2021 BCPS Retiree Guide
Transcript of 2021 BCPS Retiree Guide
2021 BCPS
Retiree
Guide
Effective January 1, 2021—December 31, 2021
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October 2020
Dear BCPS Retiree,
During this period of unprecedented events affecting our safety and our health, I am
pleased to be able to continue to offer a competitive benefits package for you and
your family. Your health and overall well-being is essential to enjoying your retire-
ment.
The Retiree Benefits Guide provides details of your 2021 benefit plan options as well
as information about how to enroll in coverage or make changes to existing coverage.
Every effort has been made to ensure that the information presented in this Guide is
accurate; however, if there are any discrepancies, the summary plan documents and
actual contract for each plan will govern. Copies of these and other plan materials are
available electronically on the webpage for the Office of Benefits, Leaves, and Retire-
ment, or from the insurance carriers.
Retirees Under Age 65
Our employer-sponsored health plans meet or exceed the Minimum Essential Cover-
age and the Affordable and Minimum Value requirements under the Affordable Care
Act. Retirees are encouraged to assess their own circumstances when making benefit
election decisions. Retirees under age 65 may view their options for enrolling in medi-
cal plans offered through the Health Care Exchange by visiting www.healthcare.gov.
Medicare-Eligible Retirees
Enrollment in Medicare Parts A&B is still required for retirees to participate in our
Medicare-supplement health plans. Retirees are encouraged to assess their own cir-
cumstances when making benefit elections. Medicare-eligible retirees may also view
their options for enrolling in other medical and prescription plans offered by visiting
www.medicare.gov or by calling 1-800-Medicare (1-800-633-4227).
Sincerely,
Darryl L. Williams, Ed.D.
Superintendent
Table of Contents
Content Page
Important Resources 2
Changes For This Plan Year 3
Eligibility & Enrollment 4
Medicare Supplemental Overview 5
Medicare Monthly Benefit Costs 6
ID Cards 7
Medicare Medical Plan Summary 8-11
Prescription Drug Coverage 12
Medicare Explanation of Benefits (EOB) 13-14
Dental Insurance 15
Vision Insurance 16
Basic & Supplemental Optional Life Insurance 17
Cancer, Catastrophic, and Other Insurances 18
Non-Medicare Cigna Resources 19
Non-Medicare Kaiser Permanente Resources 20
Non-Medicare Monthly Benefit Costs 21-45
Non-Medicare Medical Plan Summary 46-48
Non-Medicare Prescription Drugs 49
Frequently Asked Questions 50
The purpose of this Retiree Benefits Guide is to provide information about your benefit options and how to enroll for coverage or make changes
to existing coverage. This Guide is only a summary of your choices and does not fully describe each benefit option. Please refer to your carrier
Guide or Certificate of Coverage for information about the plans.
Every effort has been made to ensure that the information presented in this Guide is accurate; however, if there are any discrepancies, the sum-
mary plan documents and actual contract for each plan will govern. Copies of the Retiree Benefit Guide, plan documents, and other plan materials
are available upon request from the Office of Benefits, Leaves, and Retirement or from the insurance carriers
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Important Resources
Coverage/Service Phone Number Website/Email
Office of Retirement—BCPS (443) 809-8949 bcps.org
Maryland State Retirement Agency (SRA) (410) 625-5555 sra.state.md.us
Baltimore County Employees Retirement System (410) 887-8246 baltimorecountymd.gov
Medicare Help Line (800) 633-4227 Medicare.gov
Social Security Administration (800) 772-1213 ssa.gov
Non-Medicare Medical—Cigna (800) 896-0948 myCigna.com
Cigna Medicare Supplement (800) 896-0948 myCigna.com
Cigna Medicare Prescription Drugs (800) 558-9562 myCigna.com
Cigna Home Delivery Pharmacy (800) 285-4812 myCigna.com
Behavioral Health—Cigna (800) 724-7603 myCigna.com
Non-Medicare Medical—Kaiser Permanente (800) 777-7902 kp.org
Behavioral Health—Kaiser Permanente (800) 777-7904 kp.org
Kaiser Permanente Medicare Advantage (HMO) (888) 777-5536 kp.org
Labor First (443) 290-3114 laborfirst.com/bcps
Dental – CareFirst (866) 891-2802 member.CareFirst.com
Dental—Cigna (800) 896-0948 myCigna.com
Vision—CareFirst Davis (888) 336-7125 member.CareFirst.com
Cancer Insurance (877) 372-5916 my.washingtonnational.com
Life Insurance Claims & Beneficiaries—MetLife (888) 280-6083 metlife.com/mybenefits
Retiree Benefits Billing—Benefit Strategies LLC (888) 401-3539 benstrat.com
Catastrophic Insurance—CareFirst (410) 581-3404 N/A
Website: hr.bcps.org/departments/human_resources_operations/benefits_leaves_and_retirement/
Email: [email protected]
Benefits, Leaves, and Retirement Representatives are available to help answer your questions and address any concerns you have regarding your BCPS
benefits. All benefits information and forms can be found and downloaded from our website. The office is open year round; closures are reflected in
the School Year calendar. When sending an email you will get an automatic confirmation reply that your message has been received. Please allow 2
business days for a response if one is needed.
