Retiree decision guide for plan year 2014

Resources/Contact Information State Health Benefit Plan (SHBP)

Vendor Medical and Medicare Advantage (MA) BlueCross BlueShield of Georgia
Hours: 8:00 a.m. 8:00 p.m. ET; Monday Friday
Customer Service (Non-MA Inquiries) MA Pre-enrollment Inquiries MA Post-enrollment Inquiries
Wellness - Healthways Customer Service (Non-MA Inquiries)* Hours: 8:00 a.m. 8:00 p.m. ET; Monday Friday *Customer Service Center not available until 12/16/2013
Pharmacy - Express Scripts Customer Service (Non-MA Inquiries) Hours: 24 hours a day / 7 days a week
SHBP Call Center Hours: 8:30 a.m. 5:00 p.m. ET; Monday Friday
Additional Information Centers for Medicare & Medicaid (CMS)
24 hours a day / 7 days a week Social Security Administration
TRICARE Supplement PeachCare for Kids

Member Services
1-855-641-4862 (TTY 711) 1-855-322-7060 1-855-322-7062 1-888-616-6411
1-877-841-5227
1-800-610-1863 Member Services
1-800-633-4227 TTY 877-486-2048 1-800-772-1213 1-866-637-9911 1-877-427-3224

Website www.bcbsga.com/shbp
www.BeWellSHBP.com
www.dch.georgia.gov/shbp www.myshbpga.adp.com
Website www.medicare.gov
www.ssa.gov www.asicorporation.com/ga_shbp
www.peachcare.org

Listed below are common health care acronyms that are used throughout this Decision Guide.

BCBSGa > BlueCross BlueShield of Georgia CMS > Centers for Medicare and Medicaid Services DCH > Georgia Department of Community Health HRA > Health Reimbursement Arrangement
MA (PPO) > Medicare Advantage Preferred
Provider Organization

PCP > Primary Care Physician ROCP > Retiree Option Change Period SHBP > State Health Benefit Plan
SPC > Specialist SPD > Summary Plan Description

1 Retiree Decision Guide 2014

Welcome to the Retiree Option Change Period
(ROCP)
2 Retiree Decision Guide 2014

Table of Contents
Contents
> Resources/Contact Information
Inside Front Cover
> Commissioner's Welcome Letter
page 1
> Welcome to ROCP
page 2
> Table of Contents
page 3
> ROCP and Your Responsibilities
page 4
> Making Your Health Benefit Elections for 2014
page 5
> 2014 Plan Options
page 7
> Transition to 2014
page 8
> Medicare Advantage (MA) PPO Options
page 9
> Benefits Comparison: BCBSGa Medicare Advantage (MA) PPO
Standard and Premium Plans
page 10
> Non-Medicare Advantage (MA) Options
page 13
> Wellness in 2014 for Non-Medicare Advantage (MA) Members
page 14
> Benefits Comparison: Gold HRA, Silver HRA and Bronze HRA Plans
page 15
> TRICARE Supplement and PeachCare for Kids
page 19
> Legal Notices
page 20
> Terms and Conditions
page 21
3 Retiree Decision Guide 2014

RPOlCanPCahnadngYeosur Responsibilities
October 21 - November 8, 2013 for January 1 December 31, 2014 www.myshbpga.adp.com
Your Responsibilities as a SHBP Member
Make your elections online at www.myshbpga.adp.com or by telephone to the SHBP Call Center at 1-800-610-1863 no later than November 8, 2013 by 5:00 p.m. ET
Notify SHBP whenever you have a change in covered dependents (within 31 days of Qualifying Event) Read and make sure you understand the plan materials posted at www.dch.georgia.gov/shbp Check your health insurance deduction to verify the correct deduction amount is made Notify SHBP of any change in address Review all communications from the SHBP and take the required actions Appoint a personal representative if you are unable or unwilling to handle these responsibilities Pay all required premiums by the due date if they are not automatically deducted from your retirement annuity Notify SHBP when you or a covered spouse or dependent gain Medicare coverage within the time limits set by SHBP,
including gaining coverage as a result of End Stage Renal Disease Continue to pay Medicare Part B premium if you are in a Medicare Advantage (MA) PPO option
During the ROCP, You May:
Change to any option for which you are eligible (if you or your covered spouse is age 65 or older and does not enroll in a Medicare Advantage (MA) PPO option, you will pay the entire cost of the coverage)
Enroll in a new plan option Drop covered dependents Discontinue SHBP coverage
IMPORTANT NOTE
If you discontinue your SHBP coverage for yourself, you will not be able to get the coverage back unless you return to work in a position that offers SHBP benefits
If you return to work after retiring, you will need to have a health insurance deduction from your paycheck as an active employee
When you terminate your active employment, your deductions will be taken from your retirement annuity check. You must set up direct pay if your retirement annuity does not cover the cost of the premium. Call SHBP Call Center at 1-800-610-1863 for details
4 Retiree Decision Guide 2014

