page 10 for details.Who is Eligible?Employees, Retirees, Survivors, and their eligible dependentswithout Medicare are eligible.Where You Live Determines Which PlanYou May Enroll In:The Harvard Pilgrim Independence Plan is available throughoutMassachusetts.The plan is also available in the following other states:Maine, New Hampshire, Rhode IslandThe Harvard Pilgrim Independence Plan is available only incertain parts of the following states; contact the plan to find outif you live in the service area:Connecticut, New York, VermontMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Harvard Pilgrim Health Care1.800.542.1499 | www.harvardpilgrim.org/gicIn-Network Copays Effective July 1, 2013Primary Care Provider Office Visit: $20 per visitPreventive Services: Most covered at 100% – no copaySpecialist Physician Office VisitHarvard Pilgrim Health Care tiers the following Massachusettsspecialists based on quality and/or cost efficiency: Allergists/Immunologists, Cardiologists, Dermatologists, Endocrinologists,Gastroenterologists, General Surgeons, Neurologists,Obstetrician/Gynecologists, Ophthalmologists, Orthopedists,Otolaryngologists (ENTs), Pulmonologists, and Rheumatologists.★★★ Tier 1 (excellent): $20 per visit★★ Tier 2 (good): $35 per visit★ Tier 3 (standard): $45 per visitOut-of-State Specialist Office Visit: $35 per visitRetail Clinic: $20 per visitOutpatient Mental Health and SubstanceAbuse Care: $20 per individual visitInpatient Hospital Care – Medical(Maximum one copay per person per calendar year quarter;waived if readmitted within 30 days in the same calendar year)Harvard Pilgrim Health Care tiers its hospitals based on qualityand/or cost.Tier 1: $250 per admissionTier 2: $500 per admissionTier 3: $750 per admissionOutpatient Surgery(Maximum four copays per person per calendar year):$150 per occurrenceHigh-Tech Imaging (e.g., MRI, PET and CT scans)(Maximum one copay per day): $100 per scanEmergency Room:$100 per visit (waived if admitted)Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11017


EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH PLANSHARVARD PILGRIM PRIMARY CHOICE PLANHMOThe Harvard Pilgrim Primary Choice Plan, administered byHarvard Pilgrim Health Care, is an HMO plan that providescoverage through the plan’s network of doctors, hospitals andother providers. Members must select a Primary Care Provider(PCP) to manage their care, including referrals to specialists.Contact the plan to see if your doctors and hospitals arein the network. There are no out-of-network benefits,with the exception of emergency care.Members pay lower office visit copays when they see Tier 1 orTier 2 specialists. Contact the plan to see if your provider is inthe network and how he/she is rated. The plan also tiershospitals based on quality and/or cost; members pay a lowerinpatient hospital copay when they use Tier 1 hospitals. Contactthe plan to see which tier your hospital is in.Calendar Year Deductible$250 per individual up to a maximum of $750 per family.See page 10 for details.Who is Eligible?Employees, Retirees, Survivors, and their eligible dependentswithout Medicare are eligible.Where You Live Determines Which PlanYou May Enroll In:The Harvard Pilgrim Primary Choice Plan is available in thefollowing Massachusetts counties:Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex,Norfolk, Plymouth, Suffolk, WorcesterThe Harvard Pilgrim Primary Choice Plan is available only incertain parts of the following Massachusetts county; contact theplan to find out if you live in the service area:BerkshireMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Harvard Pilgrim Health Care1.800.542.1499 | www.harvardpilgrim.org/gicYOUR RESPONSIBILITYDo your doctors andhospitals participate inHarvard Pilgrim PrimaryChoice? Contact the plan.Copays Effective July 1, 2013Primary Care Provider Office Visit: $20 per visitPreventive Services: Most covered at 100% – no copaySpecialist Physician Office VisitHarvard Pilgrim Health Care tiers the following Massachusettsspecialists based on quality and/or cost efficiency: Allergists/Immunologists, Cardiologists, Dermatologists, Endocrinologists,Gastroenterologists, General Surgeons, Neurologists,Obstetrician/Gynecologists, Ophthalmologists, Orthopedists,Otolaryngologists (ENTs), Pulmonologists, and Rheumatologists.★★★ Tier 1 (excellent): $20 per visit★★ Tier 2 (good): $35 per visit★ Tier 3 (standard): $45 per visitOut-of-State Specialist Office Visit: $35 per visitRetail Clinic: $20 per visitOutpatient Mental Health and SubstanceAbuse Care: $20 per individual visitInpatient Hospital Care – Medical(Maximum one copay per person per calendar year quarter;waived if readmitted within 30 days in the same calendar year)Harvard Pilgrim Health Care tiers its hospitals based onquality and/or cost:Tier 1: $250 per admissionTier 2: $500 per admissionOutpatient Surgery (Maximum four copays per person percalendar year): $150 per occurrenceHigh-Tech Imaging (e.g., MRI, PET and CT scans)(Maximum one copay per day): $100 per scanEmergency Room:$100 per visit (waived if admitted)Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11018


EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH PLANSHEALTH NEW ENGLANDHMOHealth New England is an HMO that provides coverage throughthe plan’s network of doctors, hospitals, and other providers.Members must select a Primary Care Provider (PCP) to managetheir care; referrals to network specialists are not required.Members pay lower office visit copays when they see Tier 1or Tier 2 specialists. Contact the plan to see how your provideris rated.Contact the plan to see if your doctors and hospitals arein the network. There are no out-of-network benefits,with the exception of emergency care.Calendar Year Deductible$250 per individual up to a maximum of $750 per family.See page 10 for details.Who is Eligible?Employees, Retirees, Survivors, and their eligible dependentswithout Medicare are eligible.Where You Live Determines Which PlanYou May Enroll In:Health New England is available in the following Massachusettscounties:Berkshire, Hampden, Hampshire, FranklinHealth New England is available only in certain parts of thefollowing Massachusetts county; contact the plan to find out ifyou live in the service area:WorcesterMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Health New England1.800.842.4464 | www.hne.com/gicCopays Effective July 1, 2013Primary Care Provider Office Visit: $20 per visitPreventive Services: Most covered at 100% – no copaySpecialist Physician Office VisitHealth New England tiers the following specialists based onquality and/or cost efficiency: Cardiologists, Endocrinologists,Gastroenterologists, General Surgeons, Obstetricians/Gynecologists, Orthopedists, Otolaryngologists (ENTs),Pulmonologists, and Rheumatologists.★★★ Tier 1 (excellent): $25 per visit★★ Tier 2 (good): $35 per visit★ Tier 3 (standard): $45 per visitRetail Clinic: $20 per visitOutpatient Mental Health and SubstanceAbuse Care: $20 per visitInpatient Hospital Care – Medical(Maximum one copay per person per calendar year quarter;waived if readmitted within 30 days in the same calendar year):$250 per admissionOutpatient Surgery(Maximum four copays per person per calendar year):$110 per occurrenceHigh-Tech Imaging (e.g., MRI, PET and CT scans)(Maximum one copay per day):$100 per scanEmergency Room:$100 per visit (waived if admitted)YOUR RESPONSIBILITYDo your doctors andhospitals participate inHealth New England?Contact the plan.Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11019


EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH PLANSNHP CARE (Neighborhood Health Plan)HMONHP Care, administered by Neighborhood Health Plan, is anHMO that provides coverage through the plan’s network ofdoctors, hospitals, and other providers. Members must select aPrimary Care Provider (PCP) to manage their care, includingreferrals to specialists. Members pay lower office visit copayswhen they see Tier 1 and Tier 2 physicians. Contact the plan tosee how your provider is rated.Contact the plan to see if your doctors and hospitals arein the network. There are no out-of-network benefits,with the exception of emergency care.Calendar Year Deductible$250 per individual up to a maximum of $750 per family.See page 10 for details.Who is Eligible?Employees, Retirees, Survivors, and their eligible dependentswithout Medicare are eligible.Where You Live Determines Which PlanYou May Enroll In:NHP Care is available in the following Massachusetts counties:Barnstable, Bristol, Dukes, Essex, Hampden, Middlesex,Nantucket, Norfolk, Plymouth, Suffolk, WorcesterMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.NHP Care1.866.567.9175 | www.nhp.org/gicCopays Effective July 1, 2013Primary Care Provider Office VisitNeighborhood Health Plan tiers network Primary Care Providersbased on quality and/or cost efficiency:★★★ Tier 1 (excellent): $15 per visit★★ Tier 2 (good): $25 per visit★ Tier 3 (standard): $30 per visitPreventive Services: Most covered at 100% – no copaySpecialist Physician Office VisitNeighborhood Health Plan tiers the following specialists basedon quality and/or cost efficiency: Cardiologists, Endocrinologists,Gastroenterologists, Obstetrician/Gynecologists, Otolaryngologists(ENTs), Orthopedists, Pulmonologists, and Rheumatologists.★★★ Tier 1 (excellent): $25 per visit★★ Tier 2 (good): $35 per visit★ Tier 3 (standard): $45 per visitRetail Clinic: $20 per visitOutpatient Mental Health and SubstanceAbuse Care: $25 per visitYOUR RESPONSIBILITYDo your doctors andhospitals participate inNeighborhood Health Plan?Contact the plan.Inpatient Hospital Care – Medical(Maximum one copay per person per calendar year quarter;waived if readmitted within 30 days in the same calendar year):$250 per admissionOutpatient Surgery(Maximum four copays per person per calendar year):$110 per occurrenceHigh-Tech Imaging (e.g., MRI, PET and CT scans)(Maximum one copay per day):$100 per scanEmergency Room: $100 per visit (waived if admitted)Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11020


EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH PLANSUNICARE STATE INDEMNITY PLAN/COMMUNITY CHOICEPPO-TYPEThe UniCare State Indemnity Plan/Community Choice is aPPO-type plan with a hospital network based at community andsome tertiary hospitals. Or, you may seek care from an out-ofnetworkhospital for 80% coverage of the allowed amount forinpatient care and outpatient surgery, after you pay a copay.The plan offers access to all Massachusetts physicians andmembers are encouraged but not required to select a PrimaryCare Provider (PCP). Members pay lower office visit copayswhen they see Tier 1 and Tier 2 specialists. Contact the plan tosee how a physician is rated.The mental health benefits of this plan, administered by BeaconHealth Strategies effective July 1, 2013, offer you in-networkbenefits with a copay. Or, you may seek care out-of-network, butat higher out-of-pocket costs.Prescription drug benefits are administered by CVS Caremark.Calendar Year Deductible$250 per individual up to a maximum of $750 per family.See page 10 for details.Who is Eligible?Employees, Retirees, Survivors, and their eligible dependentswithout Medicare are eligible.Where You Live Determines Which PlanYou May Enroll In:The UniCare State Indemnity Plan/Community Choice isavailable in the following Massachusetts counties:Barnstable, Berkshire, Bristol, Essex, Franklin, Hampden,Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, WorcesterContact the plan to find out if your hospital is in thenetwork.Monthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Medical Benefits: UniCare1.800.442.9300 | www.unicarestateplan.comMental Health, Substance Abuse and EAP Benefits:Beacon Health Strategies1.855.750.8980 | www.beaconhs.com/gicPrescription Drug Benefits: CVS Caremark1.877.876.7214 | www.caremark.com/gicYOUR RESPONSIBILITYAre your hospitals in theUniCare CommunityChoice network?Contact the plan.In-Network Copays Effective July 1, 2013Primary Care Provider Office Visit: $20 per visitPreventive Services: Most covered at 100% – no copaySpecialist Office VisitUniCare tiers Massachusetts specialists based on quality and/orcost efficiency:★★★ Tier 1 (excellent): $25 per visit★★ Tier 2 (good): $35 per visit★ Tier 3 (standard): $45 per visitRetail Clinic: $20 per visitOutpatient Mental Health and Substance Abuse Care(See the GIC’s website for a Beacon Health Strategies UniCareCommunity Choice benefit grid or contact Beacon for additionalbenefit details): $20 per visitBeacon also offers EAP services.Inpatient Hospital Care – Medical(Maximum one copay per person per calendar year quarter;waived if readmitted within 30 days in the same calendar year):$250 per admissionOutpatient Surgery (Maximum one copay per person percalendar year quarter): $110 per occurrenceHigh-Tech Imaging (e.g., MRI, PET and CT scans)(Maximum one copay per day): $100 per scanEmergency Room: $100 per visit (waived if admitted)Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11024


EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH PLANSUNICARE STATE INDEMNITY PLAN/PLUSPPO-TYPEThe UniCare State Indemnity Plan/PLUS is a PPO-type plan thatprovides access to all Massachusetts physicians and hospitalsand out-of-state UniCare providers at 100% coverage, after acopayment. Out-of-state non-UniCare providers have 80%coverage of allowed charges. The plan encourages but does notrequire members to select a Primary Care Provider (PCP).Members pay lower office visit copays when they see Tier 1 andTier 2 specialists. Contact the plan to see how a physician israted. The plan also tiers hospitals based on quality and/or cost;members pay a lower inpatient hospital and outpatient surgerycopay when they use Tier 1 or Tier 2 hospitals. Contact the planto see which tier your hospital is in.The mental health benefits of this plan, administered by BeaconHealth Strategies effective July 1, 2013, offer you in-networkbenefits with a copay. Or, you may seek care out-of-network, butat higher out-of-pocket costs.Prescription drug benefits are administered by CVS Caremark.Calendar Year Deductible$250 per individual up to a maximum of $750 per family.See page 10 for details.Who is Eligible?Employees, Retirees, Survivors, and their eligible dependentswithout Medicare are eligible.Where You Live Determines Which PlanYou May Enroll In:The UniCare State Indemnity Plan/PLUS is available throughoutMassachusetts.The plan is also available in the following other states:Maine, New Hampshire, Rhode IslandThe UniCare State Indemnity Plan/PLUS is available only incertain parts of the following state; contact the plan to find outif you live in the service area:ConnecticutMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Medical Benefits: UniCare1.800.442.9300 | www.unicarestateplan.comMental Health, Substance Abuse and EAP Benefits:Beacon Health Strategies1.855.750.8980 | www.beaconhs.com/gicPrescription Drug Benefits: CVS Caremark1.877.876.7214 | www.caremark.com/gicIn-Network Copays Effective July 1, 2013Primary Care Provider Office Visit: $20 per visitPreventive Services: Most covered at 100% – no copaySpecialist Office VisitUniCare tiers Massachusetts specialists based on quality and/orcost efficiency:★★★ Tier 1 (excellent): $25 per visit★★ Tier 2 (good): $35 per visit★ Tier 3 (standard): $45 per visitOut-of-State Primary Care Provider Office Visit:$20 per visitOut-of-State Specialist Office Visit: $35 per visitRetail Clinic: $20 per visitOutpatient Mental Health and Substance Abuse Care(See the GIC’s website for a Beacon Health Strategies UniCarePLUS benefit grid or contact Beacon for additional benefit details):$20 per visitBeacon also offers EAP services.Inpatient Hospital Care – MedicalUniCare tiers hospitals based on quality and/or cost(Maximum one copay per person per calendar year quarter;waived if readmitted within 30 days in the same calendar year):Tier 1: $250 per admissionTier 2: $500 per admissionTier 3: $750 per admissionOutpatient Surgery – UniCare’s outpatient surgery copay isbased on the hospital’s tier, with Tier 1 and Tier 2 hospitals havingthe same outpatient surgery copay. (Maximum one copay perperson per calendar year quarter)Tier 1 and Tier 2: $110 per occurrenceTier 3: $250 per occurrenceHigh-Tech Imaging (e.g., MRI, PET and CT scans)Maximum one copay per day): $100 per scanEmergency Room: $100 per visit (waived if admitted)Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11025


