Pre-Medicare - Colorado PERA

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Pre-Medicare
2016 Open Enrollment Guide
Open Enrollment
October 1–November 5, 2015
Plan Information for
Pre-Medicare Health Plans
(under age 65)
Dental Plans
Vision Plans
PERACare Plan Contact Information/Resources
Anthem Blue Cross and Blue Shield
Group #195331
1-877-PERABLU (737-2258)
www.anthem.com
Cigna Dental
Dental HMO–Group #10080104
Dental PPO–Group #3171792
1-877-635-PERA (7372)
www.cigna.com
Delta Dental
Group #11869
1-800-610-0201
www.deltadentalco.com
Express Scripts
Group #COPERA2
1-866-725-2502
www.express-scripts.com
Kaiser Permanente
Group #1804
Denver/Boulder: 303-338-3800 or
1-800-632-9700
Northern Colorado: 1-800-632-9700
Southern Colorado: 1-888-681-7878
www.kaiserpermanente.org
VSP
Group #12144626
1-800-877-7195
www.vsp.com
SilverSneakers
1-888-423-4632
www.silversneakers.com
PERACare QuitLine
1-855-261-2636
September 2015
Dear PERACare Participant:
This 2016 PERACare Open Enrollment Guide includes information about the changes for 2016, plan and
premium information, and an Enrollment/Change Form. If you are considering changing plans, the information in
this Guide will be helpful to you.
Your 2016 premiums are shown in the box below. If you are eligible for PERA’s health care subsidy, it has
already been applied to the premium amount shown below. Your new premiums will be effective with your
December 2015 premium payment for January 2016 coverage. If you wish to continue the same coverage(s) for
2016, please do not complete the Enrollment/Change Form. If you plan to make changes, complete and return
the Enrollment/Change Form by November 5, 2015.
BR=Benefit Recipient, S=Spouse, C=Children
Open enrollment meetings will be held throughout Colorado in October. You may also view the open
enrollment presentation videos on the PERA website at www.copera.org.
Sincerely,
The PERACare Staff
PreMed
Open Enrollment Meeting Schedule
Alamosa
Fort Collins
Arvada
Grand Junction
Aurora
Greeley
Broomfield
Lakewood
Colorado Springs
Lamar
October 6
Rodeway Inn
333 Santa Fe Ave.
October 22
Arvada Center
6901 Wadsworth Blvd.
October 2
The Summit Event Center
411 Sable Blvd.
October 23
Omni Interlocken Resort
500 Interlocken Blvd.
October 15
Hotel Eleganté
2886 S. Circle Dr.
October 26
Colorado Springs Marriott
5580 Tech Center Dr.
Durango
October 27
Hilton Fort Collins
425 W. Prospect Rd.
October 9
Two Rivers Convention Center
159 Main St.
October 20
Island Grove Regional Park
421 N. 15th Ave.
October 19
Holiday Inn Lakewood
7390 W. Hampden Ave.
October 13
Lamar Community Building
610 S. 6th St.
Lone Tree
Longmont
October 16
Plaza Hotel & Conference Center
1850 Industrial Cir.
Montrose
October 8
Holiday Inn Express
1391 S. Townsend Ave.
Pueblo
October 14
Pueblo Convention Center
320 Central Main St.
Sterling
October 21
Sterling Elks Lodge
321 Ash St.
Westminster
October 5
Noah’s Event Venue
11885 N. Bradburn Blvd.
October 12
Denver Marriott South
10345 Park Meadows Dr.
October 7
La Plata County Fairgrounds
2500 Main Ave.
PERA staff will give three presentations at every meeting. Each session is designed for a specific audience. Please
review the schedule below to determine which presentation meets your needs.
Presentations will be available on the Colorado PERA website on October 1, 2015.
9:00–9:45 a.m.
Open Enrollment for Medicare Enrollees (Age 65+)
10:00–10:45 a.m.
Open Enrollment for Pre-Medicare Enrollees (Under 65)
11:00 a.m.–noon
Turning 65—PERACare and Medicare
For those who are already over age 65 and looking to enroll in or change
PERACare Medicare plans for 2016.
For those who are not yet age 65 and want information about what is new for
PERACare pre-Medicare plans in 2016.
