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Welcome! An Introduction to the Health Options Program and Medicare for PSERS Retirees Turning Age 65
12/17/2019
Medicare/Health Options Program Video
Perhaps you had an opportunity to review
the introductory video available on
www.HOPbenefits.com prior to this meeting.
Let’s review the important points of this information so you can make the best decision
to meet your health care needs.
2
http:www.HOPbenefits.com
3
Good Summary Shown on Decision Tree
What Is Medicare?
Medicare is a federal government program to help seniors & disabled citizens with medical costs.
• Eligibility for Medicare generally begins at age 65.
• It is possible to become eligible for Medicare before age 65 if you qualify for Social Security disability benefits.
• Medicare coverage begins the 1st day of the month of 65th birthday (unless born on first day of month)
4
Original Medicare
Medicare does not cover all medical expenses. Part A covers many Part B covers a portion of hospital expenses medical/surgical/doctor costs
Medicare Pays
Individual (or other insurance) pays
Deductible $0 $1,408
Days 1-60 100% $0
Days 61-90 100% less $552/day
$552/day
Days 91-150 100% less $704/day
$704/day
Medicare Individual Pays (or other
insurance) pays
Deductible $0 $198
Costs 80% 20%
Part B premium usually deducted from Social Security benefit
2020 Monthly Part B Premium is $144.60 for most new enrollees
No current Part A premium
5
• Part C – Medicare Advantage Combines Original Medicare benefits with managed care benefits and may cover benefits not provided by Medicare; Requires payment of Part B premium
• Part C premium paid to Medicare Advantage plan
• Part D – Provides 3 stages of prescription drug coverage; member pays part of drug costs
• Premium paid to Medicare Part D plan
Benefits are administered through insurance plans licensed by the
federal government.
Newer Parts of Medicare
6
Becoming Enrolled in Original Medicare
• If you ARE currently receiving Social Security benefits, Medicare enrollment is automatic; your Medicare card will be sent to you about three months prior to your 65th birthday and you will be automatically enrolled into Medicare Parts A & B
• If you ARE NOT receiving Social Security benefits, Medicare enrollment at age 65 requires you to contact the Social Security Office or register online at www.medicare.gov
• Must be enrolled in Medicare Parts A & B to purchase additional insurance coverage to fill gaps
• Late enrollment into Part B will result in permanently higher (penalty) premium unless eligible for exception
Part B Exception
If currently covered by employer health plan due to active employment of you or your spouse, enrollment in Part B may be deferred without future
penalty until that employer coverage is no longer available.
7
How a Medicare Part D Plan Works
You Move to the Next Coverage Stage What You Pay
Stage When…
Initial Coverage
A portion of the cost depending on the plan
A portion of the cost (portion usually different from Initial Coverage Stage )
5% of the cost ($3.60 minimum for generics; $8.95 minimum for brands)
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Total drug spending (member & plan) reaches $4,020 in 2020
Member’s costs (not the plan’s payment) reaches $6,350 in 2020
Final stage
STOP
Move to Coverage
Gap
Coverage Gap Move to
Catastrophic
Catastrophic Coverage
Two Types of Additional Insurance to Help Pay for Gaps in Medicare Benefits
Medicare Supplement Plan • Helps to fill the coverage gaps of “Original”
Medicare benefits
• Medicare is primary coverage and supplement is secondary coverage
Medicare Advantage Plan • Combines “Original” Medicare benefits with
managed care benefits and may provide added benefits not available through Medicare; sometimes called “replacing Original Medicare”
1
2
11
You must be enrolled in both Medicare Parts A and B to purchase a Medicare Supplement or a Medicare Advantage plan.
