Health Insurance Enrollment Guide Non... · provide documentation that supports the occurrence of this qualifying event. Your enrollment application must be submitted within 31 days

Health InsuranceEnrollment Guide

for Non-Medicare ASRS Retirees Effective January 1, 2020

2020

Welcome from the Director | page 5

2020 Benefit Highlights | page 6

Eligibility | page 7

Qualifying Life Events | pages 8-10

Pre-Enrollment Tasks | page 11

Online Enrollment | page 12

2020 Premium Savings | page 13

Monthly Medical & Dental Premiums | page 14

Premium Benefit | pages 15-16

Becoming Medicare Eligible | page 17

Medical & Pharmacy Plan Comparisons | pages 18-21

Finding a Provider | pages 22-23

Additional Program Benefits | pages 24-25

Dental Plan Comparisons | pages 26-29

WellCard & PerksConnect | page 30

Glossary | pages 31-32

Telephone Numbers & Websites | inside back cover

Table Of Contents

3

This guide is a summary of the official Arizona State Retirement System (ASRS) plan documents, contracts, Arizona statutes and federal regulations that govern the plans. Other important information regarding the benefits of the plans, including your rights to make claims and appeals regarding benefit decisions, are included in the official documents. You should keep a copy of this Enrollment Guide with your other important documents related to your coverage under the Plans. If there is any discrepancy between the information in this guide and the official documents, the official documents will always govern. The ASRS reserves the right to change or terminate any of its plans, in whole or in part, at any time in accordance with state laws.

Please read this guide completely

Published by:Arizona State Retirement SystemOctober, 2019

4

Welcome to the Arizona State Retirement System (ASRS) non-Medicare retiree group health insurance open enrollment period for plan year 2020.

This Enrollment Guide has been designed to provide you with an overview of our medical and dental insurance plan offerings for non-Medicare ASRS retirees, as well as other benefits afforded to you as an ASRS retiree.

You may participate in these medical and/or dental insurance plans if you retired from the ASRS, Public Safety Personnel Retirement System (PSPRS), Elected Officials’ Retirement Plan (EORP), Corrections Officer Retirement Plan (CORP), or the University Optional Retirement Plans (UORP).

For eligible retirees effective January 1, 2020 or later, the ASRS offers three focused non-Medicare plans rather than the seven plans offered in previous years. The focused plans remain on the same UnitedHealthcare Choice network, with varying costs and benefits. We structured these focused non-Medicare plans to offer better value and lower premiums to our non-Medicare retirees.

Important for those enrolled in an ASRS non-Medicare plan at the end of Plan Year 2019: Open Enrollment for Plan Year 2020 is passive, meaning that if you take no action during Open Enrollment your 2019 coverage will automatically be moved to the ASRS non-Medicare medical insurance plan that the ASRS believes most closely aligns with your existing plan so that your medical insurance coverage can continue uninterrupted. If you wish to make your own plan choice, you must complete the open enrollment process. Please read the Enrollment Guide carefully to learn more about the 2020 plan offerings.

The ASRS online health insurance application – available through your secure myASRS account – will allow you to view your current ASRS medical and dental elections, enroll in a new plan, terminate coverage, make changes to your plans, and add or remove dependents. Go to AzASRS.gov to get started, selecting the myASRS login at the top right of the website.

Finally, calendar year 2020 will be the second year that the ASRS will apply funds accumulated through a contractual arrangement between ASRS and UnitedHealthcare of Arizona (referred to as a Retrospective Rate Agreement or RRA) to reduce medical premiums for most plan participants. See “2020 Savings from the ASRS Retrospective Rate Agreement” in this Enrollment Guide for a more detailed description of this process.

We encourage you to learn more by visiting AzASRS.gov and selecting the Retiree tab and the Healthcare section. You may also wish to attend any of our upcoming open enrollment meetings. The state-wide schedule is included in your open enrollment packet.

We recognize you may have additional choices for your medical and dental insurance needs and we encourage you to explore all your options, such as programs offered through a former employer, a spouse’s plan, or the Marketplace.

Contact information for the various plan providers is included in the back of this Enrollment Guide.

To your health,

Paul MatsonDirectorArizona State Retirement System

5

6

2020 Benefit Highlights

Dental Plans Sun Life Financial dental plan premiums will remain unchanged in 2020.Two benefit enhancements have been added to the PPO plans:

• Preventive Max Waiver provides members the same coverage for preventive services without it counting towards annual maximums.

• Posterior tooth-colored fillings are now a covered benefit.

Choice 1Navigate 1Choice 2

Navigate 2Choice 3Navigate 3

Choice Premier

Choice Value

2019 Plan

2019 Plan

New 2020 Plan

New 2020 Plan

How 2019 non-Medicare plans will migrate to 2020 offerings:

Benefit Highlights Rate Structure Changes for Non-

Medicare Retirees, and Medicare / Non-Medicare Combination Plans Also new for 2020, the ASRS is reconfiguring the rate structure to a more equitable approach in which premiums are directly based on the number of participants in each plan. The result is a more balanced rate structure which will see a decrease in premiums for non-Medicare-only plans with one or no dependents, Medicare-only plans, and combination plans with only one non-Medicare dependent.

Please be aware that any non-Medicare-only family plan that covers three or more participants and any combination family plan with more than one non-Medicare participant will now assume a higher premium. While the ASRS strives to offer competitive plans for all our retirees, we highly encourage members to explore all health insurance options that may be available through the ASRS, a former employer, a spouse's plan, or the Marketplace.

The ASRS is committed to offering value-based health plans to eligible retirees and their families. Below are some plan highlights for 2020.

New Non-Medicare PlansFor non-Medicare participants, we are introducing new plans for in-state retirees in 2020. We are now offering three focused plans rather than seven plans. If you are enrolled in an in-state non-Medicare plan through the end of 2019, and take no action during the Open Enrollment period, you will automatically be enrolled in a new non-Medicare plan that the ASRS believes most closely aligns with your existing plan in order to avoid any lapse in coverage for 2020. Or, you may select a different plan during the Open Enrollment Period. The default plan migration is shown below. For more information about the new plans, see “Medical Plan Comparisons” on pages 18-22.

7

EligibilityThe following individuals are eligible to participate in the ASRS Health Insurance plans:

• Retirees of the… - Arizona State Retirement System (ASRS)

- Public Safety Personnel Retirement System (PSPRS)

- Corrections Officer Retirement Plan (CORP)

- Elected Officials’ Retirement Plans (EORP DB Plan or EORP DC Plan)

- University Optional Retirement Plans (UORP)

• Members on ASRS Long Term Disability• Eligible dependents• Eligible survivors

Who is an eligible dependent?

• Your legal spouse

• Your natural child, legally adopted or placed for adoption child, or stepchild up to age 26

• A child for whom legal guardianship has been awarded to you or your legal spouse, up to age 26

• Foster children up to age 26

• A child for whom insurance is required through a Qualified Medical Child Support Order, court order, or administrative order

• A child of any age who is, or becomes, disabled and is dependent upon you

Note: All dependents over the age of 26 must be approved as a disabled dependent and you will be required to submit documentation as proof of guardianship.

Eligibility

8

Qualifying Life Events for ASRS Medical or Dental InsuranceWhat is a Qualifying Life Event?A qualifying life event allows you the opportunity to enroll or to make changes to existing coverage for yourself or your dependents outside of the annual Open Enrollment Period.

You must make these changes no later than 31 calendar days after the event, unless a different deadline is indicated for a specific qualifying life event as noted below.

Following are the Qualifying Life Events recognized by the ASRS for enrollment and/or changes to your existing coverage outside of the annual Open Enrollment Period. ASRS has the sole discretion to determine whether a Qualifying Life Event has occurred and whether your situation allows you to enroll or to make changes to existing coverage.

RetirementNew retirees are free to enroll and add dependent coverage in any plan they are eligible for at the time of their retirement. Supporting documentation will not be required, unless you wish to cover a dependent child over the age of 26.

Your application must be submitted within 31 days of your retirement date. Coverage will be effective on the first day of the month after you retire and submit your enrollment application for coverage; however, premium deductions (retroactive to your coverage effective date) will not be deducted from your monthly pension payment until your retirement benefit has been finalized. Read more about retirement and health insurance premiums, as well as the premium benefit subsidy by visiting AzASRS.gov and selecting the Retiree tab.

Change in Marital StatusYou may enroll in a plan, change plans, and/or add dependent coverage for new dependents resulting from a new marriage, including the spouse, even if you declined to enroll in a plan during the previous Open Enrollment Period.