For those who are turning age 65 in the next year and want information about how
to enroll in Medicare and how Medicare works with PERACare.
Pre-Medicare Guide
What can you do during open enrollment?
Open enrollment is the one time each year when you can sign up for a PERACare plan (health,
dental, or vision) for yourself, add your spouse or dependent child(ren), or change from one plan
to another. Regardless of whether or not you have had prior coverage, you can sign up for a
PERACare plan during open enrollment. Open enrollment ends November 5, 2015.
What is changing for 2016?
All PERACare health, dental, and vision carriers are continuing for the 2016 plan year. Premiums
are increasing for some plans and staying the same for Cigna Dental PPO and VSP plans.
Benefits within the plans are staying the same or improving, as explained below.
Anthem
»» Premiums for PPO #2 will remain the same for 2016. Premiums for Pathway HMO, PPO #1,
and HDHP will increase by $68, $116, and $183, respectively, per month in 2016 for
single coverage.
»» The PERAFit program will be canceled. SilverSneakers is still available for enrollees.
Kaiser Permanente
»» The premium will increase between $19 and $38 in 2016 for single coverage.
»» The HMO #2 deductible of $1,000 will now apply to the out-of-pocket maximum of $4,000.
This is not a change to the benefit, but rather an administrative change.
Cigna Dental
»» Premiums for both plans will remain the same for 2016—there will be no premium increase.
»» Dental HMO copays will increase for some services.
Delta Dental
»» The premium will remain the same for 2016—there will be no premium increase.
Vision Service Plan (VSP)
»» Premiums for all plans will remain the same for 2016—there will be no premium increase.
»» Increased frame allowance for purchasing “Feature Frames” from select Marchon Eyewear
brands such as Calvin Klein, Nautica, Nine West, and Valentino.
When does open enrollment end?
Open enrollment ends November 5, 2015. Your changes become effective January 1, 2016.
Do I need to complete an enrollment form during open enrollment?
If you are satisfied with your current coverage, you do not need to submit an enrollment form. If
you wish to enroll, make changes, or add dependents to your coverage, you must submit your
enrollment form to PERA by November 5, 2015.
What do I need to do if I am turning 65 in 2016?
Turning 65 is a separate enrollment opportunity. Three months prior to your 65th birthday you
will need to enroll in Medicare Part B and then select a new PERACare Medicare plan.
1
Anthem Benefit Highlights
The information below is for using in-network providers.
Pathway HMO
In-Network Benefits
PPO #1
In-Network
Individual
$1,500
$1,500
Family
$3,000
$3,000
Individual
$10,000
$10,000
Family
$20,000
$20,000
$2,500,000, including $1,000,000
transplant lifetime benefit
$2,500,000, including $1,000,000
transplant lifetime benefit
Features
Annual In-Network Deductible1
Annual Out-of-Pocket Maximum1
Lifetime Benefit Maximum (per individual)
Benefits
Preventive Care—Covered In-Network only and not subject to deductible
Exam
No charge
No charge
Screenings
No charge
No charge
Immunizations
No charge
No charge
Colonoscopy
No charge if procedure is done at an
Ambulatory Surgery Center (ASC);
otherwise $300 copay
No charge if procedure is done at an
Ambulatory Surgery Center (ASC);
otherwise $300 copay
Outpatient Services (per visit or procedure)—Subject to deductible unless otherwise noted
Primary care office visit
$30 copay2
$30 copay2
Specialty care office visit
$45 copay2
$45 copay2
Ambulatory surgery
20% coinsurance
20% coinsurance
Diagnostic lab and X-ray
20% coinsurance
20% coinsurance
Therapeutic X-ray; MRI, PET, CT
20% coinsurance
20% coinsurance
Durable medical equipment
20% coinsurance
20% coinsurance
Oxygen
20% coinsurance
20% coinsurance
Physical, occupational, and speech therapy3
20% coinsurance
20% coinsurance
Home health care
20% coinsurance
20% coinsurance
Hospice care
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
Vision care
Not covered
Not covered
Dental care
Not covered unless resulting from an
accident in which other significant
injuries occurred
Not covered unless resulting from an
accident in which other significant
injuries occurred
Hospital care and professional visits
20% coinsurance
20% coinsurance
Skilled nursing facility care
20% coinsurance
20% coinsurance
3
Chiropractic care
3
Inpatient Care
3
1 In
Pathway HMO, PPO #1, and PPO #2, your payments for services not subject to the deductible do not accumulate toward the deductible
and out-of-pocket maximum.
