RFP_5800_SLW3030_ATT_4_v1.pdf

2026 Benefits Guide For Retirees & Surviving Dependents

Medical • Dental • Vision • Wellness • Life Insurance

Table of Contents Contact Information

Eligibility

Dependent Documentation

Coverage Information

Medical Plans

Medicare Advantage Open Access—PPO

Medicare Advantage Open Access—PPO Schedule of Benefits

Medicare Advantage Open Access—PPO Pharmacy

Medicare Advantage Open Access—PPO Programs & Additional Benefits.. . 15

Blue Access for Members

CDHP w/HRA

Your HRA Account

CDHP w/HRA, PPO, & HMO Schedule of Benefits

CDHP w/HRA, PPO, & HMO Pharmacy

CDHP w/HRA, PPO, & HMO Programs & Additional Benefits

Cost for Coverage

Retiree Medical Rates for 2026

Surviving Dependents Medical Rates for 2026

Dental Plans

Vision Plan

Retiree Wellness Program

Life Insurance

Additional Benefits

Notice of Creditable Coverage

Health Insurance Portability & Accountability Act (HIPPA)

Important Information for Retirees & Surviving Dependents

The City of Austin is committed to compliance with the Americans with Disabilities Act.

Call the Human Resources Department at 512-974-3400 (voice) or 800-735-2989 (Relay Texas TTY number) for more information.

City of Austin retirees and surviving dependents of City retirees have access to benefits approved by the City Council each year as part of the budget process. The benefits and services offered by the City may be changed or terminated at any time.

The Guide is not a comprehensive breakdown of all current Benefits program requirements, policies, and exclusions. Please refer to CitySpace for current information pertaining to Benefits programs and incentives. In the case of a conflict between information presented in this Guide and the Plan, please defer to the terms of the Plan, which will always take precedence.

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Austin Human Resources Department Employee Benefits Division

Benefits staff are available by phone or in person to discuss benefits questions. For your convenience, please make an appointment before visiting our office.

Phone Number: 512-974-3284

Email: Benefits.HRD@austintexas.gov

Fax Number: 512-974-3420

Office Hours: Monday–Friday, 8:00 a.m. to 5:00 p.m.

Office Location: 505 Barton Springs Road, Suite 600

Online Resources

To view eligibility requirements, plan choices, print the City’s retiree benefits guide, and find information about the City’s other benefits, visit austintexas.gov/retirees or scan the QR code below.

Contact Information mailto:Benefits.HRD%40austintexas.gov?subject= http://www.austintexas.gov/retirees

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B elow you w ill fi nd contact inform ation for the vendors that provide services to retirees and their dependents. P lan docum ents, claim activity, provider search can be found on the w ebsites listed below https://www.bcbstx.com/retiree-medicare-coa https://www.bcbstx.com/retiree-medicare-coa http://bcbstx.com/coa http://bcbstx.com/coa http://metlife.com/mybenefits http://avesis.com http://mybenefits.inspirafinancial.com http://mybenefits.inspirafinancial.com http://dcaustin.com http://guidanceresources.com http://afrfund.org http://www.ausprs.org http://www.coaers.org

Eligibility

Eligible Dependents

◆ Spouse: Your legally married spouse.

◆ Domestic Partner: The individual who lives in the same household and shares the common resources of life in a close, personal, intimate relationship with a City retiree if, under Texas law, the individual would not be prevented from marrying the retiree on account of age, consanguinity, or prior undissolved marriage to another person. A domestic partner may be of the same or opposite gender as the retiree.

◆ Children: Your biological children, stepchildren, legally adopted children, children for whom you have obtained court-ordered guardianship or conservatorship, qualified children placed pending adoption, and children of your domestic partner. Your children must be under 26 years of age.

◆ Dependent Grandchildren: Your unmarried grandchild for whom you have legally adopted, obtain court-ordered guardianship or court-ordered conservatorship.

◆ Disabled Children: To continue coverage for your disabled child beyond the age of 26, the dependent child must have been enrolled in your benefits the day before turning 26 and must meet the following definitions:

Covering dependents who are not eligible for the City’s insurance programs unfairly raises costs for all participants in the programs, as well as for the City.

disabled, and dependent upon you for more than one-half of their support as defined by the Internal Revenue Code of the United States.

▶ Disabled means any medically determinable condition that prevents the child from engaging in self-sustaining employment.

▶ The child must be currently covered under a City medical plan and the disability must begin before the child turns 26.

▶ You must submit satisfactory proof of the disability and dependency, and periodic recertification will be required.

▶ A dependent child who loses eligibility and later becomes disabled is not eligible for coverage.

▶ A disabled child who was not covered as a dependent immediately prior to the time the child would otherwise cease to be a dependent is not eligible for coverage.

▶ A disabled child must be covered continuously on the medical and dental plans. If coverage is dropped, the disabled child will not be allowed to re-enroll.

As a City retiree, you are eligible to enroll in medical, dental, and vision coverage. Retirees may also elect to enroll their eligible dependents listed below.

Persons Not Eligible

Dependents do not include:

◆ Individuals on active duty in any branch of military service (except to the extent and for the period required by law).

◆ Permanent residents of a country other than the United States.

◆ Parents, grandparents, or other extended family members not listed under the Eligible Dependents section.

Dependent Documentation If you are adding a dependent under any of the City's benefits programs, you must provide documentation that supports your relationship to the dependent. Social Security Numbers must be provided for all eligible dependents.