In some circumstances, you may need to make more than one call:
• Updates to beneficiaries must be handled directly with the pension system and the life insurance companies.
• If you have an address, phone number or name change, we must receive the change in writing and you must also notify the pension system.
• If you are calling to report a death, the pension system, Social Security & Medicare, and MetLife (if applicable) must also be notified.
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Changes for This Plan Year Labor First In addition to the Cigna Medicare Surround Supplemental plan and the Kaiser Permanente Medicare Advantage plan, BCPS is offering an Medi-
care advantage plan with prescription drug coverage through Cigna. Retirees that enroll in this new plan will have the added assistance of Labor
First as a third party administrator. This plan has robust coverage with an affordable monthly premium. All retirees eligible for a subsidy will be able
to carry over the subsidy level for this plan.
What is Labor First? Labor First is a retiree benefit administrator and advocacy company that specializes in retiree healthcare. If you enroll in the new Cigna Medicare
Advantage plan, Labor First is an added resource for you. Below are few of the services your dedicated advocates can assist with throughout the
plan year.
• Claims, billing, and payment support
• Real time physician and pharmacy assistance
• High cost drug issues
• CMS and carrier appeals
• Card replacements
Enrollment in the new Cigna Medicare Advantage Plan with Labor First is voluntary. No action is needed for retirees who are currently
enrolled in any of the benefit plan options who wish to maintain their active coverage.
How is the New Cigna Plan Different Than a Medicare Supplemental Plan?
• For both Medicare Surroundl and Medicare Advantage you are required to be enrolled in both Medicare Part A and Medicare Part B and
continue paying your Part B premium.
• Medicare Supplemental plans supplement original Medicare. Original Medicare pays 80% of cost as primary coverage and the Medicare Sup-
plemental plan pays for the balance minus the copay or coinsurance as secondary coverage. Medicare Supplemental coverage does not con-
tain Rx coverage and typically do not cover additional benefits such as: vision, fitness, meal delivery services after inpatient hospital care, 24/7
nurse line, at home wellness visits and more.
• In comparison, Medicare Advantage plans take the place of Original Medicare as the primary and only payer aside from any copay or coinsur-
ance left over. The government subsidizes these private plans above and beyond typical Medicare Supplemental plans resulting in lower
overall pricing. The carrier then uses those subsidies to enhance plan features and quality of care to drive better health outcomes for retirees.
You use one ID card instead of three and have the same level of coverage whether a provider is in or out of Cigna’s network.
• Medicare Advantage wellness incentives support proactive health management, adherence and chronic condition management, additional
riders for vision, fitness benefits, meal delivery services after inpatient hospital care, 24/7 nurse line, at home wellness visits and more.
