OneExchange: 2018 Retiree Open Enrollment Guide · If you are enrolled in Medicare or will become eligible to ... Open Enrollment Periods ... (medical and dental) The Open Enrollment

2018Retiree OpenEnrollment Guide

Open Enrollment PeriodEmpyrean: October 16 – November 10, 2017OneExchange: October 15 – December 7, 2017

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If you are enrolled in Medicare or will become eligible to enroll in Medicare in the next 12 months (during 2018), a Federal law gives you more choices about your prescription drug coverage. Please see page 9 for more details.

The information and descriptions in this Enrollment Guide are intended to be a summary of available benefits so you can consider alternatives suitable to your personal circumstances and requirements.

For plans governed by ERISA, this 2018 Open Enrollment Guide is a Summary of Material Modifications to the LLNS Health and Welfare Benefit Plan for Retirees (October 2017). LLNS reserves the right to amend or discontinue any benefit plan at any time. If there is a conflict between this Summary and the terms of the Plan document, the Plan document will govern.

ALL RETIREES AND ELIGIBLE DEPENDENTS Actions You Can Take During Enrollment Actions Permitted Outside of Open Enrollment (Qualifying Life Event) Dependent Eligibility Dental Benefit Choices Legal Benefit Program Vision Discount Accidental Death & Dismemberment (AD&D) HIPAA Special Enrollment Rights “Split Family“ Enrollment Beneficiaries Required Notices

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INTRODUCTION 4

MEDICAL FOR THOSE NOT ELIGIBLE FOR MEDICARE Changes for 2018 What You Need To Do During Open Enrollment Medical Plan Choices Mandatory Maintenance Prescription Mail Order Program Mental Health and Substance Abuse Benefits Health Savings Account (HSA)

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MEDICAL FOR THOSE MEDICARE ELIGIBLE AND CURRENTLY IN KAISER PERMANENTE SENIOR ADVANTAGE (KPSA) Changes for 2018 What You Need To Do During Open Enrollment Health Reimbursment Arrangement (HRA)

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MEDICAL FOR THOSE MEDICARE ELIGIBLE AND NOT IN KAISER PERMANENTE SENIOR ADVANTAGE (KPSA) Changes for 2018 What You Need To Do During Open Enrollment OneExchange California Birthday Rule (applies in California Only) KPSA Outside of California Health Reimbursment Arrangement (HRA) Medicare Prescription Drug “Gap“ (Donut Hole) Special Payment

PLAN RESOURCESCOMPARISON OF BENEFITSOPEN ENROLLMENT DATES AND EVENTS

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16 16 16 17 17 1818

TABLE OF CONTENTS

Open Enrollment Periods Empyrean: October 16 – November 10, 2017 OneExchange: October 15 – December 7, 20174

It’s Open Enrollment season again—the time of year to review your health and welfare benefits and make changes, if you choose to do so. LLNS provides you with this guide as an overview of what you can expect this Open Enrollment.

This guide is structured in five sections—information that applies to:

1 – all retirees and eligible dependents2 – those not eligible for Medicare 3 – Medicare eligible—currently in Kaiser 4 – Medicare eligible—not currently in Kaiser5 – Plan Comparison Charts (medical and dental)

The Open Enrollment presentations for retirees are scheduled for November 1, 2017 in Livermore. Presentation details are available on the back cover of this Open Enrollment guide.

In addition to this guide, you will also receive information from Empyrean Benefits Solutions (Empyrean) on your current coverages and options available for 2018. If you are eligible for Medicare you will also receive information from OneExchange.

We encourage you to carefully review the information in this guide, as well as any information you receive from Empyrean and/or OneExchange. Consider whether you are enrolled in plans that are right for you and your eligible family members and follow the instructions provided in the information you receive.

Review your Open Enrollment Information from Empyrean and OneExchange to ensure you are enrolled in the plans appropriate for you. If you do not want to make any changes to your current medical, dental, and legal plan elections, no action is required.

INTRODUCTION

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Have you recently moved?

If you have a change of address, please contact Empyrean’s Customer Care Center at (844) 750-5567 in addition to notifying your pension administrator (UC, CalPERS, or LLNS).

Open Enrollment Periods Empyrean: October 16 – November 10, 2017 OneExchange: October 15 – December 7, 2017 5

You can change your benefit elections outside of Open Enrollment if certain events occur and if you make the change within 31 days of the event. Generally, the event must affect eligibility and the election change must be due to and correspond with the event. Medical and dental plan elections may be changed during the calendar year only if you have a Qualifying Life Event. Such events include: • a change in your legal marital status or domestic partnership, including marriage, divorce, death of

your spouse or domestic partner, legal separation, or annulment; • a change in the number of your tax dependents including through birth, adoption, placement for

adoption, or death; • a change in employment status by you, your spouse, domestic partner, or dependent that results in

gaining or losing eligibility for coverage;• your dependent’s ability or inability to satisfy dependent eligibility requirements;• a change in residence by you, your spouse or domestic partner, or dependent that causes you to lose

access to providers in your plan’s network.

For more information see the LLNS Health and Welfare Benefit Plan for Retirees Summary Plan Description (October 2017) located at https://benefits.llnl.gov/content/assets/docs/retirees/LLNS-Retirees-SPD.pdf.

Open Enrollment is the only time during the calendar year when you can make changes to your medical, dental, or legal coverage unless you experience a Qualifying Life Event.

• Enroll in a different medical plan.• Enroll in the dental or legal plan.• Change to a different dental plan. (California residents only)• Suspend your medical and/or dental plan; or enroll in a plan if

you previously suspended coverage. • Enroll eligible family members in your medical, dental, and legal plans.• Cancel health plan coverage for currently enrolled family members. • If no changes are made during Open Enrollment you will remain

in the same plans. If you are enrolled in a medical plan through OneExchange, be sure to refer to the information on page 16.

ALL RETIREES AND ELIGIBLE DEPENDENTS

Open Enrollment changes go into effect on January 1, 2018.

Actions You Can Take During Open Enrollment

Actions Permitted Outside of Open Enrollment (Qualifying Life Event)

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If you are covering a dependent child whose eligibility requires tax dependency and tax dependency is lost at any time, promptly notify Empyrean at (844) 750-5567.

Note: If you do not notify Empyrean within 31 days of the event, you will not be able to add a dependent or make any other changes until the next Open Enrollment period, with benefit coverage effective the following January 1.


If an enrolled family member loses eligibility during the year, you are responsible for de-enrolling that family member. Don’t wait until Open Enrollment. A child who turns 26 is automatically de-enrolled by LLNS (legal wards are de-enrolled at 18). You are responsible for costs related to the enrollment of ineligible family members and you could be subject to penalties associated with the misuse of the plan if you continue coverage for family members who no longer meet LLNS eligibility rules. For more information see the LLNS Health and Welfare Benefit Plan for Retirees Summary Plan Description (October 2017). Questions about eligibility should be directed to Empyrean’s Customer Care Center at (844) 750-5567.

