2022RetireesRetireesiHealth BenefitsGuidePlan Year 2022

RetireesWhat’s New for 2022Medical, Vision and Dental The Health Service Board approved the addition of two new health plans available for non-Medicare eligibleretirees, Health Net CanopyCare HMO and Blue Shield of California PPO-Accolade. Health Net CanopyCareHMO combines multiple Bay Area medical groups into one network that includes access to ZuckerbergGeneral and MarinHealth Medical Center. Blue Shield of California PPO-Accolade includes 24/7 access tonurses and coordination of services and replaces the UnitedHealthcare PPO plan. Blue Shield of California Trio HMO and Access HMO infertility medications are now covered under thepharmacy benefit and can be obtained at any contracted CVS Specialty pharmacy. Patients can use theirinsurance and only need to pay their cost share at the point of sale. Prior authorization for fertility medicationsis no longer required. You can now make Open Enrollment elections and mid-year Qualifying Life Event changes online througheBenefits. Go to to get started.Well-Being SFHSS is constantly adding to our virtual class offerings. Visit for more information. Get Your Flu Shot: You can get your flu shot through an SFHSS sponsored worksite flu clinic or through yourhealth plan. For more information on flu prevention go to Access CredibleMind: Find mental health and emotional well-being content and resources online fromCredibleMind, a multi-media platform featuring books, apps, videos, podcasts, assessments, articles, andonline programs at Year 2022

Step-by-Step Open Enrollment GuideSTEP 1: Review your Open Enrollment Letter forcurrent health, dental and vision elections and new2022 rates. If you have no changes to your existingelections, you do not need to take any further action.STEP 5: Are you making changes to your visionbenefits? If yes, review the Vision benefit options onSTEP 2: Review dependent eligibility rules onour website at and thedependent(s) listed in your enclosed Open Enrollmentletter. Do you need to add or drop a dependent? If YES, review the Self-Service online enrollment instructions attached to the enclosed letter tomake your changes online using eBenefits.Save and continue through all the screens andconfirm at the end to submit your changes.Submit copies of supporting documents. Newdependents must have supporting documentationsubmitted with their elections in order to beenrolled (e.g. birth certificate, certified marriagecertificate).STEP 3: Are you or your dependent approaching age65 and about to become Medicare-eligible? If YES, and you are not yet enrolled in Medicare Part A & B, you must enroll through the SocialSecurity Administration online at or bycalling (800) 772-1213.If NO, be sure to apply for Medicare Part A & B atleast three months before your 65th birthdate.Proof of enrollment in Medicare Part A & B arerequired to maintain your SFHSS benefits. ReviewMedicare Basics and FAQs on pages 2 to 4.Submit proof of Medicare enrollment by mailing acopy of your Medicare card or letter to SFHSS.STEP 4: Are you making changes to your health planbenefits? If YES, review the Service Areas of the medical plans available to you. Non-Medicare retirees, goto page 6. Retirees with Medicare, go to page 7.If NO, proceed to Step 5.Next, review the Medical Plan benefits. Retireeswithout Medicare go to pages 8 to 11. Retireeswith Medicare go to pages 12 to 13.Review your rates on the back of your enclosedOpen Enrollment letter.Select your plan by completing the Choose aMedical Plan in eBenefits. pages 21 and 22.You must be enrolled in a medical plan to receiveVision benefits.Enrollment in the VSP Premier Plan requires thatall dependents enrolled in medical coverage beenrolled in the VSP Premier Plan.Complete the Enroll in a Vision Premier Planpage in eBenefits.STEP 6: Are you making changes to your dentalbenefits? If YES, review your Dental benefit options and associated costs on page 23 to 24 and completethe Enroll in a Dental Plan page in eBenefits.If NO, then you are done and you have no furtheraction to take.STEP 7: Complete your eBenefits elections online.Refer to the enclosed Self-Service instructionsattached to your letter or go to get started. Be sure to click Save and Continuethrough each screen. You must click Submit at theend in order to complete your enrollment. Otherwiseyour elections will not be recorded.If you are unable to enroll online, download an OpenEnrollment Application form and return your form anddocumentation by fax or mail to SFHSS. Our mailingaddress is 1145 Market Street, 3rd Floor, SanFrancisco, CA 94103 or fax to (628) 652-4701.To download an Open Enrollment Application form,visit 8: You’ll receive your Confirmation Statement inthe mail from SFHSS in December.Please review the Confirmation Statement to makesure your benefit elections are correct. Changes madeduring Open Enrollment take effect January 1, 2022.For more information visit sfhss.orgIn order to serve as many members as possible,we are providing consultations by telephone only.For HELP, call San Francisco Health Service System(SFHSS) Member Services at (628) 652-4700.Our telephone hours are Monday, Tuesday,Wednesday and Friday from 9am to 12pm and1pm to 5pm and Thursday from 10am to 12pmand 1pm to 5pm PST.Open Enrollment deadline is October 29, 2021, 5:00pm PST. No exceptions.

