2014 Open Enrollment Brochure (for Medical Benefits)

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High Option Supplement to Medicare

Medicare PPO with Rx

Medicare PPO without RxFor University of California Medicare-eligible retirees – Effective January 1, 2014

ii Blue Shield of California

Go with the plan that’s right for you

When you go with Blue Shield of California, you’re on your way to quality health coverage, large provider networks, and a wide range of proven programs and services that help you get the most value from your coverage.

In this booklet, you’ll find the information you need to choose the right health plan for you and your family, including: Plan benefits and features Pharmacy benefits

How to find a doctor Additional programs and services

Get health plan information anytime, anywhere!

•Fromasmartphonememberscancheckplancoverage,downloadtheir Blue Shield member ID card, get directions to the nearest urgent care center, and more. Just enter blueshieldca.com into the mobile browser.

•OurMemberCentergivesmembersinstantaccesstotheirentire family’s Blue Shield health coverage information from one account at blueshieldca.com. From your computer check out the Quick Start guide at blueshieldca.com/membercenter for more information.

•TolearnmoreaboutBlueShieldthroughinspiringstoriessharedbyour members, visit blueshieldca.com/memberstories.

Plan choicesDuring the 2014 annual enrollment period, the University of California is offering three health plans, administered by Blue Shield of California, to Medicare-eligible retirees:

• HighOptionSupplementtoMedicare

•MedicarePPOplanwithRx

•MedicarePPOplanwithoutRx

About the Medicare plansTheHighOptionSupplementtoMedicareandMedicarePPOplans (with and without Rx) are Medicare-coordinated plans that pay secondarily to Medicare and are available to UC retirees who have Medicare Part A and Part B.

TheHighOptionSupplementtoMedicareallowsyoutoreceive care without being limited to the Blue Shield network for most services. For those services that are not covered by Medicare, you can access care through a Blue Shield PPO networkprovider.TofindMedicareandBlueShieldPPOproviders, see page 2.

Stand Alone Health Reimbursement Account (SAHRA)If you had an SAHRA or health reimbursement account (HRA) through the UC Anthem Lumenos PPO Plan in 2013, and you enroll in one of the Medicare plans effective January 1, 2014, your unused SAHRA and/or HRA dollars will be transferred toaSAHRA*administeredbyHealthEquity.TheSAHRAisavailable to use for Medicare premiums and for medical and pharmacy expenses.

You will have access to these funds in April 2014 after a 90-day (January1–March31,2014)run-outperiod.Therun-outperiodallows your prior carrier to access these funds to pay for claims incurredin2013butnotprocessedforpaymentuntil2014.Tolearn more about the SAHRA, go to healthequity.com/ed/uc.

Care for retirees traveling abroadIf you enroll in the High Option Supplement to Medicare and Medicare PPO plans (with and without Rx) and travel overseas, you have access to care as well as emergency services.

For more information, visit blueshieldca.com/uc, and select Medicare Plans.

Blue Shield is driven to offering you the right choices for your healthcare coverage

* TheSAHRAisofferedthroughHealthEquity,acompanyindependentfromBlueShieldofCalifornia.BlueShielddoesnotoffertaxadviceforSAHRAs,asSAHRAsareofferedthrough financial institutions. For more information about SAHRAs, eligibility, and the law’s current provisions, please consult your financial or tax adviser.

Open enrollment often brings up lots of questions about health plans and benefits.Ifyouhavequestions,we’vegotanswers.TeamShieldisyourdedicated team of experts ready to help you get the right answers, right away. If you don’t understand particular aspects of your medical coverage, or how to access all the benefits of your health plan, you can go online and post a question. We’ll try to find the answers when you need them.

ConnectwithTeamShieldonFacebookoronTwitter @teamshieldbsc.

teamyour team, your answers

blueshieldca.com/uc 1

6 Blue Shield of California

Search for a network provider online

TofindproviderswhoacceptMedicare,gotomedicare.gov/ physiciancompare, the official website for people with Medicare coverage.

Some services that are covered by these plans are not covered by Medicare. For these services, please choose a Blue Shield network provider. For a list of these services, please reference the Summary Plan Description for your plan.

You can search for a Blue Shield network provider by following the steps below:

• Gotoblueshieldca.com/uc and select Find a Provider, and then choose the provider you are looking for.

• YouwillbedirectedtotheBlueShieldwebsitewhereyoucanclickon Advanced Search to further filter your search, such as by name, specialty, facility type, and more.

• EnteryourcityandstateorZIPcode,thenclickonFind now.

• Togetaprintablecopyofyoursearchresultswithupto200providerrecords, click on Get Results as PDF above the “Distance” field to download the document, or have it emailed to you.

Find a network provider

If you don’t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team toll-free at (855) 201-8375, from 7 a.m. to 7p.m.PT,MondaythroughFriday, for personal assistance or to request a provider directory.


Your green light to programs and services

Beginning on January 1, 2014, you can register at blueshieldca.com and find more information about these programs.

Condition management programs–Theseprogramsoffer nurse support as well as education and self-management tools for members with asthma, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease.