If you and your spouse or domestic partner are both LLNS employees/retirees, one of you may cover the other as a dependent, or each of you may have separate coverage. However, only one of you may cover all your children or the children of a domestic partner as dependents. You may change who covers them during the open enrollment period.

Legal insurance is offered through ARAG and is open to new enrollments this Open Enrollment period. The legal plan will be enhanced beginning January 1, 2018 with the addition of a General Law Package. The following are some of the services included in this new benefit:

• Child Custody/Child Support Agreement (Contested 8 hours)

• Elder Law• Insurance Disputes• Small Claims Court• State and Local Tax Collection Defense

• Delta Dental PPO (nationwide)• DeltaCare USA DMO (available in California only) There are no dental plan design changes for 2018. A dental plan comparison spreadsheet begins on page 26. Plan coverage details for 2018 are available by contacting Empyrean’s Customer Care Center (844) 750-5567 or at www.llnsretireebenefits.com. Please note there is a difference in the networks between these two plans. The Delta Dental PPO plan allows you to see any licensed dentist; the DeltaCare USA plan limits access to DeltaCare USA network dentists. If you have elected DeltaCare USA, make sure your dentist participates in the network by calling DeltaCare USA at (800) 422-4234.

Dependent Eligibility

Dental Benefit Choices

Legal Insurance

Additional information on covered benefits can be found athttps://benefits.llnl.gov/health-welfare/legal-insurance.

Legal Insurance - Monthly Rate

Retiree Only

Retiree & Spouse/Domestic Partner

Retiree & Child(ren)

Retiree & Family

$12.28

$16.80

$16.80

$18.30

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Legal plan billing is handled by Empyrean. Plan payments can be made to them by direct debit or check.


The vision discount program allows you to take advantage of negotiated savings from Vision Service Plan (VSP) through their Vision Savings Pass, resulting in lower out-of-pocket costs for many vision services. There is no cost to you for this plan. You and your eligible dependent(s) are automatically enrolled. Remember, only a VSP provider will be able to verify your eligibility for these discounts. Refer to page 27 for plan benefits.

Discount details are available from VSP. To speak with a VSP representative or to locate a VSP provider, call (800) 877-7195 or visit www.vsp.com.

There are no plan design or rate changes in 2018. AD&D insurance protects you and your family from the unforeseen financial hardship of an accident that causes death, dismemberment, or loss of sight, speech, or hearing. The plan provides worldwide coverage for you and your enrolled family members. Coverage details for 2018 are available by contacting AIG at (800) 772-7863.

Vision Discount

Accidental Death & Dismemberment (AD&D)

2018 AD&D Rates Per $1,000 of Coverage

An age based benefit reduction will begin at age 70 on the following schedule:

Retiree Only

Retiree & Spouse

Age

<70

70 – 75

75 – 80

80 – 85

85+

Percent of Benefit

100%

65%

45%

30%

15%

$0.90

$1.40

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If payment is not received in full by the grace period end date, all of your benefits will be cancelled (even those with no premium). Once coverages are cancelled, they may not be reinstated. To avoid cancellation, consider signing up for direct debit with Empyrean.


If you are declining enrollment in medical/dental coverage for yourself or your eligible dependents (including your spouse, domestic partner, dependent children and domestic partner’s dependent children) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in medical/dental coverage if you or your dependents lose eligibility for that other coverage (or if the employer stopped contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent due to marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. Your special enrollment request must be made within 31 days after the marriage, birth, adoption, or placement for adoption. Contact Empyrean at (844) 750-5567 for more information.

When a retiree and/or dependent reaches age 65, he or she becomes eligible to participate in a Medicare plan. If a retiree is Medicare eligible and a spouse is not (or vice versa), this is known as a “split family”. Each person’s corresponding available options will appear on the enrollment worksheet you’ll receive from Empyrean and on the “LLNS Retiree Benefits” website so that separate elections can be made. All retirees and dependents in a “split family” situation are able to review and make separate elections based on their individual eligibility.

If you or your dependent are becoming Medicare eligible in 2018 you will receive information on your new enrollment options about 120 days prior to your or your dependent’s 65th birthday.

Open Enrollment is a good time to review your beneficiary designations. You may change your designated beneficiary at any time and once your new designations are processed, all previous designations are invalid.

Contact the following organizations to change your beneficiary designation:

HIPAA Special Enrollment Rights (Health Insurance Portability and Accountability Act of 1996)

“Split Family” Enrollment

Beneficiaries

LLNS 401(k) plans

AD&D

Pension Single Sum Death Benefit (TCP1)

UCRP Lump Sum Death Benefit

PERS Death Benefit

Fidelity

AIG

LLNS Pension Center

UCRP

PERS

800-835-5095

800-772-7863

866-655-9587

800-888-8267

888-225-7377

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Be sure to contact Empyrean to:

• Update your address• Report a death

(844) 750-5567


Required Notices

Notice of Availability of Notice of Privacy Practices

The LLNS Health and Welfare Benefit Plan for Retirees (the “Plan”) provides health benefits to eligible retirees of Lawrence Livermore National Security, LLC (the “Company”) and their eligible dependents as described in the Summary Plan Description for the Plan. The Plan creates, receives, uses, maintains and discloses health information about participating retirees and dependents in the course of providing these health benefits. The Plan is required by law to provide notice to participants of the Plan’s duties and privacy practices with respect to covered individuals’ protected health information (“PHI”), and has done so by providing to Plan participants a notice of privacy practices, which describes the ways that the Plan uses and discloses PHI. To receive a copy of the Plan’s notice of privacy practices, you can go to the Benefits web site http://benefits.llnl.gov (select “Retirees” tab and click on “Privacy Notice”) or contact the Benefits Department at (925) 422-9955.

The Women’s Health and Cancer Rights Act of 1998

The Women’s Health and Cancer Rights Act of 1998 requires that if a group health plan provides medical and surgical benefits for mastectomies, it must also provide coverage for reconstructive surgery and prostheses following mastectomies.

The law mandates that a participant or beneficiary who is receiving benefits under the plan for a covered mastectomy, and who elects breast reconstruction in connection with the mastectomy, will also receive coverage for:

• Reconstruction of the breast on which the mastectomy was performed.

• Surgery and reconstruction of the other breast to produce asymmetrical appearance.

• Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.

This coverage will be provided in consultation with the patient and the patient’s attending physician and will be subject to the same annual deductible, co-insurance and/or co-payment provisions otherwise applicable under the plans.