Making Your Health Benefit Election
for 2014
For Technical Assistance in Making Your 2014 Election Online, Call 1-800-610-1863
SHBP has Gone GREEN
SHBP makes it easy for retirees to make their 2014 elections on the new web portal and by telephone for those who are unable to access online to make their election.
Before you finalize your selection, we urge you to review the plans described in this guide, discuss them with your family and choose a program that is best for you and your individual circumstance. Only you can decide which plan meets your needs.
How to Make Your 2014 Election New Web Portal www.mySHBPga.adp.com Go online today!
ROCP: October 21, 2013, 12:01 a.m. ET to November 8, 2013, 5:00 p.m. ET You must first register using the registration code SHBP-GA and set up a password
before making your 2014 election You must have a valid email address to access the web portal Once registered you should:
--Verify your address --Verify your coverage tier (you only, you & spouse, you & child(ren) or you & family) --Verify your dependents --Answer the Tobacco Surcharge question --Make sure your election is made and confirmed by clicking CONFIRM by 5:00 p.m. ET, November 8, 2013 --Make sure you print and save your confirmation code, write down the confirmation code, or save the code to your
computer's hard drive
Telephonic Election
If you are unable to make your election online, you may call the SHBP call center at 1-800-610-1863 8:30 a.m. ET to 5:00 p.m. ET Read Terms and Conditions (located at the back of this Guide) prior to calling to make your telephonic election You must agree to Terms and Conditions prior to calling to make your telephonic election
Note: If you paid a Tobacco Surcharge in 2013, it will continue to apply. If you did not pay a Tobacco Surcharge 2013, you will not pay one if you choose the default coverage election above. Remember, it is your obligation to notify the SHBP immediately if you no longer qualify for the Tobacco Surcharge waiver.
5 Retiree Decision Guide 2014

PMlakninCghaYnoguersHealth Benefit Election for 2014
What if I Do Not Take Any Action?
If SHBP does not receive an election from you through the website or telephonically, you have made a decision to take the default coverage below: If you are enrolled in a Medicare Advantage (MA) PPO option in 2013 you will be defaulted to the equivalent
BCBSGa MA PPO option. If you are enrolled in a Non-Medicare Advantage (MA) option in 2013 you will be defaulted to the SHBP Bronze
HRA option for 2014 and will continue to pay any Tobacco Surcharge you were paying in 2013. This is the option with the lowest premium, but it also has the highest deductible, the highest co-insurance and the smallest base HRA dollars. You should expect to pay out-of-pocket expenses for all medical treatment (other than covered treatment properly coded as "preventive care") that costs more than $100. If you are enrolled in the TRICARE Supplement in 2013, you will be enrolled in the TRICARE Supplement for 2014.
IMPORTANT NOTE
The election made during the 2014 ROCP will be the coverage you have for the entire 2014 Plan Year unless you have a Qualifying Event (QE) that allows a change in your coverage. See Qualifying Events below for more information.
Making Changes During the Year
Consider your benefit needs carefully and make the appropriate selections. Your selection will remain in effect for the entire calendar year. You will not have an opportunity to change your selection until the next ROCP unless you experience a Qualifying Event during the Plan Year. For a complete description of Qualifying Events, see your Summary Plan Description (SPD) available online at www.dch.georgia.gov/shbp. You may also contact the SHBP Call Center for assistance at 1-800-610-1863.
Qualifying Events include, but are not limited to:
Birth, or adoption of a child, or placement for adoption Death of a spouse or child, only if the dependent is currently
enrolled Your spouse's or dependent's loss of eligibility for other group
health coverage Marriage or divorce (once divorced, your ex-spouse is not
eligible for coverage under SHBP) Medicare eligibility
6 Retiree Decision Guide 2014

2014 Plan Options
Members will experience a number of positive enhancements as a result of the new SHBP plan options. The 2014 plan options (listed below) are designed to provide members affordable premiums and their choice of plan options that best meet their needs.
Medicare Advantage (MA) Plan Options: BCBSGa Medicare Advantage (MA) PPO - Standard BCBSGa Medicare Advantage (MA) PPO - Premium
MA plan options (Standard and Premium) are designed to mirror the 2013 SHBP MA plan options. Members may use any provider that is Medicare eligible. Premiums will not increase. MA plan options are the only subsidized options for retirees age 65 and older. OR Non-Medicare Advantage (MA) Plan Options: Gold HRA Silver HRA Bronze HRA
All Non-MA plan options are consumer-driven, Health Reimbursement Arrangement (HRA) plan options that offer medical, wellness and pharmacy benefits.
Prescription benefits are the same in each Non-MA plan option. All members get a starting balance of spending dollars in an HRA account. All Non-MA options are now wellness options. HMO and HDHP will no longer be available through SHBP.
The TRICARE Supplement will continue to be available for those members enrolled in TRICARE. PeachCare for Kids will continue to be available for those members enrolled in PeachCare for Kids. See page 19 for additional information.
Please read the Benefits Comparison table in this guide carefully and look at your medical and prescription expenses to make sure you understand the out-of-pocket costs under each option. In addition, you can find premium rates included with your ROCP packet or online at www.dch.georgia.gov/shbp.
7 Retiree Decision Guide 2014

Transition to 2014
The new plan administrators BCBSGa, Express Scripts, Inc. and Healthways will administer the 2014 plan options. Effective January 1, 2014, Cigna and UnitedHealthcare will no longer administer the SHBP plan options.
2013 Claims
1. Medical and pharmacy claims for services rendered on or before December 31, 2013, need to be filed with UnitedHealthcare or Cigna no later than March 31, 2014.
2. Any request for appeals and claim adjustments for 2013 claims must also be submitted by April 30, 2014.
3. UnitedHealthcare and Cigna will process all claims for services rendered prior to January 1, 2014.
BCBSGa Open Access POS Network
1. Be sure to check that your current provider is in-network with BCBSGa. SHBP is utilizing BCBSGa's Open Access POS network of providers.
2. If your current provider is not in-network with BCBSGa, you can search for a new provider online at www.bcbsga.com/shbp or by calling BCBSGa at 1-855-641-4862 and a customer service representative will assist you in locating an in-network provider.
3. You may also nominate a provider to join the network. Instructions are available at www.bcbsga.com/shbp.
Transition Assistance Program for Continuation of Care
1. Transition assistance is a process that allows for continued care for the Non-MA SHBP members when their treating provider is not a part of the BCBSGa Open Access POS participating provider program.
2. Continuation of care may be received if treatment is needed for certain conditions after December 31, 2013. 3. You may request Continuation of Care if:
a. You are in an active course of treatment for an acute medical condition or serious chronic condition; b. You are in an active course of treatment for any behavioral health condition; c. You are pregnant, regardless of trimester; d. You have a terminal illness; Hospice care or e. You have a surgery of other procedure scheduled that has been authorized by the previous plan. 4. If you require ongoing care for any chronic condition and you are not in an active phase of your illness, you should select an in-network provider to meet your ongoing health care needs.
For more information regarding Continuation of Care, visit www.bcbsga.com/shbp or call BCBSGa Customer Service at 1-855-641-4862.
Transition Assistance for Medicare Advantage (MA) PPO
If you have Transition of Care questions, please contact BCBSGa Customer Service at 1-855-322-7062. If you have questions prior to January 1, 2014, please call the BCBSGa First Impressions Customer Service team at 1-855-322-7060.
8 Retiree Decision Guide 2014