MEDICARE HEALTH PLANSFALLON SENIOR PLANHMOFallon Senior Plan is a Medicare Advantage HMO plan thatprovides coverage through the plan’s network of doctors,hospitals, and other providers. Members must select a PrimaryCare Provider (PCP) to manage their care, including referrals tospecialists.Contact the plan to see if your doctors and hospitals arein the network. There are no out-of-network benefits,with the exception of emergency care.Fallon Senior Plan is a Medicare plan under contract with thefederal government that includes Medicare Part D prescriptiondrug benefits. Contact the plan for details. This Medicareplan’s benefits and rates are subject to federal approvaland may change January 1, 2014.Who is Eligible?Retirees, Survivors, and their eligible dependents with MedicarePart A and Part B are eligible.Where You Live Determines Which PlanYou May Enroll In:Fallon Senior Plan is available in the following Massachusettscounties:Barnstable, Bristol, Essex, Hampden, Hampshire, Middlesex,Norfolk, Plymouth, Suffolk, WorcesterFallon Senior Plan is available only in certain parts of thefollowing Massachusetts county; contact the plan to find out ifyou live in the service area:FranklinFallon Senior Plan is only available in certain parts of thefollowing states; contact the plan to find out if you live in theservice area:Connecticut, New Hampshire, Rhode IslandMonthly Rates as of January 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Fallon Senior Plan1.866.344.4442www.fchp.org/gicCopays Effective January 1, 2013Physician Office Visit$10 per visitPreventive ServicesCovered at 100% – no copayOutpatient Mental Health and SubstanceAbuse Care$10 per visitInpatient Hospital CareCovered at 100% – no copayInpatient and Outpatient SurgeryCovered at 100% – no copayEmergency Room$50 per visit (waived if admitted)YOUR RESPONSIBILITYDo your doctors andhospitals participate inFallon Senior Plan?Contact the plan.You may change plans only during theGIC’s Spring Annual Enrollment period,even though the plan’s providers maychange on a calendar year basis.Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11026


MEDICARE HEALTH PLANSHARVARD PILGRIM MEDICARE ENHANCEINDEMNITYHarvard Pilgrim Medicare Enhance is a supplemental Medicareplan, offering coverage for services provided by any licenseddoctor or hospital throughout the United States that acceptsMedicare payment.Who is Eligible?Retirees, Survivors, and their eligible dependents withMedicare Part A and Part B are eligible.Where You Live Determines Which PlanYou May Enroll In:The Harvard Pilgrim Medicare Enhance Plan is availablethroughout the United States.Monthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information.Harvard Pilgrim Medicare Enhance1.800.542.1499www.harvardpilgrim.org/gicCopays Effective July 1, 2013Physician Office Visit$10 per visitPreventive ServicesCovered at 100% – no copayRetail Clinic$10 per visitOutpatient Mental Health and SubstanceAbuse Care$10 per visitInpatient Hospital CareCovered at 100% – no copayInpatient and Outpatient SurgeryCovered at 100% – no copayEmergency Room$50 per visit (waived if admitted)Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11027


MEDICARE HEALTH PLANSHEALTH NEW ENGLAND MEDPLUSHMOHealth New England MedPlus is a Medicare HMO plan thatprovides coverage through the plan’s network of doctors,hospitals, and other providers. Members must select a PrimaryCare Provider (PCP) to manage their care; referrals to networkspecialists are not required.Contact the plan to see if your doctors and hospitals arein the network. There are no out-of-network benefits,with the exception of emergency and urgent care.Who is Eligible?Retirees, Survivors, and their eligible dependents withMedicare Part A and Part B are eligible.Where You Live Determines Which PlanYou May Enroll In:Health New England MedPlus is available in the followingMassachusetts counties:Berkshire, Franklin, Hampden, HampshireHealth New England MedPlus is available only in certainparts of the following Massachusetts county; contact the planto find out if you live in the service area:WorcesterMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Health New England MedPlus1.800.842.4464www.hne.com/gicCopays Effective July 1, 2013Physician Office Visit$10 per visitPreventive ServicesCovered at 100% – no copayRetail Clinic$10 per visitOutpatient Mental Health and SubstanceAbuse Care$10 per visitInpatient Hospital CareCovered at 100% – no copayInpatient and Outpatient SurgeryCovered at 100% – no copayEmergency Room$50 per visit (waived if admitted)YOUR RESPONSIBILITYDo your doctors andhospitals participate in HealthNew England MedPlus?Contact the plan.Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11028


MEDICARE HEALTH PLANSTUFTS HEALTH PLAN MEDICARE COMPLEMENTHMOTufts Health Plan Medicare Complement is a supplementalMedicare HMO plan that provides coverage through the plan’snetwork of doctors, hospitals, and other providers. Membersmust select a Primary Care Provider (PCP) to manage their care,including referrals to specialists.Contact the plan to see if your doctors and hospitals arein the network. There are no out-of-network benefits,with the exception of emergency and urgent care.Who is Eligible?Retirees, Survivors, and their eligible dependents withMedicare Part A and Part B are eligible.Where You Live Determines Which PlanYou May Enroll In:Tufts Health Plan Medicare Complement is availablethroughout Massachusetts.The plan is also available in the following other state:Rhode IslandTufts Health Plan Medicare Complement is available only incertain parts of the following states; contact the plan to findout if you live in the service area:Connecticut, New Hampshire, New York, VermontMonthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Tufts Health Plan Medicare Complement1.888.333.0880www.tuftshealthplan.com/gicCopays Effective July 1, 2013Physician Office Visit$10 per visitPreventive ServicesCovered at 100% – no copayRetail Clinic$10 per visitOutpatient Mental Health and SubstanceAbuse Care$10 per visitInpatient Hospital CareCovered at 100% – no copayInpatient and Outpatient SurgeryCovered at 100% – no copayEmergency Room$50 per visit (waived if admitted)YOUR RESPONSIBILITYDo your doctors andhospitals participate inTufts Medicare Complement?Contact the plan.Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11029