Important Notice from LLNS about Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with LLNS and about your options

under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. LLNS has determined that the prescription drug coverage offered by the LLNS Health and Welfare Plan is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered Creditable Coverage. Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th. This may mean that you may have to wait to join a Medicare drug plan and that you may pay a higher premium (a penalty) if you join later. You may pay that higher premium (a penalty) as long as you have Medicare prescription drug coverage. However, if you lose creditable prescription drug coverage, through no fault of your own, you will be eligible for a sixty (60) day Special Enrollment Period (SEP) to join a Part D plan because you lost creditable coverage. In addition, if you lose or decide to leave employer sponsored coverage, you will be eligible to join a Part D plan at that time using an Employer Group Special Enrollment Period. You should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area.

If you do decide to join a Medicare prescription drug plan and drop your LLNS medical coverage (which includes prescription drug coverage), be aware that you and your dependents may not be able to get this coverage back until the calendar year after the following Open Enrollment period. Remember, your current LLNS medical coverage pays for other health expenses, in addition to prescription drugs. Contact OneExchange for more information about what happens to your coverage if you join a Medicare prescription drug plan.

You should also know that if you drop or lose your coverage


for Medicare prescription drug coverage is available. For information about this extra help visit Social Security on the web at www.socialsecurity.gov, or call them at (800) 772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).

Patient Protection Disclosure Notice

Kaiser Permanente generally requires the designation of a primary care provider. You have the right to designate any primary care provider who participates in their network and who is available to accept you or your family members. Until you make this designation, Kaiser Permanente designates one for you. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Kaiser at www.kp.org/llns or (800) 464-4000. For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from Kaiser Permanente or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in Kaiser’s network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Kaiser at www.kp.org/llns or (800) 464-4000.

The Anthem Blue Cross medical options do not require the designation of a primary care provider.

with LLNS and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 consecutive days or longer without prescription drug coverage that’s at least as good as Medicare’s prescription drug coverage, your monthly premium may go up at least 1% of the base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without coverage, your premium may consistently be at least 19% higher than the base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

Contact OneExchange at (866) 682-4841 for further information. NOTE: You will get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through LLNS changes.

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare drug coverage:

• Visit www.medicare.gov• Call your State Health Insurance Assistance Program (see

the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help

• Call 1-800-MEDICARE (1-800-633-4227); TTY users should call (877) 486-2048

If you have limited income and resources, extra help paying


MEDICAL FOR THOSE NOT ELIGIBLE FOR MEDICARE

Kaiser• Copay for Specialist visit increasing to $35 from $25• Copay for Outpatient Surgery increasing to

$150 per procedure from $100• Copay for generic prescription drugs increasing

to $15 from $10• Rates for 2018 will be provided by Empyrean

Anthem Blue Cross EPO• No plan design changes for 2018• Rates for 2018 will be provided by Empyrean

Anthem Blue Cross Plus• No plan design changes for 2018• Rates for 2018 will be provided by Empyrean

Anthem Blue Cross PPO• No plan design changes for 2018• Rates for 2018 will be provided by Empyrean

Anthem Blue Cross Core Value • No plan design changes for 2018• Rates for 2018 will be provided by Empyrean

Changes for 2018

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IMPORTANT: Details are contained in the medical plan comparison chart that begins on page 20.

Be sure to carefully review this information.

Anthem Blue Cross Plus, PPO, and Core Value DeductiblesAnthem Blue Cross will keep track of two different types of health insurance deductibles for each family member: the individual deductible and the family deductible. When a family member has met the individual deductible amount, Anthem Blue Cross begins paying for this person’s expenses, but not the health care expenses of other family members. If other family members have paid enough in individual deductibles that added together the family deductible has been met, Anthem Blue Cross begins paying the health care expenses for the entire family, even the family members that haven’t paid anything at all toward their individual deductible. This process is known as an embedded deductible.


Review all information received

• Empyrean will continue to administer non-Medicare eligible enrollees for medical coverage.

• Empyrean will continue to administer dental and legal coverages and the vision discount program for all retirees and their eligible dependents.

• You will receive a Personal Enrollment Worksheet from Empyrean in early-October that provides all available options and rates, as well as your default coverage if you do not make any changes. You can also view your options and rates online at www.llnsretireebenefits.com. Carefully review all Open Enrollment information you receive to make the best decision for your situation.

• If no changes are made during Open Enrollment, you will remain in the same plans.

Contact Empyrean(844) 750-5567 www.llnsretireebenefits.com • To make your elections, changes, or cancellations.• To set up Direct Debit payment of your account balance.

After your election has been made, a confirmation statement will be mailed to your address of record.

What You Need To Do During Open Enrollment

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Please note that Empyrean Open Enrollment lines open at 7:00 a.m. Pacific time on Monday, October 16, 2017.

The last day to make an election is Friday, November 10, 2017, 5:00 p.m. Pacific time.


You are encouraged to evaluate your options to ensure that the choice you made for the current year still meets your needs. A more detailed explanation of plan coverages and exclusions are available from Empyrean. The non-Medicare plans available for 2018 include:

All Anthem plans use the same network as the Anthem Blue Cross PPO, providing a nation-wide network for coverage. A more detailed explanation of plan coverages and exclusions are available from the carrier.

For Anthem Blue Cross plans, the mandatory mail order program for maintenance medications remains in effect in 2018. CVS/Caremark offers the Maintenance Choice program which allows you to fill a mandatory mail order drug at a local CVS pharmacy for the same cost as mail order. You can call CVS/Caremark Customer Service at 1-866-623-1438 with any questions you may have about their services.

LLNS medical plans include mental health and substance abuse benefits as follows:

Kaiser: Kaiser Members continue to access all mental health and substance abuse services through Kaiser physicians or facilities.

Anthem Blue Cross plans: All mental health and substance abuse services are provided by Anthem Blue Cross. To ensure full coverage of your services, contact Anthem Blue Cross for authorization of your visits.

Refer to the medical plan comparison chart that begins on page 20 for benefit details.

The Anthem Blue Cross Core Value plan is HSA compatible. A HSA is a tax-advantaged account which can be used to save money for eligible medical expenses. If you enroll/are enrolled in the Core Value option, you can set up a HSA through most financial institutions. The financial institution will provide you with details about eligible expenses, how much you can contribute, etc. NOTE: Your enrollment in another medical plan (including Medicare) may impact your eligibility to participate in a HSA.

Medical Plan Choices

Mandatory Maintenance Prescription Mail Order Program

Mental Health and Substance Abuse Benefits

Health Savings Account (HSA)

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If you or your dependent becomes eligible for Medicare before age 65, contact Empyrean at (844) 750-5567

• Kaiser Permanente CA• Anthem Blue Cross PPO• Anthem Blue Cross EPO

• Anthem Blue Cross Core Value• Anthem Blue Cross Plus


MEDICAL FOR THOSE MEDICARE ELIGIBLE AND CURRENTLY IN KAISER PERMANENTE SENIOR ADVANTAGE (KPSA)

Changes for 2018


• The maximum employer contribution to the Health Reimbursment Arrangement (HRA) remains at $2,450.