Dependent Type Acceptable Documents

Spouse A marriage certificate or Declaration of Informal Marriage recorded as provided by law.

Domestic Partner A City of Austin Domestic Partnership and Tax Dependent Status Form and supporting documentation.

Child A certified birth certificate, Verification of Birth Facts (for newborn), qualified medical child support order, Administrative Writ, or court order establishing legal adoption, guardianship, or conservatorship.

Child of a Domestic Partner

The child documentation listed above must be provided along with a City of Austin Domestic Partnership and Tax Dependent Status Form.

Stepchild The child documentation listed above must be provided along with a marriage certificate or Declaration of Informal Marriage indicating the marriage of the child’s parent and stepparent.

Dependent Grandchild Documentation supporting a legal adoption, court-ordered guardianship or court-ordered conservatorship.

Disabled Child A Disabled Dependent Authorization form and a Disabled Dependent Physician Certification form.

Qualified Child Pending Adoption

For children already placed in your home, an agreement executed between you and a licensed child-placing agency or the Texas Department of Family and Protective Services (TDFPS), which meets the requirements listed in Dependent Eligibility.

Enrolling In Retiree Benefits

Insurance Benefits for you and/or your dependents are effective the first day of the following month from your retirement date, provided you complete your enrollment and submit any required documentation online in the benefits enrollment system by the Retirement System payroll deadline. If you missed the deadline, you have 31 days from your retirement date to enroll in benefits, and your benefits will be effective the first of the following month after completion.

Changing Your Retiree Benefits Coverage

You can request changes to your benefits coverage:

◆ Within 31 days of your retirement date.

◆ Within 31 days of a Qualifying Life Event.

◆ During Open Enrollment (Benefits changes are effective January 1 of the following year.)

To change your benefits coverage or to add or drop a dependent, you must submit your benefit changes in Workday. The link to Workday is available at austintexas.gov/retirees.

Retiree Qualifying Life Events

You can add/drop dependents or change your benefits coverage when you experience a Qualifying Life Event, such as: marriage, divorce, birth, adoption/placement of a child, death of a dependent, establishing a committed living arrangement as domestic partners, dissolution of domestic partnership, or involuntary loss or gain of other insurance coverage. You must submit your benefit change in Workday and upload the required documentation that corresponds to the life event within 31 days of the event. The link to Workday is available at austintexas.gov/retirees.

The benefits change will be effective the first day of the following month from the date you submit the change online. In the case of a newborn dependent, adoption, placement of adoption, guardianship, or conservatorship of a child, the benefits change is effective the date of the event and you will be required to pay any benefit premiums owed, if applicable.

Retiree Coverage Ending Dates

Coverage for you and your dependents will end on the last day of the month if:

◆ You fail to pay any required premium.

◆ The City ceases to offer coverage to retirees.

◆ The plan in question is terminated.

◆ The coverage in question ended or is reduced.

◆ You voluntarily drop your or your dependent's coverage.

◆ You or your dependents no longer meet eligibility requirements.

Coverage InformationCD http://austintexas.gov/retirees

Enrolling In Surviving Dependents Benefits

As a surviving dependent, your medical, dental, and/or vision coverage will automatically continue provided you were covered in that benefit at the time of your spouse’s (retiree) death. Your benefit premiums will automatically be deducted from your monthly survivor annuity. If you are not receiving an annuity or if your annuity is insufficient, you will be responsible for submitting your monthly benefit premiums to the City of Austin's Third Party Administrator.

Note: Domestic partners and children of domestic partners are not eligible for coverage as a Surviving Dependent.

Note: In the event a retiree is eligible to enroll as a Surviving Dependent and elects benefits as a Surviving Dependent, the retiree will no longer be considered a retiree and will forgo the $1,000 life insurance benefit.

Changing your Surviving Dependents Benefits Coverage

You can request changes to your benefits coverage:

◆ Within 31 days of a Qualifying Life Event

◆ During Open Enrollment (Benefits changes are effective January 1 of the following year.)

Note: You cannot add dependents at any given time.

Surviving Dependent coverage is only available to dependents that were covered at the time of the retiree’s death.

Surviving Dependent Qualifying Life Events

You can add, drop, or change coverage for yourself and your covered dependents when you experience a Qualifying Life Event such as: involuntary loss or gain of other insurance coverage or death of a dependent. You must submit your changes and documentation online in Workday.

The benefits change will be effective the first day of the following month.

If at any time you cancel all benefits, you cannot re-enroll in surviving dependent benefits.

Surviving Dependent Coverage End Dates

Coverage for you and your dependents will end on the last day of the month if:

◆ You fail to pay any required premium.

◆ You remarry. (Only applies to retiree's surviving spouse).

◆ You are covered under another group plan, except for Medicare.

◆ The City ceases to offer coverage to surviving dependents.

◆ The plan in question is terminated.

◆ The coverage in question ended or is reduced.

◆ You voluntarily drop your or your dependent’s coverage.

◆ You or your dependents no longer meet eligibility requirements.

Duplicate Benefits Coverage

An individual is not eligible to be covered:

◆ As both a City retiree and a City employee, for the same benefit

◆ As both a City retiree or City employee and as a dependent of a City retiree or City employee, for the same benefit

◆ As a dependent of more than one City retiree, or City employee, for the same benefit

It is your responsibility to ensure that you and/or your dependents are not double covered for the same benefit.

Duplicate claims will not be paid, and premiums will not be refunded.