MEDICARE HEALTH PLANSTUFTS HEALTH PLAN MEDICARE PREFERREDHMOTufts Health Plan Medicare Preferred HMO is a MedicareAdvantage plan that provides coverage through the plan’snetwork of doctors, hospitals, and other providers. Membersmust select a Primary Care Provider (PCP) to manage their care,including referrals to specialists.Contact the plan to see if your doctors and hospitalsare in the network. There are no out-of-networkbenefits, with the exception of emergency care.Tufts Health Plan Medicare Preferred HMO is a MedicareAdvantage plan under contract with the federal governmentthat includes Medicare Part D prescription drug benefits.Contact the plan for details. This Medicare plan’s benefitsand rates are subject to federal approval and maychange January 1, 2014.Who is Eligible?Retirees, Survivors, and their eligible dependents withMedicare Part A and Part B are eligible.Where You Live Determines Which PlanYou May Enroll In:Tufts Health Plan Medicare Preferred is available in thefollowing Massachusetts counties:Barnstable, Bristol, Essex, Hampden, Hampshire, Middlesex,Norfolk, Plymouth, Suffolk, WorcesterMonthly Rates as of January 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional information on participatingproviders and benefits.Tufts Health Plan Medicare Preferred1.888.333.0880www.tuftshealthplan.com/gicCopays Effective January 1, 2013Physician Office Visit$10 per visitPreventive ServicesCovered at 100% – no copayOutpatient Mental Health and SubstanceAbuse Care$10 per visitInpatient Hospital CareCovered at 100% – no copayInpatient and Outpatient SurgeryCovered at 100% – no copayEmergency Room$50 per visit (waived if admitted)YOUR RESPONSIBILITYDo your doctors andhospitals participate in TuftsMedicare Preferred?Contact the plan.You may change plans only during theGIC’s Spring Annual Enrollment period,even though the plan’s providers maychange on a calendar year basis.Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11030


MEDICARE HEALTH PLANSUNICARE STATE INDEMNITY PLAN/MEDICARE EXTENSION (OME)INDEMNITYThe UniCare State Indemnity Plan/Medicare Extension (OME)is a supplemental Medicare plan offering access to anylicensed doctor or hospital throughout the United States andoutside of the country. The mental health benefits of this plan,administered by Beacon Health Strategies effective July 1,2013, offer you in-network benefits with a copay. Or, you mayseek care out-of-network, but at higher out-of-pocket costs.Prescription drug benefits are administered by CVS Caremark.Who is Eligible?Retirees, Survivors, and their eligible dependents withMedicare Part A and Part B are eligible.Where You Live Determines Which PlanYou May Enroll In:The UniCare State Indemnity Plan/Medicare Extension (OME)is available throughout the United States and outside of thecountry.Monthly Rates as of July 1, 2013Municipal enrollees will receive a separate rate chart.Plan Contact InformationContact the plan for additional benefit information.Medical Benefits: UniCare1.800.442.9300 | www.unicarestateplan.comMental Health, Substance Abuse and EAP Benefits:Beacon Health Strategies1.855.750.8980 | www.beaconhs.com/gicPrescription Drug Benefits: CVS Caremark1.877.876.7214 | www.caremark.com/gicCopays with CIC (Comprehensive)Effective July 1, 2013Without CIC, deductibles are higher and coverage is only80% for some services. Contact the plan for details.Physician Office Visit:None after $35 calendar year deductiblePreventive Services:Covered at 100% – no copayRetail Clinic:None after $35 calendar year deductibleNetwork Outpatient Mental Health and SubstanceAbuse Care (See the GIC’s website for a Beacon HealthStrategies UniCare OME benefit grid or contact Beacon foradditional benefit details.)First four visits $0; visits 5 and over: $10 per visitBeacon also offers EAP services.Inpatient Hospital Care (Maximum one copay per personper calendar year quarter):$50 per admissionInpatient and Outpatient Surgery: Covered at 100% –no copay – in Massachusetts and for out-of-state providerswho accept Medicare; call the plan for details if using out-ofstateproviders who do not accept Medicare.Emergency Room:$25 per visit (waived if admitted)Prescription DrugRetail up toMail Order up to30-day supply:90-day supply:Tier 1: $10 Tier 1: $20Tier 2: $25 Tier 2: $50Tier 3: $50 Tier 3: $11031