Executive Director’s MessageI used to sew my own clothes when I was younger. I don’t mean taking up thehem of my trousers or patching a hole—I followed a pattern and sewed my ownclothes. It was quite common back then.My family had a tradition of taking the scrap cloths and turning them intoquilts. I realize this story dates me, but one of my fondest memories wasmy mom’s 75th birthday. My sister organized a quilting party where threegenerations of women from my family gathered in a quilting circle with pillowsize blocks and my mom taught us all how to create a quilt using materials andscraps from five generations of my family. We each made a pillow cover thatday and I still have mine.The COVID-19 pandemic gave me lots of time for reflection. I thought aboutmy own family and how there’s so much more I want to share with them,including the gifts my mom passed on to me. I thought about the importanceof having strong foundations, not just for our families, but for our communityas well. Our community, along with the entire world, was tested this past year.When the pandemic hit, I had a front row seat allowing me to witness how allthose years of community outreach, education, listening and learning fromresidents and building public private partnership had created a foundation oftrust where our community had faith that we would get through this pandemictogether. The San Francisco Bay Area vaccination rates are just remarkablecompared to other urban areas in America.We know the work can’t stop here. There’s always more we can do to build upona good foundation. At the San Francisco Health Service System, we issued ahealth plan Request for Proposals (RFP) last year for our Active Employee andEarly Retiree health benefits and we decided to add more choices and enhanceour PPO plan. Please review your new choices carefully and select the plan thatbest meets the healthcare needs for you and your family.As we continue our journey to pandemic recovery, I want to encourage you toreflect on the foundation of the relationships you have with your family andfriends. The biggest lesson I learned after a year where I couldn’t spend timewith those I love is that we can all improve the quality of the time when we canspend time together. Maybe that means turning off our cell phones to give ourloved ones our undivided attention or maybe it’s sharing a recipe or craft, likequilting, that has been passed down from generations.Be well,Abbie Yant, RN, MAExecutive Director

Retirees2Medicare Basics3Medicare FAQs5Enrolling in Retiree Health Benefits6Service Areas for Retirees without Medicare7Service Areas for Retirees with Medicare8Medical Plans for Retirees without Medicare12 Medical Plans for Retirees with Medicare14 Medical Plan Options: Retirees without Medicare15 Medical Plan Options: Retirees with Medicare16 Medical Premiums: Retiree or Survivor without Medicare (CA)17 Medical Premiums: Retiree or Survivor without Medicare (Outside of CA)18 Medical Premiums: Retiree or Survivor without Medicare or Access to HMOs (CA)19 Medical Premiums: Retiree or Survivor with Medicare Part A&B (CA)20 Medical Premiums: Retiree or Survivor with Medicare Part A&B (Outside of CA)21 Vision Plans22 Vision Plan Benefits-at-a-Glance23 Dental Plans24 Dental Plan Benefits-at-a-Glance25 Eligibility27 Eligibility Under City Charter28 Changing Benefits Elections: Qualifying Life Events30 Retirees Living or Traveling Outside of the United States31 Legal Notices32 Medicare Creditable Coverage33 Preventive Care is 100% Free34 Mental Health & Substance Abuse Benefits35 Health Service Board Achievements36 Key ContactsThis Guide includes an overview of the San Francisco Health Service System Rules, as approved by the Health ServiceBoard. Rules can be found at er-rules or request a copy at(628) 652-4700.