2
Not subject to deductible.
3 Maximum
2
benefit may be limited.
HDHP
In-Network
PPO #2
In-Network
$3,500
$6,000
$7,000
$12,000
$6,050
$16,000
$12,100
$32,000
$2,500,000, including $1,000,000
transplant lifetime benefit
$2,500,000, including $1,000,000
transplant lifetime benefit
No charge
No charge
No charge
No charge
No charge
No charge
No charge if procedure is done at an
Ambulatory Surgery Center (ASC);
otherwise $300 copay
No charge if procedure is done at an
Ambulatory Surgery Center (ASC);
otherwise $300 copay
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
Not covered
Not covered
Not covered unless resulting from an
accident in which other significant
injuries occurred
Not covered unless resulting from an
accident in which other significant
injuries occurred
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
PERACARE SELECT HIP AND
KNEE REPLACEMENT BENEFIT
Participants in any of the Anthem
Pre-Medicare plans may take
advantage of a program that
delivers a hip or knee replacement
at significant savings by waiving
your deductible and/or coinsurance
when the procedure is performed
by a select group of participating
surgeons at certain high-quality
hospitals and surgical centers in the
Denver area.
If you need hip or knee replacement
surgery, contact Anthem at
1-877-PERABLU to get a list of
participating physicians and facilities
and to learn more about how this
program can save you thousands
of dollars.
Continued on next page
3
Anthem Benefit Highlights
Emergency and Urgent Care
Pathway HMO
In-Network Benefits
PPO #1
In-Network
Emergency room visit
20% coinsurance
20% coinsurance
After-hours care
20% coinsurance
20% coinsurance
Ambulance service
20% coinsurance
20% coinsurance
$300 deductible,
then 50% coinsurance
maximum copay is $75
$300 deductible,
then 50% coinsurance
maximum copay is $75
Generic: $35 copay
Brand: $150 copay
Generic: $35 copay
Brand: $150 copay
Prescription Drugs (Administered by Express Scripts)
Retail pharmacy (up to a 30-day supply)
Mail order (up to a 90-day supply)
Out-of-Network Information
In all Anthem plans, you can use out-of-network providers for Emergency and Urgent Care
services. Services are covered at the in-network benefit level.
If you are enrolled in Anthem’s Pathway HMO, you must use providers in Anthem’s Pathway
HMO network for all services except Emergency and Urgent Care services.
If you are enrolled in Anthem’s PPO #1, HDHP, or PPO #2, you must use in-network providers
in order to receive a benefit for the following services:
» Preventive Care
» Durable Medical Equipment
» Oxygen
» Organ Transplants
You may use doctors and other providers who do not contract with Anthem
(out-of-network providers) for other services, but you will be subject to the
following costs:
» A separate deductible that is two times the in-network deductible.
» A separate out-of-pocket maximum that is two times the in-network
out-of-pocket maximum.
» Coinsurance of 40 percent.
4
HDHP
In-Network
PPO #2
In-Network
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
(after plan deductible is met)
$500 deductible,
then 50% coinsurance;
maximum copay is $100
20% coinsurance
(after plan deductible is met)
Generic: $35 copay
Brand: $175 copay
Some important benefits and features of PERA’s Anthem plans when using
in-network providers:
» You have access to large, worldwide networks of doctors and facilities in the PPO and HDHP
plans, including all hospitals in Colorado.
» Preventive care is covered at no charge to you.
» No referrals are needed to see a specialist.
» Routine doctor visits are not subject to the deductible in the Pathway HMO and PPO #1 plans (you
pay a copay).
» You have the option of seeing out-of-network providers in the PPO and HDHP plans.
The Benefit Highlights chart summarizes and compares the features and benefits of the
four plans.
The chart shows the amounts that you will be paying when you receive care or services. For many
services, your share of costs is the same for all plans. The shaded blocks help to compare your
cost-share.