Cancelling Coverage

You may cancel medical coverage for yourself and your dependents at any time during the calendar year.

Returning to City Employment

Retirees returning to City employment in a regular, budgeted, full-time or part-time position, who wish to maintain benefits, will be required to enroll in active benefits.

Those returning to a Temporary position are not eligible for active benefits and will remain on retiree benefits.

Medicare Eligibility Requirements

If you, your covered spouse/domestic partner (DP), or covered dependent child are eligible for Medicare due to disability or age and are enrolled in a City medical plan, you and/or your covered dependent must also enroll in Part B (Medical Insurance).

When “eligible” for Medicare, the City’s traditional medical plan will pay claims as secondary. For example, Medicare covers 80% after you have met Medicare’s annual deductible. If you are enrolled in Medicare, the City’s traditional plan will coordinate payment with Medicare. If you are not enrolled in Medicare Part B, you will be responsible for paying the amount that Medicare would have paid.

If you are eligible for Medicare due to disability and are under the age of 65, you may continue coverage on the traditional plan (PPO, HMO, CDHP) or enroll in the Medicare Advantage Plan. If you choose to enroll in the Medicare Advantage plan and your covered dependent is eligible for Medicare, your dependent must follow you by enrolling in the Medicare Advantage Plan. If your covered dependent is not eligible for Medicare, your covered dependent may continue coverage on the traditional plan.

If you are eligible for Medicare due to age, the traditional plan is no longer available. You may continue coverage through the Medicare Advantage Plan. If your covered dependent (spouse/DP, child) is not eligible for Medicare your covered dependent may continue coverage on the traditional plan. Upon your spouse/DP turning 65, the traditional plan is no longer available. Your spouse/DP may continue coverage through the Medicare Advantage PPO Plan. If your dependent child is eligible for Medicare, your dependent child must follow you by enrolling in the Medicare Advantage PPO Plan.

When enrolled in Medicare, the City requires you to send a copy of your Medicare Health Insurance card or verification of Medicare enrollment from the Social Security Administration Office indicating the coverage effective dates for Parts A & B. It is your responsibility to ensure that the City receives your Medicare information before your Medicare Coverage effective date. Your reduced medical premium will take effect the following month from the date received. No refunds will be issued.

If you need assistance in enrolling in Medicare or have Medicare questions, please call the Social Security Administration Office at 800-772-1213 or visit medicare.gov.

Medicare Part D Prescription Drugs

In addition to medical coverage, the City’s medical plans provide prescription drug coverage. If you choose to continue your medical coverage through the City of Austin, you should not enroll in Medicare

Part D (Drug coverage).

Coordination of Benefits

A group health insurance provision that determines which coverage will apply when an individual is covered under more than one plan. If you are enrolled in another employer’s plan as an employee and as a retiree in a City medical plan, medical claims will be paid in the following order:

◆ Primary: your employer’s medical plan.

◆ Secondary: Medicare.

◆ Third: City of Austin medical plan.

http://medicare.gov

Pharmacy PPO HMO CDHP w/HRA

Annual Drug Deductible

$50 for Tier 2 & Tier 3 Only

$50 for Tier 2 & Tier 3 Only

N/A

Tier 1 $10 $10 20% after Deductible

Tier 2 $40 or 20% ($70 Max) $45 or 20% ($80 Max) 20% after Deductible

Tier 3 $60 or 20% ($110 Max) $65 or 20% ($120 Max) 20% after Deductible

Medical Plans Eligibility in a retiree medical plan is based on the member's age and Medicare eligibility.

Things to consider when enrolling in the CDHP, HMO, or PPO Plan:

◆ Premium costs.

◆ Copay amount.

◆ Out-of-pocket expenses.

◆ Freedom to not designate a Primary Care Physician.

◆ Freedom to seek services from a Specialist without a referral.

◆ Future expenses and the predictability of inpatient hospital expenses.

◆ Your use of maintenance prescription drugs.

For treatment before your ID card arrives You will need to pay for the services out-of-pocket, then submit a claim form and itemized receipt to BlueCross BlueShield to be reimbursed at the contracted rate.

Benefits PPO HMO CDHP w/HRA

Annual Medical Deductible

$600 $0 $1,700

Annual Out-of-Pocket Maximum $4,250 $4,750 $5,000

Primary Care Office Visit

$15 $15 20% after Deductible

Specialist Office Visit $30 $40 20% after Deductible

Inpatient Hospital Care 20% after Deductible $1,750 20% after Deductible

Outpatient Hospital Services (outpatient surgery)

20% after Deductible $750 20% after Deductible

Emergency Room $300 $350 20% after Deductible

Urgent Care $40 $50 20% after Deductible

Comparison of PPO, HMO, and CDHP w/HRA Plans for Retiree Only coverage

BlueCross BlueShield of Texas

Medicare Advantage Open Access - PPO

The City of Austin Medicare Advantage Open Access PPO Plan is available to retirees and dependents eligible for Medicare and is administered by BlueCross and BlueShield of Texas (BCBSTX).

The Medicare Advantage Open Access is a national PPO plan that combines the benefits of original Medicare, prescription drug coverage, and added health and wellness benefits that can be important in maintaining ongoing good health. It allows you to see any provider that accepts Medicare and agrees to submit claims to the plan. You are not required to get a referral to see a specialist.

Note: You must be enrolled in Medicare Part A and Part B to be a member of this retiree plan. You must also continue to pay your Part B premium, just as you do today. If you are eligible for Medicare Part A and/or Part B but are not enrolled, please contact the Social Security Administration (SSA) right away.