• KPSA enrollees may change to a plan offered by OneExchange.• Rates for 2018 will be provided by Empyrean.• See HRA information on page 15 that may affect how your premiums are paid.


• Carefully review all Open Enrollment information you receive in order to make the best decision for your situation.

• If you want your coverage to remain with Kaiser, do nothing this Open Enrollment and your coverage will continue with Kaiser.

• If you change your Medicare plan to OneExchange, a Kaiser disenrollment form is required to complete the transaction.

• Empyrean will continue to administer KPSA of California coverage for Medicare eligible enrollees with their HRA administered by Kaiser.

• OneExchange will continue to administer medical benefits and the HRA for all Medicare eligible enrollees not in KPSA of California.

Contact Empyrean(844) 750-5567www.llnsretireebenefits.com

• Suspend your Kaiser coverage to elect medical through OneExchange• If you want to change your medical coverage to a plan other than Kaiser. You will then need to contact

OneExchange at (866) 682-4841 to enroll in another medical plan. If you elect a plan other than KPSA, all Medicare eligible participants in your family must also select a new plan through OneExchange.

• For dental plan enrollments/changes/cancellations• For legal plan enrollments/changes/cancellations• To change your address or report a death• To set up Direct Debit for automatic payment of your account balance


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Health Reimbursement Arrangement (HRA)

Each year LLNS contributes a designated amount to your HRA—a special, tax-free, employer-funded account you use to pay for eligible medical expenses and prescription drugs. The employer contribution is prorated to your graduated eligibility based on your years of service determined at the time of your retirement. For 2018, the maximum contribution will remain at $2,450 for each Medicare eligible retiree and Medicare eligible dependent. Any unused amount in your HRA will rollover to the next year. Further details about KPSA of California coverage and the HRA are available from the Kaiser HRA Payment Center at (877) 761-3399.

• Your benefit dollars will be placed in a HRA account that you can use to pay for eligible medical expenses and prescription drugs.

• You pay the full cost of your KPSA of California premiums and can use the money in your HRA account for reimbursement of this cost.

• You can arrange to pay your monthly premiums by setting up an automatic payment to Empyrean. You must set up your automatic payment each year.

Note: The Kaiser plan does not have the prescription drug coverage gap (donut hole), so the donut hole special payment does not apply to KPSA enrollees.

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Contact the Kaiser HRA Payment Center to:

• Set up monthly automatic payments for your KPSA premium (required annually)• Request reimbursement of out of pocket medical or

prescription expenses

(877) 761-3399


MEDICAL FOR THOSE MEDICARE ELIGIBLE AND NOT IN KAISER PERMANENTE SENIOR ADVANTAGE (KPSA)

Changes for 2018


OneExchange

• The maximum donut hole special payment for enrollees not in KPSA will increase to $2,500 for those enrolled in a plan through OneExchange.

• The maximum employer contribution to the HRA remains at $2,450.• KPSA is available for new enrollments for those who live in California. See the medical plan comparison

chart that begins on page 20 for coverage details.• KPSA is also available for new enrollments for those who live outside California in a Kaiser service area

(see page 17).


• The Personal Enrollment Worksheet you receive from Empyrean provides all available options and rates which are offered through Empyrean. Plan offerings through OneExchange are not represented in this Worksheet. If your current medical plan election states “No Coverage” this may be because you have enrolled in a plan through OneExchange or have suspended your coverage.

• OneExchange will continue to administer health care benefits for Medicare eligible enrollees not enrolled in Kaiser. Carefully review all Open Enrollment information you receive in order to make the best decision for your situation.

• If you do not make a new plan selection with OneExchange you will remain in the same plan in 2018. • You must be enrolled in a medical plan through OneExchange to receive the HRA for 2018.• If you have been notified that your current plan will be terminating you must contact OneExchange to

select a new plan.• Please note that while your plan will continue in 2018, benefits and costs may change. Review all

information from your individual plan.• There are limitations on when you can change plans with certain Medicare plans. Make sure to discuss

your options with a OneExchange Benefit Advisor.

OneExchange will continue to administer health care benefits (except for KPSA) for Medicare-eligible retirees and their Medicare-eligible dependent(s), providing you with a wide array of coverage options and allowing you to personalize your coverage and control your costs. (Dental plan coverage remains with Empyrean.) As experts in the Medicare market, OneExchange Benefit Advisors can help you find and enroll in a plan that best fits your needs and budget. Coverage for non-Medicare eligible enrollees remains with Empyrean. If you or any eligible family member becomes Medicare eligible mid-year the coverage will be moved to OneExchange unless you enroll in KPSA.

If you are satisfied with your current health care coverage and do not wish to make any changes, there is no need to contact OneExchange. If you have been notified that your current plan will be terminating you must contact OneExchange to select and enroll in another plan.


California Birthday Rule (Applies in California only. New York, Connecticut, Oregon, Maine and Missouri have similar laws.)

KPSA Outside of California

California has a unique supplement law known as the birthday rule that allows residents to enroll for Medicare supplements with a different insurance company for 30 days following their birthday. The new Medigap plan must offer either the same benefits or fewer benefits, and companies are not allowed to deny new applicants for health reasons.

KPSA is available to retirees living outside California (in parts of Colorado, Georgia, Hawaii, Oregon, Washington, and mid-Atlantic states (Maryland, Virginia, and Washington DC)). If you live outside California and want to change to the KPSA plan, here are the steps to enroll:

• Call Kaiser at (866) 955-8510 to request an individual enrollment kit for your area, or log on to kp.org/Medicare.

• Complete the Kaiser Permanente Medicare enrollment form and send it in per the instructions on the form.• After you receive confirmation of your enrollment, notify OneExchange by submitting proof of enrollment

(e.g. KPSA card, enrollment letter). OneExchange will continue to administer the HRA for retirees enrolled in a KPSA plan outside of California. The address is:

Lisa StarrTowers Watson OneExchange

10975 S. Sterling View Drive, Suite 1ASalt Lake City, UT 84095

OneExchange will send you a HRA enrollment kit after receiving your confirmation of enrollment in a KPSA plan.

Contact OneExchange(866) 682-4841www.medicare.oneexchange.com

• If you want to find and enroll in a different medical plan and/or prescription drug plan.

• If you wish to enroll in KPSA and are currently enrolled in a plan through OneExchange.


Contact Empyrean(844) 750-5567www.llnsretireebenefits.com

• For dental plan enrollments/changes/cancellations• For legal plan enrollments/changes/cancellations• If you wish to enroll in KPSA• To setup Direct Debit for automatic payment of your account balance

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Please note that OneExchange Open Enrollment lines open at 6:00 a.m. Pacific time on Monday, October 16, 2017. The last day to make an election is Thursday, December 7, 2017, 6:00 p.m. Pacific time.