Medicare Advantage (MA) PPO Options

Medicare Advantage (MA) PPO options
BCBSGa Medicare Advantage PPO Standard or BCBSGa Medicare Advantage PPO Premium The Medicare Advantage Preferred Provider Organization (MA PPO) plan option is an approved plan by the Centers for Medicare & Medicaid Services (CMS); sometimes called a Part C Plan. This Plan takes the place of your original Medicare Part A Hospital, B Medical and includes Medicare Part D, a prescription drug benefit. This plan is very similar to a traditional PPO plan. You may receive benefits from in-network and out-of-network providers as long as the provider accepts Medicare. The MA PPO also provides a contracted network on a statewide and national basis across the United States. You will have the choice of a MA PPO Standard or Premium plan under BCBSGa. Plus, you can see non-contracted providers as long as they accept Medicare.
You do not have to select a Primary Care Physician (PCP) or obtain a referral to see a specialist Co-payments apply toward the out-of-pocket maximum (except for prescription drugs) Unlike traditional PPO plans, there is no difference in your co-payment/co-insurance levels if you see providers who are
contracted (in-network) or providers who are not contracted (out-of-network). So, you are not penalized for going to a non-contracted provider There will be no coverage if you see a provider who does not accept Medicare Enrollment in the MA PPO plans is subject to CMS approval and is prospective (retroactive enrollment is not allowed) CMS requires a street address and Medicare number before approving MA PPO coverage Once approved, CMS will notify SHBP of the effective date of your coverage You will receive a new insurance card that you will show (in place of your Medicare card) when receiving service

When everyone you cover is not eligible to participate in the MA PPO option, it is called "split eligibility." This means that the individual with Medicare enrolls in the MA PPO option and any family members that are not eligible for Medicare can enroll in one of the other plan options offered by SHBP.

IF 65 OR OLDER WITH MEDICARE

If 65 or older with Medicare

Then...

Stop Paying Part B and/or Enroll in a non-SHBP MA Plan, Medicare
Supplemental Plan or Part D Prescription Plan
Without Medicare Part B

Your MA coverage under SHBP will be terminated and SHBP will move you to the Bronze Option of your active MA vendor and you will pay 100% of the premium.
You may enroll in the Gold, Silver or Bronze HRA option and pay 100% of the premium.

Prescription Drug Coverage Under the Medicare Advantage PPO Plan Options
The Plan includes Medicare Part D coverage
$0 Co-payment Drug Program
Select Generic Program A new added benefit in 2014 under the Medicare Advantage options is the Select Generic program. The Select Generic program is designed to help retirees reduce out-of-pocket costs on certain prescription medications. With this program, retirees have access to "Select Generic" drug benefits at no cost at any network retail pharmacy or through mail-order pharmacy. A list of the select generic prescription medications for 2014 is available at www.bcbsga.com/shbp.
9 Retiree Decision Guide 2014

PMleadnicCahraenAgdevsantage (MA) PPO Options

Benefits Comparison: BCBSGa Medicare Advantage PPO Standard and Premium Plans
January 1, 2014 December 31, 2014

Covered Services Deductibles Out-of-Pocket Maximum Per Member1 Physicians' Services Primary Care Physician or Specialist Office or Clinic Visits Treatment of illness or injury Primary Care Physician or Specialist Office or Clinic Visits Annual Wellness Visit

BCBSGa MA PPO Standard You Pay 0
$3,500 per member You Pay
PCP--$25 per office visit co-payment; SPC--$30 per office visit co-payment
$0 co-payment

BCBSGa MA PPO Premium You Pay 0
$2,500 per member You Pay
PCP--$15 per office visit co-payment; SPC--$25 per office visit co-payment $0 co-payment

Complex Radiology Services and Radiation Therapy Received in a Doctor's Office3 (Doctor's office visit copay will apply) Diagnostics Procedures and Testing Services Received in a Doctor's Office (Doctor's office visit copay will apply) Annual Screenings Note: Pap smears are covered every 24 months unless high risk, then annually Hospital Services

$35 co-payment
$0 co-payment
$0 co-payment; (mammograms, pap smears, prostate cancer screening,
colorectal cancer screening) You Pay

$35 co-payment
$0 co-payment
$0 co-payment; (mammograms, pap smears, prostate cancer screening,
colorectal cancer screening) You Pay

Inpatient Hospital Services Outpatient Hospital Services (includes observation, medical and surgical care) Outpatient Standard (X-rays, Lab and Diagnostic Tests) Complex Radiology Service and Radiation Therapy Service3 (when the service is performed at a hospital, outpatient facility or a freestanding facility imaging or diagnostic center)