For example, many of the services are subject to “20 percent coinsurance.” This means
that you will pay 20 percent of the charges and PERA’s Anthem plan will pay the other
80 percent of charges. Note that for some services, you have deductibles to meet before the plan
begins to share in costs. Until you meet the deductible, you are paying all charges after network
discounts have been applied.
Other services are subject to copays. For example, a “$30 copay” means that you will pay your
doctor $30 at the time of your visit, and your doctor will bill PERA’s Anthem plan for the rest of
the charges. If your doctor also bills Anthem for services such as blood work or X-rays, you will
have additional coinsurance to pay once Anthem applies its network discounts and processes the
charges. If you have not yet met your deductible, your coinsurance will be 100 percent until the
deductible is satisfied, then it will be 20 percent.
Questions about what services are covered?
If you enroll, you will receive a benefits booklet from Anthem which describes the terms and
conditions of your coverage in detail. You may also call Anthem’s Customer Service Center at
1-877-737-2258 if you have questions about benefits or coverage.
5
Kaiser Permanente Benefit Highlights
Features
HMO #1
In-Network OnlyOnly
HMO #2
In-Network Only
Individual plan annual deductible
None
$1,000
Family plan annual deductible1
None
$3,0001
Individual plan annual out-of-pocket maximum
$4,000
$4,000
Family plan annual out-of-pocket maximum
$10,000
$9,0001
None
None
Exam
$25 copay
No charge
Screenings
No charge
No charge
Immunizations
No charge
No charge
Colonoscopy
No charge
No charge
Primary care office visit
$25 copay3
$25 copay4
Specialty care office visit
$40 copay3
$45 copay4
Ambulatory surgery
$300 copay
20% coinsurance
Diagnostic lab and X-ray
No charge
Lab: No charge;
X-ray: 20% coinsurance
Lifetime benefit maximum (per individual)
Benefits
Preventive Care—Not subject to deductible
Outpatient Services (per visit or procedure)
Therapeutic X-ray; MRI, PET, CT
20% coinsurance
Durable medical equipment
No charge
20% coinsurance4
Oxygen
No charge
20% coinsurance4
Physical, occupational, and speech therapy5
$25 copay3
$25 copay4
Home health care
No charge
20% coinsurance
Hospice care
No charge
20% coinsurance
$25/$40 copay3
$25/$45 copay4
$25 copay
Not covered
$1,000 copay per admission
20% coinsurance
No charge
20% coinsurance
Vision care
Chiropractic care3
Inpatient Care
Hospital care and professional visits
Skilled nursing facility care5
Emergency and Urgent Care
Emergency room visit (waived if admitted)
$150 copay3
20% coinsurance
After-hours care
$50 copay3
$45 copay4
20% coinsurance (up to $500 per trip)
20% coinsurance (up to $500 per trip)
Pharmacy (up to a 30-day supply)
Generic: $15 copay3; Brand: $40 copay3
Generic: $15 copay4; Brand: $40 copay4
Mail Order (up to a 90-day supply)
Generic: $30 copay3; Brand: $80 copay3
Generic: $30 copay4; Brand: $80 copay4
Ambulance service
Prescription Drugs
6
$40 copay3; $100 copay3
HDHP
In-Network Only
The Benefit Highlights chart summarizes and compares
the features and benefits of the three plans.
$3,500
The chart shows the amounts that you will pay when you
receive care or services. For some services, your share
of costs is the same in two or all of the plans.
The shaded blocks help to compare your cost-share.
$7,000
2
$6,050
$12,1002
None
No charge
No charge
No charge
No charge
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
20% coinsurance
Not covered
Some services are covered at no charge to you;
for other services you will pay a portion of the
costs (either a fixed dollar copay or a percentage
coinsurance).
A “$25 copay” means that you will pay Kaiser
Permanente $25 at the time of your visit, and PERA’s
Kaiser Permanente plan will pay the rest.
A “20 percent coinsurance” means that you will
pay 20 percent of the charges, and PERA’s Kaiser
Permanente plan will pay the other 80 percent of
charges. For some services and procedures received
during an office visit in HMO #2, you will pay
20 percent coinsurance in addition to the office visit
copay. Services subject to coinsurance may also
be subject to the plan deductible.