GIC RETIREE DENTAL PLANGIC Retiree Dental PlanMetropolitan Life Insurance Company (MetLife) is theprovider of the GIC Retiree Dental Plan. The plan offers afixed reimbursement of up to $1,250 per member per yearfor dental services:●●●●●●Dental examinationsDental cleaningsFillingsCrownsDenturesDental implantsAs a member of this plan, you may go to the dentist of yourchoice. However, you will save money by visiting one of the over218,000 nationwide network of participating dentists. When youvisit a MetLife provider, your out-of-pocket expenses will belower, as you usually pay the lower negotiated fee, even afteryou have exceeded your annual maximum.This is an entirely voluntary plan (retiree-pay-all) that providesGIC members with coverage at discounted group insurance ratesthrough convenient pension deductions.Enroll During Annual EnrollmentEligible retirees and survivors may join the plan during thisspring’s annual enrollment for coverage effective July 1, 2013.Be sure to return the form to your municipality no later thanMay 8, 2013.Enrollment After This Initial Enrollment PeriodEligible retirees may join during any annual enrollment period,when COBRA dental coverage ends, when they become a survivorof a GIC member, or at retirement. If you drop coverage in thefuture, you can never re-enroll in the plan.GIC RETIREE DENTAL PLANIncludes 0.50% Administrative FeeMonthly GIC Plan Rates as of July 1, 2013$1,250 Maximum Annual Benefit per MemberCOVERAGE TYPERETIREE PAYS MONTHLYSINGLE $27.41FAMILY $66.01ELIGIBILITYRetirees and survivors from the following municipalities thathave elected to offer the plan are eligible:● City of Melrose ● Town of HopedaleRetiree Dental Questions?Contact MetLife: 1.866.292.9990www.metlife.com/gic● City of Peabody ● Town of Millis● City of Pittsfield ● Town of Randolph● Town of Bedford ● Town of Saugus● Town of Brookline ● Athol Roylston School District● Town of Holbrook ● Northeast Regional Technical School●Town of HoldenIf your municipality is not listed, you are not eligiblefor GIC Retiree Dental benefits. Contact your municipalbenefits office for additional information.32


NEED MORE HELP?Attend a Health FairMunicipal members who are enrolling in GIC benefits for the firsttime, thinking about changing health plans, or have other healthplan questions can attend one of the GIC’s health fairs to:● Speak with health and other benefit plan representatives;● Pick up detailed materials and provider directories;● Ask GIC staff about your benefit options;● Enroll in a health plan – remember to bring RequiredDocuments with you (for the list, see the Municipal Formssection of our website) ; and● Take advantage of complimentary health screenings.See page 34 for the schedule.Inscripción AnualLa inscripción anual tendrá lugar a partir del 10 de abrilhasta el 8 de mayo del 2013. Durante dicho período,usted como (empleado o jubilado del estado) tendrá laoportunidad de inscribirse o cambiar su seguro de salud.Si desea mantener los beneficios del seguro de saludque actualmente tiene no hace falta que haga nada.Su cobertura continúa en forma automática.Usted deberá permanecer en el plan de salud que seleccionóhasta el próximo período de inscripción anual aunque sumédico o hospital se salgan del plan, a menos que usted semude fuera del área de servicio o es elegible para Medicare.Los cambios de cobertura entrarán en vigencia el 1 de juliodel 2013. Para obtener más información, sírvase llamar aGroup Insurance Commission (Comisión de Seguros deGrupo) al 617.727.2310, extensión 1. Hay empleados quehablan español que le ayudarán.年 度 投 保 從 2013 年 4 月 10 日 開 始 , 到 5 月 8日 結 束 。 在 這 段 期 間 , 您 ( 因 為 您 是 這 個 州 的 員工 或 退 休 員 工 ) 有 機 會 可 以 投 保 或 變 更 您 的 健 康保 險 。 如 果 您 希 望 維 持 您 目 前 的 健 康 保 險 福 利 ,則 什 麼 都 不 必 做 。 您 的 承 保 會 自 動 持 續 。即 使 您 的 醫 師 或 醫 院 退 出 本 計 畫 , 您 仍 須 維 持 您目 前 選 擇 的 健 保 計 畫 , 直 到 下 一 次 開 放 投 保 期 間才 可 以 變 更 , 除 非 是 您 搬 離 服 務 區 域 或 是 您 符 合Medicare 的 資 格 。任 何 承 保 變 更 都 會 在 2013 年 7 月 1 日 生 效 。 欲查 詢 詳 情 , 請 致 電 Group InsuranceCommission, 電 話 617.727.2310, 分 機 1。我 們 有 講 中 文 的 員 工 可 以 幫 助 您 。Our Website Provides AdditionalHelpful Informationwww.mass.gov/gicSee our website for:● Benefit Decision Guide content in HTML andXML-accessible formats;● Information about and links to all GIC plans –conveniently search for participating health plandoctors and hospitals online;● The latest annual enrollment news;● Forms to expedite your annual enrollment decisions;● Answers to frequently asked questions;● GIC publications – including the Benefits At-a-Glancebrochures and our For Your Benefit newsletter;● Summary of Benefits and Coverage for all GICemployee/Non-Medicare health plans;● Benefits At-A-Glance charts for mental health andsubstance abuse benefits for all UniCare State plans andTufts Health Plan Navigator and Spirit members; and● Health articles and links to help you take charge ofyour health.Ghi danh hàng nămThời gian ghi danh hàng năm bắt đầu vào ngày 10tháng 4 và chấm dứt vào ngày 8 tháng 5, năm 2013.Trong khoảng thời gian này, quý vị (với tư cách lànhân viên hoặc nhân viên hưu trí của tiểu bang) cócơ hội để ghi danh hoặc đổi chương trình bảo hiểmsức khỏe. Nếu muốn giữ chương trình bảo hiểmsức khỏe hiện tại của mình, quý vị không cần phảilàm gì cả. Bảo hiểm của quý vị sẽ được tự độngtiếp tục.Quý vị phải giữ chương trình bảo hiểm sức khỏehiện tại mà quý vị chọn cho đến thời gian ghi danhhàng năm kế tiếp, ngay cả khi bác sĩ hoặc bệnhviện của quý vị không còn tham gia trong chươngtrình, trừ khi quý vị di chuyển ra khỏi khu vực phụcvụ của chương trình hoặc khi quý vị hội đủ điều kiệnđược hưởng chương trình Medicare.Những thay đổi của quý vị sẽ có hiệu lực vào ngày1 tháng 7, năm 2013. Để biết thêm thông tin chi tiết,xin quý vị gọi cho Group Insurance Commission tạisố 617.727.2310, số nội bộ 1.Có nhân viên nói tiếng Việt giúp đỡ quý vị.33