Health Reimbursement Arrangement (HRA)

Medicare Prescription Drug “Gap” (Donut Hole) Special Payment

Each year LLNS contributes a designated amount to your HRA—a special, tax-free, employer-funded account you use to pay for eligible medical expenses and prescription drugs. You must be enrolled in a Medicare plan through OneExchange to be eligible for the HRA funds. The employer contribution is prorated to your graduated eligibility based on your years of service determined at the time of your retirement. For 2018, the maximum contribution will remain at $2,450 for each Medicare eligible retiree and Medicare eligible dependent. There is no reimbursement for Part B but your HRA money can be used for this expense. Any unused amount in your HRA will rollover to the next year. Further details about the HRA are available from OneExchange.

• Your benefit dollars will be placed in a HRA account that you can use to pay for eligible medical expenses and prescription drugs.

• You pay the full cost of your premiums and can use the money in your HRA account for reimbursement of this cost.

• Check with OneExchange to see if your medical and prescription drug plans are eligible for auto reimbursement.

LLNS makes a special payment to those Medicare enrollees who reach the prescription drug “gap” or “donut hole” during any year. Under Medicare Part D, once you have reached your initial coverage limit for prescription drugs, you will be responsible for paying 100% of your drug costs until you have reached a maximum out-of-pocket amount determined by Medicare. This is called the Medicare Part D coverage gap or the “donut hole.”

As a result of Healthcare Reform, once an enrollee reaches the donut hole in 2018, the $5,000 retiree out-of-pocket (donut hole) is fulfilled based on both the retiree’s 50% cost for prescription medications plus the 50% discount provided by the drug manufacturer at the point of sale. In 2018, the LLNS maximum donut hole special payment will be $2,500, representing 50% of the $5,000.

This payment will be a prorated amount based on the month the donut hole is reached. It will be calculated using a ratio of the number of months left in the current year divided by twelve times that year’s estimated donut hole amount. For example, the 2018 gap amount is estimated to be $2,500; if the donut hole is reached in September, the special payment would be 4/12 times $2,500 or $833.

To be eligible for the HRA and the “donut hole” special payment through OneExchange, you must be enrolled in a medical plan through OneExchange. For more information contact OneExchange Administrators at (866) 682-4841, Option #4.

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The deadline to submit your claim for the 2017 donut hole special payment is March 31, 2018.


PLAN RESOURCES

Empyrean

OneExchange – General, Donut Hole, & HRA

Medicare

Social Security Administration

Kaiser Permanente CA

Kaiser Senior Advantage

Kaiser HRA

Anthem Blue Cross EPO

Anthem Blue Cross PLUS

Anthem Blue Cross PPO

Anthem Blue Cross Core Value

CVS/Caremark

Delta Dental PPO

Delta Care DMO

Vision Service Plan

ARAG Legal Plan

AD&D

Carrier/Plan URL Telephone #

www.llnsretireebenefits.com

https://medicare.oneexchange.com/llns

www.medicare.gov

www.ssa.gov

www.kp.org/llns

www.kp.org/llns

www.kp.org/healthpayment

www.anthem.com/ca/llns




www.caremark.com

www.deltadentalins.com/llns

www.deltadentalins.com/llns

http://www.vsp.com/

www.araglegalcenter.com

(844) 750-5567

(866) 682-4841

(800) 633-4227

(800) 772-1213

(800) 464-4000

(800) 443-0815

(877) 761-3399

(866) 641-1689

(866) 641-1689

(866) 641-1689

(866) 641-1689

(866) 623-1438

(800) 777-5854

(800) 422-4234

(800) 877-7195

(800) 247-4184

(800) 772-7863


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less

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Sen

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pay;

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et

In-n

etw

ork:

80%

co

vere

d af

ter

dedu

ctib

le

is m

et

In-n

etw

ork:

90%

co

vere

d

$500

cop

ay p

er

adm

issi

on; $

100

copa

y fo

r tr

ansi

tiona

l re

side

ntia

l rec

over

y se

rvic

es; m

enta

l hea

lth/

chem

ical

dep

ende

ncy

serv

ices

acc

rue

to o

ut-o

f-po

cket

max

imum

$250

cop

ay p

er a

dmis

sion

; $1

00 c

opay

for

tran

sitio

nal

resi

dent

ial r

ecov

ery

serv

ices

; m

enta

l hea

lth/c

hem

ical

de

pend

ency

ser

vice

s ac

crue

to

out-

of-p

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imum

Out

-of-

netw

ork:

60%

cov

ered

af

ter

dedu

ctib

le is

met

; sub

ject

to

Max

imum

Allo

wed

Am

ount

Out

-of-

netw

ork:

60%

co

vere

d af

ter

dedu

ctib

le

is m

et; s

ubje

ct to

M

axim

um A

llow

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Amou

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Out

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ork:

60%

co

vere

d af

ter

dedu

ctib

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is m

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ubje

ct to

M

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No

cove

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Out

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wor

kN

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vera

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ut-o

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ork

No

cove

rage

Out

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wor

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Chir

opra

ctic

/A

ccup

unct

ure

In N

etw

ork

- $25

cop

ay; l

imite

d to

25

visi

ts p

er c

alen

dar

year

In N

etw

ork

- 80%

co

vere

d af

ter

dedu

ctib

le

is m

et; l

imite

d to

25

visi

ts

per

cale

ndar

yea

r

In N

etw

ork

- 80%

co

vere

d af

ter

dedu

ctib

le

is m

et; l

imite

d to

25

visi

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er y

ear;

com

bine

d in

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wor

k an

d ou

t-of

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twor

k

$25

copa

y; li

mite

d to

25

visi

ts p

er c

alen

dar

year

Mem

ber

disc

ount

s av

aila

ble

thro

ugh

Amer

ican

Spe

cial

ty

Hea

lth n

etw

ork

Mem

ber

disc

ount

s av

aila

ble

thro

ugh

Amer

ican

Spe

cial

ty

Hea

lth n

etw

ork

Out

of N

etw

ork

- 60%

cov

ered

af

ter

dedu

ctib

le is

met

; lim

ited

to 2

5 vi

sits

per

cal

enda

r ye

ar;

subj

ect t

o M

axim

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llow

ed

Amou

nt

Out

of N

etw

ork

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co

vere

d af

ter

dedu

ctib

le

is m

et; l

imite

d to

25

visi

ts p

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alen

dar

year

; su

bjec

t to

Max

imum

Al

low

ed A

mou

nt

Out

of N

etw

ork

- 60%

co

vere

d af

ter

dedu

ctib

le

is m

et; l

imite

d to

25

visi

ts p

er c

alen

dar

year

; co

mbi

ned

in-n

etw

ork

and

out-

of-n

etw

ork;

su

bjec

t to

Max

imum

Al

low

ed A

mou

nt; b

enefi

t lim

ited

to $

25 p

er v

isit

No

cove

rage

Out

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Net

wor

kN

o co

vera

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ut-o

f-N

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ork

Not

App

licab

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Pres

crip

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dru

g ve

ndor

Care

mar

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rem

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Care

mar

kCa

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Kais

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Pres

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dru

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es1-

866-

623-

1438

1-86

6-62

3-14

381-

866-

623-

1438

1-86

6-62

3-14

381-

800-

464-

4000

1-80

0-44

3-08

15(K

PSA

Mem

ber

serv

ices

)