20% co-insurance $95 co-payment Observation Room
$25 co-payment PCP $30 co-payment SPC
$0 co-payment
20% coinsurance

20% co-insurance $50 co-payment Observation Room
$15 co-payment PCP $25 co-payment SPC
$0 co-payment
20% coinsurance

Diagnostics Procedures and Testing Services (when the service is performed at a hospital, outpatient facility or a free-standing facility [imaging or diagnostic center)2

$95 co-payment

$50 co-payment

1 Not all covered services apply to out-of-pocket. Contact BCBSGa for details. 2 Other co-payments may apply. 3 The diagnostic radiology services require specialized equipment beyond standard X-ray equipment and must be performed by specialty trained or certified personnel. Examples include, but are not limited to, specialized scans, CT, SPECT, PET, MRI, MRA, nuclear studies, sonograms, diagnostic mammograms and interventional radiological procedures (angiogram and barium studies).

10 Retiree Decision Guide 2014

Benefits Comparison: BCBSGa Medicare Advantage PPO Standard and Premium Plans
January 1, 2014 December 31, 2014

Behavioral Health Mental Health and Substance Abuse Inpatient Facility

BCBSGa MA PPO Standard You Pay
20% coinsurance per inpatient admission

Mental Health and Substance Abuse Outpatient Visits
Dental Dental and Oral Care Medicare covered Vision Routine Eye Exam NOTE: Limited to one eye exam every 12 months Other Coverage Routine Hearing Services
Ambulance Services NOTE: "Land or air ambulance" to nearest facility to treat the condition Urgent Care Services

$30 co-payment Professional Individual & Group Therapy Visits
$55 co-payment Professional Partial Hospitalization visits You Pay
$30 per office visit co-payment for Medicare covered dental services You Pay
$30 co-payment per office visit--limited to 1 annual eye exam; $125 eyewear benefit (glasses/frames or contact lenses)
allowance every 24 months1 You Pay
$30 co-payment limited to one test every 12 months; $1,000 hearing aid allowance
every 48 months $50 co-payment
$25 co-payment waived if admitted to hospital within 72 hours for the same condition

Other Coverage Home Health Care Services

You Pay $0 co-payment per visit

Emergency Care

$50 co-payment waived if admitted to hospital within 72 hours for the same condition

1 $0 co-payment for one pair of eyeglasses or contact lenses after cataract surgery.

BCBSGa MA PPO Premium You Pay
20% coinsurance per inpatient admission
$25 co-payment Professional Individual & Group Therapy Visits
$50 co-payment Professional Partial Hospitalization visits You Pay
$25 per office visit co-payment for Medicare covered dental services
You Pay $25 co-payment per office visit--limited to 1 annual eye exam; $125 eyewear benefit (glasses/frames or contact lenses)
allowance every 24 months1 You Pay
$25 co-payment limited to one test every 12 months; $1,000 hearing aid allowance
every 48 months $50 co-payment
$20 co-payment waived if admitted to hospital within 72 hours for the same condition You Pay $0 co-payment per visit
$50 co-payment waived if admitted to hospital within 72 hours for the same condition

11 Retiree Decision Guide 2014

PMPllaeadnnicCCahhraaennAggdeevssantage (MA) PPO Options

Benefits Comparison: BCBSGa Medicare Advantage PPO Standard and Premium Plans
January 1, 2014 December 31, 2014

Other Coverage Skilled Nursing Facility Services Prior authorization required
Hospice Care
Durable Medical Equipment (DME) Prior approval required for certain DME. Outpatient Acute Short-Term Rehabilitation Services Physical Therapy Speech Therapy Occupational Therapy Cardiac Therapy Pulmonary Therapy Chiropractic Care

BCBSGa MA PPO Standard You Pay
$0 co-payment per day for days 120; $50 co-payment per day for days 21100
for up to 100 days per benefit period (no prior hospital stay required)
100% coverage; must receive care from a Medicare covered hospice facility; (no prior approval required). For services not related
to the terminal condition member cost-shares may apply.
20% coverage for Medicare covered items

BCBSGa MA PPO Premium You Pay
$0 co-payment per day for days 110; $25 co-payment per day for days 11100
for up to 100 days per benefit period (no prior hospital stay required)
100% coverage; must receive care from a Medicare covered hospice facility; (no prior approval required). For services not related
to the terminal condition member cost-shares may apply.
20% coverage for Medicare covered items

$25 co-payment per office visit for Medicare covered services

$10 co-payment per office visit for Medicare covered services

Medicare Covered: $18 co-payment per office visit; Medicare Covered: $18 co-payment per office visit;

Routine Non-Medicare Covered- $30 co-payment Routine Non-Medicare Covered- $25 co-payment

per office visit; limit of 20 visits per year

per office visit; limit of 20 visits per year

Foot Care Pharmacy

$30 per office visit co-payment Medicare covered; Routine Non-Medicare covered: $25 PCP-$30 SPC co-payment; limit of 6 visits per year You Pay

$25 per office visit co-payment Medicare covered; Routine Non-Medicare covered: $15 PCP-$25 SPC co-payment; limit of 6 visits per year You Pay

Select Generic Co-payment Tier 1 Co-payment Tier 2 Co-payment Tier 3 Co-payment Tier 4 Co-payment

$0 retail or mail order $15 retail--31 day supply; $37.50 mail order--90-day supply $45 retail--31 day supply; $112.50 mail order--90-day supply $85 retail--31 day supply; $212.50 mail order--90- day supply $85 retail--31 day supply; $212.50 mail order-- 90-day supply

$0 retail or mail order $15 retail--31 day supply; $37.50 mail order--90-day supply $45 retail--31 day supply; $112.50 mail order--90-day supply $85 retail--31 day supply; $212.50 mail order--90-day supply $85 retail--31 day supply; $212.50 mail order--90-day supply

After your yearly out-of-pocket cost reaches $4,550 for generic drugs, you will pay 5% coinsurance with a maximum copay of $2.55 and a maximum copay of $15.00 and for brand drugs you will pay 5% coinsurance with a minimum copay of $6.35 and a maximum copay of $45.00. You will continue to pay $0 for Select generic drugs listed in the formulary.

