Health Insurance Enrollment Guide 20212021

Everyone Qualifying Life EventsQualifying Life EventsFor ASRS Medical or Dental InsuranceWhat is a Qualifying Life Event?A qualifying life event allows you the opportunity to enroll and/or make changes to existing coverage foryourself or your dependents outside of the annual open enrollment period.You must make these changes no later than 31 calendar days from the date the qualifying life eventtook place, unless a different deadline is indicated for a specific qualifying life event.The following are the Qualifying Life Events recognized by the ASRS for enrollment and/or changes toyour existing coverage outside of the annual open enrollment period. ASRS has the sole discretion todetermine whether a Qualifying Life Event has occurred and whether your situation allows you to enrollor make changes to existing coverage. Retirement Participation in the ASRS Long Term Disability Program Change in marital status, dependent status, or primary residence that impacts your currentASRS coverage Change in eligibility for Medicaid/Children’s Health Insurance Program (CHIP) or Medicare.Medicare eligibility is NOT a Qualifying Life Event for dental plans. Loss of coverage (Spouse, Employer, COBRA)Voluntarily terminating your group or individual medical insurance plan is not a qualifying life event.Additional supporting documentation showing the reason for the qualifying life event is required. Alldependents over the age of 26 will require proof of guardianship, and must be approved as a disableddependent.Your enrollment application must be submitted within 31 days of the date of your qualifying life event.Coverage will be effective on the first day of the month after you submit your enrollment application forcoverage.For more detailed information, visit the ASRS website at AzASRS.gov by selecting “Healthcare” underthe “Retirees” tab.7

Everyone Important Time FramesImportant Time Frames The effective date for the 2021 plan year is January 1, 2021 through December 31, 2021. You must enroll no later than 31 calendar days after your retirement date or otherqualifying life event date. Submit online enrollment applications no more than 90 days before the effective date. Coverage becomes effective the first day of the month following your qualifying life eventand receipt of your completed enrollment application.Pre-Enrollment Task ListUse this handy task list to help prepare for enrollmentResearch and Choose a PlanCarefully review the Enrollment Guide to help you determine what benefits you and your familyrequire and then select your plan.Attend a 'Know Your Insurance' MeetingLearn about your health care options and meet your vendor representatives.Locate Provider ID (if required)Visit the plan provider’s website to select a provider and get the provider’s ID number, if required.Locate Medicare CardIf you or your dependent will be enrolling in a Medicare plan, have your Medicare card available.You will need to provide your Medicare number as well as your Medicare Part A & B effective dateson your online enrollment application.Gather Supporting DocumentationIf required, proof must be received within 31 days of the qualifying life event.8

Everyone Online EnrollmentOnline EnrollmentYou must complete the entire online process for your enrollment application to be submitted andprocessed. Your application cannot be saved and finished at a later time.The online system will allow you to print a copy of your enrollment application and ASRS will sendyou a confirmation email that your application has been submitted. Check the status of your onlineenrollment in the Pending Request link in your secure myASRS account.If you are retired from PSPRS, CORP, or EORP you must contact their benefits office to request thecorrect enrollment application.Complete the online Enrollment Application if you are: Enrolling for the first time with the ASRS Electing a different medical plan Electing a different dental plan Adding dependents Becoming Medicare eligible (but not morethan 90 days ahead of the effective date) Currently enrolled with ASRS and you wishto cancel your coverage or dependentcoverage. You may go online or send aletter to drop the coverage. Making a change due to a QualifyingLife EventOnline ResourcesEverything you want to know about ASRS Retiree Group Health Insurance can be found inone convenient place on the ASRS website at AzASRS.gov by selecting “Healthcare” under the“Retirees” tab.There you can explore the insurance plans and benefits information including comparison charts,FAQs, certificates of coverage and more.You will also find on-demand Health Insurance videos to assist you in selecting the plan that willbest meet your healthcare needs. You have the freedom to navigate for specific topics of interest,view sections in any order, and return as many times as needed. You can learn at your own pace.For more detailed information, watch the What You Will Need for Online Health InsuranceEnrollment video found under the “Retirees” tab by selecting “Healthcare” then the “OnlineHealth Insurance Enrollment” link.9

