Underwritten by:Blue Cross Blue Shield ND

EligibilityEligibility Retired employees receiving a retirement benefit

NDPERS ‐ NDHPRS TFFR ‐ Job Service TIAA‐CREF

Surviving spouses receiving a retirement benefit 

May enroll at time of retiree’s death, or May continue if currently participating

Deferred retirees

Enrollment“Qualifying Events”Qualifying EventsWithin 31 days of the following

1st retirement benefit check

R ti     ’  6 th bi thd     li ibilit  f   Retiree or spouse’s 65th birthday or eligibility for Medicare

  f   i     l   d  Loss of coverage in an employer sponsored health plan

Marriage, Birth, Adoption or Legal Guardianship 

General InformationGeneral Information COBRA

h 18 months coverage If not drawing a retirement benefit after 18 months, coverage will endcoverage will end

Coverage for Lifetime if drawing a retirement allowance

CopaymentsCopaymentsPPO Plan             Basic Plan

Office Visit Copayment $25 $30

Emergency Copayment $50 $50

PT, OT and ST                 $20 $25

Chiropractic Therapy and Manipulations $20 $25and Manipulations $20 $25

Cost Sharing AmountsCost Sharing AmountsPPO Plan               Basic Plan

Deductibles:Per Person $ 400 $ 400Per Family $1200 $1200Per Family $1200 $1200

Coinsurance:P  P $  $Per Person $ 750 $1250Per Family $1500 $2500

*Coinsurance applies on all covered services exceptPhysician Office Visits   80/20  75/25Physician Office Visits   80/20  75/25

Out of Pocket Maximums(Deductible and coinsurance)( )

PPO Plan Basic Plan

Per Person $1150 $1650P  F il  Per Family $2700  $3700

*Thi  d   t i l d    C t     ill h*This does not include any Copayments you will have.

Prescriptions – Non‐MedicarePrescriptions  Non Medicare Formulary ‐ Generic

$5.00 Copayment$5 p y

15% Coinsurance * Formulary ‐ Brand Name y

$20 Copayment 25% Coinsurance *

Non‐Formulary ‐ Generic or Brand $25 Copayment 50% Coinsurance

* $1,000 coinsurance maximum per person per benefit period. Covered at 100% after the $1 000 coinsurance maximum is metCovered at 100% after the $1,000 coinsurance maximum is met. Two Copayment Amounts per Prescription Order or refill for a 35 –100 day supply.

Preventive Screening ServicesPPO Plan             Basic Plan

Office Visit Copayment :                       $25                         $30Office Visit Copayment :                       $25                         $30*Then 100% of Allowed Charge subject to a Maximum Benefit Allowance of 

$200 per Member per Benefit Period.  Deductible Amount is waived.

*Benefits include: One routine physical examination per Member per Benefit Period. Routine diagnostic screenings. Routine screening procedures for cancer.

*Benefits for Mammography Screening, Routine Pap Smear, PSA, Fecal Occult Blood Testing and Immunizations do not apply to the $200 Maximum Benefit Allowance.

Employee Wellness Initiative

Blue Cross Blue Shield of North Dakota is pleased to offer two wellness programspleased to offer two wellness programs.

Employees and spouses age 18 and older who are Employees and spouses age 18 and older who are covered by the NDPERS Dakota plan are eligible to participate.

Employees and eligible spouses can each qualify to receive up to a total of $250 each year that can to receive up to a total of $250 each year that can be earned for one or both of the following programs:

Health Club Credit Employees and their eligible spouses can earn up to a $20 credit monthly for visiting a participating h lth  l b    i i   f   d     thhealth club a minimum of 12 days a month.

My Health Center

•Employees and their eligible spouses can earn points to apply toward incentive prizes in this online program.•My Health Center provides personal coaching, the QuitNet tobacco cessation program, customized plans for fitness and nutrition and family tools for kidsand nutrition, and family tools for kids.