Additional Advocacy and Support BCPS has partnered with Labor First, a Retiree Benefit Administrator and Advocacy Company that specializes in retiree healthcare for Unions and
government entities, to help BCPS’s Medicare eligible retirees and their Medicare eligible dependents evaluate the alternative health care choice
on an individual retiree basis to see if the plan is beneficial for you. Labor First advocates go far beyond just enrolling members. Labor First Retiree
Advocates dedicated to BCPS will be able to assist retirees with claims, billing, appeals, card replacements, payment support and any other situa-
tions that arise related to the plan.
What Additional Benefits are Included? Added benefits include but are not limited to:
• $0 Copay Preventive Drug list, not subject to the deductible
• Lower out of pocket maximum of $500
• Silver & Fit—-a fitness benefit
• Meal delivery services after inpatient hospital care
• 24/7 nurse line
Questions and General Interest If you wish to enroll in the Cigna Medicare Advantage plan, please mark the selection on the Enrollment form located in the back of this guide and
submit the form to the BCPS HR Office. This transition can be made at any time throughout the 2021 calendar year however, the deductible period
will restart with enrollment in the new Cigna Medicare Advantage plan. Please reach out to Labor First at 443-290-3114 or Toll Free (833) 550-
1676 if you have any questions about the services they offer.
Retiree Subsidy Changes Applicable for only those BCPS Retirees hired on or after January 1, 2011 with at least ten years of experience, BCPS will follow a flat dollar amount
subsidy schedule for Medicare-eligible retirees as well as pre-Medicare retirees to assist in covering healthcare premium costs. Additional details
including dollar subsidy amounts can be found later in this guide on the Medicare Monthly Costs and Pre-Medicare Monthly Costs pages.
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Eligibility & Enrollment Who is Eligible for Benefits?
Retirees Retirees who, immediately following active employment, begin to receive a monthly pension are eligible to enroll themselves and their eligible
dependents in medical/prescription, dental, and vision plans. Life insurance plans may be continued if enrolled while employed. Retirees who do
not qualify for a pension or who have elected to defer pension benefits are ineligible to participate in benefits.
Dependents Eligible dependents are defined below:
• Spouse: a person to whom you are legally married by ceremony
• Dependent Children: Your or your spouse’s biological, adopted, legal dependents (including grandchildren for whom you have legal custo-
dy) up to age26 regardless of student, financial, residential, or marital status. Dependent coverage terminates at the end of the month in
which they turn 26.
• Acceptable dependent verification includes a marriage certificate, birth certificates, signed federal tax return, court orders, and adoption pa-
pers.
Rehired Retirees Retirees who are re-employed are only eligible to enroll in the retiree benefit programs offered. They may not enroll in benefits as a new employ-
ee. Prior to accepting any employment (with BCPS or elsewhere), retirees should contact their pension plan to determine what effect, if any, em-
ployment will have on the amount of their pension.
• Maryland State Retirement Pension System (MSRPS) retirees who are rehired into non-MSRPS eligible positions may be eligible to participate
in the ERS pension plan
• MSRPS retirees rehired into MSRPS eligible positions are subject to an earnings limitation cap. Please direct questions to MSRPS.
• ERS retirees rehired into ERS eligible positions are only able to be hired as a temporary employee one time only for a maximum of 6 months,
regardless of the number of hours worked. There is one exception. Retirees with a service retirement may work as a school bus driver without
an earnings restriction.
• If a person is receiving a pension from MSRPS, they cannot participate in MSRPS while employed with BCPS
Domestic Partner As of July 1, 2019, BCPS has eliminated eligibility for new enrollment of domestic partners on the benefit plans. However, retirees who had a do-
mestic partner enrolled prior to July 1, 2019 will have their eligibility grandfathered. Retirees covering a domestic partner who have previously
declared their domestic partner as a tax-dependent will be required to recertify and provide supporting documentation.
Surviving Spouse/Children Upon a retiree’s death, if the spouse and dependent children have been covered under a BCPS health care plan, they will have the option to con-
tinue coverage. The Board of Education will contribute to the cost of the health care based on the retiree’s years of service for a period of one year
after the retiree's death. After one year, coverage may continue at the full cost. A surviving spouse may not add dependents.
How Do I Enroll?
Initial Enrollment Complete the Benefits Enrollment Form with your elections, dependent information and verification. Sign and date the form and submit to the
Benefits Office.