Providers

With an Open Access PPO plan, you can see any provider that accepts Medicare. That’s about 98% of providers nationwide. The provider will need to submit claims either to BlueCross and BlueShield of Texas (BCBSTX) or to their local BlueCross and BlueShield (BCBS) plan. Your benefit levels are the same whether or not you utilize a network provider.

Please note, even providers that accept Medicare can decide which patients they want to see, except in an emergency. We recommend that you confirm with providers that they will accept your Open Access PPO plan. Some high cost medical services that have more cost effective alternatives may need prior authorization from the plan before your provider can proceed. To find a provider visit bcbstx.com/retiree-medicare-coa.

What happens after you enroll in:

Medicare Approval—Medicare must approve your enrollment before you are officially a member. This generally takes about 10 business days.

◆ If an incomplete enrollment is received, the retiree will receive a Request for Information (RFI) letter within 10 days of receipt of the enrollment form. This letter will advise the retiree to contact Customer Service or the SSA to provide missing information. Centers for Medicare & Medicaid Services (CMS) allows 21 days for the Retiree to respond with the requested information.

◆ Examples of information to be requested: Legal First and Last name, Part A or B effective date, Medicare Beneficiary ID (MBI), and/or Permanent Address (cannot be a PO Box).

coverage, they could face a Late Enrollment Penalty

(LEP).

◆ Confirmation Letter: After your enrollment is approved by Medicare, BlueCross BlueShield will send a confirmation letter. It can be used as proof of insurance if you have not received your member ID card by your effective date.

◆ Member ID Card: Your member ID card will be mailed next. Provide your new card when you seek services, so you are giving the right information.

◆ Welcome Guide: This helpful kit includes plan documents and other useful information.

Personal Phone Call—A BlueCross BlueShield Representative will call you to answer any questions and to discuss any special needs you may have that they should be aware of. The representative might also ask a few basic health questions, help you schedule your Annual Wellness Visit, and talk more about the Rewards Program.

Ongoing Communication—Once you are a member, your plan becomes your partner in health. BlueCross BlueShield will send helpful reminders, and health tips and guidance throughout the year. If you have a special medical condition, you may receive even more personalized communication from medical professionals who can help you manage your health and find resources just for you.

Personalized Customer Service

If you have any questions about the Medicare Advantage Open Access plan call: 855-380-8542 (TTY) 711

Availability: October 1 – March 31: Daily, 8:00 a.m. to 8:00 p.m., local time (7 days a week).

April 1 – September 30: Monday through Friday, 8:00 a.m. to 8:00 p.m., local time.

Alternate technologies (for example, voicemail) will be used on weekends and holidays.

Online: bcbstx.com/retiree-medicare-coa https://www.bcbstx.com/retiree-medicare-coa https://www.bcbstx.com/retiree-medicare-coa

Q. What is a Medicare Advantage Plan? How does it work with Original Medicare?

A. Medicare Advantage, also known as ‘Medicare Part C’, covers all emergency and urgent care, and almost all medically necessary services Original Medicare covers.

Your rights and protections are the same. Medicare Advantage plans bundle your Part A, Part B, and usually Part D coverage into one plan. You won’t need your Medicare card to receive services [or prescription drugs], just your BCBSTX Medicare Advantage member ID card.

Q. What are the costs of Medicare outside my group retiree plan?

A. Part A will not cost you anything if you or your spouse paid into Social Security for a minimum of 10 years. You pay a premium each month for Part B. Most people will pay the standard premium amount. Your Part B premium will be automatically deducted from your benefit payment if you get benefits from one of these:

◆ Social Security

◆ Railroad Retirement Board

◆ Office of Personnel Management

If you don’t get these benefit payments, you will receive a Part B premium bill.

Part B and Part D monthly premiums change each year. And, if your income is above a certain limit, you'll pay a surcharge to the government in addition to your premium. This is called IRMAA: Income-Related Monthly Adjustment Amount. Any Part B and Part D IRMAA surcharge is based on the modified adjusted gross income reported on your IRS tax return from two years ago. A notice from Medicare will be mailed to those who will pay the IRMAA surcharge(s).

If you've had a life-changing event that reduced your household income, you can ask Social Security to lower the additional amount you'll pay.

Q. What if I did not pay into Social Security?

A. If you did not pay into Social Security, you will need to pay Medicare for your Part A and B coverage. If you have not worked for a minimum of 10 years, you may still be able to qualify for premium-free Part A through your spouse’s work history or if you have certain medical conditions or disabilities.

Q. What if I did not pay into Medicare?

A. If you did not pay into Medicare, you are not eligible to enroll into the City of Austin’s Medicare Advantage plan.

Note: If you were part of the Fire Fighter group hired prior to March 31, 1986, who did not pay into Medicare, please call the Benefits division at the City of Austin at 512-974-3284 for your options.

Q. I am already enrolled in a Medicare Advantage or Supplemental plan other than the City of Austin MA plan. Will it continue if I enroll in the City’s plan?

A. You can only be enrolled in one Medicare plan at a time. If you have enrolled in different plan, other than the City's, please contact your current carrier to cancel your coverage prior to enrolling in the City's Medicare Advantage Open Access plan. Be sure to continue coverage until the new plan’s effective date to avoid any gaps in coverage. BCBSTX can offer support as you go through this change by calling 855-380-8542.

