RETIREE HEALTH PLAN DECISION GUIDE Focus on your Choices Retiree Option Change Period April 18, 2005 May 17, 2005 State Health Benefit Plan July 1, 2005 December 31, 2005 Georgia Department of Community Health State Health Benefit Plan (SHBP) Retiree Option Change Period for 2005 April 18 May 17, 2005 Phone Numbers and Contacts for Benefit and Provider Information PPO, PPO Consumer Choice Options, Indemnity Option For benefit coverage, call the Retiree Help Line at (800) 586-9288 For rate information, call: (800) 610-1863 (outside Atlanta), or (404) 656-6332 (in Atlanta) For the Fraud and Abuse Hotline, call: (800) 831-8998 For Provider Nomination information, call Member Services at (800) 483-6983 (outside Atlanta), or (404) 233-4479 (in Atlanta) TDD line for the hearing impaired: (800) 255-0056 (voice), or (800) 255-0135 (text) For National and Georgia PPO provider information, call Member Services. Online provider information: www.healthygeorgia.com CIGNA HealthCare of Georgia (800) 564-7642 Online provider information: www.cigna.com Kaiser Permanente (404) 261-2590 (800) 611-1811 Online provider information: www.kaiserpermanente.org Kaiser Permanente/Medicare Advantage (404) 233-3700 (800) 956-1358 UnitedHealthcare of Georgia (866) 527-9599 Online provider information: www.provider.uhc.com/gdch TDD line for the hearing impaired: (800) 269-4719 TDD line for the hearing impaired: (800) 955-8770 (outside Atlanta), or (404) 842-8073 (in Atlanta) Behavioral Health Services TRICARE Supplemental Insurance Association and Society Insurance Corporation Contact Magellan for provider and referral information. 24 hours per day, 7 days per week: (800) 631-9943 (800) 638-2610 (extension 255) Online provider information: Online provider information: www.magellanhealth.com www.asitrisuppga.com TDD line for hearing impaired: (678) 319-3860 or (877) 342-6815 Prescription Drug Program For the Pharmacy Benefits Manager, Express Scripts: (877) 650-9342 Additional Information Medicare www.medicare.gov Centers for Medicare and Medicaid Services (CMS) www.cms.gov TDD line for the hearing impaired: (800) 842-5754 HMOs BlueChoice Healthcare Plan (800) 464-1367 Online provider information: www.bcbsga.com TDD line for the hearing impaired:(404) 842-8073 Social Security Administration (800) 772-1213 www.ssa.gov During the Retiree Option Change Period, call volume for these numbers is expected to be very high, and you may experience time on hold. Pages 2 through 5 of this Guide contain upcoming Plan changes effective on July 1, 2005. Prior to the start of the 2005 Plan Year, the Plan will post an Updater, which is your official notice of Plan changes effective July 1, 2005, to the DCH Web site, www.dch.state.ga.us. You may print or request a paper copy from the SHBP. Please keep your Summary Plan Description (SPD) and Updater for future reference. If you are disabled and need this information in an alternative format, call the TDD Relay Service at (800) 255-0056 (text telephone) or (800) 255-0135 (voice) or write the SHBP at P.O. Box 38342,Atlanta, GA 30334. Important After reviewing the Plan changes on page 2, you have the opportunity to decide which option may best suit your healthcare needs during this Retiree Option Change Period (ROCP), April 18 through May 17, 2005 for coverage effective July 1 through December 31, 2005. There are two ways you may make your ROCP selections this year: 1. You may use the Internet: www.shbp.org; from 12:01 a.m., Eastern time, April 18 to midnight, Eastern time, May 17; available 24 hours a day, 7 days a week.After making your selection online, be sure to print a confirmation number. This confirmation number is your documentation that an online transaction occurred. The final confirmation acknowledges your benefit selection for the 2005 Plan Year. No changes will be allowed until the next ROCP, unless you experience a qualifying event. You should check your member identification card, to verify that your selection has been processed correctly. OR 2. You may complete your Personalized Change Form (PCF) and mail it in the enclosed envelope before May 17, 2005 to: State Health Benefit Plan; P.O. Box 347069, Atlanta, GA 30303. Contents Phone Numbers and Contacts for Benefit and Provider Information . . . .Inside Front Cover SHBP Plan Changes Effective July 1, 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Eligibility Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Understanding Your Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 PPO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 HMO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 PPO and HMO Consumer Choice Options (CCO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Indemnity Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 TRICARE Supplement for Eligible Military Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Medicare+Choice HMO Option (MA HMO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Benefits Comparison: PPO, Indemnity and HMO Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Service Areas for Your Health Plan Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Member Satisfaction Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Health Insurance Portability and Accountability Act (HIPAA) Annual Notice . . . . . . . . . . 30 Department of Community Health Privacy Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Women's Health and Cancer Rights Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Penalties for Misrepresentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 PLAN CHANGES SHBP Plan Changes Effective July 1, 2005 There are a number of changes to the Plan effective July 1, 2005. Carefully read the materials explaining these changes prior to making your election for coverage.You should pay particular attention to any changes in your current option BEFORE you make your decision during the Retiree Option Change Period (ROCP). Failure to do so could have a financial impact on your premium. All Members Plan Year Change The SHBP will change to a calendar Plan Year effective January 1, 2006. Therefore, any changes listed in this Decision Guide, and any changes made to your health benefit coverage during the spring ROCP, will be effective from July 1 through December 31, 2005. There will be another ROCP during October 2005 for new Plan Year coverage effective January 1, 2006. Because this ROCP represents a short Plan Year, deductible and out-of-pocket, as well as annual limit adjustments have been made. See the chart on page 4 for details. PPO/PPO Consumer Choice and Indemnity Members The Indemnity Premier, PPO Premier and PPO Choice Premier options will no longer be offered. The name for the Indemnity Basic, PPO Basic and PPO Choice Basic will change to the Indemnity, PPO and PPO Consumer Choice. Note: The PPO, PPO Consumer Choice and Indemnity plans will no longer offer a maximum out-of-pocket limit for pharmacy benefits. There will be an increase in the deductibles and out-of-pocket maximums. See pages 45 and 1213. The reduction in the Emergency Room co-payment when referred by NurseCall will be discontinued. The new co-payments are as follows: Generic co-payment Preferred Brand co-payment Non-Preferred Brand co-payment $10 $30 $100 You may view the July 1, 2005 Preferred Drug List at www.dch.state.ga.us or you may contact Express Scripts at (877) 650-9342 or TDD (800) 842-5754 to get the most current status for any covered drug. 2 PLAN CHANGES HMO Changes New for this year, HMO members will need to meet a minimal deductible and pay a coinsurance amount with an out-of-pocket maximum for certain services (i.e., inpatient and outpatient hospital facility, inpatient professional charges, etc.). The deductible and co-insurance amounts are included as part of your annual out-of-pocket maximum. Services requiring a co-payment will not be applied toward the out-of-pocket maximum. Once your out-of-pocket maximum has been met, your covered services are payable at 100% (excluding co-payments). The deductible and co-insurance amounts apply to all services except physician office visit services, maternity and newborn care, preventive care and pharmacy. It is important to remember that all services provided in a physician's office including lab work, outpatient surgery, allergy treatment and x-rays are covered at 100% after paying the applicable co-payment. Routine mammograms, Prostate Specific Antigen and Pap smears are still covered at 100% regardless of place of service. The co-payment for Non-Preferred Brand drugs will increase from $40 to $50. Kaiser Permanente will implement a maximum lifetime benefit of $2 million. Please review the charts outlining the benefits beginning on page 12. TRICARE Supplement for Eligible Military Members Supplemental insurance will be available to retirees and dependents who are eligible for TRICARE. In order to enroll in the TRICARE Supplement, the subscriber and each dependent must be eligible for TRICARE and provide a Defense Enrollment Eligibility Reporting System (DEERS) number. According to federal regulations governing this type of coverage, the following may be eligible: Active military Retired military Some Reserve Some National Guard Qualified dependents, spouses and ex-spouses Refer to page 11 for additional information. 