2017 RETIREE OPEN ENROLLMENT GUIDE

FOR MEDICARE-ELIGIBLE RETIREES AND SPOUSES

This year’s Open Enrollment period begins on November 7, 2016 and ends December 2, 2016. During

this time, you may change your health insurance coverage for calendar year 2017.

2 2017 Medicare-Eligible Retiree Open Enrollment Guide

Dear Retiree:

As a City of Alexandria retiree, you and/or your Medicare-eligible dependents have an opportunity during this Open Enrollment Period to once again review the City-sponsored health insurance plan options and decide either to remain in your current plan or elect another plan option. This 2017 RETIREE OPEN ENROLLMENT GUIDE is designed to help you choose the plan that best meets your health needs and financial resources. Please review it very carefully.

Changes from 2016

There are no benefit plan design changes from 2016 in the UHC plan. The only plan design change in the Kaiser plan is that there is no longer a copay for routine physical exams.

2017 MONTHLY PREMIUM FOR THE MEDICARE-ELIGIBLE RETIREES PROGRAM

Plan 2017 Monthly Premium

2016 Monthly Premium

Percent Increase

Kaiser Permanente Medicare Plus Plan $241.46 $232.23 4%

UHC Medicare Advantage PPO Plan $346.50 $330.00 5%

NOTE: Those who are eligible to receive the City’s monthly health insurance subsidy of up to $260 will be required to pay any additional premium in excess of the City provided subsidy. Thus, participants in the UHC Medicare Advantage Plan would pay $86.50 per month in 2017.

ACTIONS REQUIRED:

IF YOU... THEN YOU...

are currently in the Kaiser Plan or the UHC Plan and do not want to make a change

DO NOT HAVE TO DO ANYTHING.

want to change from one plan to the other or change from the Reimbursement Program to one of the plans

MUST complete the 2017 Retiree Medical Plan Change Form (included in this packet) and return to Human Resources, with the enclosed envelope, by Friday, December 2.

are currently in the Reimbursement Program and will continue in that Program

are required that once each year, at the end of the plan year, to provide documentation regarding the plan cost. The Reimbursement Statement (the blue form included in this packet) is provided to use for that purpose at the appropriate time.

2017 Medicare-Eligible Retiree Open Enrollment Guide 3

REMINDERS:

• Only Medicare-eligible retirees/spouses may enroll in the City-sponsored Kaiser Permanente Medicare Plus and the UHC Medicare Advantage PPO Plans. Medicare-eligible retirees may not remain enrolled in the Kaiser or UHC “Employee Plans” after they become Medicare-eligible.

• If you previously opted out of the City-sponsored plans for the Retiree Health Insurance Reimbursement Program, you may re-enroll in either of the Medicare plans during this Open Enrollment period.

The following pages provide more detail about the plans. If you have questions or need additional information, we encourage you to attend one of two informational meetings to meet with the Benefits staff, Kaiser and UHC representatives. Dates and locations are included in the guide on page 8. Contact information for the Benefits staff is also included in the guide on page 8.

If you decide to change your insurance coverage, you must submit your election form so it is received by the Human Resources Department-Benefits Team (in person or postmarked) no later than December 2, 2016. Late submissions cannot be accepted. Enrollment packages will be available at the informational meetings, as well as from the Human Resources Department in City Hall, or will be mailed upon request. Sincerely,

Steven J. Mason, Sr., HCSActing Director, Human Resources Department

4 2017 Medicare-Eligible Retiree Open Enrollment Guide

What should I do first? • Read about the Kaiser Medicare Plus and UHC Medicare Advantage PPO Plans in the plan summaries on pages 12 – 15.

• Review the rate comparison chart on page 11.

• If you still have questions or are unsure about what to choose:

» Attend one of the two informational sessions provided by the City (a list of the dates, times and locations is contained on page 8).

» Contact the Benefits staff using the contact information on page 8.

» You also have the option of exploring the health insurance market place for coverage options available to those who are Medicare-eligible. The cost for coverage you purchase will be reimbursed by the City up to $260 per month. Some places to begin shopping are:

• www.medicare.gov• www.healthcare.gov• www.aarp.org

If I want to make a change, what benefit plan choices can I make during Open Enrollment?

