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Iowa State University and Affiliated Iowa Board of Regents Institutions Retiree Group Health Insurance Information for 2021 Open Enrollment

Opening October 15, 2020 – Closing December 7, 2020

News for 2021 A recent message from ISU President Wintersteen to employees addressed premium rates for 2021. Among her comments, she noted that:

Across the nation, health care costs have been rising much faster than inflation during the past decade. A 2019 report by the Kaiser Family Foundation found the average premium for family coverage has increased 22% over the last five years and 54% over the last ten years. Iowa State University has worked diligently to contain health care costs for many years, but to manage rising health care cost pressures, the University Benefits Committee (UBC) was asked to review the program and suggest changes and modifications to the health care plans and premium structure. Based in part on the UBC’s recommendations, federal guidelines and other information, changes are being made to the Wellmark BluePPO and the Wellmark BlueHMO plans. Participants will see the new health care premiums and plan changes beginning January 1, 2021. Impact to ISU Retirees For our ISU retiree population, the premium increase is averaging ~8.5% for 2021. The plan design changes will NOT affect those with Medicare as their primary insurance. For those not yet on Medicare, or if you have experienced a copay after Medicare settled a claim, the copays on each plan are increasing by $5.00 and the emergency room visit by $25.00. We regret having to increase these premiums, particularly for such a valued part of our ISU community, but the ISU plan remains an excellent plan even with these increases and modest plan design changes. Every year members have the option of dropping the ISU retiree plan. As a reminder, though, once dropped, members do not have the option of returning to the ISU plan. For the Medicare-eligible ISU Group Part D Prescription Drug Plan with Humana (Those with Medicare as the primary insurance followed by ISU Wellmark):

Remember, you must have the ISU Humana Medicare Part D when eligible and on the ISU health plan. Members are required to have both to maintain coverage. Monthly premiums are collected by Wellmark.

ID Cards – All members will be receiving new ID cards for 2021. There are no changes to the ID cards, but issuing new cards is a Medicare Part D, system-wide requirement for 2021. The ID cards will go out to existing members in early to mid-December.

Annual Notice of Change letter (ANOC) – Current members will receive the ANOC as they do each year in late November to early December. What is different this year is that the Evidence of Coverage (EOC) is not being printed/mailed to current/renewing members. The ANOC will have information that directs members to the Humana website for the EOC or to Humana customer service. New enrollees will continue to receive the EOC in the effective date month.

A presentation on the 2021 benefits will be recorded October 15. This recording will be available for viewing on the ISU webpage as soon as possible. https://www.hr.iastate.edu/benefits/retiree-life Look for “2021 Presentation for Open Enrollment”

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Postcard – Members will also receive the annual postcard with information on how to access the pharmacy network online or through customer service. This mailing, which also includes drug guide information, will go out to members before the end of the year as well.

For those on Express Scripts (not Medicare eligible): There is a change to the Express Scripts out-of-pocket maximum and the maximum copay. See the details on page 14 of this document. From Wellmark:

Telephonic doctor office visits are covered. For those with Medicare as primary coverage. If a telephonic visit has been denied by Wellmark, you may need to contact the provider. The medical providers have been given guidance on this, the provider needs to submit a provider inquiry (corrected claim) to Wellmark.

Wellmark will be mailing out new ID cards due to the change in copay, but when Medicare is primary, the copay is not usually the patient’s responsibility.

Please read the ISU medical/prescription insurance information on the following pages. The dental plan information will be mailed separately to all those currently enrolled. If possible, view the online presentations offered by the ISU Benefits Team. We will miss seeing you at an in-person session, but we hope the recordings will provide all of the information you need.

The time to make a decision is between October 15 and December 7, 2020. Changes made will become effective on January 1, 2021. Your choices are:

1) Do nothing and continue with your current ISU plan; 2) Change from one ISU plan PPO or HMO to the other; or 3) Shop for other outside coverage, leaving the ISU medical/prescription plan.

To make a change from your existing ISU plan to the other ISU plan offered, or to update your address, phone or to add an email address, complete the change form included in this packet. To drop the current ISU medical/prescription plan, complete the drop form and return it before December 7, 2020. If you drop the ISU plan, you will not be offered another opportunity to enroll in that coverage again. If you drop the ISU Wellmark plan, you must also drop the prescription plan. The ISU prescription plan is required in order to have the ISU Wellmark plan.

If you have questions, please follow up with the ISU Benefits Office by calling 515-294-4800 or toll-free 1-877-477-7485 or by emailing benefits@iastate.edu. Phone calls are strongly encouraged. The majority of the Benefits team is working from home, so phone calls will be returned as soon as possible. We anticipate a high volume of calls in October and November, so please be patient and leave a message. Again, we will work to return calls as quickly as possible. The active employee open enrollment period is November 2-20, 2020, so the month of November is extra busy for the Benefits Office staff. For those who will become eligible for Medicare in 2021 either due to turning age 65 or if on Social Security disability for 24 months, please pay particular attention to the sections regarding Medicare and Medicare Part D. ISU sends information to those turning 65, typically three months before your birth month. If eligible for Medicare prior to 65, please alert the ISU Benefits team.