Dakota Retiree PlanDakota Retiree Plan ‐mirrors Supplemental Plan F benefit design pp gwith no variations (not a Qualified Supplemental Plan F product)pp p )

Medicare Retirees must have BOTH Medicare Retirees must have BOTH Part A & B

Medicare Providers Providers not participating with Medicare may not be covered 

Provider may Accept Assignment

96% of ND providers are PAR with Medicare 4,545 total providers in ND4,545 p 4,353 providers PAR / 192 non‐PAR

% f h h d85% of ND chiropractors are PAR with Medicare 287 total Chiropractors in ND 245 Chiropractors PAR / 42 non PAR 245 Chiropractors PAR / 42 non‐PAR

Dakota Retiree Plan Must complete NDPERS retiree group health insurance application andapplication and

Medicare Blue Rx group application If required forms are filed late there is no retroactive If required forms are filed late there is no retroactive adjustment

Must provide Medicare information Photocopy of Medicare ID cardEff ti  d t   t  i id   ith D k t  R ti  Pl   Effective date must coincide with Dakota Retiree Plan effective date

Dakota Retiree Plan ( )(continued)

i i  D     Prescription Drug Program  If you enroll in other Medicare prescription drug plan  you are not eligible for the Dakota drug plan, you are not eligible for the Dakota Retiree Plan (includes both health and prescription drug benefits)

No coordination of benefits with other federal drug plans (i e  VA  Tricare coverage)drug plans (i.e. VA, Tricare coverage)

Refer to the Medicare Blue Rx Summary of yBenefits for coverage details

Senior Health Insurance CounselingCounseling

S H I C 

Contact: ND Insurance DepartmentContact: ND Insurance Department

1‐800‐247‐0560

d / di / /d ilwww.nd.gov/ndins/consumer/details

Group Dental PlanGroup Dental Plan

Underwritten By CignaUnderwritten By Cigna

Eligibilityg y•Retired employees receiving a 

i  b fi  fretirement benefit from:‐NDPERS ‐ NDHPRS‐TFFR ‐ Job ServiceTFFR Job Service‐TIAA‐CREF

•Surviving spouses receiving a Su v v g spouses ece v g aretirement benefit 

• May enroll at time of retiree’s death, ory ,• May continue if currently participating

•Deferred retirees• 1st check date

Enrollment‐“Qualifying Events”Events

t  ti t b fit  h k

Must apply within 31 days of the following:

1st retirement benefit check

Retiree’s or spouse’s 65th birthday or p 5 yeligibility for Medicare

Loss of coverage in an employer sponsored  Loss of coverage in an employer sponsored dental plan

M i  Bi th  Ad ti    L l Marriage, Birth, Adoption or Legal Guardianship 

Plan FeaturesPlan Features

d No waiting periods

Freedom to use any dentist

Claims paid at the 90th percentile of “Reasonable and Customary” charges

Plan HighlightsPlan Highlights•Dental plan annual maximum benefit per person: $1,000•Orthodontia lifetime maximum benefit per person: $1,500•The deductible includes total expenditures per person for all basic and major

treatment combinedtreatment combined.Services Deductible Coinsurance

Preventive and Diagnostic Care: oral exam, cleaning, bitewing X-rays, fluoride application,

None 100%cleaning, bitewing X rays, fluoride application, sealants, full-mouth X-rays, panoramic X-rays, emergency care to relieve pain, histopathologic exams.Basic Restorati e Care oral s rger s rgical $50 80%Basic Restorative Care: oral surgery, surgical extraction of impacted teeth, anesthetics, major & minor periodontics, root canal/therapy, relines, rebases, and adjustments, repairs to bridges crowns & inlays and repairs to

$50 Per person, per year

80%

bridges, crowns & inlays, and repairs to dentures.Major Restorative Care: crowns, bridges, dentures.

$50 Per person, per year

50%

Orthodontia: Coverage for eligible children and adults.