Except for emergency care, there are no
out-of-network benefits with Kaiser Permanente.
You must use Kaiser Permanente’s network of
physicians and providers.
Questions about what services are covered?
If you enroll, you will receive an Evidence of Coverage
(benefits booklet) from Kaiser Permanente which
describes the terms and conditions of your coverage.
You may also call Kaiser Permanente’s Customer
Service Center if you have questions about benefits or
coverage. Call 303-338-3800 or 1-800-632-9700 if you
are in Kaiser Permanente’s Denver/Boulder or Northern
Colorado service areas, or 1-888-681-7878 for their
Southern Colorado service area.
1
or family memberships in HMO #2, each enrollee is responsible
F
for meeting the individual deductible and out-of-pocket
maximum until the family limit is met.
2
20% coinsurance
or family memberships in the HDHP, the family deductible and
F
out-of-pocket maximum must be met by one or more family
members. Individual amounts do not apply.
3
20% coinsurance
Not applicable to the out-of-pocket maximum.
4
ot subject to deductible and not applicable to the out-of
N
pocket maximum.
5
Maximum benefit may be limited.
6
opays for prescription drugs in the HDHP apply after the plan
C
deductible is met.
20% coinsurance
20% coinsurance
20% coinsurance
Generic: $10 copay6; Brand: $25 copay6
Generic: $20 copay6; Brand: $50 copay6
7
Dental Plan Highlights
Cigna Dental HMO
Cigna Dental PPO
Delta Dental PPO
Individual plan annual deductible1
None
$100
$100
Family plan annual deductible1
None
$200
$200
Annual benefit maximum (per individual)
None
$1,500
$1,500
Not covered
No limitation
$1,500
$1,500
Cigna Dental
DPPO Advantage Network
Search www.cigna.com
or call 1-800-cigna24
(1-800-244-6224)
$1,500
$1,500
Features
Lifetime benefit maximums:
Implants (per individual)
Orthodontics (per individual)
Provider network
How to find a dentist
Cigna Dental HMO Network
Search www.cigna.com
or call 1-800-cigna24
(1-800-244-6224)
Delta Dental PPO Network
Search
www.deltadentalco.com
or call Delta Dental at
1-800-610-0201
Areas where plan is available
Metro Denver, Front Range,
and major metro areas
in many states
Covered Services
Covered in-network only
Covered in- and out-of-network
Your Copay
What you pay if you use a network dentist2
Diagnostic and Preventive
Nationwide
Nationwide
Office visit
$5 copay
Nothing
Nothing
Oral exams and regular cleanings
$0 copay
Nothing
Nothing
X-rays
$0 copay
Nothing
Nothing
$12 per tooth
Nothing
Nothing
Basic restorative (fillings)
$0 to $115 copay
20% of PPO Contracted Fee
20% of PPO Contracted Fee
Oral surgery (extractions)
$13 to $125 copay
20% of PPO Contracted Fee
20% of PPO Contracted Fee
Endodontics (root canal therapy)
$14 to $430 copay
20% of PPO Contracted Fee
20% of PPO Contracted Fee
Periodontics (gum disease treatment)
$42 to $430 copay
20% of PPO Contracted Fee
20% of PPO Contracted Fee
Prosthodontics (dentures, bridges)
$43 to $715 copay
50% of PPO Contracted Fee
50% of PPO Contracted Fee
Special restorative (crowns, bridges)
$13 to $500 copay
50% of PPO Contracted Fee
50% of PPO Contracted Fee
$67 to $2,376 copay
50% of PPO Contracted Fee
50% of PPO Contracted Fee
Not covered
50% of PPO Contracted Fee
50% of PPO Contracted Fee
Sealants
Basic Services
Major Services
Orthodontics (braces)
Implants
1
Deductible applies to Basic and Major Services, but not Diagnostic and Preventive.
2 In
both the Cigna Dental and Delta Dental PPO plans, you have the greatest savings if you use a PPO dentist. If you see a dentist who
does not participate in the plan’s PPO network, you will pay the difference between the PPO contracted fee and the fee charged by the
dentist, in addition to any deductible and coinsurance.