Q. Can I continue to use manufacturer coupons and/ or discount cards with this plan?

A. Federal law prohibits people who have Medicare from using coupons or other discounts in conjunction with their Part D plan. However, these coupons or other discounts may be used outside the plan.

Continuity of Care for Members

◆ CMS requires a 90-day continuation of care. This ensures that we provide the least disruptive care to the members during this transition.

◆ During the 90 days of continuity of care period, ongoing services will be paid without a prior authorization being required for all Medicare covered benefits and services delivered by a Medicare provider based on contract effective date and member effective date going forward.

◆ Outside of the 90-day continuity of care period, standard prior authorization process and claims payment rules are applied. Any adverse determination from authorization or claims payment would be accompanied by specific medical reason or explanation of benefit along with appeal rights.

?? Medicare Frequently Asked Questions0

Benefits Medicare Advantage Open Access - PPO

In-Network Out-of-Network

Deductible $0 $0

Out-of-Pocket Maximum $0 $0

Preventative Services $0 copay $0 copay

Primary Care Physician (PCP) Visits

$0 copay $0 copay

Specialist Visits $0 copay $0 copay

Emergency Care $0 copay $0 copay

Ambulance $0 copay $0 copay

Virtual Visit - MD Live $0 copay N/A

Inpatient Hospital Care $0 copay $0 copay

Outpatient Hospital $0 copay $0 copay

Outpatient Rehabilitation - Physical, Speech, & Occupational Therapy

$0 copay $0 copay

Routine Chiropractic Services (20 Visit Limit) $0 copay $0 copay

Routine Acupuncture (12 Visit Limit) $0 copay $0 copay

Mental Health Care $0 copay $0 copay

Durable Medical Equipment $0 copay $0 copay

Residency Requirements No No

Benefits Medicare Advantage Open Access - PPO

Fitness Program SilverSneakers

Meal Service 14 Meals / 7 Days; Max 3 times per year

(Authorization required after in-patient stay)

Over-the-Counter Rx Allowance $20 per month with rollover to next month

Rewards Program $25 worth of gift cards up to 4 times per year

Transportation Service $0 copay (for up to 12 one-way trip(s) to plan-approved locations every year)

Benefits Medicare Advantage Open Access - PPO

Hearing Aids Routine Hearing Exam

$0 copay for 1 Routine Exam

Hearing Services - Hearing Aids

$2,500 Allowance Combined in-network and out-of-network allowance every 3 years

(both ears)

Medicare Advantage Open Access - PPO Schedule of Benefits

Copay and Deductible: You will have copays with your prescription drug coverage along with an annual $50 deductible for tier 2 and tier 3 drugs.

Insulin: You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid any required deductible.

Vaccines: Your plan covers most Part D vaccines at no cost to you, even if you haven’t paid any required deductible.

Before you enroll, you can search for your medicines online at myprime.com:

Step 1: Select ‘Medicines,’ then:

‘Find a Medicines,’ followed by

‘Continue without sign in.’

Step 2: Under ‘Select Your Health Plan’:

Select BCBS Texas.

Answer ‘Yes.’

Select BlueCross Group Medicare Advantage (PPO) 3T Complete

Click ‘Continue.’

Step 3: Type your medicine and dosage.

Review the drug tier and requirements.

Refer to the Summary of Benefits for your cost.

Plan Features Medicare Advantage

Deductible per person per calendar year $50 Deductible for Tier 2 & Tier 3 Only

Basic Drug list - Tier 1 (Generic) $10

Basic Drug list - Tier 2 (Preferred) $30 copay or 20% of cost ($60 Max)

Basic Drug list - Tier 3 (Non-Preferred) $50 copay or 20% of cost ($100 Max)

90 Day - Mail Order 2 copays Tier 1, 2, or 3

Catastrophic Coverage

You pay $0 after your Part D maximum out-of-pocket costs reach $2,100. This includes drugs purchased through retail and mail order pharmacies but does not apply to out-of-pocket spending on Part B drugs or your monthly premium.

Medicare Advantage Open Access - PPO Pharmacy http://www.myprime.com

Managing Your Medications

Your prescription drug plan includes programs designed to encourage safe, cost-effective and appropriate use of medications. These include prior authorization, step therapy and quantity limits.

If a drug requires one or more of these programs, it will be noted in the formulary.

Home Delivery

Choose convenience with our mail-order service. A 90-day supply of the medications you take regularly can be delivered directly to your home. This service offers:

◆ Three ways to order refills: online, by phone or through the mail.

◆ Up to a 90-day supply of medications at one time.

◆ A choice to get a text, email or phone call to let you know when your order is received, and your prescriptions are mailed.

You will need to set up an account using your member ID with one of these options:

Specialty Pharmacy

Specialty medications are often prescribed to treat complex and/or chronic conditions. They have unique shipping and/or handling needs. You may be able to fill specialty prescriptions at certain retail pharmacies, if they stock the medication.

You can also use one of the two specialty pharmacy options:

https://walgreensmailservice.com/ https://pharmacy.amazon.com http://express-scripts.com/rx https://walgreensspecialtyrx.com/ http://accredo.com

24/7 Nurseline

BlueCross Group Medicare Advantage plan members can call a registered nurse, 24 hours a day, 7 days a week to get help with health concerns and general health tips.

Your call is taken by a registered nurse who can help you decide whether you should go to the emergency room, urgent care center or make an appointment with your doctor. You can also call the 24/7 Nurseline whenever you or your covered family members need answers to health questions about:

Medicare Advantage Open Access PPO Programs & Additional Benefits

You can access the 24/7 Nurseline at 800-631-7023 (TTY) 711.