NurseHelp 24/7 – Speak with registered nurses anytime, day or night, and get answers to your health-related questions, or go online to have a one-on-one personal chatwitharegisterednurseanytime.TheNurseHelp24/7SM phone number is conveniently located on the back of your member ID card.

Wellness discount programs – Blue Shield offers a variety of member discounts on popular weight loss, fitness, vision, and health and wellness programs1 that can help you save money and get healthier. For more information about these discount programs and to find participating providers, go to blueshieldca.com/hw.

• 24 Hour Fitness – Enjoy waived enrollment, processing, and initiation fees and discounts on monthly membership dues.

• Weight Watchers – Get discounts on three- and 12-month subscriptions, monthly passes, and at-home kits.

• ClubSport and Renaissance ClubSport – Obtain a 60% discount on enrollments when joining with a month-to-month agreement. Enrollment fees are waived when joiningwitha12-monthagreement.(Thereisaone-time$25 processing fee when you enroll.)

• Alternative Care Discount Program – Get 25% off usual and customary fees for acupuncture, massage therapy, and chiropractic services, plus get discounts on health and wellness products, with free shipping on most items.

• Discount Provider Network2–Take20%offthepublished retail prices when you use a participating provider in the Discount Vision Program network for exams, frames, lenses, and more.

• MESVision Optics–Takeadvantageofcompetitiveprices on contact lenses,3 sunglasses, readers, and eyecare accessories, with free shipping on orders over $50.

• QualSight LASIK – Save on LASIK surgery at more than 45 surgery centers in California. Services include pre-screening, a pre-operative exam, and post-operative visits.

• NVISION Laser Eye Centers – Receive a 15% discount on LASIK surgery from experienced surgeons with offices in Southern California and Sacramento.

• My2020EyesDirect – Get a 20% discount on prescription eyeglasses, sunglasses, and readers.3

1 ThesediscountprogramservicesarenotacoveredbenefitoftheHighOptionSupplementplantoMedicareandMedicarePPO(withandwithoutRx)plans,and none of the terms or conditions of the High Option Supplement plan to Medicare and Medicare PPO (with and without Rx) plans apply.

Thenetworksofpractitionersandfacilitiesinthediscountprogramsaremanagedbytheexternalprogramadministratorsidentifiedbelow,includinganyscreening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy, nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products.

Some services offered through the discount program may already be included as part of the High Option Supplement plan to Medicare and Medicare PPO (with and without Rx). Participants should access those covered services prior to using the discount program.

Participants who are not satisfied with products or services received from the discount program may use the grievance process described in the High Option Supplement plan to Medicare and Medicare PPO (with and without Rx) Evidence of Coverage or the High Option Supplement plan to Medicare and Medicare PPO (with and without Rx) Certificate of Insurance/Policy. Blue Shield reserves the right to terminate this program at any time without notice.

Discount programs administered by or arranged through the following independent companies:

• AlternativeCareDiscountProgram–AmericanSpecialtyHealthSystems,Inc.andAmericanSpecialtyHealthNetworks,Inc.

• DiscountProviderNetworkandMESVisionOptics.com–MESVision

• Weightcontrol–WeightWatchersNorthAmerica

• Fitnessfacilities–24HourFitness,ClubSport,andRenaissanceClubSport

• LASIK–LaserEyeCareofCalifornia,LLC;QualSight,Inc.;andNVISIONLaserEyeCenters

• My2020EyesDirect.com–AdvancedDigitalEyewearInc.

Note:Nogeneticinformation,includingfamilymedicalhistory,isgathered,shared,orusedfromtheseprograms.

2 TheDiscountProviderNetworkisavailablethroughoutCalifornia.Coverageinotherstatesmaybelimited.Findparticipatingprovidersbygoingtoblueshieldca.com/fap.

3 Requires a prescription from your doctor or licensed optical professional.


Review benefit summaries

University of California High Option Supplement to Medicare

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Blue Shield of California Highlights: A description of the prescription drug coverage is provided separately.

Effective January 1, 2014

MEDICARE (PART A) HOSPITAL SERVICES-PER BENEFIT PERIOD A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY

HOSPITALIZATION- Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,184 $ 1184

(Part A deductible) $0

61st through 90th day All but $296 day $296 day $0 91st day and after: While using 60 lifetime reserve days

All but $592 day $592 day $0

Once lifetime reserve days are used • Additional days

$0 80% of eligible expenses 20% of eligible expenses

• Beyond the additional 365 days


SKILLED NURSING FACILITY CARE- You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $148 a day Up to $148 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited co-payment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

Preferred Providers Non-Preferred

Providers Calendar Year Medical Deductible (All providers combined) (Deductible applies to non-Medicare covered services only) $50 per individual Calendar Year Copayment Maximum (Includes the plan deductible) (Copayment Maximum applies to non-Medicare covered services only) $1,050 per individual LIFETIME BENEFIT MAXIMUM None


MEDICARE (PART B) MEDICAL SERVICES-PER CALENDAR YEAR

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $147 of Medicare-approved amounts