Making Changes Retirees are permitted to make benefit changes throughout the year. To make a change, a Benefits Enrollment/Change Form must be completed
and submitted to the Benefits Office. Changes will be accepted at any time during the month and will be processed effective the first day of the
following month. Please allow 7-10 business days for processing to be completed and another 10 days for ID cards to arrive to your home.
Termination of Coverage Retiree’s coverage will terminate when:
• A request is submitted in writing
• The Plan is terminated (if continuation coverage is not available)
• The retiree fails to make any required Plan contribution or quarterly
payment
Dependent's coverage will terminate when:
• A request is submitted in writing within thirty days due to a qualify-
ing life event
• A child has reached age 26
• The retiree’s Plan is terminated for any of the reasons aforemen-
tioned
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Medicare & Supplement Overview
What is Medicare? Medicare is the federal health insurance program for people who are age 65 or older and certain younger people with disabilities.
There are three parts to Medicare:
• Medicare part A is hospital insurance which covers hospital stays, care in a skilled nursing facility, hospice care, and some home health care—
Enrollment is automatic upon turning age 65.
• Medicare part B is medical insurance which covers doctor’s services, outpatient care, medical supplies, and preventive care.
• Medicare part D is prescription drug coverage.
Cigna Medicare Surround
• National network of providers
• For most medical services, the plan pays 80% of the balance remaining after Medicare part B always present your Medicare card and your
Cigna card when receiving services.
• If you see a physician who does not accept Medicare assignment, they may charge you up to 15% above the Medicare allowed amount of
limiting amount and may ask you to pay the bill in full at the time of service.
Cigna True Choice Medicare Advantage (PPO) Enrollment in the new Cigna Medicare Advantage Plan with Labor First is voluntary. No action is needed for retirees who are currently
enrolled in any of the benefit plan options who wish to maintain their active coverage.
New for 2021, BCPS will offer a Cigna Medicare Advantage PPO plan option. Medicare Advantage plans are offered by health insurers like Cigna
through a contract with the Centers for Medicare and Medicaid Services (CMS). Cigna True Choice Medicare (PPO) is a group Medicare Advantage
PPO plan offered exclusively to BCPS retirees that combines Medicare Parts A, B, and D in one integrated easy-to-use plan.
You have the freedom to see any doctor or hospital that accepts Medicare, whether they are in Cigna’s network or not. Unlike many other PPO
plans, you pay the same cost share to see an in-network provider or out-of-network provider. Selecting a Primary care Physician (PCP) is encour-
age, but not required. No referrals are required to see a specialist. Medical and prescription drug coverage in one convenient plan: one ID card,
one customer service phone number, and one customer service team to help you.
Kaiser Permanente Medicare Advantage Enrollment in this plan is only allowed if you live in the following areas:
• Maryland: Baltimore City, Anne Arundel County, Baltimore county, Carroll County, Harford County, Howard County, Montgomery
County, Prince George’s County, Calvert County*, Charles County*, or Frederick County*
• District of Columbia
• Northern Virginia: Alexandria, Arlington, Fairfax City, Fairfax, Falls Church, Fredericksburg City, Loudon, Manassas City, Manassas
park City, Prince William County, Spotsylvania, or Stafford
• For primary and specialty care office visits, you pay a $15 copay
• If you see a physician who does not participate with Kaiser Permanente Medicare Advantage network, you must have an active referral. Other-
wise, you will be responsible for 100% of the charges
• For prescriptions filled at a Kaiser Permanente medical facility, the copay will be $15. Prescriptions filled at a Kaiser Permanente affiliated net-
work (community) retail pharmacy will have a $25 copay. Mail order is also available. There is no medical or prescription deductible on your
Kaiser Permanente Medicare Advantage Plan
*Counties with an asterisk are only partly covered by our service area. If you live in a partly covered county, please refer to your Summary of
Benefits for a list of zip codes in our service area.