9
Choose One or the Other—Not Both
Medicare Supplement
Part A Part B OR + Hospital Medical
Insurance Insurance
+
Part D Part D Medicare Prescription Medicare Prescription Drug Coverage
Drug Coverage Usually part of the combined plan
+
Medicare Supplement Insurance
Also known as Medigap
Medicare Advantage Plan
Part C (such as an HMO or PPO) Combines Parts A & B, may include Part D,
into a single plan, the benefits of which must equal or exceed the benefits provided
by Original Medicare
+
Coverage selection complete If you buy a Medicare Advantage Plan, you
don’t need and can’t be sold a Medicare Supplement
Coverage selection complete 10
Health Options Program Offers Both
Premium Assistance: Unique Advantage
Up to $100/month to reimburse basic health insurance premiums for qualifying retirees
Available only if purchasing coverage in the Health Options Program or an approved school employer plan
Non-taxable reimbursement added to your monthly retirement benefit
Premium Assistance is not payable to spouses, surviving spouses or
dependents even if the retiree qualifies.
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Eligibility for Premium Assistance
24-1/2 years of service
OR
15 years of service with termination of employment & retirement at or after age 62,
OR
PSERS disability
PLUS
Out of-Pocket Premium Cost for an approved Medical Plan:
• Former school employer’s group insurance approved for Premium Assistance
• Any option under the PSERS Health Options Program
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Health Options Program Eligibility
A PSERS retiree, survivor annuitant, their spouses and dependent children may enroll in the PSERS Health Options Program and select either one of the Medicare Supplement
plans or one of the Medicare Advantage plans
• Spouse and dependent(s) must select same carrier/similar coverage as retiree
• If both spouses are school retirees, different carrier/coverage may be selected
Pre-65 coverage is available with the Health Options Program for
spouses and/or dependent(s) not
yet eligible for Medicare.
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More Advantages of Health Options Program
Benefits with no exclusions for pre-existing conditions or benefit waiting period for PSERS retirees and dependents
Flexibility to change coverage options as needs change at time of Qualifying Events and during Annual Option Selection Period
Choices of Coverage to fit individual needs and resources
Competitive Premium Rates for comparable benefits
Premiums deducted from retiree’s monthly retirement benefit
Access to Free Resources
• Frequent Health Options Program newsletter
• Toll-free customer phone service 1-800-773-7725
• Website www.HOPbenefits.com
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http:www.HOPbenefits.com
Qualifying Events (QE)
• Qualifying Events are the only times individuals may enroll in Health Options Program.
• Enrollment must be done within the 180 days after experiencing a Qualifying Event.
• A Qualifying Event may provide an opportunity for all eligible family members to enroll.
• Initial eligibility for Medicare at age 65 is a common Qualifying Event when retirees enroll in Health Options Program.
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Qualifying Events
• A member retires or loses health care coverage under a school employer’s health plan
• An individual involuntarily loses health care coverage under a non-school employer’s health plan (including coverage under COBRA)
• An individual (including a spouse) attains age 65 and/or becomes eligible for Medicare
• A member’s status changes (including marriage, divorce, the addition of a dependent through birth/adoption, or the loss of a dependent’s eligibility for coverage)
• A retiree becomes eligible for Premium Assistance due to a change in legislation
• A plan approved for Premium Assistance terminates, or an individual moves out of an approved plan’s service area
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Personalized Statement
• Sent to current retirees 3-9 months before 65th birthday along with an invitation to Health Options Program group meeting
• Includes benefit highlights for HOP Medicare Supplement (including prescription drug options) and Medicare Advantage Plans
• Shows your personal coverage options available and monthly premiums
Don’t forget the $100 Premium Assistance non-taxable reimbursement you may be eligible to receive in your
monthly PSERS benefit payment!