$0 Up to $147 (Part b deductible)

$0

Remainder of Medicare-approved amounts

Generally 80% Generally 20% $0

Part B excess charges (above plan-approved amounts)

$0 $0 All costs

BLOOD First 3 pints $0 All costs $0 Remainder of Medicare-approved amounts

80% 20% $0

CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

ADDITIONAL BENEFITS – NON-MEDICARE COVERED SERVICES. Acupuncture Benefits (Acupuncture by a certificated acupuncturist / Up to 24 visits per calendar year)


Covered outpatient office visits with Marriage, Family, and Child counselors (MFT, MFCC)


Inpatient Residential Treatment


Hearing Aids (2 hearing aids per 36 months, analog or digital)


• Only retirees enrolled in Medicare parts A & B are eligible for this plan. • Medicare will always pay primary for Medicare covered services. • The plan will always coordinate with Medicare, paying secondary, for Medicare covered services. • The plan may cover some services not covered by Medicare; the plan contract should be consulted for detailed

description of coverage benefits and limitations.


University of California Medicare PPO with Prescription Drugs Medicare PPO without Prescription Drugs

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Blue Shield of California Highlights: A description of the prescription drug coverage is provided separately.

Effective January 1, 2014

MEDICARE (PART A) HOSPITAL SERVICES-PER BENEFIT PERIOD A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY

HOSPITALIZATION- Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,184 $1184

(Part A deductible) $0

61st through 90th day All but $296 day 80% of eligible expenses 20% of eligible expenses

91st day and after: While using 60 lifetime reserve days

All but $592 day 80% of eligible expenses 20% of eligible expenses

Once lifetime reserve days are used • Additional days


• Beyond the additional 365 days


SKILLED NURSING FACILITY CARE- You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21st through 100th day All but $148 a day 80% of remaining eligible

expenses 20% of remaining eligible expenses

101st day and after $0 $0 All costs BLOOD First 3 pints $0 80% of eligible expenses 20% of eligible

expenses Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited co-payment/coinsurance for outpatient drugs and inpatient respite care

80% of remaining eligible expenses


Preferred Providers Non-Preferred

Providers Calendar Year Medical Deductible (All providers combined) (Deductible applies to non-Medicare covered services only) $100 per individual

Calendar Year Copayment Maximum (Includes the plan deductible) $1,500 per individual LIFETIME BENEFIT MAXIMUM None


MEDICARE (PART B) MEDICAL SERVICES-PER CALENDAR YEAR

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES- IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $147 of Medicare-approved amounts

$0 $147 (Part B deductible)

$0

Remainder of Medicare-approved amounts

Generally 80% 80% of remaining eligible expenses


Part B excess charges (above plan-approved amounts)

$0 $0 All costs

BLOOD First 3 pints $0 80% of eligible expenses 20% of eligible

expenses Remainder of Medicare-approved amounts

80% 80% of remaining eligible expenses


CLINICAL LABORATORY SERVICES-TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

ADDITIONAL BENEFITS – NON-MEDICARE COVERED SERVICES. Acupuncture Benefits (Acupuncture by a certificated acupuncturist / Up to 24 visits per calendar year)


Covered outpatient office visits with Marriage, Family, and Child counselors (MFT, MFCC)


Inpatient Residential Treatment


Hearing Aids (2 hearing aids per 36 months, analog or digital)


• Only retirees enrolled in Medicare parts A & B are eligible for this plan. • Medicare will always pay primary for Medicare covered services. • The plan will always coordinate with Medicare, paying secondary, for Medicare covered services.. • The plan may cover some services not covered by Medicare, the plan contract should be consulted for detailed

description of coverage benefits and limitations.


notes


Notice on the availability of language assistance services to accompany vital documents issued in English IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.

You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198.

(Spanish)

重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。

這封信也可以用您所講的語言書寫。如需幫助，請立即撥打登列在您的Blue

Shield ID卡背面上的會員/客戶服務部的電話，或者撥打電話866-346-7198。 (Chinese)

QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số 866-346-7198. (Vietnamese)

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)Member confidentiality

Blue Shield protects the confidentiality and privacy of your personal and health information, including medical information and individually identifiable information such as your name, address, telephone number,andSocialSecuritynumber.Toensurethis,Blue Shield requires a signed authorization form for you to access health information for your spouse or dependents over the age of 18.

Torequestanauthorizationform,loginto blueshieldca.com and select My Health Plan. Click on Download Formsunder“Tools”ontherightside.Scroll down to “Release of information” and click on Personal and Health Information Release. If you don’t have access to the Internet, or have questions about how Blue Shield protects your privacy and confidentiality, please call our Privacy Office directly at (888) 266-8080.

Go with Blue Shield

and get on the road

to better health.

For any questions, visit blueshieldca.com/uc or call your dedicated Blue Shield Member Services team toll-free at (855) 201-8375, from 7a.m.to7p.m.PT,MondaythroughFriday.

Documents

2014 Open Enrollment Brochure (for Medical Benefits)