Discounts

Blue365 offers premier health and wellness discounts from top retailers (Jenny Craig®, EyeMed, Fitbit®) to BCBSTX members. There are no claims to file, and no referrals or pre-authorizations needed. Once you sign up for Blue365 online at blue365deals.com/bcbstx, weekly ‘Featured Deals’ will be emailed to you.

You can find savings like:

To learn more about Blue365, visit blue365deals.com/bcbstx.

Fitness Program - SilverSneakers

The SilverSneakers Fitness Program helps you achieve your health and fitness goals with access to more than 15,000 fitness locations and online classes led by certified Instructors.

Membership offers a welcoming community where you can have fun with friends and meet new people, all while enjoying a healthy activity. Plus, it’s available at no added cost.

You will find fitness classes designed for all fitness levels and led by certified coaches. In addition to virtual classes and hundreds of online classes.

Ready to get started?

Call 888-423-4632 (TTY) 711, Monday–Friday, 7:00 a.m.–7:00 p.m. CST, or visit SilverSneakers.com/StartHere, or email support@silversneakers.com.

Always talk with your doctor before starting an exercise program.

http://blue365deals.com/bcbstx https://www.blue365deals.com/bcbstx http://SilverSneakers.com/StartHere mailto:support%40silversneakers.com?subject=

Hearing Services

This plan includes benefits through TruHearing or another hearing provider.

Exams ▶ A hearing exam each year plus necessary follow-up visits for fitting and adjustments.

▶ $0 copay.

Over-the-Counter (OTC) Hearing Aids ▶ TruHearing provides discounts on OTC hearing aids, but the plan hearing aid allowance does not apply.

For more information, call TruHearing at 877-248-4040.

In-Home Health Assessment

This plan includes an In-Home Health Assessment (IHA) by a licensed and credentialed clinician—Certified Nurse Practitioner, Physician Assistant or MD— from our trusted partner, Matrix, at no cost to you.

How can you make the most of your 45-to 60-minute IHA or telehealth visit?

▶ Discuss health concerns and learn more about disease management programs.

questions about your physical, emotional, and mental health in the comfort of your home.

You receive a one-page summary of the evaluation. With your permission, a full report of the IHA is shared with your primary care provider (PCP).

To set up an In-Home Health Assessment, call Matrix at 1-888-779-8978 (TTY) 711 or visit matrixforme.com to schedule online.

Meal Service - Mom's Meals

At Mom's Meals, you will find programs tailored to your personal needs. Whether recovering from a hospital stay or managing a chronic condition, Mom’s Meals ensures you get the nutrition you need for better health at every stage in life.

Health-Specific Menus – Dietitian designed to support the nutritional needs of most common health conditions.

Reliability – High quality, refrigerated meals arrive at your home when you need them the most.

Simple – Meals last for 14 days in the fridge—just heat, eat, and enjoy in two minutes or less.

How it Works:

1. Contact your case manager or health plan.

2. Case manager or health plan will provide paperwork to Mom’s Meals.

3. Meals are delivered to your home.

J) https://matrixforme.com

Over the Counter Rx Allowance

What is the over-the-counter benefit?

It is a purchase allowance available with the Medicare Advantage Open Access Plan to buy OTC medicines and other health-related items.

How does it work?

Your benefit includes a monthly allowance. Any unused balance rolls over to the next month and expires at the end of the calendar year. You can also purchase OTC products from the convenience of your home by requesting an OTC catalog through BCBSTX Customer Service. The OTC catalog includes hundreds of products to choose from and includes detailed instructions about how to place your order, which you can do online or by telephone. If you have questions about how to use the benefit, please call the number on the catalog.

Items you can order:

Rewards Program

The Rewards Program gives members a healthy and easy way to earn up to $100 worth of gift cards from national and local retailers. You receive a gift card of your choice for completing Healthy Actions throughout the year.

How do you get your rewards?

Retailers include:

To register visit BlueRewardsTX.com, registration is required to participate.

http://www.BlueRewardsTX.com

Transportation Services

This plan includes coverage for travel to and from:

Non-covered services:

The plan does NOT cover trips to:

Call to schedule your ride:

Call the Customer Service number on the back of your member ID card at least three days before your appointment. Follow the instructions provided by the Customer Service representative.

If you need emergency transport, call 911 immediately.

Virtual Visits

Virtual Visits, powered by MDLIVE, allow you to access care for non-emergency situations by phone, mobile app, or online video anytime, anywhere.

These telehealth appointments allow you to talk with a doctor or a behavioral health specialist from the comfort of your home or on the go.

Below are some examples of conditions that an MDLIVE doctor can treat:

To set up an appointment:

Call 888-680-8646 or create an account online at mdlive.com.

You will need your BlueCross BlueShield medical ID number when creating your account.

For more information about any of these programs, call BlueCross BlueShield at 855-380-8542.

https://www.mdlive.com

Blue Access for Members Sign up or Log in to Blue Access for Members

Everything you need to know about your coverage — in one place.

Get the most out of your health care benefits with Blue Access for Members (BAM), a secure website and mobile app. It’s the health information you need, any time you need it. If you already have a BAM account, you do not need to set up a new one.

It’s Easy to Get Started!

Grab your smartphone and ID card and text* BCBSTXAPP to 33633 to download the mobile app so you can use BAM while you’re on the go, or visit bluemembertx.com.