Pres

crip

tion

dru

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eb

site

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com

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com

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w.k

p.or

g/lln

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org/

llns

Ann

ual p

resc

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ion

dedu

ctib

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ot a

pplic

able

Not

app

licab

le

Med

ical

ded

uctib

le

appl

ies;

mem

ber

pays

10

0% o

f the

Rx

cost

unt

il m

edic

al d

educ

tible

is

met

Not

app

licab

leN

ot a

pplic

able

Not

app

licab

le

Pres

crip

tion

ben

efi t

s ar

e co

vere

d un

der

med

ical

ded

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ble

No

No

Yes

No

Not

app

licab

leN

ot a

pplic

able

Ann

ual R

x O

ut-o

f-po

cket

max

imum

$2,8

00 In

divi

dual

; $5,

700

Fam

ily

(in-n

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ork

only

)$2

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vidu

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4,20

0 Fa

mily

(in-

netw

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only

)

Med

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out

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pock

et

max

imum

app

lies;

onc

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edic

al o

ut-o

f-po

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m

axim

um is

met

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is 1

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cov

ered

for

the

rem

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f the

ca

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ear

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divi

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000

Fam

ilyN

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able

Not

app

licab

le

2018

Med

ical

Pla

n O

ptio

ns C

ompa

riso

n of

Ben

efi t

Cov

erag

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r th

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not

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icar

e El

igib

leFo

r th

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icar

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Anth

em B

lue

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PPO

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lue

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sCo

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alue

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em B

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sEP

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xclu

sive

Kais

erKa

iser

Sen

ior

Adva

ntag

e

Reta

il ge

neri

c

In N

etw

ork

- $10

cop

ay; 3

0 da

y su

pply

Out

of N

etw

ork

- 50%

of

aver

age

who

le p

rice

sch

edul

e pl

us c

harg

es a

bove

the

sche

dule

In N

etw

ork

- $10

cop

ay;

30 d

ay s

uppl

yO

ut o

f Net

wor

k - 5

0%

of a

vera

ge w

hole

pri

ce

sche

dule

plu

s ch

arge

s ab

ove

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sche

dule

In N

etw

ork

- 80%

co

vere

d af

ter

dedu

ctib

le

is m

etO

ut o

f Net

wor

k - 6

0%

cove

red

afte

r de

duct

ible

is

met

$10

copa

y; 3

0 da

y su

pply

; Non

-par

ticip

atin

g ph

arm

acie

s: 5

0% o

f av

erag

e w

hole

pri

ce

sche

dule

plu

s ch

arge

s ab

ove

the

sche

dule

$15

for

up to

a 3

0-da

y su

pply

; $30

for

up to

a

100-

day

supp

ly; a

t Kai

ser

Phar

mac

y; a

s pr

escr

ibed

by

Pla

n Ph

ysic

ian

$10

for

up to

a 3

0-da

y su

pply

, $3

0 fo

r up

to a

100

-day

su

pply

; at K

aise

r Ph

arm

acy;

as

pres

crib

ed b

y Pl

an P

hysi

cian

Reta

il fo

rmul

ary

bran

d

In N

etw

ork

- 80%

cov

ered

; $40

m

inim

um c

opay

, $60

max

imum

co

pay;

30

day

supp

lyO

ut o

f Net

wor

k - 5

0% o

f av

erag

e w

hole

pri

ce s

ched

ule

plus

cha

rges

abo

ve th

e sc

hedu

le

In N

etw

ork

- 80%

co

vere

d; $

40 m

inim

um

copa

y, $

60 m

axim

um

copa

y; 3

0 da

y su

pply

Out

of N

etw

ork

- 50%

of

ave

rage

who

le p

rice

sc

hedu

le p

lus

char

ges

abov

e th

e sc

hedu

le

In N

etw

ork

- 80%

co

vere

d af

ter

dedu

ctib

le

is m

etO

ut o

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wor

k - 6

0%

cove

red

afte

r de

duct

ible

is

met

80%

cov

ered

; $40

m

inim

um c

opay

, $60

m

axim

um c

opay

; 30

day

supp

ly; N

on-p

artic

ipat

ing

phar

mac

ies:

50%

of

aver

age

who

le p

rice

sc

hedu

le p

lus

char

ges

abov

e th

e sc

hedu

le

$35

for

up to

a 3

0-da

y su

pply

; $10

5 fo

r up

to a

10

0-da

y su

pply

; at K

aise

r Ph

arm

acy;

as

pres

crib

ed

by P

lan

Phys

icia

n

$25

for

up to

a 3

0-da

y su

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; $7

5 fo

r up

to 1

00-d

ay s

uppl

y; a

t Ka

iser

Pha

rmac

y; a

s pr

escr

ibed

by

Pla

n Ph

ysic

ian

Reta

il no

nfor

mul

ary

bran

d

In N

etw

ork

- 60%

cov

ered

; $6

0 m

inim

um c

opay

, $10

0 m

axim

um c

opay

; 30

day

supp

lyO

ut o

f Net

wor

k - 5

0% o

f av

erag

e w

hole

pri

ce s

ched

ule

plus

cha

rges

abo

ve th

e sc

hedu

le

In N

etw

ork

- 60%

co

vere

d; $

60 m

inim

um

copa

y, $

100

max

imum

co

pay;

30

day

supp

lyO

ut o

f Net

wor

k - 5

0%

of a

vera

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hole

pri

ce

sche

dule

plu

s ch

arge

s ab

ove

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sche

dule

In N

etw

ork

- 80%

co

vere

d af

ter

dedu

ctib

le

is m

etO

ut o

f Net

wor

k - 6

0%

cove

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afte

r de

duct

ible

is

met

60%

cov

ered

; $60

m

inim

um c

opay

, $10

0 m

axim

um c

opay

; 30

day

supp

ly; N

on-p

artic

ipat

ing

phar

mac

ies:

50%

of

aver

age

who

le p

rice

sc

hedu

le p

lus

char

ges

abov

e th

e sc

hedu

le

$35

for

up to

a 3

0-da

y su

pply

; $10

5 fo

r up

to a

10

0-da

y su

pply

; at K

aise

r Ph

arm

acy;

as

pres

crib

ed

by P

lan

Phys

icia

n

Cove

red

only

whe

n de

term

ined

m

edic

ally

nec

essa

ry b

y a

plan

ph

ysic

ian

Mai

l ord

er g

ener

ic$2

0 co

pay;