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Options for Medicare-Eligible Retirees
Supplements to Original Medicare HOP Medical Plan & Value Medical Plan
May add:
• Medicare Part D Rx coverage Enhanced, Basic & Value Medicare Rx Options
• Voluntary dental benefits plan
Medicare Advantage Plans Various Medicare Part C Plans available in specific geographic areas; include Part D Rx Coverage; some include vision and dental
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The HOP Medical Plan
• A separate insurance that supplements “Original” Medicare
• Medicare remains your primary coverage; HOP Medical Plan is secondary coverage paying deductibles and coinsurance
• No annual out-of-pocket maximum, except for Major Medical benefits
• Can use any doctors/hospitals anywhere that accept Medicare; no “in” or “out” of network providers or restricted service area
• Non-profit self-insured plan for the sole benefit of participants; 100% of premiums go to pay claims & administrative expenses
• Discounted premium for this option when enrolling at age 65 or within 180 days of retirement occurring between ages 65-69
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Major Medical Benefits
A “$1 million safety net” that provides an additional level of coverage in the HOP Medical Plan to cover
some medical costs after Medicare benefits are exhausted
After you meet $250 annual deductible, benefits paid at 80%
Some examples of what’s covered: • Home intravenous (IV) therapy
• OB-GYN exams when not covered by Medicare every other year
• Medical expenses incurred while traveling outside of the United States (Medicare does not cover medical expenses incurred outside the United States)
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SilverSneakers® Fitness Program
SilverSneakers® is available to participants in the HOP Medical Plan & Pre-65 Medical Plan at no added cost
• Membership amenities include treadmills, weights, heated pools, fitness classes designed exclusively for seniors
• Special classes for SilverSneakers® members often available at participating fitness centers, now including most Curves and Snap locations
• Lists of participating fitness centers are maintained on the SilverSneakers® website www.silversneakers.com
• Use SilverSneakers® ID card sent to you after you enroll in either of these two medical plans each time you go to a participating facility
• Check with Medicare Advantage Plans to see what fitness benefits are provided by their coverage; benefits may differ by plan
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http:www.silversneakers.com
The Value Medical Plan
• Another separate insurance that supplements “Original” Medicare
• Medicare remains your primary coverage and the Value Medical Plan is your secondary coverage
• Can use any doctors/hospitals anywhere that accepts Medicare; No “in” or “out” of network providers or restricted service area
• Member pays first $300 of the Medicare Part A deductible and then the Plan pays all other Medicare eligible hospital expenses
• Member pays the Medicare Part B deductible and the Plan limits coverage for medical expenses partially paid by Part B
• Member’s annual out-of-pocket Medicare expenses capped at $5,000
• Does not include Major Medical benefits; no coverage for medical expenses incurred out of the United States
• SilverSneakers® not included
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Exclusions to Supplemental Plans
Costs Not Covered by Medicare, the HOP Medical Plan or the Value Medical Plan:
• Long-Term/Custodial Nursing Home Care
• Routine hearing (exams/hearing aids)
• Routine eye care (exams, prescription lenses, frames)
• All dental care (exams, cleanings, x-rays, fillings)
*MetLife Dental coverage can be added to either Plan
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Can be added to the HOP Medical or Value Medical Plans
The MetLife Dental Plan
• Offers in-network preventive care at no cost
• Provides up to $1,350/year in dental benefits, excludes preventative services
• In-network discounts apply after limit is reached
• No pre-existing condition restrictions
• TMJ & orthodontics are not covered
• Current HOP members may add during Fall 2019 Option Selection Period
• Opportunity to add dental at Age 65 Qualifying Event or upon initial HOP enrollment occurring after age 65
Member Pays In Network Out of Network
2 exams/cleanings +1 bite-wing x-rays $0 20%
Deductible-Basic & Major Services $0 $100
Basic services (fillings) 30% 50%
Major services (crowns) 40% 50%
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Prescription Drugs (Medicare Part D)
Rx = Prescription Drug
• Enhanced Medicare Rx Option
• Basic Medicare Rx Option
• Value Medicare Rx Option
Enhanced Medicare Rx Option
Basic Medicare Rx Option
Value Medicare Rx Option
Uses the Enhanced & Basic Formulary Uses the Gold5 Formulary
Covers more prescriptions
Lower out-of-pocket costs
Covers all of Meets Medicare’s Medicare’s required minimum coverage prescriptions requirements