Everyone 2021 Premium Savings2021 Premium SavingsThis will be the third year of a three-year planned distribution of funds accumulated through a RetrospectiveRate Agreement (RRA) with UnitedHealthcare to reduce medical premiums for plan participants. The RRAprovides for a set level of retention of revenues by the medical insurance carrier with any surplus revenuesto be returned to the ASRS. This agreement was implemented in 2011 and subsequent look-backs atrevenues versus medical costs and expenses have resulted in a return of funds to the ASRS. Those fundshave been set aside to be applied to market-rate premiums, thus providing retirees a lower premium thanthey would otherwise be required to pay.Each separate plan returned varying amounts, based on the revenues versus expenses of that particularplan. The vast majority of funds were derived from the Medicare plans, so the Medicare plans receive themost significant reduction of premiums from the RRA funds, with the non-Medicare plans receiving slightoffsets.2021In total, over the three-year planned distribution of funds duringNEWMonthlyMonthlyplan years 2019, 2020 and 2021, ASRS retirees are projected to save2021PremiumSavingsmore than 127 million in medical premiums. For plan year 2022MonthlyBEFOREdue to thePremiumSavingsand forward, an annual analysis will be completed to determine ifRRAfuture offsets can be made each planWITHOUT MEDICAREyear to reduce medical premiums.You & your dependents DO NOT have Medicare Part A and BThe table on this page shows the 2021premiums for various Medicare andnon-Medicare plans being offered.The premiums you will pay are underthe column marked “NEW 2021Monthly Premium.”The final premium shown here doesnot take into account any furtherreductions you may be entitled tofrom the Premium Benefit. See pages12 and 13 for information on thePremium Benefit and eligibility.Choice Premier (Single) 1,082 20 1,062Choice Value (Single) 906 20 886Choice Economy (Single) 795 20 775 1,381 20 1,361Choice Plus PPO(Out of State, Single)WITH MEDICARE A & BYou & your dependents have Medicare Part A and BGroup Medicare AdvantageHMO (Single) 73 73 0Group Medicare AdvantagePPO (Single) 108 41 67Monthly Dental PremiumsSingleFamily (Single 1)Family (Single 2 or more)DELTA DENTAL PPO - NATIONWIDE COVERAGEDelta Dental High Plan Option 35.75 per month 71.35 per month 100.97 per monthDelta Dental Low Plan Option 16.60 per month 35.09 per month 64.24 per monthCIGNA DHMO - SELECT STATES (EXCLUDES AK, ID, ME, MT, NH, NM, ND, PR, SD, VI, VT, WV, AND WY)Cigna DHMO10 9.75 per month 15.99 per month 24.71 per month

Everyone Monthly Medical PremiumsMonthly Medical PremiumsFrom UnitedHealthcareWITHOUT MEDICARE (You and your dependent(s) DO NOT have Medicare Part A and B)ALL ARIZONA COUNTIESSingleFamily (Single 1)Family (Single 2 or more)Choice Premier 1,062.00 per month 2,124 per month 2,974.00 per monthChoice Value 886.00 per month 1,772.00 per month 2,481.00 per monthChoice Economy 775.00 per month 1,550.00 per month 2,170.00 per month 1,361.00 per month 2,722.00 per month 3,811.00 per monthOUT-OF-STATEChoice Plus PPOWITH MEDICARE A & B (You and your dependent(s) have Medicare Part A and B)ALL ARIZONA COUNTIESSingleFamily (Single 1)Family (Single 2)Group Medicare Advantage HMO 0.00 per month 0.00 per month 0.00 per monthGroup Medicare Advantage PPO 67.00 per month 134.00 per month 201.00 per month 67.00 per month 134.00 per month 201.00 per monthOUT-OF-STATEGroup Medicare Advantage PPOCOMBINATION FAMILY PLANS: ONE person with Medicare(You, or your dependent(s), are a combination of Medicare eligible and non-Medicare eligible)1 person with Medicare,1 without Medicare1 person with Medicare,2 without MedicareGroup Medicare Advantage HMO with Choice Premier 1,062.00 per month 2,124.00 per monthGroup Medicare Advantage HMO with Choice Value 886.00 per month 1,772.00 per monthGroup Medicare Advantage HMO with Choice Economy 775.00 per month 1,550.00 per monthGroup Medicare Advantage PPO with Choice Premier 1,129.00 per month 2,191.00 per monthGroup Medicare Advantage PPO with Choice Value 953.00 per month 1,839.00 per monthGroup Medicare Advantage PPO with Choice Economy 842.00 per month 1,617.00 per month 1,428.00 per month 2,789.00 per monthALL ARIZONA COUNTIESOUT-OF-STATEGroup Medicare Advantage PPO with Choice Plus PPOCOMBINATION FAMILY PLANS: TWO people with Medicare(You, or your dependent(s), are a combination of Medicare eligible and non-Medicare eligible)2 people with Medicare,1 without Medicare2 people with Medicare,2 without MedicareGroup Medicare Advantage HMO with Choice Premier 1,062.00 per month 2,124.00 per monthGroup Medicare Advantage HMO with Choice Value 886.00 per month 1,772.00 per monthGroup Medicare Advantage HMO with Choice Economy 775.00 per month 1,550.00 per monthGroup Medicare Advantage PPO with Choice Premier 1,196.00 per month 2,258.00 per monthGroup Medicare Advantage PPO with Choice Value 1,020.00 per month 1,906.00 per monthGroup Medicare Advantage PPO with Choice Economy 909.00 per month 1,684.00 per month 1,495.00 per month 2,856.00 per monthALL ARIZONA COUNTIESOUT-OF-STATEGroup Medicare Advantage PPO with Choice Plus PPO11