3 Co-payment, Deductible and Out-of-Pocket Limit Changes: July 1 December 31, 2005 (Refer to the full Benefits Comparison on page 12) Covered Services PPO Options In-Network/Georgia Current New Deductibles/Co-payments* Deductible--Individual Deductible--Family $400 $1,200 $250 $750 Hospital Deductible/Admission All except BHS/transplant BHS and transplants $250 $100 No change No change Annual Out-of-Pocket Limits* Individual (you or one of your dependents) Family (you and your dependents) $1,000 $2,000 $550 $1,100 Preventive Care Services $500 maximum No change Home Healthcare Services** $7,500 (Home nursing care not reviewed by MCP) $3,750 Chiropractic Care 40 visits 20 visits Outpatient Acute Short-Term Rehabilitation Services 40 visits 20 visits Behavioral Care In-Hospital/Intensive Outpatient Partial Day/Intensive Outpatient Brief Visit/Substance Abuse Outpatient Care Professional Charges (inpatient)*** 60 days 30 days No change 50 visits 60 visits 30 days 15 days No change 25 visits 30 visits PPO Options PPO Options In-Network/Out-of-State Current New $500 $1,500 $300 $900 $250 $100 No change No change $2,000 $4,000 $500 maximum $7,500 $1,100 $2,200 No change $3,750 40 visits 40 visits 20 visits 20 visits 60 days 30 days No change 50 visits 60 visits 30 days 15 days No change 25 visits 30 visits PPO Options Out-of-Network Current New $500 $1,500 $300 $900 $250 $100 No change No change $2,000 $1,100 $4,000 $2,200 Not covered Not covered $7,500 $3,750 40 visits 40 visits 20 visits 20 visits 60 days Not covered No benefit 25 visits 25 visits 30 days Not covered No benefit 13 visits 13 visits Note: Pages 12 through 23 have precertification/prior authorization requirements, benefit limitations and descriptions of the Plan features. * In-network/out-of-state and out-of-network amounts are combined in the PPO options. ** Plan Year limit is a combined total in PPO options. *** Inpatient, out-of-network professional charge or visit (or ECT) counts toward the 13 outpatient visit limit per year in the PPO and Indemnity options. 4 Indemnity Option Current New BlueChoice Current New HMO Options CIGNA Kaiser Permanente UnitedHealthcare Current New Current New Current New $400 $1,200 $250 $750 $0 $100 $0 $100 $0 $100 $0 $100 $0 $200 $0 $200 $0 $200 $0 $200 $400 $100 No change N/A N/A N/A N/A N/A N/A N/A N/A No change $2,000 $4,000 $200 $1,100 $2,200 No change $7,500 $3,750 40 visits 20 visits 40 visits 20 visits 60 days 30 days No change 50 visits 25 visits 30 days 15 days No change 25 visits 13 visits N/A $500 N/A $500 N/A $500 N/A $500 $1,000 $1,000 $1,000 $1,000 Co-payment See chart on Co-payment See chart on Co-payment See chart on Co-payment See chart on pages 1415 pages 1415 pages 1415 pages 1415 120 visits 60 visits 120 visits 60 visits 120 visits 60 visits 120 visits 60 visits MA-unlimited 20 visits 10 visits 20 visits 10 visits 20 visits 10 visits 20 visits 10 visits 40 visits 20 visits 40 visits 20 visit 40 visits 20 visits 40 visits MA-unlimited 20 visits 15 days 30 days 15 days 30 days 15 days 30 days MA-unlimited 30 days 15 days Each HMO may or may not offer this benefit. Contact the HMO directly for more information. N/A No change N/A No change N/A No change N/A No change 25 visits 13 visits 25 visits 13 visits 25 visits 13 visits 25 visits 13 visits 30 visits 15 visits 30 visits 15 visits 30 visits 15 visits 30 visits 15 visits MA-unlimited 5 ELIGIBILITY INFORMATION Eligibility Information All SHBP options have the same eligibility requirements except the TRICARE Supplement. See page 11,TRICARE Supplement for Eligible Military Members. Eligible Dependents A dependent is defined as: Your legally married spouse, as defined by Georgia Law. Your never-married dependent children who are: 1. Natural or legally adopted children under age 19. 2. Stepchildren under age 19 who live with you at least 180 days per year. 3. Other children under age 19 if they live with you permanently and legally depend on you for financial support. 4. Your natural children, legally adopted children or stepchildren who were covered under the SHBP before age 19 who are physically or mentally disabled and who depend on you for primary support may continue their existing Plan coverage past age 19. 5. Your children from categories 1, 2, or 3 who are registered Full-time Students* at fully accredited schools, are not employed full time and are between the ages of 19 and 25. When you enroll or add dependents, you will be required to provide copies of certified documents such as a marriage license, birth certificate, adoption contract or judge-signed court order to verify your dependent relationship. The Plan has the right to determine whether or not the documentation satisfies Plan requirements. If verification cannot be made, the dependent's coverage will be terminated retroactively to his or her coverage effective date. The Plan will make every effort allowable under the law to recover, from the subscriber, any and all payments made by the Plan on behalf of an ineligible dependent. * TRICARE covers Full-time Students to age 23.To cover your Full-time Student after age 23 to age 26, you must select another SHBP option during the ROCP prior to your dependent reaching age 23. A Full-time Student reaching age 23 is not a qualifying event to change options. Note: Ineligible dependent determination does NOT allow a refund of a premium. Dependent eligibility cannot be determined until the subscriber presents proper documentation to SHBP. Please review eligibility requirements before selecting family coverage. 6 ELIGIBILITY INFORMATION Making Changes When You Have a Qualifying Event The option choice you make during the ROCP will stay in effect through December 31, 2005 unless you have a qualifying event. Some qualifying events may allow a change to Family coverage. A change to Single coverage is allowed at any time. Qualifying events include, but are not limited to: Marriage or divorce; Birth or adoption of a child or placement for adoption; Death of a spouse or child, if only dependent enrolled; Your spouse's or dependent's eligibility for or loss of eligibility for other group health coverage; A change in residence by you, your spouse or dependents that makes you or a covered dependent ineligible for coverage in your selected option; and Medicare eligibility. If you experience a qualifying event, you may be able to make changes for yourself and your dependents, provided you request those changes within 31 days of the qualifying event. Also, your requested change must correspond to the qualifying event. For a complete description of qualifying events, see your SPD and Updaters. You can contact the Eligibility Unit for assistance at (800) 610-1863; or in the Atlanta area at (404) 656-6322. COBRA Rights--Dependents of Retirees The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 requires that the Plan offer your spouse or an eligible dependent the opportunity to continue health coverage if Plan coverage is lost due to a qualifying event. The length of time one of your dependents may continue the coverage is based on the qualifying event. For further information refer to your SPD. Medicare Premiums for all SHBP retirees are determined by Medicare enrollment, regardless of option. It is your responsibility to provide Medicare information (Parts A and B) on you and your dependents to the Plan, prior to age 65. If covered by Medicare, you must provide a copy of the Medicare ID card or a letter from Social Security indicating the effective date of the Medicare coverage(s). If you are not entitled to Medicare, you will need to provide a letter from Social Security indicating the reason for denial. Failure to provide Medicare information within 31 days of the date you become eligible for Medicare or the denial of Medicare benefits will result in an increase in premiums for HMO options or claims disruption for the PPO, PPO CCO or Indemnity options. No refund of premiums will be issued for failure to provide Medicare information within this time period. Note: If you are not entitled to Medicare coverage and furnish the required documentation, SHBP will provide primary coverage, but you will pay a higher premium. If you are enrolled in the Indemnity Option and have Medicare Parts A and B, you should consider if the benefits offered balance the cost. 7 OVERVIEW OF PLAN OPTIONS Understanding Your Plan Options To maximize your health benefits, it is important to fully understand how each of the SHBP options works. This brief overview will help you determine which option best fits your health care needs. Keep in mind that failure to use network providers could result in a financial impact to you. PPO Options The PPO Options offer you a network of more than 14,000 Georgia participating physicians and 168 Georgia hospitals managed by 1st Medical Network in the Georgia service area. You also have the added benefit of access to a national network of participating providers and hospitals across the United States, which is managed by Beech Street Corporation. The PPO Options offer you the choice and flexibility of using in-network or out-ofnetwork providers. In order to receive the highest level of benefit coverage and avoid filing claims and balance billing, you will need to use an innetwork provider. If you choose to use an out-of-network provider, the reimbursement will be at a lower level of benefit coverage. You may access any licensed out-of-network physician, specialist, or hospital at any time. However, you will generally pay more for out-of-network services, and you are subject to balance billing. Out-of-network balance billing charges are the member's responsibility and do not apply toward deductibles and out-of-pocket limits. Note: The Transplant and Behavioral Health Services (BHS) networks are separate from the 1st Medical Network. A PPO CCO is also available. See page 10 for more details. To view the list of PPO providers, visit www.healthygeorgia.com, or call (800) 586-9288. Points to Consider You do not need to select a primary care physician (PCP) or obtain referrals to see specialists. You are protected from balance billing when you use network providers. You pay only a minimal co-payment for in-network PPO physician visits and other covered services (subject to deductibles). Your co-payments usually do not count toward your deductible or out-of-pocket limits. Your deductibles and out-of-pocket costs for in-network/Georgia services apply only to the in-network/Georgia deductible and out-of-pocket limit. Your deductibles and out-of-pocket costs for in-network/out-of-Georgia and out-of-network services apply to the same deductible and out-of-pocket limits. You must call the Medical Certification Program (MCP) to precertify inpatient stays and specified outpatient procedures when you are using out-of-network