Medicare Plan Options BCPS offers three Medicare plan options. Retirees who wish to elect one of the three plan options MUST elect to enroll in Medicare Part B as their
primary health coverage. Retirees who elect BCPS coverage do not need to enroll in Medicare part D as each plan is bundled with a prescription
drug plan
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Monthly Medicare Benefit Costs Years of Service Total Premium ($) 30 Years 20-29 Years 10-19 Years 0-9 Years
Retiree % Share 16.0 24.0 64.0 100.0
Cigna Medicare Surround Supplement Plan (Medical Only)
1 on Medicare $222.94 $35.67 $53.51 $142.68 $222.94
2 on Medicare $445.88 $71.34 $107.01 $285.36 $445.88
Cigna Rx Medicare (PDP) (Prescription Plan Only)
1 on Medicare $339.58 $54.33 $81.50 $217.33 $339.58
2 on Medicare $679.16 $108.67 $163.00 $434.66 $679.16
Total Cost
1 on Medicare $562.52 $90.00 $135.00 $360.01 $562.52
2 on Medicare $1,125.04 $180.01 $270.01 $720.03 $1,125.04
Cigna Medicare Advantage Plan (Medical + Prescription Bundled)
1 on Medicare $220.90 $35.34 $53.02 $141.38 $220.90
2 on Medicare $441.80 $70.69 $106.03 $282.75 $441.80
Kaiser Permanente Medicare Advantage Plan (Medical + Prescription Bundled)
1 on Medicare $248.16 $39.71 $59.56 $158.82 $248.16
2 on Medicare $496.32 $79.41 $119.12 $317.64 $496.32
CareFirst Regional Dental PPO
Individual $27.80
Parent/Child or Two Adults $58.08
Family $88.05
CareFirst Regional Dental Traditional
Individual $31.63
Parent/Child or Two Adults $63.51
Family $106.69
Cigna Dental Care Access DHMO
Individual $46.57
Parent/Child or Two Adults $89.28
Family $134.21
CareFirst Davis Vision
Individual $2.04
Parent/Child, Two Adults, or Family $7.82
A retiree’s monthly premium for se-
lected health insurance coverage
depends on the following factors:
1. Years of service employed with
BCPS at the time of retirement.
Eligible military service may be
added to your BCPS years. BCPS
years do no include contractual,
temporary, or substitute assign-
ments
2. The health plan chosen. The Board
of Education’s contribution to the
cost of coverage may differ be-
tween plans.
3. The level of coverage selected (ex.
Individual, Family, etc.)
Monthly premium for dental and vi-
sion coverage depends on:
1. The plan chosen. The Board of
Education does not contribute to
the cost of these coverages. Retir-
ees are responsible for the full cost
at the COBRA equivalent rate.
2. The level of coverage selected.
All BCPS Medicare Retirees retiring in 2021 hired on or after January 1, 2011 with at least 10 years of
service will receive monthly flat dollar subsidies towards their healthcare premium costs.
Medicare Retiree Only Medicare Retiree + Dependent(s)
$110.56 $165.56
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ID Cards Medicare When seeking medical care, you should always present your Medicare card. You should
also present your Medicare Supplement card if you are enrolled in the Cigna Medicare
Surround plan. You will have the least out-of-pocket costs when you are seen by a physi-
cian who accepts Medicare assignment. Please note that all physicians must submit your
claims to Medicare; however, not all physicians have to accept Medicare assignment.
• If you are enrolled in the Cigna Medicare Surround plan and you see a physician who
does not accept Medicare assignment, the physician may charge you up to 15%
above the Medicare allowed amount for services. This is also called the limiting
amount and you may be asked to pay the bill in full at the time of service.
• If you are enrolled in the Kaiser Permanente Medicare Advantage plan and you see a
physician who is outside of the Kaiser Permanente Medicare Advantage network, you
will be responsible for 100% of the cost of services if you do not have an active refer-
ral. You will likely be asked to pay the bill in full at the time of service. Kaiser Perma-
nente Medicare Advantage members need only present their KP Medicare Ad-
vantage ID Card.