Everyone Premium BenefitPremium BenefitWhat is it?As part of your benefits, the ASRS provides a health insurance premium benefit to supplement the costof retiree health insurance. The premium benefit is effective on the first day of the month following yourenrollment or qualifying life event. Retirees and Long Term Disability members with five or more years ofcredited service who have health insurance through the ASRS or non-subsidized coverage through theirformer ASRS employer are eligible for a monthly premium benefit, which is paid to the health insurer oryour former employer. A premium benefit also applies to eligible retirees participating in the ASRS healthinsurance plans from EORP, CORP, and PSPRS.How does it work?Your ASRS health insurance premiums will be automatically deducted each month from your ASRS pensionpayment, if your pension payment amount is greater than the net cost of your insurance premiums. Ifeligible, the premium benefit is applied first to dental, then to medical premiums. The premium benefitmay be delayed for one to three months while your pension is finalized. However, the eligible amount willbe reimbursed or adjusted, as applicable, and will be retroactive to the beginning of the coverage.Your insurances carrier(s) will mail a bill directly to you and it will be your responsibility to paypremiums directly to the insurance carrier(s) you if you are: On Long Term Disability Choosing your employer’s options (State of Arizona is an exception. That payment will be withheldfrom your ASRS pension payment.) Receiving a pension payment that does not cover the net cost of your insurance premiumsOptional Premium BenefitIf you are a new ASRS retiree you may elect to receive a reduced premium benefit that, upon your death,may be continued to your beneficiary. The Optional Premium Benefit is designed for those members whohave a spouse or dependent who will want to continue with ASRS insurance and receive assistance withpremium costs.Other things to note about the Optional Premium Benefit: The Optional Premium Benefit is only available to retirees who select a Term Certain or Joint &Survivor Annuity option. It is not available to retirees who select the Straight Life Annuity. You have a one-time opportunity to elect this benefit when you retire. You may rescind election at a later date and the unreduced premium benefit will be reinstated andapplied for life. The Optional Premium Benefit reduction is based on your age and the age of your beneficiary.You can find out what your reduction would be by using the online estimator in your myASRS accountat AzASRS.gov.12