Health Insurance Plans: Three options are available to Medicare-eligible retirees/spouses in 2017:

1. Kaiser Medicare Plus Plan

2. United Healthcare Medicare Advantage PPO Plan

3. Reimbursement Program coverage under any other health plan of your choice. Expenses will be reimbursed by the City for up to $260 per month for either you or your spouse, but not both.

Note: Medicare-eligible retirees and spouses may not continue in the Kaiser or UHC “employee plans.” These are the only options available to City of Alexandria retirees who are Medicare-eligible.

Open Enrollment Guide

Frequently Asked Questions

2017 Medicare-Eligible Retiree Open Enrollment Guide 5

How do I cover my spouse? • Each eligible individual (retiree or spouse) is enrolled separately in the plan of his/her choice

• The City pays for (or reimburses) up to $260 for either the retiree or the spouse but not both.

• If you and/or your spouse enroll in a covered plan (Kaiser or UHC), the City pays the monthly premium directly to the carrier for the oldest, eligible individual only.

• If you elect the UHC Medicare Advantage Plan, the City will debit your account $86.50 per month to cover the difference between the $346.50 premium and the $260 maximum City reimbursement.

• All premiums for the younger individual (whether Kaiser, UHC or another plan of your choice) are the responsibility of the retiree and must be paid directly to the health care provider chosen.

• If both you and your spouse elect a plan other than the City-sponsored plans, Kaiser or UHC, your costs up to $260 will be reimbursed on a monthly basis.

May I enroll my domestic partner in one of the City-sponsored Medicare plans?

Yes. You will be required to provide the following to the City’s Human Resources Department: a City of Alexandria Affidavit for Domestic Partnership Form along with the required documents. Contact the Benefits Team for more information.

Do I need to remain enrolled in Medicare Parts A & B if enrolled in the Kaiser or UHC Medicare Advantage Plans?

Yes. Both you and your spouse must maintain Medicare Part A and B while enrolled in the Kaiser Medicare Plus or UHC Medicare Advantage Plans to remain covered by a City plan. If you are covered by another employer’s plan, e.g., you are enrolled on your spouse’s employer-provided plan; you may be able to defer Part B. If you are unsure about how to get Medicare coverage, contact Medicare at 1-800-MEDICARE or go to www.medicare.gov.

6 2017 Medicare-Eligible Retiree Open Enrollment Guide

What do I do to change my health insurance plan?

2017 OPEN ENROLLMENTNovember 7, 2016 through December 2, 2016

• If you decide to change your and/or your spouse’s plan, complete the enrollment form (included in this packet).

• On the Enrollment Form, please check the plan of your choice:

» Kaiser Medicare Plus

» UnitedHealthcare Medicare Advantage PPO

» City of Alexandria Health Reimbursement Plan (your own coverage)

• Enrollment forms must be delivered to Human Resources no later than 5 p.m, on Friday, December 2, or postmarked December 2, in order to be processed on time.

• Enrollment forms can be submitted in-person or mailed to the address listed below:

City of Alexandria Human Resources Department, Benefits Team301 King Street, Room 2510Alexandria, VA 22314

What do I do if I want to enroll in a plan other than the City-sponsored Kaiser or UHC Medicare Plans?

If you enroll as an individual, or you and your spouse both enroll in plans other than those offered by the City, you will need to enroll in the City’s Health Insurance Reimbursement Program. Complete the enclosed Enrollment Form and elect the Reimbursement Program option. When your Enrollment Form is received, the Benefits staff will mail you the information you need to be eligible monthly for a reimbursement up to $260 per month in health care premium for either you or your spouse.

What happens after I submit my enrollment?

If you elect either of the City-sponsored Kaiser or UHC plans and you are not already enrolled in that Medicare Plan, you will be mailed an enrollment kit. Be sure to immediately complete and return the enrollment materials to ensure your enrollment is pro-cessed promptly by Kaiser or UHC. Information about non-city plans is discussed above.

2017 Medicare-Eligible Retiree Open Enrollment Guide 7

When am I eligible to enroll in Medicare Part B?

For most individuals, the Initial Enrollment Period (IEP) begins 3 months before and ends 3 months after the individual attains age 65. However, if you did not enroll during the IEP, a General Enrollment Period (GEP) takes place from January 1 through March 31 of each year and becomes effective July 1 of that same year.