Cost sharing Cost sharing and deductible
All Options have Catastrophic Stage coverage for extreme Rx expenses
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Abridged Prescription Drug Formularies
• Two separate formularies showlist of drugs covered—alphabetically and by medicalcondition• Purple – Enhanced & Basic Rx• Blue – Value Rx (Gold5)
• Explains limitations/exceptions
• Comprehensive & AbridgedFormularies available online
• Enhanced Rx Option coversmedications not covered at allunder other plans—seeComprehensive Formulary fordetails
• Drugs available by mail order orat local pharmacies
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How Much You Pay for Prescription Drugs
Cost you pay depends on the tier of drug purchased and in what coverage stage you are at time of purchase
Different Benefits for Different Drug Types
Preferred Generic (Tier 1)
Drug chemically equivalent to name brand; not under patent; usually least costly
Non-Preferred Generic (Tier 2)
Drug chemically equivalent to name brand; not under patent
Preferred Brand (Tier 3)
Patented name brand drug for which a generic equivalent is not available
Non-Preferred Brand (Tier 4)
Name brand drug for which a generic equivalent is available (patent expired)
Specialty (Tier 5) High cost oral or injectable drugs used to treat complex conditions
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- -
Enhanced Rx Option - 2020
You Pay Retail Pharmacy Mail Order
$0 Annual Deductible
Initial Coverage Stage up to a total drug cost of $4,020
Tier 1
Tier 2
Tier 3
Tier 4
Tier 5
30 day supply 31-90 day supply Up to 90 day supply
$4 maximum $12 $12
$11 maximum $33 $33
25% to maximum of $150
25% to maximum of $300
25% to a maximum of $280
35% to maximum of $200
35% to maximum of $400
35% to a maximum of $380
33% no maximum (30 days only)
Coverage Gap Stage up to TrOOP (True Out of Pocket) Maximum of $6,350
All Tiers 25% (70% manufacturer discount also applies to TrOOP)
Catastrophic Coverage Stage after reaching TrOOP (True Out-of-Pocket) Maximum of $6,350
Generic
Name Brand
Greater of 5% or $3.60 to maximum of $100
Greater of 5% or $8.95 to maximum of $100
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- -
You Pay
Basic Rx Option - 2020
Retail Pharmacy Mail Order
$100 (excludes generics) Annual Deductible
Initial Coverage Stage up to a total drug cost of $4,020
Tier 1
Tier 2
Tier 3
Tier 4
Tier 5
30 day supply 31-90 day supply Up to 90 day supply
$5 maximum $15 $15
$12 maximum $36 $36
30% to maximum of $200
30% to maximum of $500
30% to a maximum of $450
40% no maximum
30% no maximum (30 days only)
Coverage Gap Stage up to TrOOP (True Out of Pocket) Maximum of $6,350
All Tiers 25% (70% manufacturer discount also applies to TrOOP)
Catastrophic Coverage Stage after reaching TrOOP (True Out-of-Pocket) Maximum of $6,350
Generic
Name Brand
Greater of 5% or $3.60 to maximum of $250
Greater of 5% or $8.95 to maximum of $250
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- -
Value Rx Option - 2020
You Pay
Uses the OptumRx Gold5 Formulary
Retail Pharmacy & Mail Order
$435 Annual Deductible
Initial Coverage Stage up to a total drug cost of $4,020
Tier 1
Tier 2/3/4/5
$2 for 30 day supply; $6 for 31-90-day supply (not subject to annual deductible)
25% no maximum
Coverage Gap Stage up to TrOOP (True Out of Pocket) Maximum of $6,350
All Tiers 25% no maximum
(70% manufacturer discount also applies to TrOOP)
Catastrophic Coverage Stage after reaching TrOOP (True Out-of-Pocket) Maximum of $6,350
Generic
Name Brand
Greater of 5% or $3.60
Greater of 5% or $8.95
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Medicare Rx Options
Enhanced Basic Value Medicare Rx Medicare Rx Medicare Rx
Option Option Option
Single $128 $69 $23
Rates shown in Personalized Statement include the Rx premium Premium Assistance not payable for enrollment in a Rx plan only Prior Authorization & Step Therapy requirement for some medications On-line tool for prescription drugs covered through OptumRx:
Access www.HOPbenefits.com Click on “Find a Drug” Select “Formulary Lookup Tool” Enter the name of your medication in the “Drug name” box Click search button
32
http:www.HOPbenefits.com
Tips for Selecting a Medicare Rx Plan
Some General “Rules of Thumb”
Adequate Rx coverage at the lowest overall cost to you (considering the deductible, co-pays and premiums you pay) may be provided by:
• The Value Rx Plan - if you are taking a very minimal number of low-cost drugs and primarily want coverage for the unexpected
• The Basic Rx Plan - if your total drug costs remain within the Initial Stage of Part D benefits
• The Enhanced Rx Plan - if your total drug costs cause you to reach the Coverage Gap Stage and remain there for the balance of the year
• The Enhanced or Basic Rx Plan - if you reach the Catastrophic Stage, depending on the maximum out-of-pocket for your high cost medications
Individual circumstances may vary these general guidelines as to which plan best suits your needs.