If the change in marital status results in the loss of other coverage (for example due to divorce, legal separation, annulment, or the death of a spouse), you and your dependents may enroll in a plan or change plans. You may (and must in the case of a spouse) also remove a dependent due to a change in marital status such as divorce, legal separation, annulment, or death of a spouse. You may be asked to provide documentation that supports the occurrence of this qualifying event.

Your enrollment application must be submitted within 31 days of the date of your qualifying event. Coverage will be effective on the first day of the month after you submit your enrollment application.

Change in Dependent StatusYou may enroll in a plan, change plans and/or add dependent coverage for new dependents resulting from a change in dependent status such as a birth or adoption, even if you declined to enroll in a plan during the previous Open Enrollment Period. In such cases, you may also add a dependent not previously covered. You may also remove dependent coverage in the event of a change in dependent

Qualifying Life Events

9

Qualifying Life Events for ASRS Medical or Dental Insurance (continued)status. You may be asked to provide documentation that supports the occurrence of this qualifying event.


Change in Primary ResidenceYou may enroll in a plan, change plans, and/or add or remove dependents if you have a change in your place of residence affecting coverage availability. Your address on file with the ASRS must correspond to the coverage area in which you are enrolling (Arizona or nationwide).


Change in Medicare EligibilityYou may enroll in a Medicare medical plan when you become Medicare eligible. If you and/or your dependent are already enrolled in non-Medicare medical coverage through the ASRS, you and/or your dependent must switch to a Medicare plan upon becoming Medicare eligible. Failure to enroll in a Medicare plan will result in the termination of coverage for you and/or your dependent. If this occurs, you may not be able to re-enroll in an ASRS medical plan unless you have a Qualifying Life Event or until the next Open Enrollment Period.

Please note: Medicare eligibility is NOT a Qualifying Life Event for dental plans; only for medical plans.

Your enrollment application must be submitted within 90 days of your Medicare eligibility date. Coverage will be effective on the first day of the month you become Medicare eligible if your enrollment application is submitted prior to the effective date or on the first day of the month after the enrollment application has been received.

If you are already enrolled in a Medicare Advantage plan you may be able to make changes to your plan outside of the annual Open Enrollment Period in other special circumstances. For more information such special circumstances, visit https://www.medicare.gov/sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/special-circumstances-special-enrollment-periods. You can also talk with a Medicare specialist by calling (800) 432-4040 if you reside in Arizona, or you can check the Medicare.gov website for contact information if you reside outside of Arizona.

Loss of Other Coverage (Spouse, Employer, COBRA)You may enroll in a plan, change plans and/or add dependent coverage when:

• you or your dependent has lost group or individual health insurance coverage due to a loss of eligibility for the coverage (including termination of employment or reduction in hours, but not including a failure to pay premiums or voluntary termination of coverage),

• the group medical plan option in which you or your dependent are enrolled terminates,

• the employer sponsoring the group medical plan in which you or your dependent are enrolled


10

ceases making contributions towards the costs of coverage, or

• you or your dependent exhaust COBRA continuation coverage.

You may be asked to provide documentation that supports the qualifying event. Voluntarily terminating your non-ASRS group or individual medical insurance plan is not a qualifying event.


Change relating to Medicaid or Children’s Health Insurance Program (CHIP)If you or your dependents who become eligible for a Medicaid or CHIP subsidy or lose coverage under Medicaid or CHIP, you may enroll in a plan, change plans, and/or add or remove dependent coverage. Supporting documentation may be required.

Your enrollment application must be submitted within 60 days of the date you or your dependent is determined to be eligible for the subsidy or the date coverage is terminated. Coverage will be effective on the first day of the month after you submit your enrollment application.

To select this Qualifying Life Event in the ASRS online system, choose “Loss of Other Coverage” in the dropdown menu of choices.

Long Term DisabilityIf you are approved for the ASRS Long Term Disability Program, you may enroll yourself and your dependents in any plan for which you are eligible. Supporting documentation will not be required, unless you wish to cover a dependent child over the age of 26.

Your enrollment application must be submitted within 31 days of your disability benefit effective date. Coverage will be effective on the first day of the month after you submit your enrollment application.

Open EnrollmentKeep in mind that during the Open Enrollment Period, you are free to make changes in your plan selections or dependent coverage. Supporting documentation will not be required, unless you wish to cover a dependent child over the age of 26.

Qualifying Life Events for ASRS Medical or Dental Insurance (continued)


11

Pre-Enrollment Tasks

Pre-Enrollment Task List

Research and Choose a PlanCarefully review the Enrollment Guidebook to help you determine what benefits you and your family require and then select your plan.

Attend a 'Know Your Insurance' Meeting or Webinar Learn about your health care options and meet your vendor representatives.

Locate Provider ID (if required)Visit the plan provider’s website to select a provider and get the provider’s ID number, if required.

Locate Medicare CardIf you or your dependent will be enrolling in a Medicare plan, have your Medicare card available. You will need to provide your Medicare number as well as your Medicare Part A & B effective dates on your online enrollment application.

Gather Supporting Documentation If required, proof must be received within 31 days of the qualifying event.

Important Timeframes• The effective date for the 2020 Plan year is January 1, 2020 through December 31, 2020.

• You must enroll no later than 31 calendar days after your retirement date or other qualifying life event date.

• Submit online enrollment applications no more than 90 days before the effective date.

• Coverage becomes effective the first day of the month following your qualifying life event and receipt of your completed enrollment application.

Use this handy task list to help prepare for Enrollment.

12

Online Enrollm

ent

Everything you want to know about ASRS Retiree Group Health Insurance can be found in one convenient place on the ASRS website at AzASRS.gov by selecting “Healthcare” under the “Retirees” tab.

Here you can explore insurance plans and benefits information including: Comparison Charts, Cost Analysis, Frequently Asked Questions, and Certificates of Coverage.

You will also find a variety of self-paced Health Insurance eLearnings to assist you in selecting the plan that will best meet your healthcare needs. With these interactive eLearnings, you have the freedom to search for specific topics of interest, view sections in any order, and return as many times as needed. You are in charge of learning at your own pace.

For more detailed information, watch the What You Will Need for Online Health Insurance Enrollment video found under the "Retirees" tab by selecting "Healthcare" then the "Online Health Insurance Enrollment" link.

Online Enrollment

Online Resources

You must complete the online Enrollment Application if you are:

• Enrolling for the first time with the ASRS

• Electing a different medical plan

• Electing a different dental plan

• Adding dependents

• Becoming Medicare eligible (but not more than 90 days ahead of the effective date)

• Currently enrolled with ASRS and you wish to cancel your coverage or dependent coverage, you may go online or send a letter to drop the coverage.

• Making a change due to a Qualifying Life Event

You must complete the entire online process for your application to be submitted and processed. Your application cannot be saved and finished at a later time.

The online system will allow you to print a copy of your enrollment application and ASRS will send you a confirmation email that your application has been submitted. Check the status of your online enrollment in the Pending Request link in your secure myASRS account.

If you are retired from PSPRS, CORP, or EORP you must contact their benefits office to request the correct enrollment application.

13

2020

Premium

Savings

This will be the second year that the ASRS will apply funds accumulated through a Retrospective Rate Agreement (RRA) with UnitedHealthcare of Arizona to reduce medical premiums for plan participants.

The RRA provides for a set level of retention of revenues by the health insurance provider with any surplus revenues to be returned to the ASRS. This agreement was implemented in 2011 and subsequent look-backs at revenues versus medical costs and expenses have resulted in a return of funds to the ASRS. Those funds have been set aside to be applied to market-rate premiums, thus providing retirees a lower premium than they would otherwise be required to pay.

The table on this page shows the 2020 premiums for various Medicare and non-Medicare plans being offered. The premiums you will pay are under the column marked “NEW 2020 Monthly Premium.”

The shaded column shows the savings retirees will realize this year due to the infusion of funds from the RRA. The first column marked “Monthly Premium Before Savings” shows the market-rate premiums.

Each separate plan returned varying amounts, based on the revenues versus expenses of that particular plan. The vast majority of funds were derived from the Medicare plans, so the Medicare plans receive the most significant reduction of premiums from the RRA funds, with the non-Medicare plans receiving slight offsets.

In total, ASRS retirees will save more than $49.5 million in medical premiums in 2020 thanks to the infusion of the RRA funds.

RRA funds are expected to be applied to offset market rate premiums in 2021 also, with an analysis to be done to determine if future offsets to regular market rates can continue.

The final premium shown here does not take into account any further reductions you may be entitled to from the Premium Benefit. See pages 15 and 16 for information on the Premium Benefit and eligibility.