RetireesMedicare BasicsSFHSS requires all retirees and dependents to enroll inMedicare Part A and Part B at least three months beforeturning 65.The Social Security Administration is the federalagency responsible for Medicare eligibility, enrollmentand premiums. Start by downloading the Medicareand You handbook at BasicsMedicare is a federal health insurance programadministered by the Centers for Medicare andMedicaid Services ( for people age 65years or older, under 65 with Social Security-qualifieddisabilities or anyone with End Stage Renal Disease(permanent kidney failure requiring dialysis ortransplant). The different parts of Medicare helpcover specific types of services: Medicare Part A: Hospital Insurance Medicare Part B: Medical Insurance Medicare Part D: Prescription Drug CoverageAll eligible retired members and covered eligibledependents must enroll in Medicare Part A andPart B. Failure by a member or dependent to enrollin Medicare by the required deadlines will result in achange or loss of medical coverage.If you are not currently receiving Social Security, itis your responsibility to contact the Social SecurityAdministration to apply for Medicare at leastthree months prior to your 65th birthday or if youbecome disabled. Failure to do so could result inpenalties being assessed by the Social SecurityAdministration and the San Francisco HealthService System.If you have a Social Security-qualified disability or EndStage Renal Disease, you should contact the SocialSecurity Administration immediately to apply forMedicare.2In the case where an SFHSS member and theircovered dependent(s) are enrolled in a Blue Shieldof California HMO plan (Access or Trio HMO), wheneither member or dependent(s) become eligible forMedicare, they must enroll in the UnitedHealthcareMedicare Advantage PPO plan.Medicare Part A: Hospital InsuranceSFHSS rules require all retired members anddependents to enroll in premium-free Medicare PartA as soon as they are eligible. Most people do not paya premium for Part A because they made sufficientcontributions via payroll taxes while working.Medicare Part A helps cover inpatient care inhospitals, including critical access hospitals andskilled nursing facilities (but not custodial orlong-term care). It also helps cover hospice care andsome home healthcare. Beneficiaries must meetcertain conditions to qualify for these benefits.You are eligible for premium-free Medicare PartA if you are age 65 or older and have worked andcontributed to Social Security for at least 10 years(40 quarters). You may also qualify for Medicare PartA through a current, former, or deceased spouse.If you are under age 65 and have End Stage RenalDisease or a Social Security-qualified disability, youmay also qualify for Medicare Part A.If you are under age 65 with a qualifying disability,Medicare coverage generally starts 24 to 30 monthsfollowing eligibility. If you have questions about youreligibility for premium-free Medicare Part A, contactthe Social Security Administration at(800) 772-1213.All SFHSS members are required toenroll in Medicare as soon as theybecome eligible or face penalties.Plan Year 2022