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Steps if you want to make changes to your ISU Plan for January 1, 2021: o Complete the Open Change Form, included in this packet, indicating your new choice. o If adding a Medicare-eligible person enrolling in the Plan for January 1, 2021, such as a spouse or

partner or other eligible dependent, please request a Humana application from the ISU Benefits Office. It is not included in this packet.

o Make a copy of the completed forms for your own records. o Mail to ISU Benefits Office, 3810 Beardshear Hall, 515 Morrill Rd., Ames IA 50011-2033.

Steps to enroll in coverage elsewhere for January 1, 2021: o Visit with Senior Health Insurance Information Program (SHIIP) consultants or insurance brokers selling

individual insurance plans. o Fill out forms for those companies, as needed. o So that we have a record of your intentions, please submit the drop notice by December 7, 2020 to: ISU

Benefits Office, 3810 Beardshear Hall, 515 Morrill Rd., Ames IA 50011-2033 Life-Long Coverage?

ISU Retiree insurance is not guaranteed, but ISU plans to continue to provide group health benefits to retirees and their family members for years to come. With over 3,000 retirees/spouses on the retiree insurance currently, the ISU Plan is projecting to be stable for the future. Automatic Payment?

The member is responsible for the timely payment of all premiums. Consider setting up automatic payments with Wellmark. Forms are available upon request. Who may you insure on the ISU insurance plans? --You may insure your spouse or domestic partner and eligible children. --You may insure an eligible child on your insurance through the end of the year in which they turn 26. After 26, only an unmarried, full-time student, adult child or a permanently disabled child is eligible for coverage on the retiree policy. Contact ISU to remove your child when their eligibility changes.

--Disabled children may continue on the retiree’s plan if: there has not been any lapse in coverage for the child and prior to reaching age 26; the disability is verified by the child’s physician to be total and permanent; and the verification is provided to ISU Benefits Office. --A spouse/partner of the retiree. If the spouse/partner is insured on the retiree’s plan at the time of the retiree’s death, the surviving spouse/partner should contact the ISU Benefits Office to report the death. The surviving spouse/partner would then complete a form to transfer the policy to their name. --If you decide to drop the ISU Plan coverage, you will not be able to rejoin those specific coverages at a later date. If you decide to drop the ISU Plan coverage, any family member on the plan will also be dropped. --If a family member leaves the ISU plan but the retiree continues coverage; the retiree may add a dropped family member back on to the retiree’s ISU plan policy next open enrollment time, provided they meet the eligibility requirements. Likewise, if a family member is losing coverage mid-year, the retiree may add the eligible family member within 30 days of a qualifying event. Coverage is effective the first of the month following satisfactory evidence of the event as determined by the ISU Benefits Office.

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--If a retiree divorces their spouse, the divorce must be reported to ISU and the spouse will be offered COBRA or could seek coverage elsewhere. They are not allowed to remain on the group plan. If the spouse is Medicare eligible, they should seek out a replacement health and prescription plan to avoid penalties. What is Medicare Eligibility?

Typically Medicare eligibility is the first of the month in which you will reach age 65, but it can also be determined by a medical diagnosis such as ALS or End Stage Renal Disease or after 24 months of a Social Security disability determination. If an ISU retiree or disabled employee or their family member qualifies for Medicare and are continuing ISU insurance; Medicare Part A & B must be the primary insurance for those Medicare eligible individuals. Medicare would receive the health service claim first and once the claim is processed by Medicare, the claim is electronically filed to Wellmark in most cases. For providers not participating with Medicare, the patient may be instructed to file their own claim. If the retiree/disabled employee or an insured family member postpones enrollment in Medicare, there will be a penalty from two places.

1) The ISU Plan penalty is, the member would be responsible for the portion Medicare would typically pay and pay a higher premium.

2) When the person finally enrolls in Medicare, the member would then incur a lifelong, late enrollment penalty from Social Security. That penalty is added to the total a member pays for their Medicare Part B monthly premium.

Medicare eligible now or becoming eligible in 2021 Those who elect to begin Social Security Income (SSI) benefits prior to age 65 typically receive their Medicare card three months before their 65th birthday month. If not currently receiving the SSI benefits, the plan member should enroll in Medicare A and B. ISU recommends enrolling at the first opportunity, three months before the 65th birth month. https://www.ssa.gov/benefits/medicare/ When the Medicare card arrives, it is good to be proactive in contacting the ISU Benefits Office to relate the Medicare information and to further understand how Medicare is involved in the ISU retiree medical coverage. ISU does mail information to members to make the transition with our plan, but it is your responsibility to make contact and follow up. The ISU retiree plan, for Medicare participants, becomes secondary coverage to Medicare A and B. The ISU Plan is not a standardized, supplemental individual or group “Medigap” plan such as Plan F or Plan G or Plan N. It is not a Medicare Advantage Plan (also called Medicare C) and it is not a Private-Fee-For-Service Plan. The ISU University Benefits Committee investigated those options in the past and believe the existing Wellmark BluePPO or BlueHMO health plans with the addition of the Humana custom Group Medicare Part D plan are the best options to offer our Medicare eligible retirees. Enrolling in other plans – Understanding the ISU Plan difference Each year Medicare eligible participants have an opportunity to enroll in any “Medigap” Medicare supplement plan. However, electing to move to any individual plan may require medical screening and ISU would also require you to leave the ISU Group Humana Prescription Drug Plan (PDP).