In the Delta Dental plan, if you see a dentist who does not participate in the PPO network, but does participate in the Premier network, you will
have greater savings than seeing an out-of-network dentist, but you will pay the difference between the PPO contracted fee and the Premier
contracted fee, in addition to any deductible and coinsurance.
8
Vision Plan Highlights
Vision PPO #1
In-Network
Plan Availability
Well Vision Exam (Every 12 months)
Prescription Glasses1
Out-of-Network
Nationwide
Vision PPO #2
In-Network
Out-of-Network
Nationwide
Vision PPO #3
In-Network
Out-of-Network
Nationwide
$10 copay, then $10 copay, then $25 copay, then $25 copay, then $10 copay, then $10 copay, then
covered in full covered up to $45 covered in full covered up to $45 covered in full covered up to $45
$25 copay for lenses and frame
$25 copay for lenses and frame
Single Vision
Covered in full
Covered up to $30
Bifocal
Covered in full
Covered up to $50
20% discount off
complete pair of
glasses only; no
Covered once every 12 months
discount for lenses
only, frame only, or
Covered in full Covered up to $30 replacement parts
or repairs
Covered in full Covered up to $50
Trifocal
Covered in full
Covered up to $65
Covered in full
Lenses
Frame
Covered once every 12 months
Covered once every 12 months
$160 retail
allowance
Contacts1
Covered up
to $70
Covered once every 12 months
Covered up to $65
Covered once every 24 months
$115 retail
allowance
Covered up
to $70
Covered once every 12 months
$130 allowance for $105 allowance for $105 allowance for $105 allowance for
evaluation, fitting, evaluation, fitting, evaluation, fitting, evaluation, fitting,
and lenses
and lenses
and lenses
and lenses
Lens Options
Not covered
15% discount
for evaluation
and fitting,
no discount
for lenses
Not covered
Discounts average
20–25%
Not covered
Discounts average
20–25%
Not covered
20% discount
Not covered
Additional Glasses
(Including Sunglasses)
20% discount
Not covered
20% discount
Not covered
20% discount
Not covered
Laser Vision Correction
15% discount
Not covered
15% discount
Not covered
15% discount
Not covered
VSP Network Doctors
See VSP Choice Network directory
for a complete list of current doctors
Nationwide
access to
thousands of
private practice
VSP doctors
Non-VSP
providers
licensed or
certified to
provide covered
benefits
Nationwide
access to
thousands of
private practice
VSP doctors
Non-VSP
providers
licensed or
certified to
provide covered
benefits
Nationwide
access to
thousands of
private practice
VSP doctors
Non-VSP
providers
licensed or
certified to
provide covered
benefits
VSP Member Services
1-800-877-7195 or www.vsp.com
1 You
1-800-877-7195 or www.vsp.com
1-800-877-7195 or www.vsp.com
may choose prescription glasses or contacts, but not both, once every 12 or 24 months as noted above.
9
Anthem Monthly Premiums
(BR = Benefit Recipient S = Spouse C = Children)
Pathway HMO
BR BR+S
BR+C
BR+S+C
PPO #1
$744.00
1,488.00
1,339.00
2,083.00
$890.00
1,780.00
1,602.00
2,492.00
HDHP PPO #2
$913.00 1,826.00 1,643.00 2,556.00 $361.00
722.00
650.00
1,011.00
Kaiser Permanente Monthly Premiums
(BR = Benefit Recipient S = Spouse C = Children)
BR
BR+S
BR+C
BR+S+C
HMO #1
HMO #2
HDHP
$949.00$795.00 $472.00
1,898.001,590.00 944.00
1,709.001,432.00 850.00
2,658.002,227.00 1,322.00
Cigna Dental Monthly Premiums
(BR = Benefit Recipient S = Spouse C = Children)
HMO PPO
BR BR+S
BR+C
BR+S+C
$18.50
$36.99
37.0173.98
42.5685.09
59.21118.37
Delta Dental Monthly Premiums
(BR = Benefit Recipient S = Spouse C = Children)
PPO
BR $37.02
BR+S74.04
BR+C85.13
BR+S+C118.45
VSP Monthly Premiums
(BR = Benefit Recipient S = Spouse C = Children)
PPO #1
BR BR+S
BR+C
BR+S+C
PPO #2
PPO #3
$7.47
$4.94
$0.78
11.947.94 1.27
12.208.11 1.30
19.6713.08 2.08
To calculate your net health care premium, subtract your PERA subsidy from the above health
care premium. You may use the formula on page 11 or the “PERACare Premium Inquiry for
Retirees” calculator on the PERA website at www.copera.org.