providers or Beech Street providers (national PPO network). It is ultimately your responsibility to verify that a provider is in the PPO network prior to receiving services. Providers may enter or leave the network at any time. 8 OVERVIEW OF PLAN OPTIONS HMO Options HMO Options are available to SHBP-eligible retirees who live in an approved HMO's service area in Georgia. The list of approved service areas begins on page 25. If you cease to live in an approved service area or move outside of Georgia during the Plan Year, you must change to another Plan option. HMOs provide 100% benefit coverage for preventive health care needs after paying applicable co-payments. There are no bills or claim forms. Certain services are subject to a deductible and co-insurance amount (i.e., inpatient and outpatient hospital facility, inpatient professional charges, etc.). These deductibles and co-insurance amounts have an annual out-of-pocket maximum.When you meet this maximum, the HMO pays your covered services at 100%. Co-payment amounts are excluded from the annual out-of-pocket maximum. In HMOs, you are responsible for selecting a Primary Care Physician (PCP) from a list of participating providers (see note). You must receive care from your PCP or from a physician or facility referred by your PCP for your expenses to be covered, except in emergencies and in other limited cases. If you receive care from a provider other than your PCP, or without your PCP's referral, there is no coverage even if the physician or facility is in the HMO network. An HMO CCO is also available. See page 10 for more details. Points to Consider You choose a PCP, to serve as your first point of contact for most healthcare services, by calling the HMO. Your covered family members must also select a PCP. The PCP is responsible for coordinating your healthcare services--specialists, ancillary providers, hospitals (see note). You must access physicians, specialists and hospitals offered through the HMO's network to receive benefits, except for emergencies as defined by the HMO. Providers may drop out of the network at any time during the year and this is not a qualifying event to change coverage. You pay the full cost for non-referred services and for services received outside the HMO's participating providers, except for emergencies. You have coordinated care through a network of HMO participating providers. There are no pre-existing condition limitations. You may be required to follow the HMO's standardized treatment plan for your condition. For example, you may be required to receive treatment from your PCP for a specified period before being referred to a specialist. All services received outside the State of Georgia must be coordinated through the HMO. Note: UnitedHealthcare HMO does not require you to select a PCP or obtain referrals to see specialists. It is ultimately your responsibility to verify that a provider is in the HMO network prior to receiving services. Providers may enter or leave the network at any time. 9 OVERVIEW OF PLAN OPTIONS PPO and HMO Consumer Choice Options (CCO) Benefits under the PPO CCO are the same as under the PPO. Benefits under the HMO CCO are the same as under the respective HMO Option. The CCO premiums are higher than the corresponding Option. For the increased cost, you can request that a Georgia out-of network provider be reimbursed as an in-network provider. This is referred to as a nomination. The out-of-network provider must accept the fees and conditions of the network and be approved by the network BEFORE you receive any services from that provider. This in-network relationship between you and the provider exists only for you and the provider. Other family members who wish to receive in-network benefits from that provider must complete a provider nomination form. You may nominate as many providers as you wish. SHBP rules do not allow you to change your coverage option if the provider you would like to nominate rejects the nomination. Only providers located and licensed in Georgia are eligible for nomination. For further details and to obtain the necessary paperwork, please call the membership number on the back of your ID card. Note for PPO members: The Behavioral Health Services (BHS) and transplant provider networks are separate from the PPO provider network. To nominate a BHS provider, contact the BHS Program at (800) 631-9943. For transplant provider nominations, call (800) 828-6518. Indemnity Option The Indemnity Option is a traditional feefor-service plan that generally provides the same benefit coverage level no matter which qualified medical provider you use. The Plan reimburses up to the Plan's allowed amounts for covered services. The Indemnity Option also uses contracted healthcare providers who have agreed to discounted rates without balance billing for charges over the allowed amount. As long as you see a participating provider, you may not be balance billed for covered services. However, not all Georgia providers participate in these special arrangements and there are no participating Indemnity providers outside of Georgia. In most instances, non-participating providers' billed charges are considerably higher than the Plan's allowed amounts. Hospital stays (even for emergencies) outside of Georgia can result in significant balance billing amounts. In some cases, this can be well in excess of $10,000. The SHBP does not have the legal authority to intervene when non-participating providers balance bill you. As a result, the SHBP cannot reduce or eliminate amounts balance billed. The SHBP cannot make additional payments above the allowed amounts when you are balance billed by non-participating providers. Not all Georgia providers participate in this program. Non-participating providers' billed charges are considerably higher than the Plan's allowed amount. If you are enrolled in the Indemnity Option and have Medicare Parts A and B, you should consider if the benefits balance the cost. 10 OVERVIEW OF PLAN OPTIONS TRICARE Supplement for Eligible Military Members SHBP offers a TRICARE supplemental insurance to retirees and dependents who are eligible for TRICARE. Any TRICARE eligible member may have both TRICARE and the TRICARE Supplement. In order to enroll in the TRICARE Supplement, the subscriber and each dependent must: a qualifying event and be allowed to change to another Plan option at that time. However, your spouse's attainment of Medicare eligibility does not meet the requirements of a qualifying event. If your spouse will reach age 65 and become Medicare eligible and if you wish to cover your spouse under the SHBP, you will need to select another option during the ROCP prior to your spouse's Medicare eligibility. Be eligible for TRICARE; and Have a Defense Enrollment Eligibility Reporting System (DEERS) number. Points to Consider Effective July 1, 2005,TRICARE will become your primary coverage. The TRICARE Supplement will become the secondary coverage for retirees who select the TRICARE Supplement. COBRA legislation requires the SHBP to offer continuation of coverage when coverage is lost. If COBRA is elected and the premiums paid, there is NO break in SHBP coverage. If you elect coverage through the Association and Society Insurance Corporation's (ASI) portability feature instead of COBRA, you will no longer be covered by SHBP. TRICARE covers Full-time Students only to age 23. To cover a Full-time Student from age 23 to age 26, you must select another SHBP option during the ROCP prior to your Full-time Student reaching age 23. (Reaching age 23 as a Full-time Student is not a qualifying event to change options.) When you turn 65 and are eligible for Medicare, Medicare will be your primary insurance,TRICARE for Life your secondary, and TRICARE Supplement tertiary. When you and/or your spouse reach age 65, if you or your spouse are ineligible for Medicare, your coverage will continue through the TRICARE Supplement with submission of disallowance by Social Security. When you and/or your spouse reach age 65 and reside overseas, your coverage will continue through the TRICARE Supplement if you are entitled to Medicare Part A and are enrolled in Medicare Part B. When you reach age 65 and become eligible for Medicare, you will experience If you elect the TRICARE Supplement and you are not eligible for this option, you will automatically be enrolled in the PPO Option. Medicare+Choice HMO Option (MA HMO) The name of the Medicare+Choice Option offered by Kaiser Permanente has changed to the Medicare Advantage (MA) HMO. Kaiser's MA Option is available only to those retirees who are enrolled in Part A and Part B Medicare coverage and live in the MA service area. Check page 28 in this Guide to find a listing of counties serviced by the Kaiser MA HMO. Points to Consider You will pay an SHBP premium, but it will be lower than the regular HMO Option premiums. See your Personalized Change Form for premium information. You will have the advantage of lower out-of-pocket costs and reduced paperwork. All your services and payments will be coordinated through Kaiser Permanente MA. The benefits available through the Kaiser Permanente MA are similar to that of the regular HMO. You must use providers in the Kaiser Permanente MA network.The affiliated provider network differs from the regular HMO, but all Kaiser Permanente facilities are covered under both plans. To enroll in Kaiser Permanente MA, you must complete the Kaiser Permanente MA form. Please call Kaiser Permanente at (404) 233-3700 or (800) 956-1358 to obtain your enrollment materials. 