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If enrolling in any individual health/prescription (Medicare Supplement, Medicare Advantage or Part D PDP) for 2021, please communicate with the ISU Benefits Office if you, or a covered family member, intend to enroll elsewhere. This will help the transition go smoothly. The drop coverage form is included in this mailing to complete and return. If a retiree signs up for other insurance, the retiree and any family member, on the plan with them, would need to terminate the ISU Plan medical coverage as well. Once the contract holder (retiree or surviving spouse) voluntarily drops the ISU Plan, they will not be able to rejoin the group plan later. ISU is aware you can find plans for a lower premium. Carefully consider your choices; there is typically a cost shift where you could pay more for services or may have to switch plans when moving to another part of the country. Learn how other plans work before making a decision to enroll. While some Medicare Advantage plans have a $0.00 premium, there could be steep out-of-pocket costs for services. Some doctors and hospitals may not be in the network or may drop out of the network in future years. And some plans ended coverage in certain regions. Some Medigap plans increase as you age and could cost more than the ISU plan that includes prescription drug coverage with a $2,500 maximum out of pocket. The ISU PPO plan is a national provider, and since Medicare does not cover travel abroad, the PPO is a great plan for international travelers. If individual plans offer any coverage abroad, there are usually lifetime limits on coverage abroad. Once the limit is reached, there is no coverage. The ISU plan does not have a lifetime limit. The Iowa State University Health Insurance Choices

Wellmark Blue Cross and Blue Shield of Iowa administers both plan options for Iowa State University. 1. Wellmark BluePPO (a Blue Cross/Shield Association Preferred Provider Organization) The BluePPO plan network is a nation-wide plan. Participants can find participating providers all over the U.S.A. This plan is an ISU plan for retirees residing in or outside of Iowa. It is the preferred plan for those residing in Iowa but who travel extensively. Or for those that want to have service from Mayo Clinic or other out-of-state providers. In some cases, you may have PPO in-network services even when out of the country. The BluePPO requires in-network providers for routine services. If all eligible services are received from providers in the BluePPO network, BluePPO participants will have less to pay.

2. Wellmark BlueHMO (a Wellmark Health Plan of Iowa network) The Wellmark Health Plan of Iowa (WHPI) or BlueHMO network is a large network of Iowa health providers. The network does include some counties in some bordering states. Contact Wellmark or use their website to check for network providers. Or check with your local providers (Clinics, Hospitals, Specialists, Chiropractors, etc.) regarding their participation in the network. For services outside of the network, only emergencies or prior-authorized care would be covered. Each member in the BlueHMO contract is required to designate a Primary Care Provider (PCP), which can be a different doctor for each participant on your plan. Physician Assistants and Nurse Practitioners may be a designated PCP. Report the name of your PCP on your form when switching to the BlueHMO. Contact Wellmark directly to change the PCP in the future. The BlueHMO offers a guest membership for long term (90-180 days) absence from Iowa. This guest membership does not have an additional premium cost to the member. For those who have a permanent

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residence in Iowa but travel to another area for more than 90 days at a time, the BlueHMO can still be an option. The guest membership, would allow for non-emergency medical care outside of Iowa. Contact Wellmark directly for more details. Changing between the two ISU Wellmark options

Participants may change between the two offered Wellmark ISU insurance plans each year. For a change for 2021, complete and submit the change form prior to December 7, 2020. The earlier, the better. Changes made during open enrollment are effective on January 1, 2021. New cards are issued once the enrollment process is complete. If moving out of Iowa and the BlueHMO network area after the open enrollment time is over, contact the ISU Benefits Office in advance to change to the PPO mid-year, due to the move. Members who need to make mid-year changes (such as adding a newly eligible, family member to the plan) should contact the ISU Benefits Office. This needs to be within 30 days of the event, and it is best to be proactive! Have a conversation with our office to understand if your event qualifies to make a change. Changes are effective as determined by the qualifying event date and must be reported in a timely manner and also require evidence of the event. If you want to compare the two ISU plan medical options, the detailed plan certificates are on the ISU web pages. https://www.hr.iastate.edu/benefits/retiree-life/retiree-isu-plan#medical If you want to have a conversation about the plan differences between the ISU HMO and PPO, for medical services you may be considering for next year, you may contact Wellmark customer service and they can offer assistance in understanding the plan difference. The number is on your ID card. If the retiree’s benefit eligible family member leaves the plan for 2021 but the retiree stays on the ISU Plan, the family member may be added back to the retiree’s plan during open enrollment, provided they are still eligible by the rules of our plan. Ask the ISU Benefits Office if you have a question on eligibility. For participants enrolled in Medicare Part A & B and the ISU Plan, the Wellmark network rules still apply for the secondary coverage which effects coverage. Medicare must process all claims first, either to pay or deny. After Medicare, the claim will be processed by Wellmark. Wellmark begins the process by looking at the claim without the Medicare settlement. They check to see if the provider is in network and determine how they would settle on the claim. Then, the Medicare settlement, as reported to Wellmark, is applied to the claim again and usually reduces the member liability. If you receive coinsurance or copay bills from a provider after Medicare and Wellmark have processed the claims, this should be verified by comparing your two Explanation of Benefits, Medicare and Wellmark. Member liability, as indicated in the ISU plan comparisons in this guide, deductible, copays and coinsurance; are usually reduced or eliminated. The liability reduction is dependent on Medicare and Wellmark coordination. If any health provider tells a member they do not file the claim because Medicare will not pay on the service; please ask the provider to file the claim with Medicare anyway. Wellmark must have Medicare’s determination to process a claim. If the provider does not participate with Medicare, you may need to file the claim to Medicare yourself. This must be timely! Once Medicare processes a claim, Wellmark should get the claim per normal process.