• If you are enrolled in the Cigna True Choice Medicare Advantage plan, you need
only show your one Cigna ID card. Your Cigna Medicare Advantage ID card helps
you access your medical and prescription drug benefits. You should show your
Cigna Medicare Advantage card when you go to the doctor or pharmacy. You don’t
need to show your original Medicare card, but you should keep it in a safe place.
Dental & Vision When seeking dental and vision services, you will have the least out-of-pocket costs when you are seen by a participating provider.
• If you are enrolled in either the CareFirst Regional Preferred Dental PPO or the CareFirst Traditional dental and you see a dentist who does
not participate in the network, the provider may bill you for the difference between the allowed amount for covered services and their charge.
• If you are enrolled in the Cigna DHMO and you see a dentist who does not participate in the network, you will be responsible for 100% of the
cost of services. You will likely be asked to pay the bill in full at the time of service.
• Vision care is provided through the Davis Vision network of providers. If you see a provider who does not participate in the network, you will
have to pay the bill in full at the time of service. You can submit a claim form to Davis vision and be reimbursed for a portion of the charges.
Need an ID Card? ID cards for medical, prescription, dental, and vision benefits must be requested from the insurance companies directly. Contact numbers can be
found on the Resources page in the front of this guide. ID cards may also be requested and temporary cards downloaded electronically by setting
up a personal online account on the insurance company’s website.
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Cigna Medicare Plan Summaries
Plan Name Medicare A&B* Cigna Medicare Surround Cigna Medicare
Advantage
Payer Medicare Pays First Plan Pays After Medicare A&B Plan Pays After Retiree
Group Number N/A 32560-0002 N/A
Network Nationwide Nationwide Nationwide
Plan Features
Calendar Year Deductible Verify with Medicare Not Applicable $0
Calendar Year Out-of Pocket Maximum
(Medical Services) Not Applicable $650 $500
Lifetime Benefit Maximum Not Applicable Unlimited (Applies to all Part A and
Part B Expenses) Unlimited
Other Professional/Outpatient Services
Office Visit for Illness or Injury 80% After Deductible* 80% of Balance Due 90%
Advanced Imaging (CT, MRI, PET) 80% After Deductible* 100% of Balance Due 100% for Lab Tests; 90% for X-Rays
Laboratory Tests & X-Rays 80% After Deductible* 100% of Balance Due 90%
Physical/Speech/Occupational Therapy 80% After Deductible* 80% of Balance Due 90%
Radiation Therapy/Chemotherapy/Renal
Dialysis 80% After Deductible* 100% of Balance Due 90%
Outpatient Surgery 80% After Deductible* 100% of Balance Due 90%
Allergy Testing/Covered Injections 80% After Deductible* 80% of Balance Due 90%
Acupuncture 80% After Deductible* 80% of Balance Due 90%
Preventive/Well Care (Routine)
Adult Physicals, Immunizations, and Diag-
nostic Tests 100%* Limit One Per 12 Months 100%
100% for Annual Wellness Visits
and Immunizations, 90% for Routine
Screenings
GYN (PAP) Services 100%* Limit One Per 12 Months 100% 100%
Prostate Screening (PSA Test) After Age
50 100%* Limit One Per 12 Months 100% 100%
Mammogram screening After Age 40 100%* Limit One Per 12 Months 100% 100%
Emergency Care
Urgent Care 80%* After Deductible 100% of Balance Due 90%
Accidental Injury/First Aid/Medical Emer-
gency/Life Threatening Emergency 80%* After Deductible 100% of Balance Due 100%
Ambulance (Ground) 80%* After Deductible 100% of Balance Due 90%
Prosthetic Devices and Orthopedic Braces
Purchase, Repair, or Replacement 80%* After Deductible 100% of Balance Due 90%
Durable Medical Equipment 80%* After Deductible 80% of Balance Due 90%