11 Benefits Comparison: PPO, Indemnity and HMO Options Schedule of Benefits for You and Your Dependents--July 1 December 31, 2005 Dollar amounts, visit limitations, deductibles and out-of-pocket limits are based on a July 1 December 31, 2005 Plan Year. Exclusions and limitations vary among Plan options. Contact your specific Plan option for more information. PPO Options Covered Services PPO Options In-Network/Georgia The Plan Pays: PPO Options In-Network/Out-of-State The Plan Pays: PPO Options Out-of-Network The Plan Pays: Maximum Lifetime Benefit (combined for all SHBP Options) Pre-Existing Conditions (1st year in Plan only, subject to HIPAA) $2 million $1,000 Lifetime Benefit Limit for Treatment of: (combined for PPO Option and Indemnity) Temporomandibular joint dysfunction (TMJ) Substance abuse Organ and tissue transplants Home hyperalimentation Deductibles/Co-Payments: Deductible--individual Deductible--family maximum Hospital deductible/admission-- excluding BHS and transplants Hospital deductible/admission-- BHS and transplants $250 $750 $250 $100 $1,100 3 episodes $500,000 $500,000 In-Network/Out-of-State & Out-of-Network amounts combined $300 $900 $250 $250 $100 $100 Annual Out-of-Pocket Limits: Individual (you or one of your dependents) Family (you and your dependents) $550 $1,100 In-Network/Out-of-State & Out-of-Network amounts combined $1,100 $2,200 BHS program (per patient); BHS authorized care only Physicians' Services Primary Care Physician and/or Referral Required Primary Care Physician or Specialist Office or Clinic Visits: Treatment of illness or injury $1,250 No No 100% of NR after a $30 per visit co-payment; not subject to deductible 100% of NR after a $30 per visit co-payment; not subject to deductible No 60% of OONR; subject to deductible Legend NR = Network Rate for in-network PPO services 12 OONR = Out-of-Network Rate for out-of-network PPO services IR = Indemnity Rate for Indemnity services Indemnity Option The Plan Pays: $2 million $1,000 BlueChoice The Plan Pays: $2 million None HMO Options CIGNA Kaiser Permanente UnitedHealthcare Kaiser Permanente MA The Plan Pays: The Plan Pays: The Plan Pays: $2 million None $2 million Kaiser Permanente MA; unlimited None $2 million None $1,100 3 episodes $500,000 $500,000 $250 $750 $400 $100 $1,100 $2,200 $1,250 No No separate lifetime No separate lifetime No separate lifetime No separate lifetime benefit limit benefit limit benefit limit benefit limit $100 $200 Not applicable Not applicable $100 $200 Not applicable Not applicable $100 $200 Not applicable Not applicable $100 $200 Not applicable Not applicable $500* $1,000; includes deductible Not applicable $500* $500* $1,000;includes deductible $500* $1,000; Kaiser Permanente MA; $1,000; includes deductible $500 individual; $1,000 includes deductible family per Plan Year Not applicable Not applicable Not applicable Yes Yes Yes No 90% of IR; subject to deductible 100% after a per visit 100% after a per visit 100% after a per visit 100% after a per visit co-payment of $20** for co-payment of $20** for co-payment of $20** for co-payment of $20** for primary care and $25 primary care and $25 primary care and $25 primary care and $25 for specialty care for specialty care for specialty care for specialty care * Deductibles are included as part of out-of-pocket maximum. ** Includes lab and x-rays done in the physician's office. Chart continued pg.14 13 Covered Services PPO Options In-Network/Georgia The Plan Pays: PPO Options PPO Options In-Network/Out-of-State The Plan Pays: PPO Options Out-of-Network The Plan Pays: Primary Care Physician or Specialist Office or Clinic Visits for the Following: Wellness care/preventive healthcare Well-newborn exam Well-child exams and immunizations Annual physicals Annual gynecological exams Note: These services are not subject to the deductible. 100% of NR after 100% of NR after $30 co-payment per office $30 co-payment per office visit. 100% of NR with visit. 100% of NR with no co-payment for associated no co-payment for associated tests and immunizations. tests and immunizations. Maximum of $500 payable Maximum of $500 payable per person per Plan Year per person per Plan Year for all preventive services. for all preventive services. Maximum combined with Maximum combined with In-Network/Out-of-State benefit. In-Network/Georgia benefit. Not covered. Charges do not apply to deductible or annual out-of-pocket limits. Notes: Lab and test charges include such services as mammograms, prostate screenings/PSAs, and Pap smears. Covered according to preventive care age schedules. Covered care schedules are online at www.healthygeorgia.com or call Member Services at (800) 483-6983 (outside Atlanta) or (404) 233-4479 (inside Atlanta). Maternity Care 90% of NR; 80% of NR; (prenatal, delivery and postpartum) not subject to deductible not subject to deductible after initial $30 co-payment after initial $30 co-payment 60% of OONR; subject to deductible Physician Services Furnished in a Hospital Surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist Inpatient well-newborn exams 90% of NR; subject to deductible 100% of NR; not subject to deductible 80% of NR; subject to deductible 100% of NR; not subject to deductible 60% of OONR; subject to deductible Not covered Physician Services for Emergency Care 90% of NR; subject to deductible 90% of NR; subject to in-network/Georgia deductible 90% of NR; subject to in-network/Georgia deductible Outpatient Surgery-- When billed as office visit 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible When billed as outpatient surgery at a facility 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Hospital Services Inpatient Services Inpatient care, delivery and inpatient short-term acute rehabilitation services Outpatient services Non-emergency use of the emergency room Other 90% of NR; subject to a $250 per admission deductible 90% of NR; subject to deductible; subject to $100/visit co-payment 80% of NR; subject to a $250 per admission deductible 80% of NR; subject to deductible; subject to $100/visit co-payment 60% of OONR; subject to a $250 per admission deductible 60% of OONR; subject to deductible; subject to $100/visit co-payment Well-newborn care 14 100% of NR; not subject to deductible 100% of NR; not subject to deductible Not covered Indemnity Option The Plan Pays: 90% of IR per office visit after deductible. 100% of IR with no deductible for associated lab and test charges, up to a maximum of $200 per person per Plan Year; additional $125 benefit for screening mammogram. BlueChoice The Plan Pays: HMO Options CIGNA Kaiser Permanente UnitedHealthcare Kaiser Permanente MA The Plan Pays: The Plan Pays: The Plan Pays: 100% after a per visit co-payment of $20 for primary care and $25 for specialty care. No co-payment for immunizations and mammograms. 100% after a per visit co-payment of $20 for primary care and $25 for specialty care. No co-payment for immunizations and mammograms. 100% after a per visit co-payment of $20 for primary care and $25 for specialty care. No co-payment for immunizations and mammograms. 100% after a per visit co-payment of $20 for primary care and $25 for specialty care. No co-payment for immunizations and mammograms. Note: PPO notes to the left also apply here. 90% of IR; subject to deductible 100% after initial $25 co-payment 100% after initial $25 co-payment 100% after initial $25 co-payment 100% after initial $25 co-payment 90% of IR; subject to deductible 90%; 90%; 90%; 90%; subject to deductible subject to deductible subject to deductible subject to deductible Not covered 90% of IR; subject to deductible 90% of IR; subject to deductible 90% of IR; subject to deductible 100%; not subject to deductible 100%; not subject to deductible 100%; not subject to deductible 100%; not subject to deductible 100% after applicable 100% after applicable 100% after applicable 100% after applicable co-payment co-payment co-payment co-payment 100% after $25 co-payment if billed as office visit 100% after $25 co-payment if billed as office visit 90%; subject to deductible 100% after $25 co-payment if billed as office visit 90%; 90%; 90%; 90%; subject to deductible subject to deductible subject to deductible subject to deductible 90% of IR; subject to a $400 per admission deductible 90%; 90%; 90%; 90%; subject to deductible subject to deductible subject to deductible subject to deductible 90% of IR; subject to deductible. If services are in conjunction with non-emergency use of the emergency room, benefit also subject to $100/visit co-payment 90% of IR; subject to per admission deductible of $100 non emergency use of non emergency use of non emergency use of non emergency use of the emergency room the emergency room the emergency room the emergency room not covered not covered not covered not covered 100%; not subject to deductible 100%; not subject to deductible 100%; not subject to deductible Chart continued pg.16 100%; not subject to deductible 15 Covered Services Outpatient Surgery-- Hospital/Facility Emergency Care Treatment of an emergency medical condition or injury PPO Options In-Network/Georgia The Plan Pays: 90% of NR; subject to deductible PPO Options PPO Options In-Network/Out-of-State The Plan Pays: 80% of NR; subject to deductible PPO Options Out-of-Network The Plan Pays: 60% of OONR; subject to deductible 90% of NR after a $100 90% of NR after a $100 90% of OONR after a $100 per visit co-payment; per visit co-payment; per visit co-payment; co-insurance and hospital co-insurance and hospital co-insurance and hospital deductible apply, if admitted deductible apply, if admitted deductible apply, if admitted. Outpatient Testing, Lab, etc. Laboratory; X-Rays; Diagnostic Tests; Injections, including Medications Covered Under Medical Benefits--for the Treatment of an Illness or Injury 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Allergy Shots and Serum 100% of NR; not subject to 100% of NR; not subject to deductible. If physician is seen, deductible. If physician is seen, visit is treated as an office visit visit is treated as an office visit subject to the $30 per visit subject to the $30 per visit co-payment co-payment 60% of OONR; subject to deductible Allergy Testing 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible Behavioral Health Mental Health and Substance Abuse Inpatient Facility 90% of NR; subject to deductible and separate hospital deductible, if admitted when authorized by BHS 90% of NR; subject to deductible and separate hospital deductible, if admitted when authorized by BHS 60% of NR; subject to deductible and separate hospital deductible, if admitted when authorized by BHS Note: 1. All services require prior authorization. 