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If you are Medicare eligible and continuing with the ISU Wellmark medical plan, you must have the ISU Group Medicare Part D Prescription Drug Plan (PDP) with Humana. If you want to add a Medicare eligible family member during this open enrollment, that family member must also complete an ISU - Humana enrollment form. Request the form from the ISU Benefits Office prior to the end of open enrollment. This action is with the ISU Benefits Office and never directly with Humana. There are other Humana plans that are individual plans. To stay in the ISU Wellmark plan, you must have the ISU Group PDP with Humana. Family members on the plan that are not yet Medicare eligible will have the ISU Express Scripts drug coverage. And the reverse, if you are not Medicare eligible but they are.

If you decide to leave the ISU plan and instead apply for an individual Medigap plan, make certain to also enroll in an individual Medicare Part D for prescriptions as well as a medical plan. Members cannot stay in the ISU Humana group plan without the Wellmark medical plan. The Iowa State University Prescription Drug Coverage Regardless of where you purchase your prescriptions, you are using the ISU Prescription insurance to lower your out-of-pocket expense. Any pharmacy with your insurance information is reporting your prescription purchases to the prescription insurance plan you are enrolled in. That Pharmacy Benefit Management Company (Express Scripts or Humana) then reports back to the pharmacy, what the charge to you should be.

The premium you pay to Wellmark includes prescription drug coverage. The ISU Plan members have prescription drug coverage with either Express Scripts or Humana. Medicare eligibility determines which plan you are required to be in. 1. Express Scripts is the plan for retiree/disabled members and the family members on the plan that are not yet Medicare eligible. This is the exact same prescription coverage that active employees have. The copay-coinsurance structure does not change. 2. Humana is the ISU Group Medicare Part D Prescription Drug Plan (PDP) for retiree/disabled members and the family members on the plan that are Medicare eligible. CMS does not allow more than one PDP. Members in our retiree group plan must transfer from Express Scripts to Humana when eligible for Medicare. ISU assists with this transition. Enrollment is completed by following the ISU Benefits Office direction to get the ISU PDP plan. The ISU Plan is not available through a general individual Humana enrollment application. You enroll with the ISU PDP to stay in our Wellmark ISU plan that follows Original Medicare.

During the 2021 year or any year, if you receive notice that you have been or are being dropped from your ISU Express Scripts or Humana plan and you did not take this action to terminate the coverage yourself, please contact the ISU Benefits Office.

Prescription Drug Coverage Required Notice

Iowa State University has determined that both the Express Scripts and Humana prescription drug coverage with the ISU Plan are as good as or better coverage than the standard Medicare prescription drug coverage (Part D). This means that your ISU Plan coverage is considered “creditable coverage” and that you will not pay extra if you later decide to leave our plans and timely enroll in an individual Medicare prescription drug plan. (Please see enclosed Notice of Creditable Coverage)

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If an assisted living facility, nursing home or other facility wants to enroll you or your dependent in a different prescription plan because the facility is not participating with Humana, our Part D plan, remember it is necessary to keep our prescription plan to be in our group medical plan. Humana can assist you in working with the long term care provider. Humana Pharmacy mail delivery might be an option. Transitioning between ISU Prescription Drug Plans

Express Scripts For ISU health plan members adding new dependents to the plan, that are not yet Medicare eligible, the

enrollment form, submitted to the ISU Benefits Office, will begin the process for enrollment to the ISU Express Scripts plan for January 1, 2021. Those dependents should be mindful of the need to get refills from their current plan they are leaving prior to the end of December so they have time to transition to Express Scripts. Until enrollment is complete, Express Scripts cannot advise on transitioning current medications.

Humana

For ISU health plan members adding new dependents to the plan, who are Medicare eligible, in addition to electing on the ISU change form included, request the Humana for the eligible family members from the ISU Benefits Office. The ISU Humana enrollment form and the 2021 Open Enrollment form should be returned to ISU.