Please note that penalties may be incurred by retirees who miss their IEP. Please contact your local Centers for Medicare and Medicaid Services (CMS) office for more details.

For details on special enrollment periods, visit: http://www.cms.gov/Medicare/Eligibility-and-Enrollment/OrigMedicarePartA-BEligEnrol/ or contact your local Medicare or Centers for Medicare and Medicaid Services (CMS) offices.

After I enroll in the United Healthcare Medicare Advantage Plan, I understand that I may receive a letter from the Federal Department of Health and Human Services reporting that I did not have prescription drug coverage that met Medicare’s minimum standards prior to enrolling in the Medicare plan. Is that correct, and if so, what should I do?

You may receive such a letter. However, if your prior health insurance coverage was through a City-sponsored health insurance plan, you did have prescription drug coverage. Please contact a member of the Benefits Team using the contact information on page 8 promptly so the City can submit a form to the appropriate authorities attesting to your coverage, including a pharmacy benefit. The City’s attestation will satisfy the request and you will not be subject to a late enrollment penalty.

What impact does ACA have on me if I drop my City coverage?

You would need to return to original Medicare or an appropriate alternative due to the ACA’s Individual Mandate provision. You could also pay the penalty for not having coverage, but this would also involve paying higher premiums if you ultimately returned to Medicare.

If my spouse and I were covered in the Individual + One category before we were 65, how do we transition to the Medicare-eligible plan?

Each individual becomes eligible for the Medicare-eligible plan when he or she reaches age 65. If retired at that time, the retiree applies for coverage and begins participating in that plan. In many cases the spouse’s eligibility is at a different time, and so they may participate in different plans for a period of time (one in the Medicare-eligible plan and one in an employee plan).

Are spouses of retirees allowed to continue participating in the plan after the retiree passes away?

Current eligibility rules allow the spouse of a retiree to continue participation in the plan after the retiree passes away.

8 2017 Medicare-Eligible Retiree Open Enrollment Guide

On-Site Meetings & Benefits Contacts

SCHEDULE OF OPEN ENROLLMENT ON-SITE MEETINGS

Kaiser and United Healthcare representatives and the City’s Benefits Team will be available to an-swer questions during the following scheduled meetings. Carriers will be on hand to describe plan benefits and answer your questions.

WEDNESDAY, NOVEMBER 910 a.m. to Noon

City Hall301 King St., Sister Cities Conference Room 1101

TUESDAY, NOVEMBER 15 10 a.m. to Noon

Nannie J. Lee Center 1108 Jefferson St., Gold Room

BENEFITS TEAM CONTACTS

NAME PHONE EMAIL

Jina Edwards 703.746.3789 jina.edwards@alexandriava.gov

Sonja Jones 703.746.3787 sonja.jones@alexandriava.gov

Jim Davis 703.746.3786 james.davis@alexandriava.gov

City of AlexandriaHuman Resources Department, Benefits Team

301 King Street, Room 2510Alexandria, VA 22314

2017 Medicare-Eligible Retiree Open Enrollment Guide 9

Common Health Insurance Terms

COMMON HEALTH INSURANCE TERMS DEFINED

MEDICARE: Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Medicare consists of four (4) parts:

• Medicare Part A (Hospital Insurance): Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care. There is no premium for people with 40 quarters of Medicare-covered employment.

• Medicare Part B (Medical Insurance): Part B is optional and covers certain doctors' services, outpatient care, medical supplies, and preventive services. The cost is based on household income.

• Medicare Part C (Medicare Advantage Plan): A Medicare Advantage Plan is a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you're enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

• Medicare Part D (Prescription Drug Coverage): Optional benefits for prescription drugs available to all people with Medicare for an additional charge. This coverage is offered by insurance companies and other private companies approved by Medicare.

Copayment (copay): This is a specific amount you pay when you receive certain covered services or prescriptions. Copayments vary depending on the plan and the service.

• In-Network copays are fixed amounts you pay for covered services to providers who contract with your health insurance plan and are usually less than out-of-network copays.

• Out-of-Network copays are fixed amounts you pay for covered services from providers who do not contract with your health insurance plan and are usually more than in-network copays.