2. Inpatient facility charges (limited to 30 combined mental health and substance abuse days per person per Plan Year). 3. Substance Abuse coverage limited to three episodes per lifetime. Partial Day Hospitalization and Intensive Outpatient 16 90% of NR; 90% of NR; subject to deductible and subject to deductible and separate hospital deductible, separate hospital deductible, if admitted when if admitted when authorized by BHS authorized by BHS No benefit Note: 1. Maximum benefit of 15 combined PHP/IOP visits/days per person per Plan Year. 2. Benefit coverage is only available when using an in-network Magellan provider for partial/day hospitalization and intensive outpatient charges. Indemnity Option The Plan Pays: 90% of IR; subject to deductible BlueChoice The Plan Pays: HMO Options CIGNA Kaiser Permanente UnitedHealthcare Kaiser Permanente MA The Plan Pays: The Plan Pays: The Plan Pays: 90%; 90%; 90%; 90%; subject to deductible subject to deductible subject to deductible subject to deductible 90% of IR after a $100 per visit co-payment; co-insurance and hospital deductible, if admitted, apply Note: PPO note to the left also applies here. 100% after a $100 per visit co-payment (co-payment waived if admitted) 100% after a $100 per visit co-payment (co-payment waived if admitted) 100% after a $100 per visit co-payment (co-payment waived if admitted) 100% after a $100 per visit co-payment (co-payment waived if admitted) non emergency use of non emergency use of non emergency use of non emergency use of the emergency room the emergency room the emergency room the emergency room not covered not covered not covered not covered 90% of IR; subject to deductible 90%; 90%; 90%; 90%; subject to deductible subject to deductible subject to deductible subject to deductible 90% of IR; subject to deductible 90% of IR; subject to deductible 90% of IR; subject to deductible if admitted when authorized by BHS 100% for shots and serum after a $25 per visit co-payment 100% after a $25 per visit co-payment 100% for shots and serum after a $25 per visit co-payment $5 for shots and $50 for a three-month supply of serum; Kaiser MA: $5 shots and no serum charge 100% for shots and serum after a $25 per visit co-payment 100% after a $25 per 100% after a $25 per 100% after a $25 per visit co-payment visit co-payment visit co-payment 90%; not subject to deductible and limited to 15 days per Plan Year 90%; not subject to deductible and limited to 15 days per Plan Year 90%; subject to deductible and unlimited days for mental health; 15-day limit for substance abuse MA-unlimited for substance abuse 90%; not subject to deductible and limited to 15 days per Plan Year Note: PPO notes to the left also apply here. 90% of IR; subject to deductible and separate hospital deductible, if admitted Note: PPO notes to the left also apply here. Each HMO may or may not offer this benefit; contact the HMO directly for more information Chart continued pg.18 17 Covered Services PPO Options In-Network/Georgia The Plan Pays: PPO Options PPO Options In-Network/Out-of-State The Plan Pays: PPO Options Out-of-Network The Plan Pays: 23-Hour Observation Room (requires prior authorization to receive coverage) 90% of NR; 90% of NR; subject to $100 deductible subject to $100 deductible No benefit Professional Charges Inpatient (combined total for substance abuse and mental health) 80% of NR; subject to 80% of NR; subject to deductible. Maximum 1 visit deductible. Maximum 1 visit per authorized day when per authorized day when authorized by BHS. authorized by BHS. 50% of NR; subject to deductible. Maximum of 13 professional visits per person per Plan Year. Outpatient (precertification required to receive coverage) 80% of NR; subject to 80% of NR; subject to 50% of NR; subject to deductible when authorized deductible when authorized deductible (without by BHS, limited to 25 visits by BHS, limited to 25 visits authorization). Maximum per Plan Year per Plan Year combined 13 mental health, substance abuse and brief therapy visits per person per Plan Year. Limited to services rendered by a psychiatrist (M.D.) or a psychologist (Ph.D.). Note: In-network maximum coverage of 25 combined mental health, substance abuse, and brief therapy visits per person per Plan Year. Limit includes 13 out-of-network counseling sessions and 3 brief visits. Brief-Visit Therapy (limit: three visits per Plan Year; requires BHS prior authorization) 100%; not subject to deductible 90%; not subject to deductible No benefit Note:Visits are included in the 25-visit limit of outpatient care. Dental Dental and Oral Care Coverage for most procedures for the prompt repair of sound natural teeth or tissue for the correction of damage caused by traumatic injury 90% of NR; subject to deductible and, if admitted, to hospital deductible. Network providers may not be available for all covered services; charges are paid at 90% of NR. 80% of NR; subject to deductible and, if admitted, to hospital deductible. Network providers may not be available for all covered services; charges are paid at 80% of NR. 60% of OONR; subject to deductible and, if admitted, to hospital deductible Coverage of specific osseous surgeries for the treatment of periodontal disease Temporomandibular joint syndrome (TMJ) Note: Coverage for diagnostic testing and non-surgical treatment of TMJ, up to $1,100 per person lifetime maximum benefit. This does not apply to the HMOs. Not covered 90% of NR; subject to deductible Not covered 80% of NR; subject to deductible Not covered 60% of OONR; subject to deductible 18 Indemnity Option The Plan Pays: 90% of IR; subject to $100 deductible 80% of IR; subject to deductible; PPO benefits apply when authorized by BHS 80% of IR; subject to deductible when authorized by BHS; limited to 25 visits per Plan Year Note: PPO notes to the left also apply here. 100%; not subject to deductible Note: PPO note to the left also applies here. BlueChoice The Plan Pays: Not applicable HMO Options CIGNA Kaiser Permanente UnitedHealthcare Kaiser Permanente MA The Plan Pays: The Plan Pays: The Plan Pays: Not applicable Not applicable Not applicable 90%; not subject to deductible 90%; not subject to deductible 90%; subject to deductible 90%; not subject to deductible 100% after $25 per visit co-payment; limited to 13 visits per Plan Year Not applicable 100% after $25 per visit co-payment; limited to 13 visits per Plan Year 100% after $25 per visit co-payment; limited to 13 visits for substance abuse per Plan Year 100% after $25 per visit co-payment; limited to 13 visits per Plan Year Kaiser MA: unlimited days per Plan Year. Outpatient services covered at 100% after $25 co-payment per visit Kaiser MA: unlimited visits per Plan Year. Detoxification: co-payments same as above. No coverage limits on number of episodes, inpatient days or outpatient visits. 100% Not applicable Not applicable Not applicable 90% of IR; subject to deductible and, if admitted, to hospital deductible Not covered 90% of IR; subject to deductible 100% after 100% after Services/appliances 100% after applicable oral surgery applicable oral surgery for accidental injury to applicable oral surgery co-payment and dental co-payment and dental sound and natural teeth: co-payment and dental services for accidental services for accidental 50% coverage services for accidental injury to sound teeth injury to sound teeth on first $1,000 injury to sound teeth if inpatient/outpatient if inpatient/outpatient if inpatient/outpatient if inpatient/outpatient facility not subject to facility not subject to facility not subject to facility not subject to deductible deductible deductible deductible Not covered Not covered Not covered Not covered 100% after applicable 100% after applicable 50% for non-surgical 100% after applicable co-payment for related co-payment for related treatment; excludes co-payment for related surgery and diagnostic surgery and diagnostic appliances and surgery and diagnostic services; excludes services; excludes orthodontic treatment; services; excludes appliances and appliances and if inpatient/outpatient appliances and orthodontic treatment; orthodontic treatment; facility, 90% subject orthodontic treatment; if inpatient/outpatient if inpatient/outpatient to deductible if inpatient/outpatient facility, 90% subject facility, 90% subject facility, 90% subject to deductible to deductible to deductible Chart continued pg.20 19 Covered Services Vision Other Coverage Ambulance Services for Emergency Care Note:"Land or Air Ambulance" to nearest facility to treat the condition. Note: Limited to transportation for emergencies and benefits subject to balance billing for non-participating providers of ambulance services. Urgent Care Services in an Approved Urgent Care Center Home Healthcare Services Approved in Advance by the MCP PPO Options In-Network/Georgia The Plan Pays: PPO Options PPO Options In-Network/Out-of-State The Plan Pays: PPO Options Out-of-Network The Plan Pays: Note: PPO Options include a discount program for vision screenings and eyewear. Contact BlueCross BlueShield at (800) 377-6436 or visit www.bcbsga.com for more information.Vision program availability is subject to change during the Plan Year. 90% of NR; subject to deductible 90% of NR; subject to in-network/Georgia deductible 90% of OONR; subject to in-network/Georgia deductible 90% of NR after a $45 per visit co-payment; subject to deductible 90% of NR; subject to deductible 90% of NR after a $45 per visit co-payment; subject to deductible 80% of NR; subject to deductible Not applicable 60% of OONR; subject to deductible Skilled Nursing Facility Services Notes: Home nursing care not reviewed by the MCP; covers two hours of medically necessary skilled home care per day by RN or LPN if ordered by a physician; $3,750 per Plan Year limit is a combined total in PPO Options. Member's share of cost is not applied to Plan Year out-of-pocket limits. Not covered Not covered Not covered Hospice Care Note: Indemnity--MCP may approve additional benefits in lieu of Acute Care hospitalization. Durable Medical Equipment (DME)--Rental or Purchase Outpatient Acute Short-Term Rehabilitation Services 100% of NR; subject to deductible 100% of NR; subject to deductible 60% of OONR; subject to deductible 90% of NR; subject to deductible 80% of NR; subject to deductible 60% of OONR; subject to deductible 90% of NR; subject to deductible and $20 per visit co-payment 80% of NR; subject to deductible and $20 per visit co-payment 60% of OONR; subject to deductible Note: Coverage for up to 20 visits per Plan Year when conditions are met for physical, speech and occupational therapies, and for cardiac rehabilitation. 