For anyone on the plan transitioning to Medicare in the future, the ISU Benefits Office does send the ISU-Humana application approximately 90 days prior to your Medicare eligible birth month. Contact the ISU Benefits Office if you or any family member on the plan becomes Medicare eligible prior to age 65. This could be due to a medical diagnosis or Social Security disability. ISU will provide the Humana application to move to the Part D plan. Those becoming eligible due to age 65, receive a lot of mail from many insurance companies offering a plan. It is important to watch for the Iowa State University envelope to take steps to continue the ISU group plan correctly. Or contact the ISU Benefits Office if you did not get our mailing. The Humana forms must be returned to the ISU Benefits Office. ISU takes care of submitting the form to Humana for enrollment in the ISU group. Then the Humana card replaces the Express Scripts card. Family members who are not eligible for Medicare Part B will remain in the ISU Express Scripts group plan and get a new card as well.

Your prescription history as processed by your previous prescription plans cannot be shared with any new plan. So regardless of where you purchase your prescriptions, the new plan may need to have medications go through a new authorization. The account representatives will assist members in any transition. You will have a member number and a phone number to call listed on the new ID cards. Mail order is an option, not a requirement. If you use your local pharmacy, they will request to make a copy of your new prescription card. If you want to use the mail order, customer service can assist in that transition. If the prescription ID does not arrive by January 4, 2021, you may contact ISU Benefits Office to assist you. For those with Medicare, enrolling in the ISU Humana plan, the Center for Medical Services (CMS) requires the Part D plan providers to send a renewal kit. These kits will have the Annual Notice of Change, Evidence of Coverage, and a Prescription Formulary which is an Abbreviated Drug List and a new ID card. For the comprehensive formulary, please use the website or call the customer service number on your ID card. The web link is: https://www.humana.com/pharmacy/insurance-through-employer/tools/druglist/

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Medicare Part D Prescription Drug Plan (Standard Framework) Stages All Medicare Part D prescription drug plans must follow the framework of rules and regulations established

by CMS but an approved plan can be “as good” or “better” than a standard Part D plan. The ISU Plan with Humana is approved by CMS and follows the CMS framework but the ISU plan in aggregate is better. The ISU Part D PDP plan is custom for having maximum limits per prescription and a $2,500.00 limit for the participant’s maximum out-of-pocket (MOOP); therefore our plan allows the coinsurance amount of 30% in the Coverage Gap instead of a standard D plan of 25%. Individual Standard D plans typically do not have an out-of-pocket maximum limit. Many individual standard D plans begin with a deductible for a member to pay first. The ISU Humana Plan does not have a deductible for the member to pay. We begin with a copay or coinsurance. All Part D plans have an initial stage of coverage, which lasts until the total drug spend (the amount the member pays plus the amount Humana pays) reaches $4,130.00. During the initial stage, members in the ISU PDP plan pay a copay or a coinsurance percentage but the ISU PDP Plan has a maximum of $50.00 per 30 day supply when in the initial stage. Stage two is referred to as the coverage “gap” or “donut hole.” Prior to 2011, the Part D standard framework did not include coverage for anyone while they were in stage two. It was called the gap or donut hole because nothing was there! Since 2011, ACA rules have closed the gap for all plans. What the gap coverage signifies now is the beginning of the ACA gap discounts for medication, where the cost of medication is reduced. This reduction does not necessarily reduce what our member pays while in stage two. For the ISU Plan, in stage two, the 30% coinsurance maximum is still capped at $10.00 for 30-day supply of generics and $50.00 for 30-day supply of preferred brand name medication. For the non-preferred brand or specialty medication, the coinsurance percentage applies without the $50.00 cap. So, it is possible that a prescription that cost $50.00 for one purchase could cost hundreds the next time it is purchased, if the member reached the gap. For all covered prescriptions, the maximum out-of-pocket for each person with the ISU Humana plan is $2,500.00 annually. After your out-of-pocket drug costs reach the $2,500.00, Humana pays 100% of your total drug costs. The stages of the framework are referred to in each individual’s “SmartSummaryRx” sent by Humana to members purchasing prescription medications using the ISU Humana plan. Stage three is also known as the catastrophic stage. This stage begins when the total drug costs reach $6,550.00. You could reach this stage without reaching the maximum out of pocket amount for the ISU Humana plan. If you haven’t reached the maximum out of pocket, you would pay which is greater, 5% or $3.40 for generics/ multiple source drugs/ $8.50 for all other drugs until the end of the year or you reach the maximum of $2,500.00. You might have a prescription that your pharmacy may indicate as not covered by Humana due to coverage by Medicare Part B. For the prescriptions considered to be Part B, Wellmark will follow Medicare. An example of this type of prescription may be diabetes test strips or transplant auto-immune suppressive medications. However, if neither Part B nor Part D covers your prescription, Wellmark will not cover that expense. There would not be coverage for that expense.