Deductible: A fixed amount you pay out of pocket before a health insurance plan begins to cover your health care costs.

Emergency Room: Typically, emergency room services include all services provided when a patient visits an emergency room for an emergency condition. An emergency condition is any medical condition of recent onset and severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or

10 2017 Medicare-Eligible Retiree Open Enrollment Guide

her condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of a bodily organ or part.

Out-Of-Pocket Maximum (Costs): The most you pay in a plan year before your health insurance plan begins to pay 100% of the allowed amount. This limit never includes your premium and the design of a healthcare plan will determine if all, some, or none of your copays, deductibles, co-insurance, etc. count towards the limit.

Premium: The fixed amount that you will pay every month for health insurance coverage.

Preventive Care: Medical care rendered not for a specific complaint, but focused on prevention and early-detection of disease. Specified by your plan, preventive care generally includes screening exams, routine preventive physical exams for adults and children, prenatal care, and vaccines (immunizations).

Primary Care Physician (PCP): A patient may be required to choose a primary care physician (PCP). A primary care physician usually serves as a patient's main healthcare provider. The PCP serves as a first point of contact for healthcare and may refer a patient to specialists for additional services.

Urgent Care: Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. SOURCES:

• http://www.ehealthinsurance.com/health-insurance-glossary/terms-a/• http://www.usa-healthinsurance.com/kaiser-permanente-glossary.html• http://info.kaiserpermanente.org/html/deductibleplans/glossary.html• http://www.uhc.com/source4women/understanding_health_insurance/common_terms_

defined.htm• http://www.medicare.gov/glossary/a.html

Common Health Insurance Terms, Cont'd.

2017 Medicare-Eligible Retiree Open Enrollment Guide 11

Retiree Health Insurance Rates

MONTLY PREMIUM RATES FOR THE MEDICARE-ELIGIBLE RETIREES INSURANCE PROGRAM

The tables below list the monthly health insurance premium rates for the two City plans in 2016 and 2017. The City monthly retiree health insurance subsidy or reimbursement rate is the cost of insurance or $260, whichever is less.

2017 COMPARISON OF PREMIUM RATES

Plan Option UHC Medicare Advantage Plan

Kaiser Permanente Medicare Plus Plan

Premium Per Member $346.50 $241.46

2016 COMPARISON OF PREMIUM RATES

Plan Option UHC Medicare Advantage Plan

Kaiser Permanente Medicare Plus Plan

Premium Per Member $330.00 $232.23

12 2017 Medicare-Eligible Retiree Open Enrollment Guide

UHC Summary of BenefitsCITY OF ALEXANDRIA 12231Effective January 1, 2017 to December 31, 2017

This is a short description of plan benefits. For complete information, please refer to your Summaryof Benefits or Evidenceof Coverage. Limitations, exclusions, and restrictionsmay apply.

Medical Benefits In-Network Out-of-NetworkBenefits covered by Original Medicare and your plan

Doctor’s office visit PrimaryCareProvider:$15co-pay

PrimaryCareProvider:$15co-pay

Specialist:$15co-pay Specialist:$15co-payPreventive services $0co-payforMedicare-coveredpreventiveservices.Refer to

theEvidenceofCoverageforadditional information.Inpatient hospital care $100 co-pay per admission $100 co-pay per admissionSkillednursing facility (SNF) $0 co-pay per day up to 100

days$0 co-pay per day up to 100days

Outpatient surgery $0 co-pay $0 co-payOutpatient rehabilitation (physical, occupational, orspeech/language therapy)

$15 co-pay $15 co-pay

Diagnostic radiologyservices(such as MRIs, CT scans)

$0 co-pay $0 co-pay

Lab services $0 co-pay $0 co-payOutpatient x-rays $0 co-pay $0 co-payTherapeutic radiology services(suchasradiationtreatment forcancer)

$15 co-pay $15 co-pay

Ambulance $0 co-pay $0 co-payEmergencycare $50 co-pay (worldwide)Urgentlyneededservices $15 co-pay (worldwide) $15 co-pay (worldwide)Annual out-of-pocket maximum Yourplanhasanannualcombined in-networkandout-of-

networkout-of-pocketmaximumof$3,400eachplanyearAdditional benefits and programs not covered by Original Medicare