12 Retiree Decision Guide 2014

Non-Medicare Advantage (MA) Options
Health Reimbursement Arrangement (HRA)
SHBP members who do not elect a Medicare Advantage (MA) PPO plan option, can select one of the HRA plan options for 2014: Gold HRA Silver HRA Bronze HRA
How the HRA Plan works

HRA
Every year, SHBP contributes money to your HRA.
These dollars are used to help pay for your covered medical expenses, like office visits, lab work and tests. It's important to note that when you go to the doctor, you don't pay a copay. Instead, you pay the contracted or discounted rate for service, even if the provider typically charges more. You can use the Blue Cross Blue Shield online tools to have a better idea of what those costs will be.
If you don't use all of the money in your HRA, it rolls over from year to year, as long as you remain enrolled in the HRA plan.

Annual deductible

Coinsurance

You are responsible for paying an annual After you meet your annual deductible, deductible before the plan begins to pay you pay a percentage of the cost of your a percentage of your covered expenses. covered expenses, called coinsurance.

The money in your HRA is used to help meet your deductible. And if you've been enrolled in the plan for more than one year, you may have enough saved to pay for your entire deductible.

If you still have money in your HRA after you've met your annual deductible, you can use the funds to pay your share of coinsurance.
Once you reach your annual coinsurance maximum, the plan pays 100 percent of any of your remaining covered expenses for the rest of the year.

The HRA plan options offer access to a quality provider network, and all plan options pay 100% of covered services provided by network providers that are properly coded as "preventive care" within the meaning of the Affordable Care Act (ACA).
Under the pharmacy benefits, the member pays no cost for certain types of drugs identified by the ACA as "preventive care" such as oral contraceptives. A member actively complying with the requirements of the disease management co-insurance waiver program pays no cost for certain maintenance medications. Otherwise, there is no deductible and no out-of-pocket maximum for pharmacy benefits. Instead, the member pays a percentage of costs for a prescription, subject to a per-prescription minimum and maximum. These member costs are paid with available HRA dollars.
IMPORTANT NOTE
Any unused dollars in your HRA account under Cigna or UnitedHealthcare will rollover to the next Plan Year if you are participating in a Non-MA option. HRA dollars remaining from 2013 will rollover by April 2014. This allows 2013 HRA dollars to be used to pay your out-of-pocket expenses for 2013 claims filed no later than January 31, 2014
Member and/or spouse (if covered) who met the 2013 Wellness Requirements (in either the 2013 Wellness or Standard options) will each have $240 credited to the member's HRA account on January 1, 2014

13 Retiree Decision Guide 2014

2W0e14llness in 2014 for Non-Medicare Advantage (MA)Members

SHBP is excited to announce the addition of the new wellness partner, Healthways, to provide members with comprehen-

sive well-being resources and incentive programs. Healthways will also administer the 2014 action-based HRA incentives

that will allow Non-MA members and covered spouses to earn additional dollars into their HRA account. To earn these

HRA dollars, complete the following requirements any time between January 1 December 31, 2014:

What to DO

What you EARN

1 Assess Your Health
Complete your Healthways Well-Being Assessment (WBA), a confidential, online questionnaire that will take about 20 minutes.
2 Know Your Numbers
Complete a biometric screening and submit results (body mass index, blood pressure, cholesterol, glucose). The biometric screening must be completed at an SHBP sponsored screening event or by your physician or other providers identified by SHBP in published materials and your results submitted appropriately.

Complete both and earn $240 into your HRA account
(WBA must be completed before HRA dollars can
be earned)

3 Take Action
It's your choice! Complete the coaching pathway, online pathway or a combination of both.
Coaching Pathway
Create your Well-Being Plan as determined by your personal well-being coach. Actively engage in telephonic coaching.
Online Pathway
Create your Well-Being Plan. Record 5 online well-being activities using the same tracker within 4 consecutive weeks and earn $40 into your HRA account. You can earn these HRA dollars ($40) up to 6 times. Sample activities: track exercise five times, record daily steps five times, track food five times.

Earn up to $240 into your HRA account
(WBA must be completed before HRA dollars can
be earned)

By completing the incentive actions you are investing in your health and increasing the amount in your HRA account as outlined in the chart below. This will reduce the amount you will have to pay in deductibles and co-insurance.

Tier

Gold

Gold HRA after Silver

Silver HRA after Bronze Bronze HRA after

HRA

completion of all HRA

completion of all HRA

completion of all

Dollars 2014 incentive Dollars 2014 incentive Dollars 2014 incentive

actions (initial

actions (initial

actions (initial

HRA $ + earned

HRA $ + earned

HRA $ + earned

HRA $)

HRA $)

HRA $)

You You + Child(ren) You + Spouse You + Family

$400 $600 $600 $800

$880 $1,080 $1,560 $1,760

$200 $300 $300 $400

$680 $780 $1,260 $1,360

$100 $150 $150 $200

$580 $630 $1,110 $1,160

Non-MA members will have access to a variety of Healthways' tools, activities and services. To learn more, visit BeWellSHBP.com beginning January 1, 2014.

