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Retired Employees

Non-Medicare Retirees (Under 65)

Medicare Retirees

2014 Retiree Benefit Matters
Summary of Benefits and Coverage
Medical Summary Plan Document
Eligibility/Dependent Eligibility
Life Events
Medical
Prescription Drug Benefit
Voluntary Vision Plan Benefit
Voluntary Dental Plan Benefit
HIPPA Notice of Privacy Policies
Medicaid and the Children's Health Insurance Program (CHIP)
Retired Employees of the City of San Antonio (ReCoSA)

2014 Retiree Benefit Matters
Eligibility/Dependent Eligibility
Life Events
Medical
Voluntary Vision Plan Benefit
Voluntary Dental Plan Benefit
HIPPA Notice of Privacy Policies
Medicaid and the Children's Health Insurance Program (CHIP)
Retired Employees of the City of San Antonio (ReCoSA)


What You Need To Know

Complete plan details are available in the Summary Plan Documents available from the Human Resources Department. In the event of any discrepancy between any document and the official Plan Document, the Plan Document shall govern.

Eligibility

Eligible Retiree
City of San Antonio employees who leave the City with at least 20 years of service or have five years of service and are 60 years of age are eligible for City of San Antonio retiree medical benefits as follows:

  • Employees with a hire date prior to October 1, 2007 are eligible to enroll in a City retiree medical plan with a total combined premium subsidy of 67%.
  • Employees with a hire date on or after October 1, 2007 are eligible as follows:
    • 5-9 years of City service are eligible to participate with no City subsidy
    • 10+ years of City service are eligible to participate with 50% City-subsidized premium

Retirees who meet eligibility requirements for retiree medical benefits must enroll in a City retiree medical plan within
31 days
from the date of separation from service. If no election is made or coverage is terminated anytime after the initial enrollment, your City retiree eligibility will permanently end.

Eligible Dependent
Dependents may be enrolled in City retiree health benefits if they were covered at the time of your retirement and you enroll them at the time of your initial retiree medical election. Dependents who continue to meet eligibility requirements will remain on the plan until you remove them, cease to make the required contribution, or the dependent no longer meets the eligibility criteria.


Life Events
Selections made during Annual Enrollment will be effective for the upcoming plan year, January 1 through December 31, 2014. There are certain life events that can happen during the year that will allow you to change the level of coverage (retiree only, retiree plus one, or retiree plus two or more) for your health plan.

Those life events are:
• Divorce, Annulment, Dissolution of a Domestic Partnership
• Death of a dependent

You must notify the Employee Benefits Office within 31 calendar days of your life event and provide all required documentation in order for the changes in your coverage to take effect during the calendar year. If you fail to notify the Employee Benefits Office within 31 days and do not provide documentation, you forfeit any past premium refund.


Medical
For 2014, non-Medicare retirees can enroll in one of three (3) Preferred Provider Organization (PPO) health plan options administered by UnitedHealthcare. With the Consumer Choice, New Value, and Premier health plans, you have the ability to see any physician or other health care professional from the UnitedHealthcare network, including specialists, without a referral. In addition, the coverage is the same for all three plans; however, the amount you pay out-of-pocket varies from plan to plan. In-network preventive care services are covered at 100% for all four plans.

Below is a a brief overview of each plan. A detailed, side-by-side comparison of each plan can be found on page four (4) of the 2014 Retiree Benefit Matters guide.

Consumer Choice (Consumer-Driven Health Plan) PPO
No co-pays, deductible must be met before the health plan pays, lowest premium contribution

In-Network Benefits - Retirees who choose in-network providers pay:

  • Annual deductible of $1,250 for individual ($2,500 for family coverage) for plan year 2014 
  • With this plan, there are no co-pays. You are responsible for 100% of the cost of health care services (ex: prescription medications, office visits, x-rays) until the deductible is satisfied.
  • Once the deductible is satisfied, you pay 20% of discounted eligible expenses up to a maximum of $4,000 for an individual or $8,000 for family coverage per year, excluding the deductible. Amounts above this annual maximum are paid by the City at 100% of eligible expense.
  • Consumer Choice allows you to save for future and pay for current qualified health care expenses with a Health Savings Account (HSA). In 2014, the City will contribute $500 ($1,000 for a family) into your HSA. Unlike a Flexible Spending Account, you own the funds in an HSA and they roll over from year to year, including interest.

More information about Consumer Choice and HSAs is available on page six (6) of the 2014 Retiree Benefit Matters guide.

NEW! NEW VALUE PPO
Mid-level out-of-pocket expense, mid-level premium contribution

In-Network Benefits - Retirees who choose in-network providers pay:

  • Annual deductible of $1,250 for individual ($2,500 for family coverage) for plan year 2014
  • Office visit co-pays: Primary Care - $30 Premium Designation Specialist - $35 Urgent Care - $50 Specialist - $55 These payments are not subject to the deductible or co-insurance, but they do count toward your out-of-pocket maximum.
  • Once the deductible is satisfied, you pay 20% of discounted eligible expenses up to a maximum of $3,000 for an individual or $6,000 for family coverage per year, excluding the deductible. Amounts above this annual maximum are paid by the City at 100% of eligible expense.

PREMIER PPO
Lower out-of-pocket expenses, higher premium contribution

In-Network Benefits - Retirees who choose in-network providers pay:

  • Annual deductible of $600 for individual ($1,500 for family coverage) for plan year 2014
  • Office visit co-pays: Primary Care - $30 Premium Designation Specialist - $35 Urgent Care - $50 Specialist - $55 These payments are not subject to the deductible or co-insurance, but they do count toward your out-of-pocket maximum.
  • Once the deductible is satisfied, you pay 20% of discounted eligible expenses up to a maximum of $2,200 for an individual or $4,400 for family coverage per year, excluding the deductible. Amounts above this annual maximum are paid by the City at 100% of eligible expense.