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More Tips for Choosing a Medicare Rx Plan
Individual circumstances (numbers of drug taken, costs of those drugs) may vary the general guidelines as to which plan best suits your needs.
Enhanced Rx Option does not have an annual deductible.
Basic Medicare Rx Option has a $100 deductible for Brand & Specialty drugs.
Value Rx Option: • requires you to pay an up-front, out-of-pocket deductible ($435 annually for
2020, excluding Preferred Generics) for prescription drug costs before the coverage begins to pay a portion of your costs.
• uses a different formulary than the Enhanced & Basic Rx Options.
In selecting an Rx option, be sure to consider your total out-of-pocket costs (deductibles plus co-payments/co-insurance) plus the cost of the
monthly premiums to determine your best overall option.
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Combines “Original” Medicare and
managed care benefits • Enrollee must continue to pay Medicare Part B premium
• Must be enrolled in Health Options Program group Medicare Advantage plan to receive Premium Assistance
Medicare Advantage Plans
• Receive the highest level of benefits when using network or participating providers (doctors & hospitals)
• Emergency benefits covered for medical services received when traveling outside service area of any Medicare Advantage plan
• Medicare Advantage plans may provide some vision, hearing and dental allowances not available through Medicare/HOP Medical Plan
• Most Medical Advantage Plans include fitness and wellness benefits
See Personalized Statement for details about benefits and premium costs of various Medicare Advantage plan(s) available where you live
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Medicare Advantage Plans
Different Types of Coverage
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Require use of network providers and referrals
No referrals required
No non-emergency coverage for out-of-network services
Fixed co-pays when using in-network providers
Provides both in-network and out-of-network
services after deductibles & coinsurance
Plans have limited geographic service areas
Call the HOP Administration Unit at 1-800-773-7725 to request
detailed materials for the Medicare Advantage plan(s) available
where you live.
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Aetna Service Area
Aetna Medicare VO2 PPO Erie
Crawford
Mercer
Law-rence
Beaver
Washington
Greene
Warren
Venango
Forest
Butler
Clarion
Arm-strong
Allegheny
Westmoreland
Fayette Somerset
Bedford
Cambria Indiana
Elk
Jeffer-son
Clearfield
McKean
Hunting -don
Fulton
Franklin
Blair
Centre
Cameron
Clinton
Mifflin
Potter
Perry
Adams
Juniata
Lycoming
Snyder
Tioga
Sullivan
Col-umbia
Montour
Bradford
Dauphin
Lebanon
Lancaster
North-umberland
York
Wyom -ing
Luzerne
Carbon
Susque-hanna
Schuylkill
Berks
Chester
Lehigh
Wayne
Pike
Monroe
Lacka-wanna
Northampton
Delaware Philadelphia
Bucks
Available in all of Pennsylvania & New Jersey and parts of Florida, Maryland and New York
37
Capital BlueCross Service Area
Capital BlueCross BlueJourney PPO
38
Available in Pennsylvania + all other states except DE & MD Erie
Crawford
Mercer
Law-rence
Beaver
Washington
Greene
Warren
Venango
Forest
Butler
Clarion
Arm-strong
Allegheny
Westmoreland
Fayette Somerset
Bedford
Cambria Indiana
Elk
Jeffer-son
Clearfield
McKean
Hunting -don
Fulton
Franklin
Blair
Centre
Cameron
Clinton
Mifflin
Potter
Perry
Adams
Juniata
Lycoming