10
Calculating Your Health Care Premium
After you have selected a health plan and chosen a level of coverage, you are ready to calculate your
premium for that plan.
A.Enter the total premium amount
(from the premium chart on page 10)
A.
$
B.Enter your Pre-Medicare Benefit Recipient Subsidy
(from the subsidy chart below)
B.
$
C.Subtract line B from line A (A – B) C.
$
This is your monthly
health care premium.
Pre-Medicare Benefit Recipient (BR) Subsidy Chart
YEARS OF SERVICE
PRE-MEDICARE BR SUBSIDY
20+
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
$230.00
218.50
207.00
195.50
184.00
172.50
161.00
149.50
138.00
126.50
115.00
103.50
92.00
80.50
69.00
57.50
46.00
34.50
23.00
11.50
11
PERACare Enrollment/Change Form
Pre-Medicare Coverage—2016
Colorado Public Employees’ Retirement Association
PO Box 5800, Denver, Colorado 80217-5800
1-800-759-PERA (7372) • Fax: 303-863-3727 • www.copera.org
Your SSN
Open enrollment ends on November 5, 2015
Complete and return this form if you want to add coverage(s), make changes, or cancel coverage(s). If you do not want to make any
changes, your current coverage(s) will remain in place, and you do not need to complete this form.
Your
Information
Name __________________________________________________________________________
Last
First
MI
(
)
/
/
Birthdate _____________________
Daytime Phone Number ________________________________
Email Address ____________________________________________________________________
Sign up for electronic delivery of PERA information?
Signature
Certification
q Yes q No
By signing the form, I am certifying and agreeing with the following: I have reviewed the information about
PERACare. I am eligible to enroll in the Program, and if I am enrolling my spouse and/or dependents, I certify
that they also are eligible to be enrolled. The information I provided on this form is correct and complete. I
authorize Colorado PERA to deduct from my monthly benefit the premium for my coverage. Finally, I agree
that, if I wish to cancel this coverage, I must provide PERA with a 30-day advance written notice.
Sign Here è Your Signature ___________________________________________ Date ___________________
Effective
Date
If I enroll, make changes, or cancel coverage during open enrollment (October 1–November 5, 2015),
I understand the effective date will be January 1, 2016.
Dependent
Enrollment
Information
Complete this section if you are adding coverage(s) for your spouse and/or dependent children who are under
age 65. If you are adding coverage for dependents with Medicare, use the PERACare Combination
Pre-Medicare and Medicare Coverage Enrollment/Change Form.
_______________________________________________________________________________
/
/
Spouse’s Last Name
First Name
MI
Birthdate
SSN
M/F
_______________________________________________________________________________
/
/
Child’s Last Name
First Name
MI
Birthdate
SSN
M/F
_______________________________________________________________________________
/
/
Child’s Last Name
First Name
MI
Birthdate
SSN
M/F
_______________________________________________________________________________
/
/
Child’s Last Name
First Name
MI
Birthdate
SSN
M/F
Select your health, dental, and vision plans on the reverse
2/213-pcretpm (REV 8-15)
PERACare Enrollment/Change Form
Pre-Medicare Coverage—2016 (Page 2)
Your Name _____________________________________________________ Your SSN _________________________________