FOR MORE INFORMATION, ATTEND A GIC HEALTH FAIRAPRIL 201312 FRIDAY 11:00-2:00Berkshire Community CollegePaterson Field House1350 West StreetPITTSFIELD13 SATURDAY 10:00-2:00Mass Maritime AcademyGymnasiumAcademy DriveBUZZARDS BAY17 WEDNESDAY 11:00-3:00Bristol Community CollegeBuilding H777 Elsbree StreetFALL RIVER18 THURSDAY 10:00-3:00Quinsigamond Community CollegeHarrington Learning Center, Room 109670 West Boylston StreetWORCESTER19 FRIDAY 10:00-3:00Middlesex Community CollegeCafeteria591 Springs RoadBEDFORD20 SATURDAY 11:00-3:00Northern Essex Community CollegeThe Technology Center, Rooms 103 A & B100 Elliott StreetHAVERHILL23 TUESDAY 10:00-3:00McCormack State Office BuildingOne Ashburton Place, 21st FloorBOSTON24 WEDNESDAY 11:00-3:00Peabody Public School AdministrationKiley Brothers Memorial School21 Johnson StreetPEABODY25 THURSDAY 11:00-4:30Lakeview Junior High School1570 Lakeview AvenueDRACUT29 MONDAY 11:00-3:00Wrentham Developmental CenterGraves AuditoriumLittlefield StreetWRENTHAM30 TUESDAY 11:00-3:00State Transportation Building10 Park Plaza, 2nd FloorConference Rooms 2 and 3BOSTONMAY 20131 WEDNESDAY 11:00-3:00U-Mass AmherstStudent Union BallroomAMHERST2 THURSDAY 10:00-3:00Hampden County Sheriff’s Dept.Hampden County Correctional Center627 Randall RoadLUDLOW3 FRIDAY 11:00-3:00Massasoit Community CollegeConference Center770 Crescent StreetBROCKTON34


FOR MORE INFORMATION, CONTACT THE PLANSFor more information about specific plan benefits, call a plan representative.Be sure to indicate you are a GIC insured.HEALTH INSURANCEFallon Community Health Plan 1.866.344.4442 www.fchp.org/gicDirect CareSelect CareSenior PlanHarvard Pilgrim Health Care 1.800.542.1499 www.harvardpilgrim.org/gicIndependence PlanPrimary Choice PlanMedicare EnhanceHealth New England 1.800.842.4464 www.hne.com/gicHMOMedPlusNeighborhood Health Plan 1.866.567.9175 www.nhp.org/gicNHP CareTufts Health Plan 1.800.870.9488 www.tuftshealthplan.com/gicNavigatorSpirit● Mental Health/Substance Abuse and EAP 1.855.750.8980 www.beaconhs.com/gic(Beacon Health Strategies)Medicare ComplementMedicare Preferred1.888.333.0880 www.tuftshealthplan.com/gicUniCare State Indemnity Plan/ 1.800.442.9300 www.unicarestateplan.comBasicCommunity ChoiceMedicare Extension (OME)PLUSFor all UniCare Plans● Prescription Drugs (CVS Caremark) 1.877.876.7214 www.caremark.com/gic● Mental Health/Substance Abuse and EAP 1.855.750.8980 www.beaconhs.com/gic(Beacon Health Strategies)OTHER BENEFITSGIC Retiree Dental Plan (MetLife) 1.866.292.9990 www.metlife.com/gicADDITIONAL RESOURCESEmployee Assistance Program for Managers 1.855.750.8980 www.beaconhs.com/gicand Supervisors (Beacon Health Strategies)Internal Revenue Service (IRS) 1.800.829.1040 www.irs.govMassachusetts Teachers’ Retirement System 1.617.679.6877 (Eastern MA) www.mass.gov/mtrs1.413.784.1711 (Western MA)Medicare 1.800.633.4227 www.medicare.govSocial Security Administration 1.800.772.1213 www.ssa.govOTHER QUESTIONS?Call the GIC: 1.617.727.2310, ext. 1, TDD/TTY: 1.617.227.8583 ● www.mass.gov/gic35