14 Retiree Decision Guide 2014

Non-Medicare Advantage (MA) Options

Benefits Comparison: Gold, Silver and Bronze HRA Plans
January 1, 2014 December 31, 2014

Gold HRA Option

Silver HRA Option

Bronze HRA Option

Covered Services Deductible You You + Spouse You + Child(ren) You + Family
Out-of-Pocket Maximum You You + Spouse You + Child(ren) You + Family
HRA HRA Credits You You + Spouse You + Child(ren) You + Family Physicians' Services

In-Network Out-of-Network You Pay

In-Network Out-of-Network You Pay

In-Network Out-of-Network You Pay

$1,500* $2,250* $2,250* $3,000*

$3,000* $4,500* $4,500* $6,000*

*HRA credits will reduce this amount

$4,000* $6,000* $6,000* $8,000*

$8,000* $12,000* $12,000* $16,000*

*HRA credits will reduce this amount

The Plan Pays

$2,000* $3,000* $3,000* $4,000*

$4,000* $6,000* $6,000* $8,000*

*HRA credits will reduce this amount

$5,000* $7,500* $7,500* $10,000*

$10,000* $15,000* $15,000* $20,000*

*HRA credits will reduce this amount

The Plan Pays

$2,500* $3,750* $3,750* $5,000*

$5,000* $7,500* $7,500* $10,000*

*HRA credits will reduce this amount

$6,000* $9,000* $9,000* $12,000*

$12,000* $18,000* $18,000* $24,000*

*HRA credits will reduce this amount

The Plan Pays

$400 $600 $600 $800 The Plan Pays

$200 $300 $300 $400 The Plan Pays

$100 $150 $150 $200 The Plan Pays

Primary Care Physician or Specialist Office or Clinic Visits Treatment of illness or injury Maternity Care (non-routine, prenatal, delivery and postpartum) Primary Care Physician or Specialist Office or Clinic Visits for the Following: Wellness care/preventive
health care Annual gynecological exams
(these services are not subject to the deductible) Prenatal care coded as preventative Physician Services Furnished in a Hospital Visits; surgery in general, including charges by surgeon, anesthesiologist, pathologist and radiologist Physician Services for Emergency Care Allergy Shots and Serum

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; sub-
ject to deductible

60% coverage; subject to deductible

100% coverage; not subject
to deductible

Not covered

100% coverage; not subject to deductible

Not covered

85% coverage; subject to deductible

60% coverage; subject to de-
ductible

80% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; subject to in-network deductible

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to in-network deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

100% coverage; not subject to deductible

Not covered

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to in-network deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

15 Retiree Decision Guide 2014

Non-Medicare Advantage (MA) Options

Benefits Comparison: Gold, Silver and Bronze HRA Plans
January 1, 2014 December 31, 2014

Gold HRA Option

Silver HRA Option

Bronze HRA Option

Physicians' Services Outpatient Surgery When billed as office visit
Outpatient Surgery When billed as outpatient
surgery at a facility

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

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

80% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

Hospital Services Inpatient Services Inpatient care, delivery and
inpatient short-term acute rehabilitation services Inpatient Services Well-newborn care
Outpatient Surgery Hospital/facility
Emergency Care--Hospital Treatment of an emergency
medical condition or injury

The Plan Pays

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; subject to deductible
85% coverage; subject to deductible

60% coverage; subject to deductible
60% coverage; subject to de-
ductible

80% coverage; subject to deductible
80% coverage; subject to deductible

60% coverage; subject to deductible
60% coverage; subject to deductible

85% coverage;

80% coverage;

subject to in-network deductible subject to in-network deductible

The Plan Pays

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to in-network deductible

Outpatient Testing, Lab, etc. Non Routine laboratory; X-Rays; Diagnostic Tests; Injections Including medications
covered under medical benefits--for the treatment of an illness or injury

The Plan Pays

The Plan Pays

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

16 Retiree Decision Guide 2014

Benefits Comparison: Gold, Silver and Bronze HRA Plans
January 1, 2014 December 31, 2014

Gold HRA Option

Silver HRA Option

Bronze HRA Option

Behavioral Health

In-Network Out-of-Network The Plan Pays

In-Network Out-of-Network The Plan Pays

In-Network Out-of-Network The Plan Pays

Mental Health and Substance Abuse Inpatient Facility and Partial Day Hospitalization*

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; 75% cover- 60% coverage;

subject to

age; subject to

subject to

deductible

deductible

deductible

Mental Health and Substance Abuse Outpatient Visits and Intensive Outpatient* Other Coverage

85% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

80% coverage; subject to deductible

60% coverage; subject to deductible

The Plan Pays

75% cover- 60% coverage;

age; subject to

subject to

deductible

deductible

The Plan Pays

Outpatient Acute Short-Term Rehabilitation Services Physical Therapy Speech Therapy Occupational Therapy Other short term
rehabilitative services

85% coverage; subject to deductible; up to 40 visits per
therapy per Plan Year (not
to exceed a total of 40 visits combined, including any out-of-network
visits)

60% coverage; subject to
deductible; up to 40 visits per therapy per Plan Year (not to exceed a total of 40 visits combined, including any in- network
visits)

80% coverage up to 40 visits
per therapy per Plan Year; subject to deductible (not
to exceed a total of 40 visits combined, including any
out-of- network visits)

60% coverage up to 40 visits per therapy per Plan Year; subject to deductible (not to exceed a total of 40 visits combined, including any innetwork visits)

75% coverage; subject to deductible; up to 40 visits per
therapy per Plan Year (not
to exceed a total of 40 visits combined, including any out-of-network
visits)

60% coverage; subject to deductible; up to 40 visits per therapy per Plan Year (not to exceed a total of 40 visits combined, including any in- network
visits)

Chiropractic Care Coverage up to a maximum of 20 visits, per Plan Year; Up to a maximum of 20 days, per Plan Year