Routinephysical $0 co-pay; 1per plan year* $0 co-pay; 1per plan year*Foot care - routine $15 co-pay

(Up to 6 visits per plan year)*$15 co-pay(Up to 6 visits per plan year)*

Hearing-routineexam $0 co-pay(1examevery12months)*

$0 co-pay(1examevery12months)*

Hearingaids Plan pays up to $500 (every 3years)*

Plan pays up to $500 (every 3years)*

Vision-routineeyeexams $15 co-pay(1examevery12months)*

$15 co-pay(1examevery12months)*

Fitness program through SilverSneakers® Fitness program

Stay activewith abasic membership at a participating locationat no extra cost to you

NurseLineSM Speak with a registered nurse (RN) 24 hours a day, 7 days aweek

6

Medical Benefits In-Network Out-of-Network

Benefit Highlights

Benefit Highlights

2017 Medicare-Eligible Retiree Open Enrollment Guide 13

UHC Summary of Benefits

VirtualDoctorVisits Speak to specific doctors using your computer or mobiledevice. Find participating doctors online atwww.UHCRetiree.com.

*Benefitsarecombinedinandout-of-network

Prescription Drugs Your CostInitial Coverage Stage Network Pharmacy

(30-day retail supply)Mail Service Pharmacy(90-day supply)

Tier1: Preferredgeneric $10 co-pay $10 co-payTier2: Preferredbrand (includessome generic)

$25 co-pay $10 co-pay

Tier 3: Non-preferred drug(includessomegeneric)

$25 co-pay $10 co-pay

Tier4: Specialty tier $25 co-pay $10 co-payCoveragegap stage After your total drug costs reach $3,700, the plan continues to

pay its share of the cost of your drugs and you pay your shareof the cost

Catastrophic coverage stage Afteryour totalout-of-pocketcostsreach$4,950,youwillpaythegreater of $3.30 co-pay forgeneric (including branddrugstreatedasgeneric), $8.25co-pay forall otherdrugs,or5%ofthe cost

Your plan sponsor has elected to offer additional coverage on some prescription drugs that arenormally excluded from coverageon your Formulary. Please see your Additional Drug Coverage listfor more information.Plansare insured throughUnitedHealthcare InsuranceCompanyoroneof itsaffiliated companies,aMedicareAdvantageorganization with aMedicare contract and aMedicare-approved Part Dsponsor. Enrollment in the plan depends on theplan’s contract renewal with Medicare.Retireeplan prospectsmust meet the eligibility requirements to enroll for group coverage. Thisinformation is not a complete description ofbenefits. Contact theplan for more information.Limitations, co-payments, and restrictions may apply.Benefits,premiumand/orco-payments/co-insurancemaychangeeachplanyear.

CITY OF ALEXANDRIA 12231Effective January 1, 2017 to December 31, 2017

This is a short description of plan benefits. For complete information, please refer to your Summaryof Benefits or Evidenceof Coverage. Limitations, exclusions, and restrictionsmay apply.

Medical Benefits In-Network Out-of-NetworkBenefits covered by Original Medicare and your plan

Doctor’s office visit PrimaryCareProvider:$15co-pay

PrimaryCareProvider:$15co-pay

Specialist:$15co-pay Specialist:$15co-payPreventive services $0co-payforMedicare-coveredpreventiveservices.Refer to

theEvidenceofCoverageforadditional information.Inpatient hospital care $100 co-pay per admission $100 co-pay per admissionSkillednursing facility (SNF) $0 co-pay per day up to 100

days$0 co-pay per day up to 100days

Outpatient surgery $0 co-pay $0 co-payOutpatient rehabilitation (physical, occupational, orspeech/language therapy)

$15 co-pay $15 co-pay

Diagnostic radiologyservices(such as MRIs, CT scans)

$0 co-pay $0 co-pay

Lab services $0 co-pay $0 co-payOutpatient x-rays $0 co-pay $0 co-payTherapeutic radiology services(suchasradiationtreatment forcancer)