RetireesMedicare FAQsMedicare Part B: Medical InsuranceSFHSS rules require that all retired members andtheir dependents enroll in Medicare Part B as soonas they are eligible. Medicare Part B helps coverthe cost of doctors’ services and outpatient medicalservices. Most people pay a monthly premium to thefederal government for Part B. The Medicare Part Bmonthly premium, which is based on your incomeper CMS regulations, is usually deducted from yourSocial Security check. If your income decreases afteryou enroll in Part B, you may be eligible for a PartB premium reduction. For information on MedicarePart B premiums or to request a Part B premiumreduction, contact the Social Security Administration.If you do not enroll in Medicare Part B when you firstbecome eligible, your Part B premium will be higherand penalties may be charged when you do enroll.This higher premium and/or penalty will continue forthe entire time you are enrolled in Medicare.QWhat if I’m not eligible for premium-freeMedicare Part A?AIf you are not eligible for premium-free MedicarePart A, you are not required to enroll in MedicarePart A. You must submit a statement to SFHSS fromthe Social Security Administration verifying that youare not eligible for premium-free Medicare Part A.SFHSS still requires you to enroll in Medicare Part B,even if you are not eligible for Medicare Part A.QWhat if either I or my dependent did notenroll in Medicare Part A and/or Part B whenoriginally eligible?AIf you or a dependent were eligible at age 65 orsooner due to a disability, but did not enroll inMedicare Part A and/or Part B, the Social SecurityAdministration may assess a late enrollment penaltyfor each year in which the individual was eligible butfailed to enroll. SFHSS members and dependentsare required to enroll in Medicare in accordance withSFHSS rules, even if they are paying a federal penaltyfor late Medicare enrollment.Plan Year 2022QWhat happens if I enroll after age 65 or changeSFHSS plans during Open Enrollment?AIf you enroll in Medicare after age 65 or changeMedicare plans during Open Enrollment, your planmay ask you for information about your currentprescription drug coverage. If you fail to respondtimely, CMS may assess a Part D Late EnrollmentPenalty (LEP). Contact your new plan or SFHSS ifyou have questions.QWhat is the SFHSS penalty for not enrollingin Medicare Part A and B when eligible orfor failing to pay Medicare premiums afterenrollment?AFor Medicare-eligible SFHSS members not enrolledin Medicare or who fail to pay their Medicarepremium(s), existing SFHSS medical plan coveragewill be terminated and the member will beautomatically enrolled in Blue Shield of CA PPOAccolade 20. For Medicare-eligible dependents notenrolled in Medicare, SFHSS medical coverage willbe terminated. Full SFHSS coverage for a member ordependent may be reinstated at the beginning of thenext available coverage period after SFHSS receivesproof of Medicare enrollment.Blue Shield of CA PPO-Accolade 20 significantlyincreases premium and out-of-pocket costs. UnderAccolade 20, you will be responsible for paying the80% that Medicare would have paid for a coveredservice, plus any amounts above usual and customaryfees.In addition, under Blue Shield of CA PPO-Accolade20, yearly out-of-pocket limits increase to 10,950.For information on Blue Shield of CA PPO-Accolade20, visit

RetireesMedicare FAQsDo not enroll in a third party individual Medicare Part Dprescription drug plan. Doing so will result in the termination ofyour SFHSS medical coverage.Medicare Part D: Prescription Drug InsuranceThere are two types of Medicare Part D prescriptionplans: individual and group. Individual Part Dprescription drug coverage is purchased directly byan individual from an insurer or pharmacy.QAIf you are charged a Part D premium, but yourincome changes and falls below the threshold,contact Social Security to request an adjustment.Medicare enrollees with income exceeding certainthresholds are charged a monthly Part D premiumalso known as the Income Related Monthly AdjustedAmount (IRMAA). In most cases, this Part D premiumwill be deducted from your Social Security check.UHC Medicare Advantage PPO members will receiveonly one card that covers medical and pharmacyservices.Should either I or my dependents enroll inMedicare Part D?ADo not enroll in any third party Medicare Part Dprescription drug plan.If you are Medicare-eligible, enhanced groupMedicare Part D drug coverage is included with yourSFHSS Medicare plan.Private insurance companies, pharmacies, and otherentities may try to sell you an individual Medicare PartD prescription drug plan.If you enroll in any private, individual Medicare PartD prescription drug plan, your Medicare coveragewill be assigned to that plan and your SFHSS groupmedical coverage will be terminated.You may be required to pay a Part D premium tothe Social Security Administration if your incomeexceeds acertain threshold.SFHSS members should not enroll in any individualMedicare Part D plan. SFHSS members areautomatically enrolled in group prescription drugcoverage under Medicare Part D when they enrollin any medical plan offered through SFHSS. SFHSSmedical plans offer enhanced group Medicare Part Dprescription drug coverage.QAm I required to pay a premium forMedicare Part D?For information on Medicare Part D premiums,visit ms.html or call Social Security at(800) 772-1213.QWhat is the SFHSS penalty if I or mydependent fail to pay a Part D premium toSocial Security?ARetirees and dependents who fail to pay a requiredPart D premium will result in Part D coverage beingterminated by the Social Security Administration.Consequently, SFHSS medical coverage will alsobe terminated. SFHSS members who have lost PartD eligibility due to lack of payment will be enrolledin Blue Shield of CA PPO-Accolade 20 memberonly coverage and their dependent coverage willbe terminated. Full SFHSS medical coverage fora member or dependent may be reinstated at thebeginning of the next available coverage periodafter SFHSS receives proof of Medicare Part Dreinstatement.If you are enrolled in Medicare, do not enroll in any outside Part D plans. Prescription benefitsare already included in your SFHSS medical plan. Doing so will terminate your coverage.4Plan Year 2022