90

day

supp

ly; m

ust

use

plan

mai

l ord

er fa

cilit

y

$20

copa

y; 9

0 da

y su

pply

; mus

t use

pla

n m

ail o

rder

faci

lity

80%

cov

ered

aft

er

dedu

ctib

le is

met

$20

copa

y; 9

0 da

y su

pply

; mus

t use

pla

n m

ail o

rder

faci

lity

$15

for

up to

a 3

0-da

y su

pply

; $30

for

up to

a

100-

day

supp

ly; m

ail

orde

r as

pre

scri

bed

by

Plan

Phy

sici

an

$10

for

up to

a 3

0-da

y su

pply

; $2

0 fo

r up

to a

100

-day

sup

ply;

m

ail o

rder

as

pres

crib

ed b

y Pl

an P

hysi

cian

Mai

l ord

er fo

rmul

ary

bran

d

80%

cov

ered

; $80

min

imum

co

pay,

$12

0 m

axim

um c

opay

; 90

day

sup

ply;

mus

t use

pla

n m

ail o

rder

faci

lity

80%

cov

ered

; $80

m

inim

um c

opay

, $12

0 m

axim

um c

opay

; 90

day

supp

ly; m

ust u

se p

lan

mai

l ord

er fa

cilit

y

80%

cov

ered

aft

er

dedu

ctib

le is

met

80%

cov

ered

; $80

m

inim

um c

opay

, $12

0 m

axim

um c

opay

; 90

day

supp

ly; m

ust u

se p

lan

mai

l ord

er fa

cilit

y

$35

for

up to

a 3

0-da

y su

pply

; $70

for

up to

a

100-

day

supp

ly; m

ail

orde

r as

pre

scri

bed

by

Plan

Phy

sici

an

$25

for

up to

a 3

0-da

y su

pply

; $5

0 fo

r up

to a

100

-day

sup

ply;

m

ail o

rder

as

pres

crib

ed b

y Pl

an P

hysi

cian

Mai

l ord

er

nonf

orm

ular

y br

and

60%

cov

ered

; $12

0 m

inim

um

copa

y, $

200

max

imum

cop

ay;

90 d

ay s

uppl

y; m

ust u

se p

lan

mai

l ord

er fa

cilit

y

60%

cov

ered

; $12

0 m

inim

um c

opay

, $20

0 m

axim

um c

opay

; 90

day

supp

ly; m

ust u

se p

lan

mai

l ord

er fa

cilit

y

80%

cov

ered

aft

er

dedu

ctib

le is

met

60%

cov

ered

; $12

0 m

inim

um c

opay

, $20

0 m

axim

um c

opay

; 90

day

supp

ly; m

ust u

se p

lan

mai

l ord

er fa

cilit

y

$35

for

up to

a 3

0-da

y su

pply

; $70

for

up to

a

100-

day

supp

ly; m

ail

orde

r as

pre

scri

bed

by P

lan

Phys

icia

n an

d de

emed

med

ical

ly

nece

ssar

y

Cove

red

as p

resc

ribe

d by

Pl

an P

hysi

cian

and

dee

med

m

edic

ally

nec

essa

ry

2018

Med

ical

Pla

n O

ptio

ns C

ompa

riso

n of

Ben

efi t

Cov

erag

esFo

r th

ose

not

Med

icar

e El

igib

leFo

r th

ose

Med

icar

e El

igib

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Anth

em B

lue

Cros

sPl

usAn

them

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oss

PPO

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em B

lue

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sCo

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alue

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em B

lue

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sEP

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xclu

sive

Kais

erKa

iser

Sen

ior

Adva

ntag

e

Not

e: If

ther

e is

a d

iscr

epan

cy b

etw

een

the

bene

fits

as d

escr

ibed

in th

e ch

arts

and

the

plan

adm

inis

trat

or’s

syst

ems,

the

plan

adm

inis

trat

or’s

syst

em g

over

ns fo

r de

term

inin

g be

nefit

cov

erag

e.


Reta

il ge

neri

c

In N

etw

ork

- $10

cop

ay; 3

0 da

y su

pply

Out

of N

etw

ork

- 50%

of

aver

age

who

le p

rice

sch

edul

e pl

us c

harg

es a

bove

the

sche

dule

In N

etw

ork

- $10

cop

ay;

30 d

ay s

uppl

yO

ut o

f Net

wor

k - 5

0%

of a

vera

ge w

hole

pri

ce

sche

dule

plu

s ch

arge

s ab

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sche

dule

In N

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ork

- 80%

co

vere

d af

ter

dedu

ctib

le

is m

etO

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wor

k - 6

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duct

ible

is

met

$10

copa

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0 da

y su

pply

; Non

-par

ticip

atin

g ph

arm

acie

s: 5

0% o

f av

erag

e w

hole

pri

ce

sche

dule

plu

s ch

arge

s ab

ove

the

sche

dule

$15

for

up to

a 3

0-da

y su

pply

; $30

for

up to

a

100-

day

supp

ly; a

t Kai

ser

Phar

mac

y; a

s pr

escr

ibed

by

Pla

n Ph

ysic

ian

$10

for

up to

a 3

0-da

y su

pply

, $3

0 fo

r up

to a

100

-day

su

pply

; at K

aise

r Ph

arm

acy;

as

pres

crib

ed b

y Pl

an P

hysi

cian

Reta

il fo

rmul

ary

bran

d

In N

etw

ork

- 80%

cov

ered

; $40

m

inim

um c

opay

, $60

max

imum

co

pay;

30

day

supp

lyO

ut o

f Net

wor

k - 5

0% o

f av

erag

e w

hole

pri

ce s

ched

ule

plus

cha

rges

abo

ve th

e sc

hedu

le

In N

etw

ork

- 80%

co

vere

d; $

40 m

inim

um

copa

y, $

60 m

axim

um

copa

y; 3

0 da

y su

pply

Out

of N

etw

ork

- 50%

of

ave

rage

who

le p

rice

sc

hedu

le p

lus

char

ges

abov

e th

e sc

hedu

le

In N

etw

ork

- 80%

co

vere

d af

ter

dedu

ctib

le

is m

etO

ut o

f Net

wor

k - 6

0%

cove

red

afte

r de

duct

ible

is

met

80%

cov

ered

; $40

m

inim

um c

opay

, $60

m

axim

um c

opay

; 30

day

supp

ly; N

on-p

artic

ipat

ing

phar

mac

ies:

50%

of

aver

age

who

le p

rice

sc

hedu

le p

lus

char

ges

abov

e th

e sc

hedu

le

$35

for

up to

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2018 Dental Plan Option Comparison of Benefi t Coverages