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MEDICAL/PRESCRIPTION MONTHLY PREMIUMS FOR 2021 Your ISU Medical/Prescription Plan is a two-part plan for one price. The premium is for both medical and

prescription coverage. Express Scripts for those not yet eligible for Medicare or the Humana Part D for those eligible for Medicare drug coverage. ISU has Wellmark collect the full retiree premium for ISU Plan participants. ISU Retirees on the plan do not pay a premium directly to either of the prescription managers, Express Scripts or Humana. The payments you make fund the retiree pool; ISU then uses the pool to pay for the medical claims and the applicable pharmacy coverage and claims. The member must continue to pay the premiums to the insurance company in a timely manner, so you may want to consider setting up automatic payments, where Wellmark pulls the payment from your account. Many current participants find this an effective way to pay but it is not required. You may continue to get invoices and send in checks. 2021 Medical/Pharmacy Premiums are listed for two group categories. The former Faculty, Professional/Scientific and Supervisory/Confidential Merit have a different premium than former Merit retirees. This is due to the limited history of the Merit retirees’ claims experience. As the plan experience and trend are evaluated over a longer period of time, the expectation is the two groups will be blended to eventually have the same premiums. Insurance Premium changes for those with Medicare and Low Income or High Income

Medicare Part A is usually at no cost to those eligible. Medicare Part B premiums are income-based and annually assessed by Social Security. The Medicare Part D premium for any Part D plan (including our Humana Part D plan) is also based on income. The premium for our Humana plan is rolled into the premium you pay to Wellmark but there could be an adjustment due to the income level you had in 2019. Social Security will base your Medicare Part B and D premiums for 2021 on your 2019 modified adjusted gross income. This is deducted from your Social Security Income (SSI) or billed to you if not yet collecting your SSI.

For those Medicare participants with high modified adjusted gross income reported in 2019, an Income-Related Monthly Adjustment Amount (IRMAA) will be assessed in 2021. This amount, based on reaching a higher income tax level, is deducted directly from the Social Security Income (SSI). CMS notifies the member of this annually applied assessment for Medicare B and D. If assessed the fee and the participant does not agree to have the fee deducted from the SSI, CMS would advise Humana to terminate the Medicare Part D, which would be your ISU Humana group plan. Any appeal regarding this assessment is directly to SSA.

Also in 2021, based on 2019 income, members might qualify for a low income subsidy (LIS) for the Medicare Part D PDP. The premiums listed in this document do not reflect the LIS. CMS notifies Humana when a member qualifies as LIS. ISU then gets notice from Humana. ISU then alerts Wellmark to have the member charged a lower premium. The LIS is based on the reduction of the cost for the Humana plan for the applicable member. You may contact the ISU Benefits Office if you have questions about either LIS or IRMAA. 2021 Premiums are listed on page 12 of this document. The Iowa Senior Health Insurance Information Program (SHIIP), sponsored by the Iowa Insurance Commission and not selling any product, can assist you with understanding Medicare, Medigap, Part D PDP and Medicare Advantage plans. They also have information to help evaluate the possible need for long-term care insurance. Their publication, Iowa Guide to Long-Term Care Insurance is available online or through the mail. You may call 1-800-351-4664 or go to the SHIIP link: www.shiip.state.ia.us.

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Blue365® Member Discounts and Services As a member of any Wellmark medical plan, you have access to discounts and services through a program

designed by the Blue Cross Blue Shield Association. Check out the website below or call Wellmark regarding discounts or services related to: Diet, Family Care, Financial, Fitness, Hearing (aids), Travel and Vision (eyewear). http://www.wellmark.com/Member/UsingBenefits/Blue365.aspx Humana

As a member of the ISU Humana PDP, at the beginning of the year, Humana may offer discounts/services similar to Wellmark, you will receive Humana information at the beginning of the plan year. Iowa State University Benefits Office Email benefits@iastate.edu or call 1-515-294-4800 or toll-free 877-477-7485

As a member of the ISU retiree insurance, you may contact the ISU Benefits Office throughout the year to assist you with any issue with insurance that might warrant questions. The ISU Benefits Office may have to pass your issue on to the insurance carrier for resolution or to clarify understanding, but we will do our best to assist you. The ISU HR Service Center gets the call and may transfer you to a Benefits Consultant’s voicemail. If you can, please leave a detailed message and we’ll call you back as soon as possible.

The Patient Protection and Affordable Care Act (ACA) requests employers provide a notice to retirees regarding coverage options available through a Marketplace. The Department of Labor’s notice is available by request or at the ISU benefits website for your review: https://www.hr.iastate.edu/benefits/insurance/notices-resources

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2021 ISU PLAN MONTHLY PREMIUMS for former Merit staff of ISU and Affiliated Board of Regents Institutions Prices include either Express Scripts or Humana pharmacy - based on Medicare eligibility

BluePPO and Rx

BlueHMO and Rx

Retiree Only

Not Medicare eligible $745.00 $722.00

Medicare eligible $333.00 $318.00

Retiree and Spouse or Partner – Two people

Two not Medicare eligible $1,701.00 $1,655.00

Two people - one with Medicare/one without Medicare $1,076.00 $1,038.00

Two Medicare eligible $664.00 $634.00

Retiree and Child(ren) only – Two or more

Retiree is not Medicare eligible $1,329.00 $1,295.00

Retiree is Medicare eligible $917.00 $891.00

Family- Retiree, Spouse/Partner & child(ren)- 3 or more

Three or more - none are Medicare eligible $2,180.00 $2,105.00

One with Medicare and others without Medicare $1,555.00 $1,488.00

Two Medicare eligible and others without Medicare $1,143.00 $1,084.00

2021 ISU PLAN MONTHLY PREMIUMS for former Faculty, Professional & Scientific, Supervisory or Confidential Merit staff of ISU and Affiliated Board of Regents Institutions