Prescription Drug Benefit

The City’s prescription drug benefit, administered by UnitedHealthcare, provides you with access to a wide variety of drugs while helping to make the medications you need more affordable. You also have access to more than 60,000 in-network pharmacies to fill your next prescription.

The 2014 prescription drug co-pays are below. For additional details, including information about the Automatic Generics and Value-Based Co-pays Programs and the convenience of the OptumRx Mail Service Pharmacy Program, see page seven (7) of the 2014 Retiree Benefit Matters guide.

2013 Prescription Drug Plan


New Value and Premier
Co-pays

Value-Based Co-pays
(Diabetes Medications)

                                                                            30-day Retail

Tier 1 (generics)

$10

$0

Tier 2 (preferred brand formulary)

$35

$10

Tier 3 (non-preferred brand)

$65

$20

Tier 4 (specialty)

$100

N / A

                                                                            90-day Mail Order

Tier 1 (generics)

$20

$0

Tier 2 (preferred brand formulary)

$70

$20

Tier 3 (non-preferred brand)

$130

$40

Tier 4 (specialty)

$200

N / A

Remember, Consumer Choice does not have co-pays. You are responsible for 100% of the cost of your medication until you reach your deductible. For IRS-approved maintenance medications you only pay 20% of the cost since these medications are not subject to the deductible. Click here for a complete list of these medications.


Vision
Retirees continue to have a voluntary vision plan benefit available to them. The City's vision plan benefit, administered by Davis Vision, provides you and your dependents with access to a national network of doctors and retail providers to help you care for your eyes. Eye exams, eyeglasses, and contacts are available to you at only the cost of applicable co-pays. To locate a vision provider near you or for additional information, log onto www.davisvision.com, click on the Members tab, and enter the 2471 (City's Client Code) in the Open Enrollment section. You can also call Davis Vision at 1-800-448-9372. View page 10 of the 2014 Retiree Benefit Matters for additional vision plan details.

Contact Lens and Frame Benefits
Contact lenses selected (in lieu of eyeglasses) from Davis Vision's Contact Lens Collection are covered in full. With Davis Vision's Frame Collection, you have access to several designer and brand name frames (in lieu of contacts) at only the cost of applicable co-pays. Plan eyewear includes a one-year eyeglass breakage warranty at no cost to you.

Davis Vision Collection
To maximize your vision plan benefit, consider purchasing frames or contact lenses from the Davis Vision Collection. The Collection is available at most participating independent provider locations. Independent providers do not include retail stores such as Visionworks or Walmart. To locate a participating independent provider near you, visit www.davisvision.com.

Benefit Summary

Comprehensive Eye Exam - $10 co-pay, one exam per year

Frames (in lieu of contacts)

Contacts (in lieu of eyeglasses)

Once per calendar year beginning January 1.

Once per calendar year beginning January 1.

$130 retail allowance toward any frame from provider, plus 20% off balance³.

$150 retail allowance toward Non Collection Contact lenses, plus 15% off balance².

                                          OR                                           OR

Any Fashion or Designer frame from Davis Vision’s Collection¹ (value up to $175).

Any contact lenses from Davis Vision’s Contact Lens Collection¹.

One year eyeglass breakage warranty included at no additional cost.

Contact Lens Evaluation, Fitting & Follow Up
Care - Once per calendar year beginning January 1. Collection contact lenses covered in full, including fitting fee. Fitting fee is an additional charge minus 15% discount if Non Collection contact lenses².

Spectacle Lenses - Once per calendar year beginning January 1. For standard single-vision, lined bifocal, or trifocal lenses.

 

¹The Davis Vision Collection is available at most participating independent provider locations.
²For dependent children, monocular patients, and patients with prescriptions of 6.00 diopters or greater.
³Additional discounts not applicable at Walmart or Sam’s Club locations.


Dental
Retirees now have the opportunity to participate in a voluntary dental benefit administered by Delta Dental. For detailed plan information, including a directory of dental providers, the enrollment form, premiums, and plan highlights, visit www.deltadentalins.com/cityofsanantonio/retirees.html. You can also call 1-800-422-4234.

DeltaCare Dental HMO administered by Delta Dental

The DeltaCare Dental HMO is a dental plan that provides comprehensive dental care when services are obtained from an
in-network primary dentist. During open enrollment, select a dentist within a 35-mile radius of your zip code from the DeltaCare network to serve as your primary dentist.

With this plan, you are only responsible for the co-pays for any covered services you receive from your selected dentist. There are no deductibles, yearly maximums, or paperwork claims to file. Examples of common services and co-pays are listed below.

Description

Procedure Code

Co-Pay

Office Visit

D0999

$5

Oral exam, x-rays, and fluoride treatment

N/A

No cost

Prophylaxis (teeth cleaning twice a year)

D1110

No cost

Periodontal scaling and root planning, per quadrant

D4341

$40

Fillings (amalgam or resin) for one surface, anterior

D2140

$5

Surgical extraction, erupted tooth

D7210

$45

Root canal – molar (excluding final restoration)

N/A

$280

Crown– porcelain fused to predominantly base metal

D2750

$295

Orthodontics for children and adults

D8070 (children) / D8090 (adults)

$1,700 / $1,900



HIPAA Notice of Privacy Policies
Click here to view the HIPAA Notice of Privacy Policies.


Medicaid and the Children's Health Insurance Program (CHIP) Notice
Click here to view the Medicaid and CHIP notice.