20 Indemnity Option The Plan Pays: Note: PPO note to the left also applies here. BlueChoice The Plan Pays: HMO Options CIGNA Kaiser Permanente UnitedHealthcare Kaiser Permanente MA The Plan Pays: The Plan Pays: The Plan Pays: Each HMO Option may offer vision care discounts or benefits. Contact the HMO directly for more information. 90% of IR; subject to deductible 100% 100% 100% after a $50 per trip co-payment when medically necessary 100% 90% of IR; subject to deductible 90% of IR; subject to deductible Note: PPO notes to the left also apply here. 100% after $25 co-payment; referral required 100%; up to 60 visits per Plan Year 100% after $25 co-payment 100% after $30 co-payment 100% after $25 co-payment 100%; up to 60 days per Plan Year 100%; up to 60 visits per Plan Year Kaiser Permanente MA: 100%; no day limit 100%; up to 60 visits per Plan Year Not covered 100% of IR, up to Medicare's approved lifetime maximum; subject to deductible 90% of IR; subject to deductible 90% of IR; subject to deductible Note: PPO note to the left also applies here. 90%; prior approval required, up to 23 days per Plan Year; subject to deductible 90%; prior approval required, up to 23 days per Plan Year; subject to deductible 90%; prior approval required, up to 23 days per Plan Year; subject to deductible MA: up to 100 days per plan year subject to deductible 90%; prior approval required, up to 60 days per Plan Year; subject to deductible 100%; prior approval required; subject to deductible 90%; prior approval required; subject to deductible. Out patient - 100% not subject to deductible 100%; prior approval required; subject to deductible 100%; prior approval required; subject to deductible 100% when medically necessary 100% when medically necessary 100% when medically necessary 100% when medically necessary 100% after $25 per visit co-payment; up to 20 visits per Plan Year 100% after $25 per visit co-payment; up to 20 visits per Plan Year 100% after $25 per visit co-payment; up to 20 visits per Plan Year MA: unlimited visits 100% after $25 per visit co-payment; up to 20 visits per Plan Year Chart continued pg.22 21 Covered Services Chiropractic Care Note: Coverage for up to a maximum of 20 visits per Plan Year. Transplant Services Pharmacy Generic Co-payment PPO Options In-Network/Georgia The Plan Pays: PPO Options PPO Options In-Network/Out-of-State The Plan Pays: PPO Options Out-of-Network The Plan Pays: 90% of NR; after a $30 per visit co-payment and not subject to deductible 80% of NR; after a $30 per visit co-payment and not subject to deductible 60% of OONR; subject to deductible 90% of NR; subject to deductible at Unicare contracted network facility 90% of NR; subject to deductible at Unicare contracted network facility 60% of NR; subject to deductible Note: Services provided through Unicare Centers of Excellence for PPO and Indemnity. $10 $10 $10 Preferred Brand Co-payment $30 $30 $30 Non-Preferred Brand Co-payment $100 $100 $100 PPO and Indemnity Progressive Drug Management Program (PDMP) This program assists your doctor in finding the most appropriate drug for you.The first step is usually a proven, less expensive treatment known to be safe and effective. If the drug does not work for you, your doctor may progress to another drug.A prior authorization may be required as the next step in the program. Note: If you should go to the pharmacy and are told that your prescription cannot be filled because it requires prior authorization, please have your doctor call Express Scripts with your clinical information. Important PPO and Indemnity Considerations See the Summary Plan Description and Updaters for coverage details, including limitations and exclusions. Charges from non-participating providers are subject to balance billing.These charges are the member's responsibility and do not count toward deductibles or out-of-pocket spending limits. Services covered under the PPO from an in-network/Georgia provider will apply only to the in-network/Georgia deductible and out-of-pocket limit. Services covered under the PPO from in-network/out-of-state and out-of-network providers apply to the same deductible. Some PPO annual maximums and limitations are combined totals. Some services may require MCP precertification, prior approval or letters of medical necessity before such services are covered. Co-payments do not apply toward deductibles or out-of-pocket limits unless otherwise noted. Notes Apply to All Options (continued on page 23) Preferred Drug Lists for SHBP members are subject to change. Prior to purchasing your medication(s), PPO and Indemnity members may view the drug lists at www.dch.state.ga.us or contact Express Scripts at (877) 650-9342 or TDD (800) 842-5754. HMO members may contact the HMO plan in which they are enrolled. Many drugs listed as non-preferred have a generic or a preferred brand name alternative. Preferred drug alternatives are therapeutically equivalent while being more cost effective. If the drug cost is less than the co-payment, you do not have to pay the co-payment but the actual cost of the drug. No co-payments for drugs covered under the SHBP will be changed or overridden on an individual basis. 22 Indemnity Option The Plan Pays: 90% of IR; subject to deductible 90% of NR at contracted facility; 60% of NR subject to $100 hospital deductible Note: PPO note to the left also applies here. BlueChoice The Plan Pays: HMO Options CIGNA Kaiser Permanente UnitedHealthcare Kaiser Permanente MA The Plan Pays: The Plan Pays: The Plan Pays: 100% after 100% after 100% after 100% after $25 co-payment per $25 co-payment per $25 co-payment per $25 co-payment per visit; limited to 10 visits visit; limited to 10 visits visit; limited to 10 visits visit; limited to 10 visits per Plan Year per Plan Year per Plan Year per Plan Year 90%; 90%; 90%; 90%; subject to deductible subject to deductible subject to deductible subject to deductible $10 $30 $100 $10 $10 Kaiser facility: $10 $10 Eckerd Drugs: $16 $25 $25 Kaiser facility: $25 $25 Eckerd Drugs: $31 $50 $50 N/A $50 Important HMO Considerations Some services may require prior authorization by the HMO before such services are covered. Also, some services may have limitations not contained in this summary. Most HMOs require the selection of a Primary Care Physician (PCP) to manage your care. Failure to specify a PCP could delay receipt of your ID card. However, in some instances the HMO assigns you a PCP located near your residence if a PCP is not specified. Note: UnitedHealthcare does not require the selection of a PCP. Most HMOs require you to obtain referrals to see most specialists. Failure to obtain a referral could result in denial of your claim. Note: UnitedHealthcare does not require a referral for coverage of specialist services. Contact the HMO directly for more details regarding covered services, exclusions and limitations. Notes Apply to All Options (continued from page 22) The SHBP defines maintenance drugs as medications for specified chronic conditions. PPO, PPO Consumer Choice, Indemnity and Kaiser members may obtain up to a 90-day supply of maintenance prescription(s) at one time for three co-payments. BlueChoice, CIGNA, and UnitedHealthcare members may receive a 90-day supply of maintenance prescriptions for two co-payments.Your co-payments are based on supplies of up to 30 days as this is the industry standard. However, some drugs are limited to a standard other than the 30-day supply for one co-payment. Lifetime benefit maximums are combined totals among the PPO Options, Indemnity Option and HMO Options. Annual dollar and visit limitations, deductibles and out-of-pocket spending limits are based on July 1, 2005 to December 31, 2005. 23 PLAN OPTIONS' SERVICE AREAS Service Areas for Your Health Plan Options Service Areas Service areas are State-approved geographic areas, such as counties or zip codes, where providers participate in the network offered by the Plan option in which you have enrolled. PPO and PPO Consumer Choice Options Georgia Service Area The Georgia service area includes the state of Georgia and the border communities of the Chattanooga,Tennessee area, including Bradley County; and Phenix City, Alabama. The zip code area in which you receive a service is used to determine whether or not you are in the Georgia service area. If you receive covered services from a 1st Medical Network provider located in one of the zip codes to the right, you receive the highest level of coverage available in the PPO options. Out-of-State/National Service Area The out-of-state service area includes all national locations outside of the Georgia service area described to the right. By using Beech Street providers outside of the Georgia service area, you are protected against balance billing (being charged more than what the Plan allows). However, use of Beech Street providers inside the Georgia service area is considered out-of-network care with lower levels of coverage and separate deductibles, unless the provider also is a 1st Medical Network participant. Georgia: All counties; all zip codes Alabama: Russell County (Phenix City area): 36851, 36856, 36858, 36859, 36860, 36867, 36868, 36869, 36870, 36871 and 36875. Tennessee: Bradley County (Cleveland area): 37310, 37311, 37312, 37320, 37323, 37353 and 37364. Hamilton County (Chattanooga area): 37302, 37304, 37308, 37315, 37341, 37343, 37350, 37351, 37363, 37373, 37377, 37379, 37384, 37401, 37402, 37403, 37404, 37405, 37406, 37407, 37408, 37409, 37410, 37411, 37412, 37414, 37415, 37416, 37419, 37421, 37422, 37424 and 37450. 