2020 Savings from the ASRS Retrospective Rate Agreement

Monthly Premium BEFORE Savings

2020 Monthly

Savings Due to Year 2 of

the RRA

NEW2020

Monthly Premium

WITHOUT MEDICARE You & your dependents DO NOT have Medicare Part A and B

Choice Premier (Single) $846 $21 $825

Choice Value (Single) $708 $21 $687

Choice Plus PPO(Out of State, Single) $1,317 $21 $1,296

WITH MEDICARE A & B You & your dependents have Medicare Part A and B

Group Medicare Advantage HMO (Single) $171 $96 $75

Group Medicare Advantage PPO (Single) $254 $104 $150

14

Monthly Medical Premiums from UnitedHealthcare

Effective Date: 1st of _____________________, 2020 (MONTH)

Reason for Enrollment Form: Open Enrollment (Applicable to ASRS Open Enrollment only) New Retiree - Retirement Date: ___/___/_____

2020 MEDICAL COVERAGE ENROLLMENT FORMATTN: HEALTH INSURANCEP.O. BOX 33910PHOENIX, AZ 85067

Not sure which plan to choose? Enroll online in your secure myASRS account at www.azasrs.gov. Our online process helps you every step of the way!

Disclosure of your Social Security number is mandated by Section 6109 of the Internal Revenue Code. The ASRS will use Social Security numbers only to obtain information about an individual’s ASRS account and to inform the Internal Revenue Service of distributions and withholdings. SOCIAL SECURITY NUMBER LAST NAME FIRST NAME MI DATE OF BIRTH

PRIMARY RESIDENCE STREET ADDRESS CITY STATE ZIPCODE

HI ASRS Medical Enrollment

PRIMARY PHONE NUMBER COUNTY OF RESIDENCE IS THIS A CHANGE OF ADDRESS: □ Yes □ No

CURRENT MARITAL STATUS: □ Single □ Married

GENDER: □ Male □ Female

CURRENT EMAIL ADDRESS NAME OF FORMER EMPLOYER MEMBER OF: □ ASRS □ PSPRS □ CORP □ EORP □ UORP

MAILING ADDRESS (if different than above) CITY STATE ZIPCODE

You are: Retired Disabled Surviving Dependent

Qualifying Event: (as defined in ASRS Guide)

MEDICAL INSURANCE PLANS - Insured by UnitedHealthcare

ALL ARIZONA COUNTIES


OUT OF STATE

OUT OF STATE

Choice Premier

Choice Value

Group Medicare Advantage HMO

Group Medicare Advantage PPO

Choice Plus PPO


□ $ 1,649.00 per month□ $ 1,374.00 per month

□ $ 825.00 per month□ $ 687.00 per month




□ $ 150.00 per month □ $ 300.00 per month



□ $ 3,630.00 per month

□ $ 450.00 per month

WITHOUT MEDICARE (You and your dependent(s) DO NOT have Medicare Part A and B)

WITH MEDICARE A & B (You and your dependent(s) have Medicare Part A and B)

Family (Single +1)Single

Single Dual

Family (Single +2 or more)

Triple


Group Medicare Advantage HMO with Choice Premier

Group Medicare Advantage HMO with Choice Value

Group Medicare Advantage PPO with Choice Premier

Group Medicare Advantage PPO with Choice Value

□ $ 900.00 per month□ $ 762.00 per month□ $ 975.00 per month□ $ 837.00 per month

□ $ 1,724.00 per month□ $ 1,449.00 per month□ $ 1,799.00 per month□ $ 1,524.00 per month

COMBINATION FAMILY PLANS: ONE person with Medicare

1 person with Medicare, and 1 without Medicare

1 person with Medicare, and 2+ without Medicare

OUT OF STATEGroup Medicare Advantage PPO with Choice Plus PPO □ $ 1,446.00 per month □ $ 2,743.00 per month

(You, or your dependent(s), are a combination of Medicare eligible and non-Medicare eligible)



2020 MEDICAL COVERAGE ENROLLMENT FORMATTN: HEALTH INSURANCEP.O. BOX 33910PHOENIX, AZ 85067

Not sure which plan to choose? Enroll online in your secure myASRS account at www.azasrs.gov. Our online process helps you every step of the way!

Disclosure of your Social Security number is mandated by Section 6109 of the Internal Revenue Code. The ASRS will use Social Security numbers only to obtain information about an individual’s ASRS account and to inform the Internal Revenue Service of distributions and withholdings. SOCIAL SECURITY NUMBER LAST NAME FIRST NAME MI DATE OF BIRTH


HI ASRS Medical Enrollment








MEDICAL INSURANCE PLANS - Insured by UnitedHealthcare



OUT OF STATE

OUT OF STATE

Choice Premier

Choice Value

Group Medicare Advantage HMO


Choice Plus PPO







□ $ 150.00 per month □ $ 300.00 per month



□ $ 3,630.00 per month


WITHOUT MEDICARE (You and your dependent(s) DO NOT have Medicare Part A and B)

WITH MEDICARE A & B (You and your dependent(s) have Medicare Part A and B)

Family (Single +1)Single

Single Dual

Family (Single +2 or more)

Triple






□ $ 900.00 per month□ $ 762.00 per month□ $ 975.00 per month□ $ 837.00 per month


COMBINATION FAMILY PLANS: ONE person with Medicare





Primary Member

Spouse

Dependent

Dependent

Dependent

Dependent

Please list all eligible individuals to be enrolled in medical coverage.

Name of Covered PersonPhysician Name &

Physician ID number(Group Medicare Advantage HMO only)

Network Name(Group Medicare

Advantage HMO only)

Do you have End Stage Renal

Disease (ESRD)?*

ATTENTION: If you and/or your dependents are enrolling in the UnitedHealthcare Group Medicare Advantage HMO, you will need to select a Primary Care Physician. If you do not list a medical doctor, one will be automatically assigned to you.

□ Yes □ No

□ Yes □ No

□ Yes □ No

□ Yes □ No

□ Yes □ No

□ Yes □ No

* If you have End Stage Renal Disease (ESRD), you may not be eligible to enroll in the UnitedHealthcare Group Medicare Advantage Plans at this time. Please contact an on-site UnitedHealthcare representative for further information at (602) 240-2113 Monday through Friday 8:00AM to 5:00PM MST.

I request enrollment in the Arizona State Retirement System (ASRS) Retiree Group Insurance Program and verify the information that I’ve provided is true and accurate. I hereby authorize premium deductions to be taken from my monthly retirement check if sufficient to cover the premium; otherwise, I understand I will be required to make premium payments directly to the insurance carrier. If either I or my dependent(s) are enrolled in Medicare and are enrolling in the Group Medicare Advantage HMO or the GroupMedicare Advantage PPO Plan with UnitedHealthcare MedicareRx for Groups Prescription Drug Coverage, I understand that this enrollment form must be received by the ASRS prior to the requested effective date of coverage. I understand that if I’m changing coverage due to a temporary address change, it is my responsibility to notify the ASRS of my impending return.

Primary Member Signature: _____________________________________________________________ Date: _________________

Last Name First Name Date of BirthSocial Security Number

Medicare ClaimNumber (if applicable)

MI Sex(M/F)






□ $ 975.00 per month□ $ 837.00 per month□ $ 1,125.00 per month□ $ 987.00 per month


COMBINATION FAMILY PLANS: TWO people with Medicare





Premium

s: Medical &

Dental

Monthly Dental Premiums from Sun Life Financial

2020 DENTAL ENROLLMENT FORMATTN: HEALTH INSURANCEP.O. BOX 33910PHOENIX, AZ 85067

SOCIAL SECURITY NUMBER LAST NAME FIRST NAME MI DATE OF BIRTH







NATIONWIDE COVERAGE

AVAILABLE IN ARIZONA ONLY

AVAILABLE IN: CA, CO, FL, GA, KS, MO,NE, NM, NV, OH, OK, OR, TX, & UT

Freedom Advance (High Option)Freedom Basic (Low Option)

Prepaid DHMO Dental Plan 220 with Ortho Heritage Secure w/SBA

Prepaid










Not ApplicableNot Applicable

Single Coverage

Member+1 dependent

Member+2 or more dependents

Dentist ID Number(Facility ID number can be found in the Sun Life

directory)

Primary Member

Spouse

Dependent

Dependent

Dependent

Dependent

Last Name First Name Date of BirthSocial Security NumberMI

Please list all eligible individuals to be enrolled in dental coverage.

HI ASRS Dental Enrollment

2020ASRSDEF

I request enrollment in the Arizona State Retirement System (ASRS) Retiree Dental Program and verify the information that I’ve provided is true and accurate. I hereby authorize premium deductions to be taken from my monthly retirement check if sufficient to cover the premium; otherwise, I understand I will be required to make premium payments directly to the insurance carrier. I understand that if I’m changing coverage due to a temporary address change, it is my responsibility to notify the ASRS of my impending return.