* Message and data rates may apply.

Here are a few things you can do with BAM:

◆ View your claims status and up to 18 months of claims activity.

◆ See your prescription history.

◆ Search for a health care provider, hospital, urgent care facility or pharmacy.

◆ Compare providers on a single page — you can view and sort providers by quality, cost and accessibility.

◆ Request or print your ID card.

◆ View or print Explanation of Benefits statements.

◆ And more!

Forms You May Need

All forms can be found on BAM online at bluemembertx.com.

◆ Appointment of Representative

This form lets you choose someone to make decisions on your behalf. It also lets them get your health information such as Explanation of Benefits. This form may also be used to let the plan share your health information with a third party such as another health plan or provider.

Having this completed form on file is vital for caregivers.

◆ Prescription Mail Order

Be sure to take advantage of the mail-order program for eligible maintenance medicines.

You’ll enjoy the ease of home delivery and the chance to save money. When you have a new prescription, use the online form from the website of the home delivery pharmacy of your choice.

◆ Authorization to Disclose Protected Health Information (PHI)

Use this form to allow the plan to share your PHI with a person or entity you choose.

◆ Coverage Determination

If the plan will not cover a prescription drug or medical service, you may ask for a coverage determination.

http://bluemembertx.com http://bluemembertx.com

CDHP w/HRA CDHP w/HRA is the Consumer Driven Health Plan with a Health Reimbursement Account. Like the PPO and HMO medical plans, the CDHP w/HRA is administered by BlueCross BlueShield.

The same network of doctors and facilities as those on the PPO are available. Despite these similarities, the plan works differently. Read on to see if the CDHP w/HRA plan is right for you.

How the CDHP w/HRA Works Before enrolling in the CDHP w/HRA, it is important to understand how the plan works. Here are a few things to know about this plan:

◆ Preventive services mandated by the Affordable Care Act (ACA) continue to be covered at 100%.

◆ You must meet your calendar year deductible for medical services before the plan pays for any covered services (except for preventive services).

◆ Once you meet your calendar year deductible, the plan will pay 80% for in-network providers covered services.

◆ Once you meet your calendar year out-of-pocket maximum, the plan will pay 100% for all in-network covered services and prescriptions for the remainder of the calendar year.

◆ The CDHP w/HRA includes three prescription formularies:

▶ ACA Preventive Drug List—The plan pays 100%, no deductible.

▶ CDHP w/HSA Preventive Drug List—The plan will pay 80%, no deductible.

▶ Basic Drug List (Tier 1, 2, & 3 Drugs)—The plan will pay 80% after you meet your deductible.

The City funds a Health Reimbursement Account (HRA) for you on an annual basis based on your years of service and level of coverage. An HRA is an account that helps pay for eligible health care expenses, including those that may apply to your annual deductible. BlueCross BlueShield will automatically draw the funds from your HRA account when medical or prescription claims are processed.

Even though the money in the HRA is City money, think of it as yours. By doing so, you’ll realize that spending your HRA wisely can help you save. As long as you have money in your HRA, that’s less you pay out of your pocket for health care expenses. HRA money does not rollover each year.

1. Your Deductible.

Your HRA pays first. When you have an eligible expense, like a doctor visit, the entire cost of the visit will apply to your deductible. The HRA will pay for all of your eligible expenses first, up to the amount contributed by the City. This means you won’t have to pay anything until the money in the HRA is spent.

If you spend all of the HRA money, you will need to pay out of pocket. You will pay the BCBS contracted rate for your health care expenses until the deductible is met.

2. Your Coverage.

Your plan pays a percentage of your expenses after the deductible is met. The plan will pay 80% of each eligible expense and you pay 20% for In-Network Providers.

3. Your Out-of-Pocket Maximum.

You are protected from major expenses. The out-of-pocket maximum amount is the most you have to pay each year for covered services. The out-of-pocket maximum for the CDHP w/HRA plan is $5,000 for Retiree Only coverage. For Retiree with Dependent coverage, the out-of-pocket maximum is $6,850. The plan will then pay 100% of all remaining in-network covered expenses, including prescriptions, for the rest of the plan year. Your deductible and coinsurance will go toward your out-of-pocket maximums.

Your Out-of-Pocket Maximum:

Retiree Only: $5,000

Retiree & Dependents:

$6,850 when you reach your out-of-pocket maximum the Plan pays 100%.

You are Protected

3Your Coverage:

Your Plan Pays 80% for In-Network Providers

You Pay 20% for

In-Network Providers

Your Deductible:

Retiree Only: $1,700

Retiree & Dependents: $3,400

+Your HRA Pays First

You Pay

Years of Service Retiree Only Retiree & Dependent

Less than 5 $100 $200

5 through 9 $200 $400

10 through 14 $300 $600

15 through 19 $400 $800

20 or more $500 $1,000

City Annual Contributions to the HRA

Your HRD Account

CDHP w/HRA, PPO, & HMO Schedule of Benefits

Benefits CDHP (BlueChoice PPO) PPO (BlueChoice PPO) HMO (BlueEssentials)

In-Network Out-of- Network In-Network In-Network

Deductible

$1,700 EO/

$3,400 Family

$3,200 EO/

$6,400 Family $600 Individual/ $1,800

Family No Deductible

Out-of-Pocket Maximum

$5,000 EO/

$6,850 Family

$10,000 EO/

$20,000 Family

$4,250 Individual/ $13,250 Family

$4,750 Individual/ $9,500 Family

Preventative Services

Covered at 100%, No Deductible

40% after Deductible

Covered at 100%, No Deductible

Covered at 100%

Primary Care Physician (PCP) Selection not required Selection is not required Required