24 PLAN OPTIONS' SERVICE AREAS HMO Options You must live in the HMO's approved service area to be eligible for coverage under that option. Below are the HMO Options' service areas by county. If you live in a county marked "Yes" under any of the HMOs listed, you may enroll in that HMO. If the county where you live is not listed below, you are not eligible for HMO coverage. Service area changes for the 2005 Plan Year are in bold type. County of Residence Appling Atkinson Bacon Baldwin Banks Barrow Bartow Ben Hill Berrien Bibb Bleckley Brantley Brooks Bryan Bulloch Burke Butts Candler Carroll Catoosa Charlton Chatham Chattahoochee Chattooga Cherokee Clarke Clay Clayton BlueChoice Not Available Not Available Not Available Not Available Yes Yes Yes Not Available Not Available Yes Yes Not Available Not Available Yes Yes Yes Yes Not Available Yes Not Available Not Available Yes Not Available Yes Yes Yes Not Available Yes CIGNA Yes Not Available Yes Not Available Not Available Yes Yes Not Available Not Available Yes Yes Not Available Not Available Yes Yes Yes Yes Yes Not Available Yes Not Available Yes Not Available Yes Yes Yes Not Available Yes Kaiser Permanente Not Available Not Available Not Available Not Available Not Available Yes Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Yes UnitedHealthcare Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Chart continued pg.26 25 PLAN OPTIONS' SERVICE AREAS County of Residence Clinch Cobb Coffee Colquitt Columbia Cook Coweta Crawford Dade Dawson Decatur DeKalb Dodge Douglas Early Echols Effingham Elbert Emanuel Evans Fannin Fayette Floyd Forsyth Franklin Fulton Gilmer Glascock Gordon Grady Greene Gwinnett Habersham Hall Hancock Haralson Harris Hart Heard Henry Houston BlueChoice Not Available Yes Not Available Not Available Yes Not Available Yes Yes Not Available Yes Not Available Yes Not Available Yes Not Available Not Available Yes Yes Yes Not Available Not Available Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Not Available Yes Not Available Not Available Yes Yes Not Available Yes Yes CIGNA Not Available Yes Not Available Not Available Yes Not Available Yes Not Available Yes Not Available Not Available Yes Yes Yes Not Available Not Available Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Not Available Not Available Yes Not Available Yes Yes Not Available Yes Not Available Not Available Yes Not Available Not Available Yes Yes Kaiser Permanente Not Available Yes Not Available Not Available Not Available Not Available Yes Not Available Not Available Not Available Not Available Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Yes Not Available UnitedHealthcare Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Not Available Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Not Available Yes Yes 26 PLAN OPTIONS' SERVICE AREAS County of Residence Irwin Jackson Jasper Jeff Davis Jefferson Jenkins Johnson Jones Lamar Lanier Laurens Liberty Lincoln Long Lowndes Lumpkin Macon Madison Marion McDuffie Meriwether Miller Mitchell Monroe Montgomery Morgan Muscogee Newton Oconee Oglethorpe Paulding Peach Pickens Pierce Pike Polk Pulaski Putnam Quitman Rabun Richmond BlueChoice Not Available Yes Not Available Not Available Yes Yes Not Available Yes Yes Not Available Not Available Yes Yes Not Available Not Available Yes Not Available Yes Yes Yes Yes Not Available Not Available Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Not Available Not Available Yes Yes Not Available Not Available Not Available Yes CIGNA Not Available Yes Not Available Not Available Yes Not Available Not Available Yes Yes Not Available Yes Yes Yes Yes Not Available Not Available Not Available Yes Yes Yes Not Available Not Available Not Available Yes Not Available Not Available Yes Yes Yes Yes Yes Yes Not Available Not Available Yes Yes Yes Not Available Not Available Not Available Yes Kaiser Permanente Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available UnitedHealthcare Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Chart continued pg.28 27 PLAN OPTIONS' SERVICE AREAS County of Residence Rockdale Screven Seminole Spalding Stephens Stewart Sumter Talbot Taliaferro Tattnall Taylor Telfair Thomas Tift Toombs Towns Treutlen Troup Turner Twiggs Union Upson Walker Walton Ware Warren Washington Wayne Webster Wheeler White Whitfield Wilkes Wilkinson Worth BlueChoice Yes Yes Not Available Yes Not Available Not Available Not Available Yes Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Not Available Yes Not Available Yes Not Available Not Available Not Available Not Available Yes Not Available Yes Yes Not Available CIGNA Yes Yes Not Available Yes Not Available Not Available Not Available Not Available Not Available Yes Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Yes Yes Not Available Kaiser Permanente Yes Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Yes Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available Not Available UnitedHealthcare Yes Yes Yes Yes Yes Yes Not Available Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Kaiser Permanente Medicare Advantage County of Residence Kaiser Permanente MA HMO Cherokee DeKalb Fulton Clayton Douglas Gwinnett Yes Cobb Fayette Henry Coweta Forsyth Paulding 28 Yes, only if you live in zip code 30127, 30134 or 30141 MEMBER SATISFACTION SURVEY Member Satisfaction Survey The respective healthcare vendors conducted the surveys within the past 12 months and independent research firms compiled all survey results.You will notice on certain questions, the total percentage of responses does not add up to 100%. For your convenience, we condensed responses into two categories:"satisfied" or "dissatisfied." Note: UnitedHealthcare and CIGNA Healthcare used national surveys based on the National Committee for Quality Assurance (NCQA) uniform measures that are used to compare the performance of managed care plans nationally. Both health plans will be conducting SHBP specific Member Satisfaction Surveys within the next 12 months. Please contact the health plans directly if you have questions regarding SHBP Member Satisfaction Survey results. Question Quality of Care Are you satisfied with the overall quality of care and services received from your health care provider? Provider Courtesy Are you satisfied with the friendliness and courtesy shown to you by providers? Customer Service Courtesy Are you satisfied with the friendliness and courtesy shown to you by customer service representatives? Access to Care Are you satisfied with the geographic accessibility of the physician's office? Waiting Times Are you satisfied with the length of time you had to wait to schedule an appointment for routine care? Customer Service Problem Solving Are you satisfied with the ability of customer service representatives to provide specific directions or answers to any claim issues or problems you may have? Customer Service Performance Are you satisfied with the overall performance of customer service representatives? Overall Satisfaction All things considered, are you satisfied with your current health plan? Kaiser BlueChoice Permanente UnitedHealthcare CIGNA PPO Satisfied Dissatisfied Satisfied Dissatisfied Satisfied Dissatisfied Satisfied Dissatisfied Satisfied Dissatisfied 92 4 96 4 79 -- 87 3 97 2 93 4 97 3 79 -- 92 1 98 1 88 5 92 8 ---- 87 -- 90 3 91 5 92 8 83 -- 88 8 95 3 84 8 87 13 80 -- 82 16 93 4 77 12 84 16 80 -- 87 13 76 12 80 9 88 12 86 -- 74 14 85 7 90 4 93 7 84 -- 82 7 88 4 29 Health Insurance Portability and Accountability Act (HIPAA) Annual Notice This section describes certain rights available to you under the Health Insurance Portability and Accountability Act (HIPAA) when you add a dependent to your SHBP coverage. The PPO, PPO CCO and Indemnity Options contain a pre-existing condition (PEC) limitation. Specifically, the Health Plan will not pay charges that are over $1,000 for the treatment of any pre-existing condition during the first 12 months of a patient's coverage, unless the patient gives satisfactory documentation that he or she has been free of treatment or medication for that condition for at least six consecutive calendar months. However, a preexisting condition limitation does not apply to coverage for: Pregnancy; or Newborns or children under age 18 who are adopted or placed for adoption, if the child becomes covered within 31 days after birth, adoption or placement for adoption. In certain situations, SHBP dependents can reduce the 12-month pre-existing condition limitation period.The reduction is possible by using what is called "creditable coverage" to offset a pre-existing condition period. Creditable coverage generally includes the health coverage a family member had immediately prior to joining the SHBP. Coverage under most group health plans, as well as coverage under individual health policies and governmental health programs, qualifies as creditable coverage. To reduce the pre-existing condition limitation period for your dependents (including your spouse), you must provide the SHBP with a certificate of creditable coverage stating when coverage started and ended for each dependent that you want to cover. Any period of prior coverage for that dependent will reduce the 12-month limitation period if no more than 63 days have elapsed between the dependent's loss of prior coverage and the first day of coverage under the SHBP. If your dependent (including a spouse) had any break in coverage lasting more than 63 days, your dependent will receive creditable coverage only for the period of time after the break ended. Within two years after your dependent's former coverage terminated, he or she has the right to obtain a certificate of creditable coverage from his or her former employer(s) to offset the pre-existing condition limitation period under the SHBP. The SHBP will evaluate the certificate of creditable coverage or other documentation to determine whether any of the pre-existing condition limitation period will be reduced or eliminated. After completing the evaluation, the SHBP will notify you as to how the pre-existing condition limitation period will be reduced or eliminated. Please submit the certificate of creditable coverage to the Plan with your dependent's enrollment paperwork. 