Primary Member Signature: _____________________________________________________________ Date: _________________



Not sure which plan to choose? Enroll online in your secure myASRS account at www.AzASRS.gov. Our online process helps you every step of the way!

Disclosure of your Social Security number is mandated by Section 6109 of the Internal Revenue Code. The ASRS will use Social Security numbers only to obtain information about an individual’s ASRS account and to inform the Internal Revenue Service of distributions and withholdings.



15

from UnitedHealthcare Understanding Your Premium BenefitAs part of your benefits, the ASRS provides a health insurance premium benefit to supplement the cost of retiree health insurance. The premium benefit is effective on the first day of the month following your enrollment or qualifying life event. Retirees and Long Term Disability members with five or more years of credited service who have health insurance through the ASRS or non-subsidized coverage through their ASRS employer are eligible for a monthly premium benefit, which is paid to the health insurer or your former employer. The premium benefit also applies to retirees participating in the ASRS health insurance plans from EORP, CORP, and PSPRS.

How does this work?How monthly premiums are paid depends on your health insurance option. Your ASRS health insurance premiums will be automatically deducted each month from your ASRS pension payment, if your pension payment amount is greater than the net cost of your insurance premiums. If eligible, the premium benefit is applied first to dental, then to medical premiums. The premium benefit may be delayed for one to three months while your pension is finalized. However, the eligible amount will be reimbursed or adjusted, as applicable, and will be retroactive to the beginning of the coverage.

Your insurances carrier(s) will mail a bill directly to you if you are:• On Long Term Disability• Choosing your employer’s options (State of Arizona is an exception. That payment will be withheld

from your ASRS pension payment.)• Receiving a pension payment that does not cover your insurance premiums

It will be your responsibility to pay premiums directly to the insurance carrier(s).

If you are a new ASRS retiree you may elect to receive a reduced premium benefit that, upon your death, may be continued to your beneficiary. The Optional Premium Benefit is designed for those members who have a spouse or dependent who will want to continue with ASRS insurance and receive assistance with premium costs.

Other things to note:

• The Optional Premium Benefit is only available to retirees who select a Term Certain or Joint & Survivor Annuity option. It is not available to retirees who select the Straight Life Annuity.

• You have a one-time opportunity to elect this benefit when you retire. • You may rescind election at a later date and the unreduced premium benefit will be reinstated and

applied for life.• The Optional Premium Benefit reduction is based on your age and the age of your beneficiary.

You can find out what your reduction would be by using the online estimator in your myASRS account at AzASRS.gov.

Optional Premium Benefit

Premium

Benefit

16

WITHOUT MEDICAREWITH

MEDICARE A & B COMBINATIONS

Retiree Only

Retiree & Dependents

Retiree Only



One with Medicare,

the other(s) without

Retiree & Dependent

with Medicare,

other dependents

without

ARIZONA STATE RETIREMENT SYSTEM (ASRS) MEMBERS5.0–5.9 $75.00 $130.00 $50.00 $85.00 $107.50 $107.506.0–6.9 $90.00 $156.00 $60.00 $102.00 $129.00 $129.007.0–7.9 $105.00 $182.00 $70.00 $119.00 $150.50 $150.50

8.0–8.9 $120.00 $208.00 $80.00 $136.00 $172.00 $172.009.0–9.9 $135.00 $234.00 $90.00 $153.00 $193.50 $193.50

10.0+ $150.00 $260.00 $100.00 $170.00 $215.00 $215.00

ELECTED OFFICIALS’ RETIREMENT PLAN (EORP) MEMBERS5.0–5.9 $90.00 $156.00 $60.00 $102.00 $129.00 $129.006.0–6.9 $112.50 $195.00 $75.00 $127.50 $161.25 $161.257.0–7.9 $135.00 $234.00 $90.00 $153.00 $193.50 $193.50

8.0+ $150.00 $260.00 $100.00 $170.00 $215.00 $215.00

CORRECTIONS OFFICER RETIREMENT PLAN (CORP) MEMBERSnot applicable $150.00 $260.00 $100.00 $170.00 $215.00 $215.00

PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM (PSPRS) MEMBERSnot applicable $150.00 $260.00 $100.00 $170.00 $215.00 $215.00

Years of Service

Premium BenefitDetermine your premium benefit amount

The worksheet below will help you determine your monthly insurance premiums.Monthly Health Insurance Cost Worksheet

A. Your monthly medical plan premium (from page 14)

B. Add your monthly dental plan premium (from page 14)

C. Total Premium (A plus B)

D. Subtract your Premium Benefit (See chart above)

+

–

=

=

Your Net Premium (C minus D)

Premium

Benefit

17

If you, or your dependent(s), will become Medicare eligible on your or their next birthday, there are some things to consider as plan options, premiums, premium benefits and coverage will change.Currently enrolled non-Medicare members on ASRS plans are sent a packet 90 days prior to Medicare eligibility. If a member does not respond by switching to a Medicare plan, this will result in termination of your medical coverage and you will not be able to enroll in an ASRS Medicare medical plan until the next Open Enrollment period.Medicare is the federal health insurance program for individuals age 65 or older and some disabled individuals under age 65. It is administered by the Centers for Medicare and Medicaid Services (CMS). You become eligible for Medicare the first day of the month in which you turn age 65 unless your birthday falls on the first of the month, in which case you become Medicare-eligible the first of the prior month.Enrollment in Medicare may have exceptions and nuances specific to each individual’s situation. Visit www.medicare.gov or call (800) 633-4227 and TTY users should call (877) 486-2048, 24 hours/day, 7 days/week as a good starting point to learn more about Medicare and how to enroll.When you (and/or your covered dependents) become eligible for Medicare, Parts A and B must be elected and retained in order to enroll in the Medicare plans offered by ASRS. Medicare Part D is included in both of the ASRS Medicare plans offered.

Medicare has different parts that help cover specific services:

Client Alts

2Internal & External TeamDate: 7.30.19Client Contact: Becky Pelant, Scott HelmerArt Director/Designer: catchfire

Project DetailsDepot #: SPRJ50278Name: GRR 2020 ASRS Annual Enrollment Guide Content Stage: In ReviewReading Level: 6.9File Name: SPRJ50278.indd

ColorPantone 2935 + Black

DimensionsFlat: 8.5” x 11”Software: InDesign CC

Notes

Becoming Medicare Eligible

Simple things to know about enrolling in an ASRS Medicare plan:

• Three months before your 65th birthday, contact Medicare to enroll in MedicareParts A and B

• Before your Medicare effective date (1st day of birth month), submit your ASRSenrollment form online (but no more than 90 days ahead of the effective date)

One of the perks of turning Medicare age is your medical insurance premiums go down. Now there’s something to look forward to as you get closer to age 65.

Medicare Part AHospital Insurance

Medicare Part BMedical Insurance

Medicare Part CMedicare

Advantage plans

Medicare Part DOutpatient prescription

drug coverage

SPRJ50278

Medicare Eligibility

18

More benefits that are part of the plans.UnitedHealthcare’s digital tools and online resources help make managing your health - and health plan - easier and more convenient. Here are just a few examples of what’s included.

Get your info on the go.

Connect with a doctor now.

We’re here to help. 18003570971

Review your health plan options.You have three different plans to choose from, each with its own benefits. To compare the details of each plan, including coverage amounts, see the charts on the next few pages.

In-Network coverage onlyYou must receive care for covered benefits from contracted networkproviders. Out-of-Network coverage not available. In and out-of-network benefitsYou may receive care and services from providers and facilities in and out of our network, but staying in the network can help lower your costs. Virtual VisitsGet care with Virtual Visits anywhere, on your computer or mobile device* for medical conditions like pink eye, the flu, and more.(*data rates may apply)

Nationwide networkUnitedHealthcare has access to a broad network of physicians andhospitals nationwide.

Pharmacy benefitsOrder up to a 3month supply of medications you take regularly and have them delivered right to your home, or 30-day retail.

Tier 1 providersUsing Tier 1 providers may bring you the greatest value from your health care benefits. These PCPs and medical specialists meetnational standard benchmarks for quality care and cost savings.

Access your plan easily.

myuhc.com® is your personalized health hub. Find a doctor, manage

your claims, estimate cost and more.

Our UnitedHealthcare® app helps you find care, review and pay claims and even

gives you a digital health plan ID card - all from the palm of your hand.

Have fun and get healthier.

Spark your transformation with Real Appeal®, a free digital

program that provides you with up to a full year of support for lasting

weight loss. Start today at success.realappeal.com.