PCP Visits (including telehealth)

20% after Deductible

40% after Deductible

$15 copay $15 copay

Specialist Visits (including telehealth)

20% after Deductible

40% after Deductible

$30 copay $40 copay

Urgent Care 20% after

Deductible 40% after

Deductible $40 copay $50 copay

Emergency Room 20% after

Deductible 40% after

Deductible $300 copay $350 copay

Emergency Room Surgery

20% after Deductible

40% after Deductible

20% after Deductible plus $300 ER copay

Covered at 100% after $350 ER copay

Ambulance 20% after Deductible 20% after Deductible $300 copay

Virtual Visit - MD Live

Approximately $49 for general health, $100 per session for therapy counseling, and $175 per session for psychiatry

N/A $10 copay $10 copay

Inpatient Hospital Stay

20% after Deductible

40% after Deductible

20% after Deductible $1,750 copay

Outpatient Surgery

20% after Deductible

40% after Deductible

20% after Deductible $750 copay

Allergy Services & Immunizations

20% after Deductible

40% after Deductible

Covered at 100% (Office visit copays may apply)

Covered at 50% (Office visit copays may apply)

CDHP w/HRA, PPO, & HMO Schedule of Benefits

* Preauthorization is required

Benefits CDHP (BlueChoice PPO) PPO (BlueChoice PPO) HMO (BlueEssentials)

In-Network Out-of- Network In-Network In-Network

Physical, Speech, & Occupational Therapy, Chiropractic Care (24 Visit Limit)

20% after Deductible

40% after Deductible

$40 copay $50 copay

Acupunture (24 Visit Limit)

20% after Deductible

40% after Deductible

$40 copay Not Covered

CT, MRI, PET Scans* 20% after

Deductible 40% after

Deductible $100 copay $150 copay

Mental Health Care Outpatient

20% after Deductible

40% after Deductible

$15 copay $15 copay

Durable Medical Equipment

20% after Deductible

40% after Deductible

20% after Deductible Member pays $0

Insulin Pump 20% after

Deductible 40% after

Deductible $100 copay $150 copay

Out-of-Network Benefits

Please refer to Out-of-Network Column

$2,000 deductible per covered person. Member pays 40%, up to maximum allowable charge.

Out-of-network benefits are subject to network benefit plan limits, pre-approval, and pre-notification requirements.

Inpatient Admission are subject to a $500 copay per admission.

None, except in case of a medical emergency.

Benefits CDHP (BlueChoice PPO) PPO (BlueChoice PPO) HMO (BlueEssentials)

In-Network In-Network Out-of-Network

Referrals Required No No

Yes. A referral is required to seek services from a Specialist. No benefit coverage without a referral.

Residency Requirements

None None Must receive services in the state of Texas. No benefit coverage outside of Texas.

CDHP w/HRA, PPO, & HMO - Pharmacy

Pharmacy Benefits CDHP (BlueChoice PPO) PPO (BlueChoice PPO) HMO (BlueEssentials)

ACA Preventative Drugs

Covered at 100%, No Deductible Covered at 100%, No Deductible Covered at 100%, No Deductible

CDHP w/HSA Preventative Drugs

20%, No Deductible N/A N/A

Deductible Per Person Per Calendar Year

20%, after Deductible $50 Deductible for Tier 2 & Tier 3 Only

$50 Deductible for Tier 2 & Tier 3 Only

Basic Drug List Tier 1 (Generic)

20%, after Deductible $10 $10

Basic Drug List Tier 2 (Preferred)

20%, after Deductible $40 copay or 20% of cost

($70 Max) $45 copay or 20% of cost

($80 Max)

Basic Drug List Tier 3 (Non-Preferred)

20%, after Deductible $60 copay or 20% of cost

($110 Max) $65 copay or 20% of cost

($120 Max)

90 Day - Mail Order

20%, after Deductible 2 copays Tier 1, 2, or 3 3 copays Tier 1, 2, or 3

Diabetic Supplies CDHP (BlueChoice PPO) PPO (BlueChoice PPO) HMO (BlueEssentials)

Retail Supplies are covered at participating pharmacies.

Mail Order Copays for insulin needles/syringes and/or diabetic supplies are waived when dispensed on the same day as your insulin and oral agents, but only when the insulin or oral agent is dispensed first.

Hearing & Vision Benefits CDHP (BlueChoice PPO) PPO (BlueChoice PPO) HMO (BlueEssentials)

Hearing Aids 20%, after Deductible, One pair covered every

48 months

20%, after Deductible, One pair covered every

48 months

One pair covered every 48 months

Optometrists 20%, after Deductible $15 copay $15 copay

Ophthalmologists 20%, after Deductible $30 copay $40 copay

Using Mail Order

To begin mail order:

◆ Have your doctor write a prescription for a 90-day supply of your medication (ask for three refills).

◆ Complete the mail order form and attach your prescription.

◆ Provide a check or credit card information.

◆ Within 10 days, your prescription will be delivered to you, postage paid.

If your doctor allows you to take a generic drug, this should be indicated on the prescription. Three weeks before your mail order supply runs out, you will need to request a refill.

Your cost:

◆ CDHP w/HRA participants will pay 20%…