RetireesEnrolling in Retiree Health BenefitsNEW Retirees: Don’t Miss the 30-Day Deadline. Thetransition of health benefits from active employee toretiree status does not happen automatically.You must enroll in retiree health coverage as a retireeby submitting a Retiree Enrollment Application formand supporting documents by fax to (628) 6524701 or mail to SFHSS by the required deadlines.Get started by visiting a new Retiree does not complete enrollment inretiree health coverage within 30 calendar days ofyour retirement date, you will only be able to enrollin benefits during the next Open Enrollment period(unless you have a Qualifying Life Event).New retirees should plan ahead. If you are Medicareeligible, you must be enrolled in Medicare to keepSFHSS benefits. See pages 3 and 4 for MedicareFAQs.Your SFHSS retiree premium contributions will bededucted from your monthly pension check. Be sureto review your monthly check to verify that the correctpremium contribution is being deducted. If yourpension check does not cover your required premiumpayment, you must make payments directly throughthe City of San Francisco Payment Portal.To create an account to make online payments, You can schedulerecurring payments through the portal. There are noservice fees for payment by electronic check.All Medicare-eligible retirees and dependentsmust maintain continuous enrollment in Medicare.To ensure that there is no break in your medicalcoverage, you must pay all Medicare premiums thatare due to the federal government on time.Open Enrollment is your annual opportunity tochange your benefit elections for you and your eligibledependents without a qualifying event. Changes madeduring the October Open Enrollment period becomeeffective January 1, 2022.Outside of Open Enrollment, you can only makechanges to benefit elections during the plan year ifthere is a Qualifying Life Event.To be eligible for retiree health benefits, employeeshired after January 9, 2009 must have at least fiveyears of credited service with a City employer: Cityand County of San Francisco, San Francisco UnifiedSchool District, City College of San Francisco, orSuperior Court of San Francisco. Other governmentservice is not credited.Make sure you understand the City Charterrules determining your eligibility and premiumcontributions before finalizing your retirement date.See page 27 for more information.And remember.Depending on your retirement date, there can be agap between when employee coverage endsand retiree coverage begins. Setting your retirementdate at the end of the month will help to avoid gapsin SFHSS coverage.For instructions on how to make online payments, goto about health benefits, premiumcontributions or eligibility documentation?Call (628) 652-4700.Plan Year 20225

RetireesService Areas for Retirees without MedicareCountyAlamedaBlueShieldof CAHealthNetKaiserPerm.CanopyCare HMONonMedicareHMOTrio HMONonMedicareHMOAccess neAmador ButtenCalaverasColusaContra CostanBlueShieldof CACountyPPOAccoladeNonMedicarePPOBlueShieldof CAHealthNetCanopyCare HMONonMedicareHMOTrio HMONonMedicareHMOKaiserPerm.Access HMONonMedicareHMOnOrangennnnPlacer nnPlumasnRiverside n nnSacramento nnnnSan BenitonSan Bernardino n nnnnnnnnnnnSan DiegoEl Dorado nSan FranciscoFresno n nSan JoaquinnnnSan Luis Obispo nnSan MateonnnSanta BarbaraGlennHumboldtImperial Kingsnnnnnnn nSanta Clarannn n nSanta Cruznnn nn InyoKernPPOAccoladeNonMedicarePPOnnDel NorteTraditionalNonMedicareHMOBlueShieldof CAnnnShastanLakenSierranLassennSiskiyounLos Angelesn nSolano n nSonoma nnnStanislaus Ventura n nnYolo n nnYuba nOutside CA n evada nnnn nnnnn n nn Available in this county Available in some zip codes OR, WA, HIBlue Shield of California PPO AccoladeNon-Medicare members and their non-Medicare dependents who lack geographic access to Trio HMO or Access HMO, both offered by Blue Shield of California, Health Net CanopyCare HMO, or Kaiser Permanente HMO, areeligible to enroll in Blue Shield of California Accolade PPO with lower premiums.6Plan Year 2022