Get care with Virtual Visits®any time - on your mobile

device* for medical conditions like pink eye,

the flu and more. *Data rates may apply

Choice Plus PPO

ChoiceChoicePremier Value

Health Plan Details

Medical Plan C

omparisons

19

PLAN BENEFITS

Single Only Premium: $825 Single Only Premium: $687Single + 1 Premium: $1,649 Single + 1 Premium: $1,374

Single + 2 or more Premium: $2,309 Single + 2 or more Premium: $1,923

DEDUCTIBLE (Calendar Year)

IndividualFamily (2 or more)

IndividualFamily (2 or more)COVERED SERVICES

Virtual Visit (online)

Office Visit - Primary Care

Office Visit - Specialist

Screening and CounselingImmunizationsWell-Woman/Man VisitsPreventive Labs & Imaging Tests

Urgent Care VisitEmergency Room (waived if admitted)Ambulance

Outpatient Mental HealthInpatient Mental Health

Inpatient Hospital ExpensesHearing Aids#

Vision (1 exam every 24 months)

Outpatient Surgery and Scopic Procedures

30%** at a free-standing surgery center or in a Physician's office

40%** at a hospital-based facility

30%** at a free-standing surgery center or in a Physician's office

40%** at ahospital-based facility

Other Care

$30 Copay* $30 Copay*

$40 Copay*$100 Copay* plus 30% 30%**

$20 Copay*

$100 Copay* plus 30% 30%**30%** 30%**

$50 Copay* $75 Copay*$150 Copay* $300 Copay*No Charge 30%**

$250 Copay* at a free-standing facility or in a Physician's office

$350 Copay* at a hospital-based facility

Emergency Care

Major Diagnostic


$250 Copay* at a hospital-based facility

No ChargeNo Charge No Charge

Diagnostic Labs & Imaging Tests

Minor Lab & X-ray


$30 Copay* at ahospital-based facility



$40 Copay*$20 Copay* - Tier 1




Doctors and SpecialistsNo Charge No Charge

$8,000 OUT-OF-POCKET LIMIT

$4,000 $6,000 $8,000 $12,000

Medical Plan ComparisonsCHOICE PREMIER

(AZ Plan) In-Network OnlyCHOICE VALUE

(AZ Plan) In-Network Only

Preventive CareNo Charge No ChargeNo Charge No ChargeNo Charge

Member Pays Member Pays

$500 $4,000 $1,000

These Plan Comparisons are to highlight your benefits. Don't use this document to understand your exact coverage for certain conditions. If these Plan Comparisons conflict with the Certificate of Coverage (COC), Riders, and/or Amendments, those documents are correct. Review your COC for an exact description of the services and supplies that are and are not covered, those which are excluded or limited, and other terms and conditions of coverage.

* per visit/occurrence ** after the medical deductible has been met # Limited to a single purchase (including repair & replacement) per hearing impaired ear every calendar year

Medical Plan C

omparisons

20

Medical Plan ComparisonsPLAN BENEFITS

Single Only Premium: $1,296Single + 1 Premium: $2,593

Single + 2 or more Premium: $3,630DEDUCTIBLE

(Calendar Year)IN-NETWORK Member Pays

OUT-OF-NETWORK Member Pays

Individual $1,000 $1,500 Family (2 or more) $2,000 $3,000 OUT-OF-POCKET LIMITIndividual $4,500 $7,000 Family (2 or more) $8,000 $14,000 COVERED SERVICESDoctors and SpecialistsVirtual Visit (online) No Charge 45%**

Office Visit - Primary Care $40 Copay*$20 Copay* - Tier 1 45%**

Office Visit - Specialist $100 Copay*$50 Copay* - Tier 1 45%**

Preventive CareScreening and Counseling No Charge 45%**Immunizations No Charge 45%**Well-Woman/Man Visits No Charge 45%**Preventive Labs & Imaging Tests No Charge 45%**Diagnostic Labs & Imaging Tests



20% at a free-standing facility orin a Physician's office

30% at a hospital-based facility

Emergency CareUrgent Care Visit $75 Copay* 45%**Emergency Room (waived if admitted) $300 Copay* $300 Copay*Ambulance 20%** 20%**Other CareOutpatient Mental Health $20 Copay* 45%**Inpatient Mental Health $100 Copay* plus 30% 45%**

30% at a free-standing surgerycenter or in a Physician's office

40% at a hospital-based facility

Inpatient Hospital Expenses 30%** 45%**Hearing Aids# 30%** 45%**Vision (1 exam every 24 months) $20 Copay* 45%**

CHOICE PLUS PPO (Out-of-State Plan)

45%**

45%**

Minor Lab & X-ray

Major Diagnostic

Outpatient Surgery and Scopic Procedures

45%**

These Plan Comparisons are to highlight your benefits. Don't use this document to understand your exact coverage for certain conditions. If these Plan Comparisonsconflict with the Certificate of Coverage (COC), Riders, and/or Amendments, those documents are correct. Review your COC for an exact description of the services andsupplies that are and are not covered, those which are excluded or limited, and other terms and conditions of coverage.

* per visit/occurrence ** after the medical deductible has been met # Limited to a single purchase (including repair & replacement) per hearing impaired ear every calendar year

Medical Plan C

omparisons

21

These plan comparisons are to highlight your benefits. Don't use this document to understand your exact coverage for certain conditions. If these plan comparisons conflict with the Certificate of Coverage (COC), Riders, and/or Amendments, those documents are correct. Review your COC for an exact description of the services and supplies that are and are not covered, those which are excluded or limited, and other terms and conditions of coverage.

If you choose OptumRx home delivery:

ePrescribe Your doctor can send an electronic prescription.

Online Register at myuhc.com.

Phone Call the number on your health plan ID card.

If you choose a CVS Pharmacy location:

In-Store Bring in your prescriptions or empty prescription bottles and the pharmacist will do the rest.

Phone Call your local CVS Pharmacy and a pharmacy staff member will help you.

Online Transfer your prescriptions in a few simple steps. Just go to CVS.com/transfer.

OptumRx® and CVS Pharmacy® make it easy for you to get your maintenance medications and save money. The CVS90 Saver Plus program allows you to get 90day supplies of your maintenance medications at nearly 9,700 CVS Pharmacy locations, while OptumRx offers home delivery - the choice is yours.

Whether you decide to get your maintenance medications from a CVS Pharmacy location or through OptumRX home delivery, it is easy to get started.

Two Choices to get your 90-Day Supply of Prescriptions: Mail-Order (OptumRx) and In-Store (CVS90)

Pharmacy Plan Comparison

Pharmacy Plan C

omparisons

A COMPARISON OF PRESCRIPTION BENEFITS BY PLANPrescription

Drug Tier

Tier 1Tier 2Tier 3

$10$50$100

$10$60$120

$20$60$120

Tier 1Tier 2Tier 3

$25$125$250

$25$150$300

$50$150$300

Any Retail Pharmacy (up to a 31-day supply)

Choice Premier Choice Value Choice Plus PPO(In Network & Out of Network)

Mail Order / CVS (90-day Supply)

The UnitedHealthcare Prescription Drug List (PDL) is the list of medications that are covered by the plan. The PDL is organized by cost levels, known as tiers. Choosing medications in the lower tiers may save you money. To find what tier your medication is on, login to myuhc.com or visit the Health Care page of the Retiree section at AzASRS.gov.

22

Three ways to search and save: online, the mobile app, or over the phoneUse doctors, hospitals, pharmacies, labs and other providers and facilities in our network to help lower your health care costs. Here are three ways to start your search.

What is a “network”?A network is a group of doctors, hospitals and other providers and facilities that have a contract with UnitedHealthcare. As part of their contract, they have agreed to follow our guidelines and provide health careservices to you at lower prices.

Why is this important? If your plan is an in-network only plan and you seek services from a non-network provider, you will be 100% responsible for the costs.

Go online

If you are not a member:1. Visit welcometouhc.com2.

3.

4.

5.

To select or search for a doctor click the "Find a network doctor or hospital" from the drop down box.

Select the "Choice or Choice Plus" Network depending on your plan.

Next, click on "Change Location" and enter zip code of search area.

Finally, either type in the name of physician in the Search field or click on the People tile to search byprovider specialty type.

If you are a current member:1. Log in to your myuhc.com ® account

2. Select Find a Doctor.3.

4.

On the next screen, click on the Medical Directory tile.Next, either type in the name of physician in the Search field or click on People tile tosearch by provider specialty type.

5. Finally, look for the Tier 1 Premium Providersymbol next to each physician forlower office copays.

1. Download the UnitedHealthcare App.

2. Sign in as a guest under UnitedHealthCare.

3. From the Menu select Search and People tobegin your provider search.

Call us: 1-866-873-3903A customer care professional will be happy to help you with your doctor search over the phone!

If you are a member, you can also call the number on your health plan ID card.