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; 75% cover- 60% coverage;

subject to

age; subject to

subject to

deductible

deductible

deductible

Hearing Services Routine hearing exam Urgent Care Services Pharmacy - You Pay

85% coverage for routine exam and fitting; subject to deductible.
$1,500 hearing aid allowance every 5 years; not subject to the
deductible

85% cover- 60% coverage;

age;subject to subject to

deductible

deductible

You Pay

80% coverage for routine exam and fitting; subject to deductible.
$1,500 hearing aid allowance every 5 years; not subject to the
deductible

80% coverage; 60% coverage;

subject to

subject to

deductible

deductible

You Pay

75% coverage for routine exam and fitting; subject to deductible.
$1,500 hearing aid allowance every 5 years; not subject to
the deductible

75% coverage; 60% coverage;

subject to

subject to

deductible

deductible

You Pay

Tier 1 Co-insurance**

15% ($20 min/$50 max) not subject to deductible

15% ($20 min/$50 max) not subject to deductible

15% ($20 min/$50 max) not subject to deductible

Tier 2 Co-insurance Preferred Brand**

25% ($50 min/$80 max) not subject to deductible

25% ($50 min/$80 max) not subject to deductible

25% ($50 min/$80 max) not subject to deductible

Tier 3 Co-insurance Non-Preferred Brand**

25% ($80 min/$125 max) not subject to deductible

25% ($80 min/$125 max) not subject to deductible

25% ($80 min/$125 max) not subject to deductible

90-Day Voluntary Mail Order OR Retail 90-Day Network

Tier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max) Tier 325% ($200 min/$312.50 max) (Does not apply to deductible
or out-of-pocket max)

Tier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max) Tier 325% ($200 min/$312.50 max) (Does not apply to deductible
or out-of-pocket max)

Tier 115% ($50 min/$125 max) Tier 225% ($125 min/$200 max)
Tier 325% ($200 min/$312.50 max)
(Does not apply to deductible or
out-of-pocket max)

*Contact vendor regarding prior authorization **Not subject to out-of-pocket max

17 Retiree Decision Guide 2014

Non-Medicare Advantage (MA) Options

Benefits Comparison: Gold, Silver and Bronze HRA Plans
January 1, 2014 December 31, 2014

Other Coverage Home Health Care Services NOTE: Prior approval required
Skilled Nursing Facility Services NOTE: Prior approval required

Gold HRA Option

Silver HRA Option

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

The Plan Pays

85% coverage; subject to deductible

60% coverage; subject to deductible

85% coverage; up to 120 days per Plan Year; subject to deductible

Not covered

The Plan Pays

80% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; up to 120 days per Plan Year; subject to deductible

Not covered

Bronze HRA Option

In-Network Out-of-Network

The Plan Pays

75% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; up to 120 days per Plan Year;
subject to deductible

Not covered

Hospice Care NOTE: Prior approval required

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

Durable Medical Equipment (DME)--Rental or purchase NOTE: Prior approval required for certain DME

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

60% coverage; subject to deductible

Foot Care NOTE: Covered only for neurological or vascular diseases Transplant Services NOTE: Prior approval required

85% coverage; subject to deductible

60% coverage; subject to deductible

80% coverage; subject to deductible

60% coverage; subject to deductible

75% coverage; subject to deductible

Contact vendor for coverage details

60% coverage; subject to deductible

* The Plan pays a percent of eligible expenses for out-of-network providers; eligible expenses are usually 110% of the Medicare rate for the treatment. Deductibles and out-of-pocket maximums are based only on these eligible expenses, and do not include amounts you pay when out-of-network providers balance bill for the difference. You cannot use HRA funds to pay for amounts balance billed.
NOTE: For out-of-network providers, the plan does not accept assignment of benefits. You will receive a payment of benefits and it will be your responsibility to pay that to the provider.

18 Retiree Decision Guide 2014

2TR0I1C4ARE Supplement and
PePalacnhCChaanrgeesfor Kids
TRICARE Supplement for Eligible Military Members
The TRICARE Supplement Plan is an alternative to SHBP coverage that is offered to employees and dependents who are eligible for SHBP coverage and enrolled in TRICARE. The TRICARE Supplement Plan is not sponsored by the SHBP, the Department of Community Health or any employer. The TRICARE Supplement Plan is sponsored by the American Military Retirees Association (AMRA) and is administered by the Association & Society Insurance Corporation. In general, to be eligible, the employee and dependents must each be under age 65, ineligible for Medicare and registered in the Defense Enrollment Eligibility Reporting System (DEERS). For complete information about eligibility and benefits, contact 1-866-637-9911 or visit www.asicorporation.com/ga_shbp. You may also find information at www.dch.georgia.gov/shbp
PEACHCARE FOR KIDS
As state or public school retirees, you could be eligible to enroll your children in PeachCare for Kids. Visit www.peachcare.org or call 1-877-427-3224 for information. You may also qualify for a lower cost health insurance plan through the Health Insurance Marketplace under the Affordable Care Act. To find out if you qualify, visit www.healthcare.gov. Open Enrollment for the Health Insurance Marketplace begins October 1, 2013, for coverage starting as early as January 1, 2014.
19 Retiree Decision Guide 2014