30 Department of Community Health Privacy Notice This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The Plan's Privacy Commitment to You The Georgia Department of Community Health (DCH) understands that information about you and your family is personal. DCH is committed to protecting your information. This notice tells you how DCH uses and discloses information about you. It tells you your rights and the Plan's requirements about your information. Understanding the Type of Information That the Plan Has SHBP records indicate that you have previously provided information to us. This information included your name, address, birth date, phone number, Social Security Number, gender and Medicare information, if applicable.When your healthcare providers send claims to the Plan's claims administrator for payment, the claims include your diagnoses and the medical treatments you received. For some medical treatments, your healthcare providers send additional medical information to the Plan such as doctor's statements, x-rays or lab test results. Your Health Information Rights You have the following rights regarding the health information that DCH has about you: You have the right to see and obtain a copy of your health information. An exception is psychotherapy notes. Another exception is information that is needed for a legal action relating to DCH. You have the right to ask DCH to change health information that is incorrect or incomplete. DCH may deny your request under certain circumstances. You have the right to request a list of the disclosures that DCH has made of your health information beginning in April 2003. You have the right to request a restriction on certain uses or disclosures of your health information. DCH is not required to agree with your request. You have the right to request that DCH communicates with you about your health in a way or at a location that will help you keep your information confidential. You have the right to receive a paper copy of this notice. You may ask DCH staff to give you another copy of this notice, or you may obtain a copy from DCH's Web site, www.dch.state.ga.us (click on "Privacy"). 31 Privacy Law's Requirements DCH is required by law to: Maintain the privacy of your information. Give you this notice of DCH's legal duties and privacy practices regarding the information that DCH has about you. Follow the terms of this notice. Not use or disclose any information about you without your written permission, except for the reasons given in this notice. You may take away your permission at any time, in writing, except for the information that DCH disclosed before you stopped your permission. If you cannot give your permission due to an emergency, DCH may release the information if it is in your best interest. DCH must notify you as soon as possible after releasing the information. In the future, DCH may change its privacy practices. If its privacy practices change significantly, DCH will provide a new notice to you. DCH will post the new notice on its Web site at www.dch.state.ga.us (click on "Privacy"). This notice is effective April 14, 2003. How DCH Uses and Discloses Healthcare Information There are some services the Plan provides through contracts with private companies. For example, BlueCross and BlueShield of Georgia pays most medical claims to your healthcare providers.When services are contracted, the Plan may disclose some or all of your information to the company so that they can perform the job the Plan has asked them to do. To protect your information, the Plan requires the company to safeguard your information in accordance with the law. The following categories describe different ways that the Plan uses and discloses your health information. For each category, we will explain what we mean and give an example. For Payment The Plan may use and disclose information about you so that it can authorize payment for the health services that you received. For example, when you receive a service covered by the Plan, your healthcare provider sends a claim for payment to the claims administrator. The claim includes information that identifies you, as well as your diagnoses and treatments. For Medical Treatment The Plan may use or disclose information about you to ensure that you receive necessary medical treatment and services. For example, if you participate in a Disease State Management Program, the Plan may send you information about your condition. 32 To Operate Various Plan Programs The Plan may use or disclose information about you to run various Plan programs and ensure that you receive quality care. For example, the Plan may contract with a company that reviews hospital records to check on the quality of care that you received and the outcome of your care. To Other Government Agencies Providing Benefits or Services The Plan may give information about you to other government agencies that are giving you benefits or services. The information must be necessary for you to receive those benefits or services and will be authorized by you or by law. To Keep You Informed The Plan may mail you information about your health and well-being. Examples are information about managing a disease that you have, information about your managed care choices, and information about prescription drugs you are taking. For Overseeing Healthcare Providers The Plan may disclose information about you to the government agencies that license and inspect medical facilities, such as hospitals, as required by law. For More Information and to Report a Problem If you have questions and would like additional information, you may contact the SHBP at (404) 656-6322 (Atlanta calling area) or (800) 610-1863 (outside of Atlanta calling area). If you believe your privacy rights have been violated: You can file a complaint with the Plan by calling the SHBP at (404) 656-6322 (Atlanta calling area) or (800) 610-1863 (outside of Atlanta calling area), or by writing to: SHBP--HPU, P.O. Box 38342,Atlanta, GA 30334. You can file a complaint with the Health and Human Services Office for Civil Rights by writing to: U.S. Department of Health and Human Services Office for Civil Rights, Region IV, Atlanta Federal Center, 61 Forsyth Street SW, Suite 3B70,Atlanta, GA 30303-8909. Phone (404) 562-7886; Fax (404) 562-7881;TDD (404) 562-7884. You also may contact the HHS Office for Civil Rights by calling (866) OCR-PRIV (866) 627-7748 or e-mailing the OCR at OCRComplaint@hhs.gov. There will be no retaliation for filing a complaint. For Research The Plan may disclose information about you for a research project that has been approved by a review board. The review board must review the research project and its rules to ensure the privacy of your information. The research must be for the purpose of helping the Plan. As Required by Law The Plan will disclose information about you as required by law. Under the HIPAA Privacy Law, you may authorize the Plan to release your Personal Health Information (PHI) to another individual. If you have authorized the release of PHI to another individual, the personal representative form authorizing the release of your PHI is not transferred between options. This is for the protection of your privacy. If you wish to continue to designate another individual after changing health options, you may be asked to complete a new personal representative form. 33 Women's Health and Cancer Rights Act The Plan complies with the Women's Health and Cancer Rights Act of 1998. Mastectomy, including reconstructive surgery, is covered the same as other surgery under your Plan option. Following cancer surgery, the SHBP covers: All stages of reconstruction of the breast on which the mastectomy has been performed. Reconstruction of the other breast to achieve a symmetrical appearance. Prostheses and mastectomy bras. Treatment of physical complications of mastectomy, including lymphedema. Note: Reconstructive surgery requires prior approval, and all inpatient admissions require MCP precertification. For more detailed information on the mastectomy-related benefits available under the Plan, you can contact the Member Services unit for your coverage option. Telephone numbers are on the inside front cover. Penalties for Misrepresentation If an SHBP participant misrepresents eligibility information when applying for coverage, during change of coverage or when filing for benefits, the SHBP may take adverse action against the participant, including but not limited to terminating coverage (for the participant and his or her dependent[s]) or imposing liability to the SHBP for fraud or indemnification (requiring payment for benefits to which the participant or his or her beneficiaries were not entitled). Penalties may include a lawsuit, which may result in payment of charges to the Plan or criminal prosecution in a court of law. In order to avoid enforcement of the penalties, the participant must notify the SHBP immediately if a dependent is no longer eligible for coverage or if the participant has questions or reservations about the eligibility of a dependent. This policy may be enforced to the fullest extent of the law. Disclaimer This material is for informational purposes and is not a contract. It is intended only to highlight principal benefits of the medical plans. Every effort has been made to be as accurate as possible; however, should there be a difference between this information and the Plan documents, the Plan documents govern. It is the responsibility of each member, active or retired, to read all Plan materials provided in order to fully understand the provisions of the option chosen. 34 Notes 35 Notes 36