How to find a doctor or hospital in our Choice and Choice Plus networks

6. Search for the two blue hearts Premium Care Physiciansymbol for lower office co-pays.

Mobile App

Medical Plan C

omparisons

23

You pay less by using Tier 1 providers. They have been recognized for providing the greatest value.

There’s no need to select a primary care physician (PCP) or get referrals to see a specialist.However, by selecting a PCP, your PCP can be your partner in managing your care. They can help you avoid duplicating tests and services and connect you to a specialist.

Preventive care is covered 100% in our network 1 .

TIER1

Look for Tier 1 care first.Where you go for care can make a difference. Tier 1 providers are network doctors that are recognized for value in health care delivery. Your doctor’s Tier 1 status may change throughout the calendar year. Please check and verify your doctor’s Tier 1 status before you schedule your next appointment.

1 Age appropriate preventive care services are covered 100% when received in the plan network.

1

Non-members not logged into myuhc.com will see this:

Premium Care Physician The physician meets the criteria for providing quality and cost-efficient care.

Quality Care PhysicianThe physician meets the criteria for providing quality care.

Quality Not EvaluatedThe physician does not have enough claims data to be evaluated for quality, so the physician is not eligible for the costefficient care designation.

Does Not Meet Quality The physician does not meet the criteria for providing quality care, so the physician is not eligible for the costefficient care designation.

Members logged into myuhc.com will see this:

Non Tier 1

Tier

Tier 1

Tier 1

Non

Non

The Tier 1 symbol looks like this:Tier 1 Provider: Members in a tiered benefit plan through ASRS will pay a lower copay when using a Tier 1 provider.

1Tier1

Tier

Choice Premier, Choice Value, and Choice Plus PPO Get a plan with access to a national network and help save with Tier 1 providers.

Look for the Tier 1 symbol when doing a network search at welcometouhc.com.

or

(blue hearts)

Finding a Provider

24

At UnitedHealthcare®, we want to make it easier for you and your doctor to take care ofyour health. As a member, you have an array of programs and services available. Here are some of the ways we can help.

Virtual Doctor Visits - No CostSee a doctor or a Behavioral Health specialist using your computer, tablet or smartphone. With Virtual Visits, you’re able to live video chat - anytime, day or night.

With Virtual Doctor Visits you can ask questions, get a diagnosis, or even get medication prescribed and have it sent to your pharmacy. All you need is a strong internet connection.

Virtual Doctor Visits are good for minor health concerns like:• Allergies, bronchitis, cold/cough• Fever, seasonal flu, sore throat

Virtual Behavioral Health Visits may be best for: • Initial evaluation• Medication management• Addiction or depression

Register and then schedule an appointment. On your tablet or smartphone you candownload the UnitedHealthcare®, Doctor on DemandTM, Teladoc®, or AmWell® apps.

Real Appeal® - No CostGet help losing weight and keeping it off. Whether you want to lose a lot of weight or just a few extra pounds, Real Appeal® is designed to help with simple steps and support along the way for lasting weight loss.

As a benefit of your health plan, it includes:

• A personalized transformation coach will guide you and customize steps to fityour needs, personal preferences, medical history and goals.

• 24/7 online support and a mobile app to help you stay on track and help youreach your goals.

• A success kit featuring a personal blender, digital food scale and more.

Join Real Appeal at signup.realappeal.com.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change on January 1st of each year.

Programs and Services to Help You Live a Healthier Life

Additional Program

Benefits

25

Quit for life® – No Cost Quit For Life is a clinically proven tobacco cessation program offered in collaboration with the American Cancer Society®. The program combines digital and telephonic tools and resources, along with physical, psychological and behavioral strategies to provide members with a personalized quit plan to overcome their tobacco addiction.

Get the support you need to quit your way:

• Personalized Quit Plan tailored to specific quit-tobacco goals.• Flexible access to QuitCoach® staff through secure messages or phone.• Multiple support options such as Text2Quit®, online learning and urge

management tools.• 24/7 support for easy access to coaching services.

Start living TOBACCO-FREE by enrolling today at 1-866-QUIT-4LIFE orwww.quitnow.net

SilverSneakers® fitnessprogram–NoCostDesigned for all fitness levels and abilities, SilverSneakers includes access toexercise equipment, classes and more at 16,000+ fitness locations.* SilverSneakers signature classes, offered at select locations1, are led by certified instructors trained specifically in adult fitness.

Find a fitness location at silversneakers.com or call toll-free 1-888-423-4632, TTY 711, 8 a.m. - 8 p.m. ET, Monday – Friday.

* At-home kits are offered for members who want to start working out at home or forthose who can’t get to a fitness location due to injury, illness or being homebound.

Hear the moments that matter most with custom-programmedhearing aidsYour hearing is an important part of your overall well-being and can impact not onlyyour health, but the way you communicate with those around you. Treating yourhearing loss helps you to stay connected so you don’t miss out on the moments thatmatter most. With UnitedHealthcare Hearing, you have access to a wide selection ofhearing aid styles and technology from name brand and private label manufacturersat significant savings. Plus, you’ll receive personalized care from experienced hearingproviders along with professional support every step of the way, helping you to hearbetter and live life to the fullest.

Every person’s hearing loss is unique—that’s why UnitedHealthcare Hearing is comprised of two hearing aid companies, allowing you to choose the best option foryour hearing health.

Learn more now at 1-855-523-9355 or www.uhchearing.com1Consult a health care professional before beginning any exercise program. Availability of the SilverSneakers program varies by plan/market. Refer to your Evidence of Coverage for more details. Tivity Health and SilverSneakers are registered trademarks or trademarks of Tivity Health, Inc., and/or its subsidiaries and/or affiliates in the USA and/or other countries. © 2018All rights reserved.

Additional Program

Benefits

26

DENTAL Arizona State Retirement System 2020 benefit options

Continued

Four dental plans to choose from – No Premium change for 2020!

Indemnity PPO Plan• Freedom to choose any dentist or specialist

• In-network and out-of-network coinsurance is thesame; no penalty for using out-of-network dentist

• Access to over 3,500 unique dentists inArizona (and more than 120,000 nationwide)offering up to 30% off their usual fees

• Coverage for up to 2 cleanings per year• Preventive services do not count towards your

yearly maximum

Prepaid/DHMO Plan• No additional charge for many procedures• 250+ procedures covered by set copayments• No deductibles or claim forms, annual

benefit maximums, or waiting periods• Pre-existing dental conditions are covered• Each family member may choose their own Plan

Dentist from the list of participating general dentists

The following scenarios were developed to help you decide whether an Indemnity PPO or Prepaid plan is the best choice for you and your family.

If the following situation is true for you… Consider choosing…

Indemnity PPO Plan Prepaid/DHMO Plan

I need a lot of dental work that might cause me to exceed the Freedom Advance maximum of $2,500 per person. ü

I have a pre-existing dental condition that needs treatment. For example, a missing tooth. ü

I live in a rural part of the state. ü

There is an in-network dentist that I would be satisfied selecting. üMy family is in multiple locations and needs the flexibility of being able to go to any dentist. ü

I expect to only need Preventive services (exams, cleanings, etc.) this year. ü

Dental Plan C

omparisons

27

DENTAL Arizona State Retirement System 2020 benefit options

Continued

Four dental plans to choose from – No Premium change for 2020!

Indemnity PPO Plan• Freedom to choose any dentist or specialist

• In-network and out-of-network coinsurance is thesame; no penalty for using out-of-network dentist

• Access to over 3,500 unique dentists inArizona (and more than 120,000 nationwide)offering up to 30% off their usual fees

• Coverage for up to 2 cleanings per year• Preventive services do not count towards your

yearly maximum

Prepaid/DHMO Plan• No additional charge for many procedures• 250+ procedures covered by set copayments• No deductibles or claim forms, annual

benefit maximums, or waiting periods• Pre-existing dental conditions are covered• Each family member may choose their own Plan

Dentist from the list of participating general dentists

The following scenarios were developed to help you decide whether an Indemnity PPO or Prepaid plan is the best choice for you and your family.

If the following situation is true for you… Consider choosing…

Indemnity PPO Plan Prepaid/DHMO Plan

I need a lot of dental work that might cause me to exceed the Freedom Advance maximum of $2,500 per person. ü

I have a pre-existing dental condition that needs treatment. For example, a missing tooth. ü

I live in a rural part of the state. ü

There is an in-network dentist that I would be satisfied selecting. üMy family is in multiple locations and needs the flexibility of being able to go to any dentist. ü

I expect to only need Preventive services (exams, cleanings, etc.) this year. ü

Other Policy Provisions Benefits will be coordinated with any other dental coverage. Under the Alternative Treatment provision, benefits will be payable for the most economical services or supplies meeting broadly accepted standards of dental care. If the cost of a proposed Dental Treatment Plan exceeds $300, it should be submitted for an estimate of benefits payable.