WITHOUT MEDICAREWITH MEDICARE A & BCOMBINATIONSRetiree eeOnlyRetiree &DependentsRetireeOnlyRetiree &DependentsRetiree &DependentsOne withMedicare,the 99.0–9.910.0 75.00 90.00 105.00 120.00 135.00 150.00 130.00 156.00 182.00 208.00 234.00 260.00 50.00 60.00 70.00 80.00 90.00 100.00 85.00 102.00 119.00 136.00 153.00 170.00 107.50 129.00 150.50 172.00 193.50 215.00 107.50 129.00 150.50 172.00 193.50 215.005.0–5.96.0–6.97.0–7.98.0 90.00 112.50 135.00 150.00 156.00 195.00 234.00 260.00 60.00 75.00 90.00 100.00 102.00 127.50 153.00 170.00 129.00 161.25 193.50 215.00 129.00 161.25 193.50 215.00not applicable 150.00 260.00 100.00 170.00 215.00 215.00not applicable 150.00 260.00 100.00 170.00 215.00 215.00Years of ServiceArizona State Retirement System (ASRS) MembersElected Officials’ Retirement Plan (EORP) MembersCorrections Officer Retirement Plan (CORP) MembersPublic Safety Personnel Retirement System (PSPRS) MembersEveryone Premium Benefit: Determine Your AmountPremium Benefit: Determine Your AmountMonthly Health Insurance Cost WorksheetThe worksheet below will help you determine your monthly insurance premiums.B. Add your monthly dental plan premium (from page 10)C. Total Premium (A plus B)D. Subtract your Premium Benefit (See chart above) A. Your monthly medical plan premium (from page 11)– Your Net Premium (C minus D)13

Everyone Additional BenefitsAdditional BenefitsAs an ASRS retiree, you have a myriad of benefits available to you at no cost. Some are includedwith our medical and dental insurance plans and some are available to all retirees regardless of yourinsurance carrier. Visit AzASRS.gov for examples of these beneficial resources to help you manage allaspects of your health, your care and your costs.WellCardDid you know that you have a FREE discount cardavailable to you as an ASRS retiree? This programis designed to help you save money on health carerelated services and prescriptions. Not only is it free,but it is also available to anyone in your household.There’s no need to enroll in any of the ASRS healthinsurance plans to be eligible.Once you are retired, you simply go online toAzASRS.gov/ Retirees/Healthcare/AdditionalBenefitsto register for your card. You will use the Group ID “ASRSH” when youregister for the card. This isn’t insurance, but a DISCOUNT program available for timeswhen insurance does not pay for a service or prescription.EXCLUSIVE SAVINGS &BENEFITS FOR RETIREESRegister for FREE today! azretirees.perksconnection.comClick “Activate your account now” to get startedInsurance & BenefitsHome/Auto Insurance, Long Term Care & more14Local & National DiscountsGet exclusive savings from popular national retailers – categories includeentertainment, health & wellness, travel, electronics and more. You’ll also getexclusive access to local merchants right in your community and surrounding area.

Non-Medicare NON-MEDICARERETIREEINFORMATIONThe following pages contain plan information that isapplicable to retirees that are not yet eligible for Medicare15

Non-Medicare Medical Plans ComparisonMedicalPlans ComparisonReview your medical plan options.It’s all inthe details.Let’sbreak itdown.You have four different plans to choose from, each with its own benefits.To compare the details of each plan, including coverage amounts,see the charts on the next few pages.Arizona only plansOut of State PlanChoiceChoiceChoiceChoicePlus PPOPremierValueEconomyMedical Plan DetailsIn-Network coverage onlyYou must receive care for covered benefits from contracted networkproviders. Out-of-Network coverage not available. In and out-of-network benefitsYou may receive care and services from providers and facilities in andout of our network, but staying in the network can help lower your costs.Virtual VisitsGet care with Virtual Visits anywhere, on your computer or mobiledevice* for medical conditions like pink eye, the flu, and more.(*data rates may apply)Nationwide NetworkUnitedHealthcare has access to a broad network of physicians andhospitals nationwide.Pharmacy BenefitsOrder up to a 3-month supply of medications you take regularly andhave them delivered right to your home, or 30-day retail.Tier 1 ProvidersUse Tier 1 providers for lower copays. These PCPs and medicalspecialists meet national standard benchmarks for quality careand cost savings. More benefits that are part of the plans.UnitedHealthcare’s digital tools and online resources help make managing your health - and health plan - easier andmore convenient. Here are just a few examples of what’s included.Access yourplan easily.myuh

HEALTH INSURANCE ENROLLMENT GUIDE For Non-Medicare & Medicare Eligible ASRS Retirees Effective January 1, 2021 2021. This guide is a summary of the official Arizona State Retirement System (ASRS) plan documents, contracts, Arizona statutes and federal regulations that govern the plans. Other important information regarding