RetireesService Areas for Retirees with MedicareKaiserPermanenteUnitedHealthcareSenior AdvantageHMOMedicareAdvantageOrangennnPlacer nnPlumasButtenRiverside nCalaverasnSacramentonnColusanSan BenitonSan Bernardino nnSan Diego or AdvantageHMOMedicareAdvantagennAlpineAmador Contra CostanDel NorteCountyPPOPPOnnEl Dorado nSan FrancisconnFresno nSan JoaquinnnGlennnSan Luis ObispoHumboldtnSan MateoImperialnSanta BarbaraInyonnnnnSanta Clara nKern nSanta Cruz nKings nShastannSierranLakeLassennSiskiyouLos Angeles nSolanonnMadera nSonoma nMarinnnStanislausnnMariposa nSutter TuolumneMontereynVentura nnYolo nnYuba nOutside CA NapanNevadan nn Available in this county Available in some zip codes OR, WA, HI Service area includes all 50 states, District of Columbia, Puerto Rico, the United States Virgin Islands, Guam,American Samoa, and the Northern Mariana IslandsMoving? Change of Address? Contact SFHSS (628) 652-4700 or visit you move out of the service area covered by your plan, you must elect an alternate medical plan thatprovides coverage in your area. Failure to change your elections may result in non-payment of claimsfor services rendered.Plan Year 20227

Retirees2022 Medical PlansHEALTH NET CANOPYCAREBLUE SHIELD OF CALIFORNIACANOPYCARE HMOTrio HMO and Access HMODEDUCTIBLESNo DeductibleNo DeductibleAnnual out-of-pocket maximum 2,000/individual; 4,000/familyAnnual out-of-pocket maximum 2,000/individual; 4,000/familyRoutine PhysicalNo chargeNo chargeMost Immunizations and InoculationsNo chargeNo chargeWell Woman Exam and Family PlanningNo chargeNo chargeRoutine Pre/Post-Partum CareNo chargeNo charge visits limited; see EOCOffice and Home Visits 25 co-pay 25 co-payInpatient Hospital VisitsNo chargeNo chargePharmacy: Generic Drugs 10 co-pay 30-day supply 10 co-pay 30-day supplyPharmacy: Brand-Name Drugs 25 co-pay 30-day supply 25 co-pay 30-day supplyPharmacy: Non-Formulary Drugs 50 co-pay 30-day supply 50 co-pay 30-day supplyMail Order: Generic Drugs 20 co-pay 90-day supply 20 co-pay 90-day supplyMail Order: Brand-Name Drugs 50 co-pay 90-day supply 50 co-pay 90-day supplyMail Order: Non-Formulary Drugs 100 co-pay 90-day supply 100 co-pay 90-day supplyDeductible and Out-of-Pocket Maximum(Medical)PREVENTIVE CAREPHYSICIAN AND OTHER PROVIDER CAREPRESCRIPTION DRUGS20% coinsurance20% coinsuranceup to 100 per prescription, 30-day supplyup to 100 per prescription, 30-day supplyNo chargeNo charge 100 co-pay waived if hospitalized 100 co-pay waived if hospitalized 25 co-pay in-network and out-of-network 25 co-pay in-networkInpatient 200 co-pay per admission 200 co-pay per admissionOutpatient 100 co-pay per surgery 100 co-pay per surgerySpecialty DrugsOUTPATIENT SERVICESDiagnostic X-ray and LaboratoryEMERGENCYHospital Emergency RoomUrgent Care FacilityHOSPITAL / SURGERY82019Plan Year 2022