ASRS Dental PPO Plans

Freedom Basic – Low Option

Monthly PremiumonRetiree $16.82

Retiree and one Dependent $35.56

Retiree and Family $65.10

Yearly Benefit Maximum: • Per Person, Per Policy Year: $1,000 (Preventive services do not count

towards your yearly maximum)

Coinsurance Percentage Per Person: • Type I Dental Services: 100%• Type II Dental Services: 80%

Deductible:• Per Person, Per Policy Year: $50/$150• Waived for Type I Services: Yes

If you are currently enrolled in the Limited (Low Option) Indemnity Dental Plan and you would like to enroll in the Comprehensive (High Option) Indemnity Dental Plan, your benefits for major services will be paid at the 25% coinsurance level for the first year.

Type I Preventive Dental Services, Including: • Oral Evaluations – no more than 2 times per Calendar Year• Routine Dental Cleanings – no more than 2 times per Calendar Year

(Frequencies combined with Periodontal Maintenance)• Bitewing X-Rays – once in any 12-month period

Type II Basic Dental Services, Including:• X-Rays:

–Panoramic or complete series – once in any 60-month period–Other X-Rays (See Certificate of Insurance)

• New Fillings (includes tooth colored)• Replacement Fillings – once in any 24-month period per Filling• Simple Extractions, Removal of Exposed Roots, Incision and Drainage• Certain Lab Tests, Pain Treatment, Therapeutic Drug Injections• Minor Gum Disease Treatment: (Minor Periodontics)• Scaling and Root Planing – once in any 24-month period per area• Periodontal Maintenance – no more than 2 times per Calendar Year

(Frequencies combined with Routine Dental Cleanings)

Freedom Advance – High Option

Monthly PremiumonRetiree $35.82

Retiree and one Dependent $71.49

Retiree and Family $101.17

Yearly Benefit Maximum: • Per Person, Per Policy Year: $2,500 (Preventive services do not count

towards your yearly maximum)

Coinsurance Percentage Per Person: y Type I Type II Type IIIDuring the 1st Year 80% 80% 25%

During the 2nd Year 80% 80% 50%

During the 3rd Year and thereafter 80% 80% 50%

Deductible: • Per Person, Per Policy Year: $50/$150• Waived for Type I Services: Yes

If you are currently enrolled in the Prepaid Dental Plan and would like to enroll in the Comprehensive (High Option) Indemnity Dental Plan, your benefits for major services will be paid at the 50% coinsurance level.

Type I Preventive Dental Services, Including: • Oral Evaluations – no more than 2 times per Calendar Year• Routine Dental Cleanings – no more than 2 times per Calendar Year

(Frequencies combined with Periodontal Maintenance).• Bitewing X-Rays – once in any 12-month period• X-Rays:

–Panoramic or complete series – once in any 60-month period– Other X-Rays (See Certificate of Insurance)

Type II Basic Dental Services, Including: • Fillings (includes tooth colored)• Simple Extractions, Removal of Exposed Roots, Incision and Drainage• Endodontics (includes root canal therapy)• Minor Gum Disease Treatment: (Minor Periodontics)

–Scaling and Root Planing – once in any 24-month period per area–Periodontal Maintenance – no more than 2 times per Calendar

Year (Frequencies combined with Routine Dental Cleanings)• Major Gum Disease Treatment: (Major Periodontics)

–Gingivectomy, and Osseous Surgery

Type III Major Dental Services, Including: • Complex Oral Surgery; General Anesthesia and IV

Sedation when medically required for such Surgery• Initial Placement, Replacement and Maintenance

of Inlays, Onlays, Crowns, Fixed Partial Dentures(Bridges), and Partial and Complete Dentures

This is a brief description only. It is not a Certificate of Insurance. Please see the Group Policy, which alone determines all rights, benefits, and applicable Limitations and Exclusions.

Dental Plan C

omparisons

283

ASRS Dental Prepaid Plans These plans give you and your family access to a range of dental services from in-network providers at fixed copayment amounts. A copayment is the set fee that you pay to the plan dentist at the time of treatment for covered services that are being performed. To receive services at these fixed rates, you must use a network provider.

Plan prepayment fees

Monthly Premium AZ DHMO 220 AZ Heritage Secure

Retiree $13.96 $10.61

Retiree and one dependent $23.34 $17.41

Retiree and Family $39.23 $26.90

Procedure Type AZ DHMO 220 Member Copayment

AZ Heritage Secure Member Copayment

Office Visit No charge $10

Periodic Oral Evaluation No charge $25

Bitewing x-rays – 4 films No charge No charge

Routine Cleaning – Adult No charge $10

Resin-Based Composite (tooth-colored fillings)

2 surfaces – Posterior $65 $100

Crowns

Crown – Porcelain fused to high noble metal* $220 $340

Dentures

Complete – mandibular* $295 $385

Root Canal

Molar $275 $295

Periodontics

Periodontal scaling and root planing – 1-3 teeth per quadrant $35 $57

Periodontal maintenance (limit 2 per calendar year) $45 $55

Orthodontics**Comprehensive treatment for adult (excludes pre-treatment and removal) $2,200 25% discount

This is just a sampling of the services available. To see a complete list of services and copayments, please visit www.sunlife.com/ASRS.

*These services may also require separate payment for the cost of any precious or semi-precious alloy used in their fabrication. The additional precious or semi-precious alloy charges must be paid to the Plan Dentist in addition to any applicable copayment for the service. **The Orthodontic Copayments listed above only apply during the first 24 months of active treatment and are only available once per lifetime. After 24 months of active treatment, the above Orthodontic Copayments are no longer applicable, and the listed services will be provided to Member at a 25% reduction from the Plan Specialty Dentist’s normal retail charge. Member is responsible for paying the entire reduced charge either at the time the service is received or in accordance with Plan Specialty Dentist’s billing procedures.This is a partial copayment schedule only. It is not an Evidence of Coverage. Please see the Group Dental Service Agreement, Evidence of Coverage, and Copayment Schedule, which determine all rights, benefits, and applicable limitations and exclusions. Listed copayments apply only to Plan Specialty Dentist who perform the corresponding listed services. Plan Specialty Dentist may not perform or offer all services listed. Availability and participation of Specialty Dentist are subject to change.

Dental Plan C

omparisons

29

1. This vision discount plan is not insurance.2. Does not apply to contact lens services. See contact lens section for applicable discount.3. Discounts only offered through the VSP doctor who provided an eye exam within the last 12 months. This summary represents a general overview and is not a complete description of your plan. All of our dental plans include exclusions, limitations, and frequency requirements. The actual provisions of your contract of Evidence of Coverage will be used to determine coverage for any claims submitted to us.This dental plan does not provide coverage for pediatric oral health services that satisfies the requirements for “minimum essential coverage” as defined by the Patient Protection and Affordable Care Act. (“PPACA”).Insurance products are underwritten by Union Security Insurance Company (USIC) (Kansas City, MO) and administered by Sun Life Assurance Company of Canada (SLOC) (Wellesley Hills, MA) in all states except New York. Prepaid dental products are provided by USIC and are administered by SLOC, and are provided by prepaid dental companies, affiliated with SLOC in certain states except New York. Prepaid dental companies are United Dental Care of Arizona, Inc., UDC Dental California, Inc., United Dental Care of Colorado Inc., and United Dental Care of New Mexico, Inc.© 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us wwwat .sunlife.com/us.GDFL-EE-8655e SLPC 29653 07/19 (exp. 07/21)

One Sun Life Executive Park • Wellesley Hills, MA 02481 www.sunlife.com/us

How do I find a network PPO dentist?It’s easy to locate participating general dentists and specialists in your area.

Visit www.sunlife.com/ASRS or use our mobile app Benefit Tools• Choose Freedom PPO In-network dentists• Enter in your search criteria and a listing of participating

dentists will be provided

If your dentist is not a participating provider you may nominate them at www.sunlife.com/findadentist.

Services Available from a VSP Doctor• Eye Exams – 20% discount applied to VSP

doctor’s usual and customary fees for eye exams2

• Glasses – 20% discount applied to VSP doctor’s usual andcustomary fees for complete pairs of prescription glasses andspectacle lens options3

• Contact Lenses – 15% discount off the contact lens exam(fitting and evaluation)3

• Laser VisionCareSM – VSP has contracted with many of thenation’s laser surgery facilities and doctors, offering youa discount off PRK and LASIK surgeries, available throughcontracted laser centers

Vision Discount Services Your dental plan includes a vision discount plan1 through Vision Service Plan (VSP). The vision plan includes discounts on exams (including contact lens exams) and the purchase of eyeglasses, sunglasses and other prescription eyewear when provided by VSP doctors. VSP is available for you and everyone covered on your dental plan!