$15 co-pay $15 co-pay

Ambulance $0 co-pay $0 co-payEmergencycare $50 co-pay (worldwide)Urgentlyneededservices $15 co-pay (worldwide) $15 co-pay (worldwide)Annual out-of-pocket maximum Yourplanhasanannualcombined in-networkandout-of-

networkout-of-pocketmaximumof$3,400eachplanyearAdditional benefits and programs not covered by Original Medicare

Routinephysical $0 co-pay; 1per plan year* $0 co-pay; 1per plan year*Foot care - routine $15 co-pay

(Up to 6 visits per plan year)*$15 co-pay(Up to 6 visits per plan year)*

Hearing-routineexam $0 co-pay(1examevery12months)*

$0 co-pay(1examevery12months)*

Hearingaids Plan pays up to $500 (every 3years)*

Plan pays up to $500 (every 3years)*

Vision-routineeyeexams $15 co-pay(1examevery12months)*

$15 co-pay(1examevery12months)*

Fitness program through SilverSneakers® Fitness program

Stay activewith abasic membership at a participating locationat no extra cost to you

NurseLineSM Speak with a registered nurse (RN) 24 hours a day, 7 days aweek

6

Medical Benefits In-Network Out-of-Network

Benefit Highlights

Benefit Highlights

14 2017 Medicare-Eligible Retiree Open Enrollment Guide

Kaiser Permanente Summary of Benefits

For illustration only—Not an official Plan document. Please see Plan summary of benefits or EOC for details.

BENEFIT Plan A with D Annual Deductible No Deductibles

Annual Out-of-Pocket Maximum $ 3,400

Primary Care Physician Visits (Family Care, Internal Medicine)

$ 15 copayment per visit

Specialist

Routine Physical Exams $ 0 copayment

Diagnostic Imaging $ 0 for lab and x-ray

Therapeutic Radiology $ 15 copayment per visit

Medicare Covered Preventive Care $ 0 copayment

Prescription Drugs

Mail Order from Kaiser Permanente $ 10 copayment; Generic or BrandUp to 90 days for maintenance medications

Kaiser Permanente Medical Center Rx $ 15 copayment; Generic or BrandUp to 60 days supply

Affiliated Network Pharmacy Giant, Rite Aid, Safeway, Target, Walmart

$ 25 copayment; Generic or BrandUp to 60 days supply

Inpatient Hospitalization $100 copayment per benefit period

Outpatient Surgery @ Surgery Center $ 0 copayment

Emergency Visits $ 50 copayment, waived if admitted

Ambulance $ 0 copayment

Inpatient mental health $100 copayment per benefit period

Outpatient mental health $ 15 copayment per visit

Inpatient chemical dependency $100 copayment per benefit period

Outpatient chemical dependency $ 15 copayment per visit

Other Health Services

Medicare Covered Chiropractic $15 copayment per visit

Physical and Speech Therapy $15 copayment per visit

Home Health, Hospice $ 0 copayment

Durable Medical Equipment $ 0 copayment

Dental discount plan (25% discount when seen by participating dentists

$ 30 examination, cleaning 2x per year

Vision hardware discounts (office visit copayment will apply)

25% off frames and lenses at Kaiser Permanente vision centers

Kaiser Permanente Medicare Plus Benefits 2017 Plan A with D

$ 15 copayment per visit

2017 Medicare-Eligible Retiree Open Enrollment Guide 15

Kaiser Permanente Summary of Benefits

Hearing aids

You are covered for medically necessary hearing aids, hearing aid evaluations, and diagnostic procedures to determine the hearing aid model, which will best compensate for loss of hearing with plan providers. The following hearing aid models are covered:

• In the ear

• Behind the ear

• On the body

• On the eyeglass temple

Hearing aids—you pay nothing for one hearing aid for each ear every 36 months, limited to a $1,000 benefit maximum.

Exclusions: Replacement of parts for repair, lost or broken hearing aids, batteries, accessory parts, and routine maintenance.

Kaiser Permanente is a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year and at other times in accord with your group’s contract with us. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply.

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. 2101 E. Jefferson St., Rockville, MD 20852

60487210 MAS 10/1/16-12/31/18H2150_EG_16_07

City of AlexandriaHuman Resources Department, Benefits Team

301 King Street, Room 2510Alexandria, VA 22314

703.746.3777www.alexandriava.gov/HR