Legal
Notices
About the Following Notice
The following important legal notices are posted on the SHBP website at www.dch.georgia.gov/shbp under Plan Documents: Women's Health and Cancer Rights Act Notice describes SHBP's compliance with federal law by covering reconstructive
surgery after mastectomy Newborns' and Mothers' Health Protection Act Notice describes SHBP's compliance with federal law by covering hospital
stays following childbirth Health Information Portability and Accountability Act SHBP Notice of Information Privacy Practices describes how medical
information about you is used and protected in accordance with federal law Mental Health Parity and Addiction Equity Act Opt-Out Notice explains DCH's decision to opt out of certain coverage
mandates, as permitted by federal law Centers for Medicaid & Medicare Services Medicare Part D Creditable Coverage Notice informs you that prescription drug
coverage under all SHBP coverage options are considered Medicare Part D "creditable coverage" Summaries of Benefits and Coverage describe benefits under the Non-MA Plan Options in a standard form required by
the Affordable Care Act Georgia Law Section 33-30-13 Notice describes the impact of the Affordable Care Act on premiums for SHBP options
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 participants, including but not limited to terminating coverage (for the participant and his or her dependents) 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.
20 Retiree Decision Guide 2014

T20er1m4 s and Conditions fPolra2n0C14hanges
Announcing NEW Plan Options
IMPORTANT: In order to make any elections or changes to SHBP coverage through the Year Round Web Portal
(either online or by telephone), you must accept these terms and conditions. If your election is changed to default coverage without your affirmative action, you are deemed to have accepted these terms and conditions. Be sure to read these carefully before making your health elections or deciding to accept default coverage.
I understand that it is my responsibility to review the most recent Retiree Decision Guide. It is my responsibility to review any applicable Plan documents that are available and applicable to me (including Plan documents posted electronically at http://dch.georgia.gov/shbp-plan-documents) at the time of my decision, and to determine the SHBP option that best meets my or my family's healthcare needs.
I also understand that it is my responsibility to review the following bullets and understand which of the bullets apply to my situation:
I understand that providers may join and discontinue participation in a vendor's network, and this is not a Qualifying Event that will allow me to change my election
I understand that the costs of prescription drugs may change during a Plan Year and that these changes are not a Qualifying Event that will allow me to change my election
I understand that once I have made an election and my election window closes I will not be able to change that election until the next ROCP or if I have a Qualifying Event
I understand that it is my responsibility to select the correct tier based upon the dependents I wish to cover I understand that by electing coverage I am authorizing my retirement system to deduct from my annuity check the
applicable premium for the Plan option and coverage tier I have selected and any applicable tobacco surcharge I understand that I will have to pay premiums for the Plan option and tier I select I understand that it is my responsibility to verify that the correct deduction is taken and to immediately notify SHBP if
it is not correct I understand that if I experience a Qualifying Event I must elect to make the change by the deadline (in most cases,
within 31 days of the Qualifying Event), to my Plan option and tier in order for the corresponding monthly premium to apply for the remainder of the Plan Year. I understand that the rules governing these Qualifying Events and their deadlines are provided in the Plan documents I understand I can drop dependents at anytime but I cannot add them back without a Qualifying Event that allows the addition (except if the dependent child is enrolled in Peachcare)
21 Retiree Decision Guide 2014

Terms and Conditions
I understand that I cannot add dependent(s) to my coverage unless I experience a Qualifying Event and make the request by the deadline (in most cases within 31 days of the Qualifying Event, or 90 days for newly eligible dependent children)
I understand if I miss the deadline to add a dependent based on a Qualifying Event, or miss the deadline to provide verification documentation, I will not be able to add the dependent in the future unless another Qualifying Event allows the addition
I understand that if I have chosen to add an eligible dependent(s), I will be contacted to provide dependent verification documentation and that this documentation must be provided for each pended dependent within 90 days of receiving such a request. I understand that failure to provide verification documentation of newly added dependents within 90 days of the Qualifying Event will result in the removal of the election of coverage for the dependent from the SHBP web portal and cancellation of the election request
I understand that I must truthfully answer the Tobacco Surcharge question. It is my responsibility to immediately notify SHBP if my answer to the Tobacco Surcharge question changes. Intentional misrepresentations in my answer to the surcharge question or my failure to notify SHBP if my answer to the surcharge question changes will have significant consequences, including loss of SHBP coverage for 12 months from the date my incorrect answer or failure to notify SHBP is discovered
I understand that intentional misrepresentation or falsification of information (including verification documentation submitted when dependents are added) will subject me to penalties and possible legal action and, in the case of adding dependents, may result in termination of coverage retroactive to the dependent's effective date and recovery of payments made by SHBP for ineligible dependents
I understand that by making an election on the year round web portal either by self entry or by calling for assistance through the 800 number, or for those who choose default coverage by taking no affirmative action during ROCP, I am attesting that the information I provide (or provided in the past for default coverage) is true and correct to the best of my knowledge and that I have read and understand how my decision affects coverage for myself and my dependents. I acknowledge that I may be subject to a fine of not more than $1,000 or imprisonment for not less than one, nor more than five years, or both, if I knowingly and willfully make a false or fraudulent statement or representation to DCH pursuant to O.C.G.A. Section 16-10-20.
22 Retiree Decision Guide 2014

Website for ROCP Available
Oct. 21, at 12:01 a.m. Nov. 8, 5:00 p.m.
For Plan Coverage effective
January 1, 2014 December 31, 2014
The material in this booklet is for information purposes only and is not a contract. It is intended only to highlight principal benefits of the SHBP Plan options. 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. For all Plan options other than Medicare Advantage Option, the Plan documents include the SHBP regulations, Summary Plan Descriptions and reimbursement guidelines of the vendors. The Plan documents for Medicare Advantage are the insurance certificates. It is the responsibility of each member, active or retired, to read the Plan documents in order to fully understand how that Option pays benefits. Availability of SHBP Options may change based on federal or state law changes or as approved by the Board of the Department of Community Health (DCH). Premiums for SHBP Options are established by the DCH Board and may be changed at any time by the Board resolutions subject to advance notice.
23 Retiree Decision Guide 2014