None 50%

Premium InformationRetiree

I di id l  l   Individual only $ 39.82

Individual & spouse $ 76.88

Individual & child(ren) $ 89.22

Family  $127.04

Rates guaranteed through December 2011

Group Vision Plan

Underwritten By Superior VisionUnderwritten By Superior Vision

Eli ibilitEligibilityRetired employees receiving a retirement p y gbenefit from:

NDPERS NDHPRSTFFR TIAA‐CREFJob Service

S i i     i i     i  Surviving spouses receiving a  retirement benefit 

M   ll    i   f  i ’  d h  •May enroll at time of retiree’s death, or•May continue if currently participating

Deferred retireesDeferred retirees• 1st check date

Enrollment“Qualifying Events”

Within 31 days of the following

1st retirement benefit check

R i ’     ’  6 h bi hd     Retiree’s or spouse’s 65th birthday or eligibility for Medicare

Loss of co erage in an emplo er  Loss of coverage in an employer sponsored vision plan

Marriage, Birth, Adoption or Legal Marriage, Birth, Adoption or Legal Guardianship

Plan HighlightsPlan Highlights

Co paymentsCo‐payments•$0 Comprehensive Eye Exam•$35 Materials•$35 Contact Lens FittingIn‐network co‐pays are paid directly to the provider.y pMaterials co‐pay applies to lenses and/or frames, not contact lenses

For Detailed description please see plan handbook

Plan Highlights ContinuedPlan Highlights ContinuedServices In Network Out of NetworkComprehensive Eye Exam:

Ophthalmologist (MD) Covered in Full Up to $45

Optometrist (OD) Covered in Full Up to $45

Standard Lenses (Per Pair):

Single Vision Covered in Full Up to $35

Bifocal Covered in Full Up to $50

Trifocal Covered in Full Up to $70Trifocal Covered in Full Up to $70

Lenticular Covered in Full Up to $70

Progressives Covered toproviders retailProgressives trifocal amount

Up to $70

Plan Highlights ContinuedPlan Highlights ContinuedContact Lenses (Per Pair):

In Network Out Of Network

Medically Necessary Covered in Full Up to $210Medically Necessary Covered in Full Up to $210

Elective Up to $100 Up to $100

Contact Lens Fitting

Standard Covered in Full Not Covered

Specialty Up to $50 Not Covered

Frames ‐ Standard Up to $75 Up to $40p 75 p 4

Plan Services Frequency

Comprehensive Eye Exam 1 per Calendar YearComprehensive Eye Exam 1 per Calendar Year

Contact Lens Fitting Exam 1 per Calendar Year

Lenses 1 Pair per Calendar Year

F    C l d  YFrames 1 per Calendar Year

Contact Lenses 1 Allowance per Calendar Year

Locate a Pro iderLocate a Provider

Click onMap

In‐Network Claims

M b    dIn NetworkProvider

Member pays Provider for Copay 

and Upgrades

Provider files Claim with SVS

SVS pays Provider for services

Provider gets approval from 

SVS

MemberMember

Out‐of‐Network Claims

MemberMember

Out‐of‐NetworkProvider Member pays 

Provider in full Member sends Claim/Receipt to 

SVS

SVS reimburses Member at OON 

rates

Premium Information2011 Premium Amounts2011 Premium Amounts

Individual only $ 4.92

Individual & spouse $9.84

Individual & child(ren) $ 8.96

Family $13.88

Term Life InsuranceUnderwritten by Prudential

EligibilityEligibility Employees who participated in the NDPERS life insurance as an active employeep y

Retired, receiving a retirement benefit

4NDPERS4NDPERS4NDHPRS4TIAA‐CREF4TFFR4Job Service

Levels of CoverageLevels of CoverageRetiree may maintain their current level of coverage or decrease coverage

Basic = $1,300 coverage ($4.32 monthly premium) Employee Supplemental * Basic Dependent * Spouse Supplemental *

*Premium is based on age and level of coverage.  

*Coverage ends at age 65, retiree may apply for       conversion of coverage at age 65

Conversion RightsConversion Rights Loss of Coverageg

Rates are age rated at date of conversion

Obtain form and rate information from Prudential