GLOSSARYCIC (Catastrophic Illness Coverage) – an optional part ofthe UniCare State Indemnity Plan/Basic and Medicare Extension(OME) plans. CIC increases the benefits for most coveredservices to 100%, subject to deductibles and copayments.It is a Commonwealth of Massachusetts enrollee-pay-all benefit.Enrollees without CIC receive only 80% coverage for someservices and pay higher deductibles. Over 99% of currentIndemnity Plan Basic and Medicare Extension Plan membersselect CIC.COBRA (Consolidated Omnibus Budget ReconciliationAct) – a federal law that allows enrollees to continue theirhealth coverage for a limited period of time after their groupcoverage ends as the result of certain employment or life eventchanges.CPI (Clinical Performance Improvement) Initiative –a GIC program which seeks to improve health care quality whilecontaining costs for the Commonwealth and our members. Claimsdata from all six GIC health carriers are aggregated to identifydifferences in physician quality and cost efficiency, and thisinformation is given back to the plans to develop benefit designs.GIC members are subsequently rewarded with copay incentiveswhen they use higher-performing providers.Deductible – a set dollar amount which must be satisfied withina calendar year before the health plan begins making paymentson claims.Deferred Retirement – allows you to continue your grouphealth insurance after you leave state service with vestedpension rights until you begin to collect a pension. Until youreceive a retirement allowance, you will be responsible for theentire life and health insurance premium costs, for which you arebilled directly. If you withdraw your pension money, you are noteligible for GIC coverage.EAP (Enrollee Assistance Program) – mental health servicesthat include help for depression, marital issues, family problems,alcohol and drug abuse, and grief. Also includes referral servicesfor legal, financial, family mediation, and elder care assistance.EGR (Elderly Governmental Retiree) – a state employee whoretired from state service prior to January 1, 1956. EGRs alsoinclude certain municipal employees who retired prior to the datetheir city or town elected to provide health insurance benefits totheir employees/retirees and whose municipality has elected toparticipate in the EGR program.EPO (Exclusive Provider Organization) – a health planthat provides coverage for treatment by a network of doctors,hospitals and other health care providers within a certaingeographic area. EPOs do not offer out-of-network benefits, withthe exception of emergency care. EPOs encourage but do notrequire the selection of a Primary Care Provider (PCP).GIC (Group Insurance Commission) – a quasi-independentstate agency governed by a 17-member commission appointedby the Governor. The mission of the GIC is to provide high-valuehealth insurance and certain other benefits to state, particularauthority, and participating municipality employees, retirees, andtheir survivors and dependents.HMO (Health Maintenance Organization) – a health planthat provides coverage for treatment by a network of doctors,hospitals and other health care providers within a certaingeographic area. HMOs do not offer out-of-network benefits, withthe exception of emergency care. An HMO requires the selectionof a Primary Care Provider (PCP).IRBO (Integrated Risk Bearing Organization) – a health careentity that manages a broad range of health care services andaccepts full or partial financial risk for its patients. IRBOs mayqualify as Accountable Care Organizations (ACOs).Limited Network Plan – a less expensive health plan thatoffers essentially the same benefits as more expensive, widernetwork plans, but with fewer physicians, hospitals, and otherproviders.Networks – groups of doctors, hospitals and other health careproviders that contract with a benefit plan. If you are in a planthat offers network and non-network coverage, you will receivethe maximum level of benefits when you are treated by networkproviders.PCP (Primary Care Provider) – includes nurse practitioners,physician assistants, and physicians with specialties in internalmedicine, family practice, and pediatrics. For HMO members, youmust select a PCP to coordinate your health care.PPO (Preferred Provider Organization) – a health insuranceplan that offers coverage by network doctors, hospitals, and otherhealth care providers, but also provides a lower level of benefitsfor treatment by out-of-network providers. A PPO plan encouragesbut does not require the selection of a Primary Care Provider (PCP).Preventive Services – generally, health care services, suchas routine physicals, that do not treat an illness, injury, or acondition.RMT (GIC Retired Municipal Teacher) – a retired teacher froma city, town or school district who is receiving a pension from theTeacher’s Retirement Board and whose municipality has electedto participate in the GIC RMT program. Retired teachers whoparticipate in the municipal program for GIC health-only benefitsare not RMTs.39-Week Layoff Coverage – allows laid-off employees tocontinue their group health and life insurance for up to 39 weeks(about 9 months) by paying the full cost of the premium.36


P.O. Box 8747Boston, MA 02114-8747COMMONWEALTH OF MASSACHUSETTSDeval L. Patrick, GovernorTimothy P. Murray, Lieutenant GovernorGroup Insurance CommissionDolores L. Mitchell, Executive Director19 Staniford Street, 4th FloorBoston, MassachusettsTelephone: 617.727.2310TDD/TTY: 617.227.8583MAILING ADDRESSGroup Insurance CommissionP.O. Box 8747Boston, MA 02114-8747Website: www.mass.gov/gicCOMMISSIONERSThomas A. Shields, ChairRichard E. Waring, Vice Chair (NAGE)Suzanne Bailey, Designee (for Joseph G. Murphy,Commissioner, Division of Insurance)Theron R. BradleyStephen B. Chandler (Local 5000, S.E.I.U., NAGE)Robert J. Dolan (Massachusetts Municipal Association)Kevin Drake (Council 93, AFSCME, AFL-CIO)Edward A. Kelly (President, Professional Fire Fighters ofMassachusetts)Melvin A. Kleckner (Massachusetts Municipal Association)Eileen P. McAnnenyCandace Reddy, Designee (for Glen Shor, Secretary ofAdministration and Finance)Anne M. Paulsen (Retiree Member)Laurel SweeneyTimothy D. Sullivan, Ed. D. (Massachusetts TeachersAssociation)

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