Health Plan
Selection
1. What do you want to do? (Check only one box.)
q Add or change coverage as indicated below
q Keep current PERACare health care coverage
q Cancel current PERACare health care coverage
2. Check one box below to select a plan and coverage level if you are adding or changing coverage.
(BR=Benefit Recipient)
q BR Only q BR+Spouse q BR+Child(ren) q BR+Spouse+Child(ren)
Anthem PPO #1
q BR Only q BR+Spouse q BR+Child(ren) q BR+Spouse+Child(ren)
Anthem PPO #2
q BR Only q BR+Spouse q BR+Child(ren) q BR+Spouse+Child(ren)
Anthem HDHP
q BR Only q BR+Spouse q BR+Child(ren) q BR+Spouse+Child(ren)
Anthem HMO*
q BR Only q BR+Spouse q BR+Child(ren) q BR+Spouse+Child(ren)
Kaiser Permanente HMO #1
Kaiser Permanente HMO #2 q BR Only q BR+Spouse q BR+Child(ren) q BR+Spouse+Child(ren)
q BR Only q BR+Spouse q BR+Child(ren) q BR+Spouse+Child(ren)
Kaiser Permanente HDHP
* If you are enrolling in the Anthem HMO plan, please select your Primary Care Physician(s) and indicate their
provider ID(s) below. Provider IDs can be obtained by calling Anthem at 1-877-PERABLU (1-877-737-2258).
Anthem HMO Provider ID(s):
Dental Plan
Selection
_______________ ___________________ _________________
Benefit Recipient
Spouse
Child(ren)
1. What do you want to do? (Check only one box.)
q Add or change coverage as indicated below
q Keep current PERACare dental coverage
q Cancel current PERACare dental coverage
2. Check one box below to select a plan and coverage level if you are adding or changing coverage.
(BR=Benefit Recipient)
Cigna Dental PPO
Cigna Dental HMO*
Delta Dental PPO
q BR Only
q BR Only
q BR Only
q BR+Spouse
q BR+Spouse
q BR+Spouse
q BR+Child(ren)
q BR+Child(ren)
q BR+Child(ren)
q BR+Spouse+Child(ren)
q BR+Spouse+Child(ren)
q BR+Spouse+Child(ren)
* If you are enrolling in the Cigna Dental HMO, please select your dentist(s) and indicate their provider office
number(s) below. Provider office numbers can be obtained by calling Cigna at 1-877-635-PERA (7372).
Cigna Dental HMO Office Number(s): ______________ ________________ ________________
Benefit Recipient
Spouse
Child(ren)
Vision Plan
Selection
1. What do you want to do? (Check only one box.)
q Add or change coverage as indicated below
q Keep current PERACare vision coverage
q Cancel current PERACare vision coverage
2. Check one box below to select a plan and coverage level if you are adding or changing coverage.
(BR=Benefit Recipient)
VSP PPO #1
VSP PPO #2
VSP PPO #3
q BR Only
q BR Only
q BR Only
q BR+Spouse
q BR+Spouse
q BR+Spouse
q BR+Child(ren)
q BR+Child(ren)
q BR+Child(ren)
q BR+Spouse+Child(ren)
q BR+Spouse+Child(ren)
q BR+Spouse+Child(ren)
PERA Contact Information
Colorado Public Employees’ Retirement Association
Mailing Address
Colorado PERA
PO Box 5800
Denver, CO 80217-5800
Denver Main Office
1301 Pennsylvania Street
Denver, CO 80203-5011
Denver Main Office Hours (Mountain time)
7:30 a.m.–4:30 p.m. Monday–Friday
Westminster Office
1120 W. 122nd Avenue
Westminster, CO 80234
Westminster Office Hours (Mountain time)
7:30 a.m.–4:30 p.m. Monday, Tuesday, Thursday, and Friday
1:00 p.m.–4:30 p.m. Wednesday
Customer Service Center Phone Hours (Mountain time)
7:00 a.m.–5:30 p.m. Monday–Thursday
7:00 a.m.–4:30 p.m. Friday
Phone/Website/Email
1-800-759-7372 (PERA)
303-863-3727 (Fax)
www.copera.org (email via “Contact Us” link on the PERA home page)
This booklet provides information about PERA’s health benefits program. Your rights,
benefits, and obligations as a Colorado PERA member are governed by Title 24, Article
51 of the Colorado Revised Statutes, and the Rules of the Colorado Public Employees’
Retirement Association, which take precedence over any interpretations in this booklet.
Colorado Public Employees’ Retirement Association
1301 Pennsylvania Street
Denver, Colorado 80203-5011
www.copera.org
2/258 (REV 8-15) 19M