Prices include either Express Scripts or Humana pharmacy - based on Medicare eligibility

BluePPO and Rx

BlueHMO and Rx

Retiree Only

Not Medicare eligible $541.00 $524.00

Medicare eligible $333.00 $318.00

Retiree and Spouse or Partner – Two people

Two not Medicare eligible $1,234.00 $1,200.00

Two people - one with Medicare/one without Medicare $872.00 $840.00

Two Medicare eligible $664.00 $634.00

Retiree and Child(ren) only – Two or more

Retiree is not Medicare eligible $964.00 $939.00

Retiree is Medicare eligible $756.00 $733.00

Family- Retiree, Spouse/Partner & child(ren) -3 or more

Three or more - none are Medicare eligible $1,581.00 $1,526.00

One with Medicare and others without Medicare $1,219.00 $1,166.00

Two Medicare eligible and others without Medicare $1,011.00 $960.00

13

2021 (1-1-2021 to 12-31-2021) Iowa State University Humana Medicare Part D Prescription Drug Plan

Note: This is not a complete description of benefits. If a discrepancy arises between this information and the actual Evidence of Coverage, the Evidence of Coverage will prevail in all instances.

Prescription tiers see description below in Tier Details

Retail Pharmacy 30 Day Supply (90 day cost)

Mail Order 90 Day Supply

Stage 1 = $0 to Initial Coverage Limit (ICL): When total drug cost reaches $4,130

Tier 1 $10 ($30) Maximum $0

Tier 2

30% up to $50 maximum out-of-pocket per prescription (30% up to $150)

20% up to $100 maximum out-of-pocket per prescription

Tier 3

50% up to $50 maximum out-of-pocket per prescription (50% up to $150)

33% up to $100 maximum out-of-pocket per prescription

Tier 4

50% up to $50 maximum out-of-pocket per prescription

N/A - Limited to a 30 day supply

Stage 2 = Coverage Gap – Begins when the yearly drug cost total (what you & the plan have paid) reaches $4,130

Tier 1 $10 ($30) $0

Tier 2

30% up to $50 maximum out-of-pocket per prescription (% up to $150)

20% up to $100 maximum out-of-pocket per prescription

Tier 3 30% (30%) 30%

Tier 4 30% (N/A) N/A

All Tiers

Stage 3 = Catastrophic to Unlimited - Begins When Your True Out-of-Pocket cost reaches $6,550

Greater of $3.70 for Generic/Multiple Source Drugs ($9.20 for all others) or 5% coinsurance

Annual Maximum Out-of-Pocket (MOOP)

$2,500 - After your out-of-pocket drug costs reach this total, Humana pays 100% of your total drug costs.

Tier Details

Tier 1: Generic or brand drugs that are available at the lowest cost share for this plan Tier 2: Generic or brand drugs that Humana offers at a lower cost than Tier 3 drugs Tier 3: Generic or brand drugs that Humana offers at a higher cost than Tier 2 drugs Tier 4: Some injectable medications and other higher-cost drugs

Out of Network

If a drug is purchased at an out-of-network pharmacy in an emergency situation: a) member pays the same coinsurance as would have applied at a network pharmacy but at the out-of-network pharmacy price and/or b) member will pay copayment as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy price and the network pharmacy price, no to include maximums.

14

2021 ISU Plan Express Scripts Prescription Drug Plan

Express Scripts is the required pharmacy coverage for those on the Wellmark plan not yet eligible for Medicare. Once Medicare eligible on the retiree plan, you must be enrolled in the group Humana plan.

Pharmacy Benefit Manager EXPRESS SCRIPTS

Express Scripts determines the tier of each medication.

Drug Tiers: Tier 1 is Generic drugs Tier 2 is a Preferred Brand Name drugs Tier 3 is Non-Preferred Brand Name drugs Specialty drugs may be Tier 2 or 3.

Deductibles $0

Prescription Co-insurance/Pay Maximum Out-of-Pocket (MOOP)

$2,000/single/benefit year $4,000 total/benefit year for plan with spouse/partner/child/family

30-day supply Participating Retail Pharmacy

Tier 1 - $15 copay / script Tier 2 - 30% coinsurance up to $125.00 maximum copay / script Tier 3 - 50% coinsurance up to $250.00 maximum copay /script Above applies until MOOP is reached.

90-day Supply Participating Retail Pharmacy

Tier 1 - $40 copay /script Tier 2 - 30% coinsurance up to $375.00 maximum copay / script Tier 3 - 50% coinsurance up to $750.00 maximum copay /script Above applies until MOOP is reached.

90-day Supply Express Scripts By Mail (Home Delivery)

Using Express Scripts By Mail Tier 1 - Generics - no cost to member Tier 2 - 25% coinsurance up to $300.00 maximum copay / script Tier 3 - 33% coinsurance up to $600.00 maximum copay / script Above applies until MOOP is reached.

15

ISU PLAN MEDICAL PLANS - Effective January 1, 2021 NOTE: For plan participants, eligible for Medicare, Medicare is your primary insurance.