How do I find a Prepaid Plan Dentist? Visit www.sunlife.com/ASRS or use our mobile app Benefit Tools. You will be able to customize the provider search based on your input.• Choose the in-network dentist link for the plan you selected• Enter in your search criteria and a listing of participating

dentists will be provided

When you enroll, you can select a plan provider. You must select a plan provider before you can make an appointment to receive your dental care.

Other Valuable Features for You• Immediate savings when using a VSP doctor

(find a doctor at www.vsp.com)• You may use the discounts as often as you wish• No waiting periods• No deductibles• No claim forms to fill out

To locate a VSP doctor near you, use either the web-based doctor locater at vsp.com, or call VSP at 800.877.7195 to request a doctor listing.

Dental Plan C

omparisons

30

As an ASRS retiree, you have a myriad of benefits available to you at no cost. Some are included with UHC medical insurance and some are available to all retirees regardless of your insurance provider.

Visit AzASRS.gov for examples of these beneficial resources to help you manage all aspects of your health, your care and your costs.

Did you know that you have a FREE discount card available to you as an ASRS retiree? This program is designed to help you save money on health care related services and prescriptions.

Not only is it free, but it is also available to anyone in your household. There’s no need to enroll in any of the ASRS health insurance plans to be eligible.

Once you are retired, you simply go online to AzASRS.gov/ Retirees/Healthcare/AdditionalBenefits to register for your card. You will use the Group ID “ASRSH” when you register for the card. This isn’t insurance, but a DISCOUNT program available for times when insurance does not pay for a service or prescription. Every penny saved helps now that you are on a fixed income.

Are You Using All of Your Benefits?

WellCard

Register for FREE today! azretirees.perksconnection.comClick “Activate your account now” to get started

Local & National DiscountsInsurance & BenefitsHome/Auto Insurance, Long Term Care & more Get exclusive savings from popular national retailers – categories include

entertainment, health & wellness, travel, electronics and more. You’ll also get exclusive access to local merchants right in your community and surrounding area.

EXCLUSIVE SAVINGS & BENEFITS FOR RETIREES

WellC

ard & Perksconnect

31

Register for FREE today! azretirees.perksconnection.comClick “Activate your account now” to get started

Local & National DiscountsInsurance & BenefitsHome/Auto Insurance, Long Term Care & more Get exclusive savings from popular national retailers – categories include

entertainment, health & wellness, travel, electronics and more. You’ll also get exclusive access to local merchants right in your community and surrounding area.

EXCLUSIVE SAVINGS & BENEFITS FOR RETIREES

Glossary

• ASRS Premium Benefit is provided to each eligible retired and disabled member who elects to participate in a health insurance plan sponsored by the ASRS, the Arizona Department of Administration, or a Participating Employer. This benefit helps reduce monthly health insurance premiums. The benefit to which you are entitled is dependent upon your years of credited service, enrollment in single or family coverage and whether you are Medicare eligible.

• Co-Payment is the amount an individual must pay for a medical or dental expense at the time of the visit.

• Co-Insurance is the amount an individual must pay for services after a deductible has been paid, which means that you essentially split the cost of your healthcare with your insurance carrier.

• Deductible is the amount an individual must pay for health care expenses before the insurance carrier will cover the remaining costs.

• Free Standing Facility/Place of Service is an entity that provides health care services but is not associated with, or a department of, a hospital.

• Group Medicare Advantage HMO Plan is a plan for members who are enrolled in Medicare Parts A and B and in which UnitedHealthcare has entered into a contract with The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare. This contract authorizes UnitedHealthcare to provide comprehensive health services to persons who are entitled to Original Medicare benefits and who choose to enroll in the Group Medicare Advantage (HMO) Plan. By enrolling in the Group Medicare Advantage (HMO) Plan, you have made a decision to receive all your routine health care from UnitedHealthcare contracted providers.

• Group Medicare Advantage PPO Plan is a plan for members who are enrolled in Medicare Parts A and B and in which UnitedHealthcare has entered into a contract with The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare. This contract authorizes UnitedHealthcare to provide comprehensive health services to persons who are entitled to Original Medicare benefits and who choose to enroll in the Group Medicare Advantage PPO Plan. By enrolling in the Group Medicare Advantage PPO Plan, you have access to UnitedHealthcare’s national network of providers. In addition, you can see out-of-network providers and pay the same out-of-pocket costs as in-network providers, as long as they participate in Medicare and accept the plan.

• Network is an organization that contracts with providers (hospitals, physicians, and other healthcare professionals) to provide health care services to members. Contract terms include agreed upon fee arrangements for services and performance standards.

• Out-Of-Pocket Limit is the maximum amount you could pay in a given plan year. You will never pay more than your out-of-pocket limit during the plan year. The out-of-pocket limit includes all of your network co-payment, deductible, and co-insurance payments.

A more comprehensive glossary can be found at AzASRS.gov.

Glossary

32

Glossary (continued)

• Preferred Provider is a provider who has signed an agreement with the insurance carrier not to charge that carrier’s members more than the carrier’s Allowable Amount.

• Premium is the monthly cost of the medical or dental insurance.

• Primary Care Physician (PCP) is a member’s first source of care and who can refer the member to specialists when additional care is needed. This can be general or family practitioners, internists, or pediatricians who will provide a majority of a member’s needs including routine care, annual well visits, preventive care, sickness, and injury.

• Retrospective Rate Adjustment Agreement (RRA) requires that revenue received by UnitedHealthcare in the form of subscriber premiums, in excess of medical costs and negotiated expenses, be returned to the ASRS. As a result, the ASRS has set up a fund from which to offset the ASRS plan premiums for 2019, 2020, and 2021 in proportion to the excess refunded from each plan. For example, excess funds given back to ASRS from the MAPD HMO plan would be earmarked for those enrolled in the same plan in the 2019, 2020, and 2021 payback years.

Glossary

Notes

Notes

Notes

Telephone Numbers & Websites

Medical Provider

Dental Provider

Prescription Discount Card

Hearing Benefits

PSPRS, CORP & EORP Benefits Office

ADOA Benefits Office

ASRS Member Services

Other Helpful Numbers & Websites

When calling these insurance carriers, be sure to tell them you are an ASRS retiree.

UnitedHealthcare of Arizona• Group Medicare Advantage HMO & PPO Plans

(Weekdays, 8 AM-8 PM, MST) 844-876-6161/ TTY: 711, when prompted: 844-876-6161• Choice Plans (in-state) (Non-Medicare Plans) 800-357-0971• Choice Plus PPO Plan (out-of-state) (Non-Medicare Plans) 800-509-6729• OptumRx (Available 24/7) 800-788-4863• UnitedHealthcare Vision 800-638-3120

Sun Life Financial (Group #0000G933) (M-TH 7 AM - 7 PM, CST; Friday 7 AM - 6 PM, CST ) SunLife.com/ASRS • PPO Dental Claims: 800-442-7742• Prepaid Dental: 800-443-2995• Vision Discount Services: 800-877-7195 / VSP.com

WellCard (Available 24/7) 800-562-9625 / WellCardHealth.com

UnitedHealthcare Hearing 855-523-9355

(Weekdays, 8 AM - 5 PM, MST) 602-255-5575 / PSPRS.com

(Weekdays, 8 AM - 5 PM, MST) 602-542-5008 / 800-304-3687 / BenefitOptions.AZ.gov

Phoenix Area (Weekdays, 8 AM - 5 PM, MST) 602-240-2000 / AzASRS.govTucson Area (Weekdays, 8 AM - 5 PM, MST) 520-239-3100 / AzASRS.govOut-Of-Area (Weekdays, 8 AM - 5 PM, MST) 800-621-3778 / AzASRS.gov

Social Security 800-772-1213 / SSA.govMedicare 800-633-4227 / Medicare.gov

Internet Addresses:

Medicare Plans: uhcretiree.com/asrsNon-Medicare Plans: myuhc.comBehavioral Health: liveandworkwell.comUnitedHealthcare Vision: myuhcvision.com

2020ASRSEG-Non-Medicare

Phoenix Member Services3300 North Central AvenuePhoenix, AZ 85012602-240-2000

Tucson Member Services4400 E. Broadway Blvd, Suite 200Tucson, AZ 85711520-239-3100

Find us online at:AzASRS.gov

ARIZONA STATE RETIREMENT SYSTEM

An agency of the State of Arizona

Documents

Health Insurance Enrollment Guide Non... · provide documentation that supports the occurrence of this qualifying event. Your enrollment application must be submitted within 31 days