Retirees without MedicareKAISER PERMANENTEBLUE SHIELD OF CALIFORNIA PPO-ACCOLADETraditional HMOIn-Network or Out-of-AreaNo DeductibleOut-of-Network 250 Deductible Retiree only 500 Deductible 1 750 Deductible 2 or more 500 Deductible Retiree only 1,000 Deductible 1 1,500 Deductible 2 or moreAnnual out-of-pocket maximum 3,750/person; 7,500/FamilyAnnual out-of-pocket maximum 7,500/personNo charge100% covered no deductible50% covered after deductibleNo charge100% covered no deductible100% covered no deductibleNo charge100% covered no deductible50% covered after deductibleNo charge visits limited; see EOC85% covered after deductible50% covered after deductible 20 co-pay85% covered after deductible50% covered after deductibleNo charge85% covered after deductible50% covered after deductible 5 co-pay 30-day supply 10 co-pay 30-day supply 15 co-pay 30-day supply 25 co-pay 30-day supplyPhysician authorized only 50 co-pay 30-day supply 10 co-pay 100-day supply 20 co-pay 90-day supplyNot covered 30 co-pay 100-day supply 50 co-pay 90-day supplyNot coveredPhysician authorized only 100 co-pay 90-day supplyNot covered 50 co-pay 30-day supply 50 co-pay, plus 50% Coinsurance;30-day supplyNo charge85% covered after deductible50% covered after deductible; prior notification 100 co-pay waived if hospitalized85% covered after deductible; if non-emergency50% after deductible85% covered after deductible; if non-emergency50% after deductible 20 co-pay85% covered after deductible50% covered after deductible 100 co-pay per admission85% covered after deductible; notification required50% covered after deductible; notification required 35 co-pay85% covered after deductible50% covered after deductibleAnnual out-of-pocket maximum 1,500/individual; 3,000/family20% coinsurance up to 100 perprescription, 30-day supply 10 co-pay plus 50% coinsurance;30-day supply 25 co-pay plus 50% coinsurance;30-day supply 50 co-pay, plus 50% coinsurance;30-day supplyEach plan’s Evidence of Coverage (EOC) contains a complete list of benefits and exclusions. If any discrepancy exists9between the information provided in this Guide and the EOC, the EOC shall prevail. Download EOCs at Year 2019

Retirees2022 Medical PlansHEALTH NET CANOPYCAREBLUE SHIELD OF CALIFORNIACANOPYCARE HMOTrio HMO and Access HMOREHABILITATIVEPhysical/Occupational TherapyAcupuncture/Chiropractic 25 co-pay per visit 25 co-pay per visit 15 co-pay 30 visits of each max per 15 co-pay 30 visits of each max perplan year; ASH networkplan year; ASH networkGENDER DYSPHORIAOffice Visits and Outpatient SurgeryCo-pays applyauthorization requiredCo-pays applyauthorization requiredDURABLE MEDICAL EQUIPMENTHome Medical EquipmentNo chargeNo chargeNo chargeNo chargebased upon allowed chargesbased upon allowed chargesNo chargeNo chargewhen medically necessarywhen medically necessaryEvaluation no charge up to 5,000combined for both ears, every 36 monthsEvaluation no charge 1 aid per ear,every 36 months, up to 2,500 eachInpatient Hospitalization 200 co-pay per admission 200 co-pay per admissionOutpatient Treatment 25 co-pay non-severe and severe 25 co-pay non-severe and severeInpatient Detox 200 co-pay per admission 200 co-pay per admissionResidential Rehabilitation 200 co-pay per admission 200 co-pay per admissionNo chargeNo chargeup to 100 days/yearup to 100 days/yearNo chargeNo chargeauthorization requiredauthorization requiredUrgent care 25 co-payUrgent care 50 co-pay guest membershipbenefits for college students in some areasDiabetic Monitoring SuppliesProsthetics/OrthoticsHearing AidsMENTAL HEALTHEXTENDED & END-OF-LIFE CARESkilled Nursing FacilityHospiceOUTSIDE SERVICE AREACare Access

STEP 7:Complete your eBenefits elections online. Refer to the enclosed Self-Service instructions attached to your letter or go to to get started. Be sure to click Save and Continue through each screen. You must click Submitat the end in order to complete your enrollment. Otherwise your elections will not be recorded.