The ISU Plan, following Medicare, usually leaves no patient liability, such as the

copay or coinsurance shown listed in the columns below. Some exceptions may occur.

This is a limited comparison of benefits. The Summary of Benefit and Coverage for each plan is available the ISU web page.

Benefits will be administered as described in each plan coverage manual. Refer to those documents or call Wellmark Blue

Cross/Blue Shield. If there are discrepancies between this comparison and Wellmark’s Coverage Manual, the Manuel will

govern in all cases.

PLAN

PROVISIONS

BluePPO BlueHMO BluePPO

In - Network

BluePPO

Out-of-Network

Plan Provisions BlueHMO

Benefits from non-

participating

providers

Limited: You are responsible for any

amounts between the billed

charge and the maximum

allowable fee paid by Wellmark.

These amounts will not

accumulate towards the medical

out-of-pocket limit.

80% coverage to MAF (maximum

allowable fee) after deductible You are responsible for any amounts

between the billed charge and the

maximum allowable fee paid by

Wellmark. These amounts will not

accumulate towards the medical out-of-

pocket limit.

None, unless prescribed and

referred by a participating

physician and approved by

Wellmark, or in an

emergency medical

situation

Yearly Deductible

$0 $400/single / $800 other levels

Was $300 single /$600 all other levels $0

Coinsurance

(member pays)

10% of Maximum Allowable

Fee

20% of Maximum Allowable Fee,

after deductible

0% directed by PCP in

network.

Yearly Out-of-

Pocket (OOP)

Maximum

$2000/single, $4000/other

levels Was $1500/single, $3000/

spouse/partner/child/ family

contract (two or more).

Separate prescription out-of-

pocket limit of $2,000/single,

$4000 other levels.

Was$1,500/single, $3,000

spouse/child/family

$4000 single/$8000 other levels

Was $3000/single, $6000

spouse/partner/child/ family

contract (two or more).

Separate prescription out-of-pocket

limit of$2,000/single,$4000 other

levels. Was $1,500/single, $3,000

spouse/child/family

None

Prescription out-of-pocket

limit of $2,000/single,$4000

other levels.

Was $1500 – single, $3,000 -

spouse/child/family

Lifetime maximum None None None

PHYSICIAN SERVICES

Office exams 100% coverage after

$25 co-pay Was $20.00

80% coverage to MAF (maximum

allowable fee) after deductible

100% coverage after

$15 co-pay - PCP or

referred by PCP within

network Was $10.00

X-ray, lab and

outpatient surgery

90% coverage 80% coverage after deductible 100% coverage referred by

PCP

Routine physicals 100% coverage after $25.00

copay, Was $20 co-pay

Not covered 100% coverage after

$15 co-pay – PCP required

Was $10

Routine eye exam

(eye glasses not

covered)

$25.00 co-pay then 90%

coverage for other office

related services. Was $20.00

Not covered $15.00 co-pay then 100%

coverage, one per calendar

year; may self-refer to a

network provider. Was $10.

Routine hearing

exam(hearing aids

not covered)

100% coverage after $25.00

copay, one per calendar year.

Was $20.00

Not covered 100% coverage after $15.00

copay, one per calendar

year. Was $10.00

16

PLAN

PROVISIONS

BluePPO BlueHMO

BluePPO

In Network

BluePPO

Out-of-Network

PREVENTATIVE SERVICES

Labs,

colonoscopies,

sigmoidoscopies

90% coverage Not covered 100% coverage - directed by

PCP

Routine pap

smears, routine

mammography

90% coverage 80% coverage after deductible

for mammography only, one

per calendar year

100% coverage - directed by

PCP

INPATIENT SERVICES

Inpatient surgery 90% coverage; prior approval

required for certain

procedures

80% coverage after deductible;

preadmission approval and

prior approval required for

certain procedures

100% coverage – PCP or

referred by PCP

Physician services,

room and board,

other inpatient care

90% coverage 80% coverage after deductible 100% coverage - directed by

PCP

MISCELLANEOUS SERVICES

Acupuncture Not covered Not covered $15/visit co-pay to $500 annual

maximum benefit/member, self

-referral to provider for up to 5

visits per condition. Over 5

need referral.

Allergy treatment 90% coverage, prior approval

for some treatment

80% coverage after deductible,

prior approval for some

treatment

100% coverage - directed by

PCP

Emergency room

care

$125 co-pay, co-pay does not

apply to OOP; co-pay is

waived if admitted

$125 co-pay, co-pay waived if

admitted, then deductible

applies

$125 co-pay, co-pay is waived

if admitted

Chiropractic care $25/visit co-pay, then 90%

coverage

80% coverage after deductible $15 per visit co-pay, then 100%

coverage, may self - refer to

network provider

Immunizations

administered in a

doctor’s office

90% coverage 80% coverage after deductible 100% coverage - directed by

PCP

Outpatient

chemotherapy

90% coverage 80% coverage after deductible 100% coverage - directed by

PCP

Speech, physical,

occupational and

respiratory

therapy

90% coverage, prior approval

for some treatment

80% coverage after deductible,

prior approval for some

treatment.

100% coverage - directed by

PCP, 20 visits/person/year for

each type of therapy