Delta Dental PPO DeltaCare DHMO(available in CA only)

Member services 1-800-777-5854 1-800-422-4234

Website deltadentalins.com/llns deltadentalins.com/llns

Network Any licensed dentist; Delta Dental PPO dentist provides higher benefi t level Not applicable

Annual deductible:Individual/Family

In Network - $50 Individual; combined for both basic and major dentistry; waived for preventive/diagnostic

care$0 Individual, $0 Family

Out of Networking - $50 Individual; combined for both basic and major dentistry; waived for preventive/

diagnostic careNot applicable

Annual maximum coverage per person

Delta Dental PPO Dentist - $1,700 Not applicable

Non Delta Dental PPO Dentist - $1,500 Not applicable

Preventive care benefi tsIn Network - 100% covered; sealant 80% covered $0-$45 copay

Out of Network - 100% covered; sealant 75% covered Not applicable

Annual service limits--preventive care

In Network - Cleaning: 2/cal yr(with a 3rd cleaning for pregnant women); 2 exams of any type /cal yr

Cleaning and fl uoride, one per 6 month period, child

to age 19.

Out of Network - same as in network Not Applicable

Basic services(including fi llings, routine extractions, endodontics,

periodontics)

In Network - 80% covered after deductible is met100% covered; for

standard benefi t; copay for endodontics, periodontics

Out of Network - 75% covered after deductible is met Not Applicable

Major services(including crowns, bridges,

implants, dentures)

In Network - 50% covered after deductible is met Copay applies


Orthodontia benefi ts

In Network - 50% covered$1,700 - Child; $1,900

Adult; $100 Start Up Fee

Out of Network - 50% covered Not Applicable

Service limits and maximums--orthodontia

In Network - Limited to $1,500 per lifetime for dependent children; $500 per lifetime for adults Check with Plan

Out of Network - Limited to $1,500 per lifetime for dependent children; $500 per lifetime for adults Not Applicable

Note: If there is a discrepancy between the benefits as described in the charts and the plan

administrator’s systems, the plan administrator’s system governs for determining benefit coverage.

VSP Vison Savings Pass (Vision Discount Program)

Service Reduced Price and Savings

WellVision Exam$50 with purchase of a complete pair of prescription glasses

20% off without purchaseOnce every calendar year

Retinal Screening Guaranteed pricing with WellVision Exam, not to exceed $39

Lenses

With purchase of a complete pair of prescription glasses:Single vision $40

Lined bifocals $60Lined trifocals $75

Polycarbonate for children $0

Lens Enhancements Average savings of 20-25% on lens enhancements such as progressive, scratch-resistant, and anti-refl ective coatings

Frames 25% savings when a complete pair of prescription glasses is purchased

Sunglasses 20% savings on unlimited non-prescription sunglasses from any VSP doctor within 12 months of your last WellVision Exam

Contact Lenses 15% savings on contact lens exam (fi tting and evaluation)

Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities


2018 Dental Plan Option Comparison of Benefi t Coverages

Delta Dental PPO DeltaCare DHMO(available in CA only)

Member services 1-800-777-5854 1-800-422-4234

Website deltadentalins.com/llns deltadentalins.com/llns

Network Any licensed dentist; Delta Dental PPO dentist provides higher benefi t level Not applicable

Annual deductible:Individual/Family

In Network - $50 Individual; combined for both basic and major dentistry; waived for preventive/diagnostic

care$0 Individual, $0 Family

Out of Networking - $50 Individual; combined for both basic and major dentistry; waived for preventive/

diagnostic careNot applicable

Annual maximum coverage per person

Delta Dental PPO Dentist - $1,700 Not applicable

Non Delta Dental PPO Dentist - $1,500 Not applicable

Preventive care benefi tsIn Network - 100% covered; sealant 80% covered $0-$45 copay

Out of Network - 100% covered; sealant 75% covered Not applicable

Annual service limits--preventive care

In Network - Cleaning: 2/cal yr(with a 3rd cleaning for pregnant women); 2 exams of any type /cal yr

Cleaning and fl uoride, one per 6 month period, child

to age 19.

Out of Network - same as in network Not Applicable

Basic services(including fi llings, routine extractions, endodontics,

periodontics)

In Network - 80% covered after deductible is met100% covered; for

standard benefi t; copay for endodontics, periodontics


Major services(including crowns, bridges,

implants, dentures)

In Network - 50% covered after deductible is met Copay applies


Orthodontia benefi ts

In Network - 50% covered$1,700 - Child; $1,900

Adult; $100 Start Up Fee

Out of Network - 50% covered Not Applicable

Service limits and maximums--orthodontia

In Network - Limited to $1,500 per lifetime for dependent children; $500 per lifetime for adults Check with Plan

Out of Network - Limited to $1,500 per lifetime for dependent children; $500 per lifetime for adults Not Applicable

VSP Vison Savings Pass (Vision Discount Program)

Service Reduced Price and Savings

WellVision Exam$50 with purchase of a complete pair of prescription glasses

20% off without purchaseOnce every calendar year

Retinal Screening Guaranteed pricing with WellVision Exam, not to exceed $39

Lenses

With purchase of a complete pair of prescription glasses:Single vision $40

Lined bifocals $60Lined trifocals $75

Polycarbonate for children $0

Lens Enhancements Average savings of 20-25% on lens enhancements such as progressive, scratch-resistant, and anti-refl ective coatings

Frames 25% savings when a complete pair of prescription glasses is purchased

Sunglasses 20% savings on unlimited non-prescription sunglasses from any VSP doctor within 12 months of your last WellVision Exam

Contact Lenses 15% savings on contact lens exam (fi tting and evaluation)

Laser Vision Correction Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Open Enrollment Dates and Events

Date

November 1, 2017

At the Bankhead Theaterin Livermore

October 16 through November 10, 2017

October 15 throughDecember 7, 2017

Retiree PresentationsBankhead Theater2400 First Street, Livermore, CA

9:00 A.M. and 1:00 P.M.

Open Enrollment for non-Medicare retirees and Medicare-eligible retirees in Kaiser

Please note Empyrean Open Enrollment lines open at 7:00 a.m. Pacific time on Monday, October 16, 2017 and the last day to make an election is Friday, November 10, 2017, 5:00 p.m. Pacific time.

Open Enrollment for Medicare-eligible retirees

Please note OneExchange Open Enrollment lines open at 6:00 a.m. Pacific time on Monday, October 16 and the last day to make an election is Wednesday, December 7, 2017, 6:00 p.m. Pacific time.

Activity

Documents

OneExchange: 2018 Retiree Open Enrollment Guide · If you are enrolled in Medicare or will become eligible to ... Open Enrollment Periods ... (medical and dental) The Open Enrollment