Snyder
Tioga
Sullivan
Col-umbia
Montour
Bradford
Dauphin
Lebanon
Lancaster
North-umberland
York
Wyom -ing
Luzerne
Carbon
Susque-hanna
Schuylkill
Berks
Chester
Lehigh
Wayne
Pike
Monroe
Lacka-wanna
Northampton
Delaware
Philadelphia
Bucks
Highmark Service Area
Freedom Blue Highmark PPO offered in 61 counties of PA and in all other states
Security Blue HMO Point-of-Service offered in Allegheny, Fayette, Greene, Indiana, Washington & Westmoreland Counties
39
Available in PA + all other states Erie
Crawford
Mercer
Law-rence
Beaver
Clearfield
Washington Bedford Lancaster
Greene
Warren
Franklin
Venango
Forest
Butler Arm-
Elk
Clarion Col-
strong
Allegheny Indiana Dauphin
Westmore-land
Fayette Fulton Philadelphia Somerset
Cambria
Jeffer
Lehigh
Delaware
-son
McKean
Hunting -don
Blair
Centre
Lebanon
Cameron Sullivan -ing
Clinton
Mifflin
Potter
Perry
Adams
Juniata
Lycoming
York
Snyder
Tioga
umbia Montour
Bradford
North-umberland
Wayne
Wyom
Luzerne
Carbon
Susque-hanna
Schuylkill
Berks
Chester
Pike
Monroe
Lacka-wanna
Northampton
Bucks
Independence Blue Cross Service Area
Independence Blue Cross Keystone 65 Select ($5/$40) HMO
Chester
Delaware
Philadelphia
Bucks
Available in Southeastern
Pennsylvania only
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UPMC Service Area
UPMC for Life HMO (University of Pittsburgh Medical Center)
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Available in parts of Pennsylvania only Erie
Crawford
Mercer
Lawr-ence
Beaver
Washington
Greene
Warren
Venango Forest
Butler
Clarion
Arm-strong
Allegheny
Westmoreland
Fayette Somerset
Bedford
Cambria Indiana
Elk
Jeffer -son Clearfield
McKean
Hunting -don
Fulton
Blair
Cameron
Clinton
Mifflin
Potter
Perry
Juniata
Lycoming
Snyder
Tioga
Sullivan
Bradford
Dauphin
Lebanon
Lancaster
York
Wyom -ing
Susque-hanna
Berks
Chester
Lehigh
Wayne
Lacka-wanna
Northampton
Delaware
Philadelphia
Bucks
HOP Pre-65 Medical Plan • Fee-for-service companion to HOP Medical Plan
and Value Medical Plan
• Details available in separate booklet
HOP Pre-65 Companion Plans
Managed Care Pre-65 Companion Plans • Aetna Premier Open Choice PPO
• Capital Blue Cross PPO
• Highmark PPO Blue (80-70 Plan)
• Independence Blue Cross – POS $20-$40/$250
• UPMC Health Plan EPO
Call the HOP Administration Unit (1-800-773-7725) if you want detailed materials for any Pre-65 Plan(s) available where you live.
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Follow These Steps to Enroll
• Review your Personalized Statement, comparing the different benefits and premiums for the options available to you
• Use enrollment application enclosed with Personalized Statement if you want to enroll in HOP Medical Plan, Value Medical Plan or HOP Pre-65 Medical Plan, one of the prescription drug options and/or dental coverage
• Call 1-800-773-7725 to request a packet if you want more details about any of the group Medicare Advantage (Part C) plans.
• Complete/submit the appropriate application about six weeks prior to your desired effective date; cannot submit more than 90 days in advance
• If you submit your application with fewer than 6 weeks before you want coverage to become effective, please include a check (payable to HOP) for the first month’s full premium
• Mail all enrollments to: HOP Administration Unit P.O. Box 1764 Lancaster, PA 17608-1764
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Questions?
Structure Bookmarks• • • • • • • • • • •
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