Medical Supplies 80%* After Deductible 80% of Balance Due 90%
Hearing Aids Not Covered 100% of Billed Charges
$0 Copay up to plan maximum
coverage amount for hearing aids
of $700 per ear per device every
three years
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Plan Name Medicare A&B* Cigna Medicare Surround Cigna Medicare
Advantage
Payer Medicare Pays First Plan Pays After Medicare A&B Plan Pays After Retiree
Group Number N/A 32560-0002 N/A
Network Nationwide Nationwide Nationwide
Home Health Care
Agency 100% 100% of Balance Due 100%
Inpatient Hospital/Facility Services
Room & Board (Includes ICU/CCU/Other
Special Care Unites and Ancillary Services)
Days 1-60: 100% After Inpatient
Deductible; Days 61-90: 100% After
Per Day deductible; After Day 90:
100% After Per Day Deductible
(Limit 60 Days Per Lifetime )
Days 1-60: 100% of Inpatient De-
ductible; Days 61-90: 80%; 91st Day
and After, while Using 60 Lifetime
Reserve Days: 80%
100%
Extended Care Facility/Skilled Nursing
Care
Days 1-20: 100%*; Days 21-100:
100%* After Per Day Deductible
Days 1-20: No Payment Necessary;
Days 21-100: 100% of Per Day
Deductible
Days 101-365: 100% of Allowed
Benefit
100% for Days 1-100
Inpatient Professional/Practitioner Services
Physician Surgical Services 80% After Deductible* 100% of Balance Due 100%
Anesthesia, Assistant Surgeon 80% After Deductible* 100% of Balance Due 100%
Consultation & Physician Visits 80% After Deductible* 100% of Balance Due 100%
Radiation Therapy/Chemotherapy/Renal
Dialysis 80% After Deductible* 100% of Balance Due 100%
Mental Health
Inpatient Hospital/Facility and Professional
Services Same as Medical
Same as Medical, also with No Cov-
erage Limit
100%, Lifetime Maximum 190 days
in a Psychiatric Hospital
Outpatient Facility and Professional
Services Same as Medical 80% of Balance Due
90% for Partial Hospitalization,
100% for Specialty Psychiatric Indi-
vidual or Group Visits, 90% for Spe-
cialty Substance Abuse Individual or
Group Visits
Other Services
Outpatient Private Duty Nursing
(Preauthorization Required) 100%*
80% of Maximum Reimbursable
Charge 90%
Cardiac Rehabilitation 80% After Deductible 80% of Balance Due 90%
Hospice Care
100% Except $5 Per Outpatient
Prescription and 5% Inpatient Res-
pite Care
100% of Balance Due 100%
Routine Dental Not Covered Not Covered Not Covered
Routine Vision Not Covered Healthy Rewards Discounts Availa-
ble
Healthy Rewards Discounts Availa-
ble
Cigna Medicare Plan Summaries
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Kaiser Permanente Medicare
Plan Summary Plan Name Medicare A&B*
Kaiser Permanente
Medicare Advantange Plan
Payer Medicare Pays First Plan Pays After Medicare A&B
Group Number N/A 7434-16
Network Nationwide MD/DC/NoVA
Plan Features
Calendar Year Deductible Verify with Medicare None
Calendar Year Out-of Pocket Maximum (Medical
Services) Not Applicable $3,400
Lifetime Benefit Maximum Not Applicable Not Applicable
Other Professional/Outpatient Services
Office Visit for Illness or Injury 80% After Deductible* $15 Copay
Advanced Imaging (CT, MRI, PET) 80% After Deductible* No Charge
Laboratory Tests & X-Rays 80% After Deductible* No Charge
Physical/Speech/Occupational Therapy 80% After Deductible* $15 Copay
Radiation Therapy/Chemotherapy/Renal Dialysis 80% After Deductible* $15 Copay
Outpatient Surgery 80% After Deductible* $15 Copay
Allergy Testing/Covered Injections 80% After Deductible* $15 Copay
Acupuncture Covers up to 12 visits in 90 days for chronic
lower back pain $15 Copay
Preventive/Well Care (Routine)
Adult Physicals, Immunizations, and Diagnostic
Tests 100%* Limit One Per 12 Months No Charge
GYN (PAP) Services 100%* Limit One Per 12 Months No Charge
Prostate Screening (PSA Test) After Age 50 100%* Limit One Per 12 Months No Charge
Mammogram screening After Age 40 100%* Limit One Per 12 Months No Charge
Emergency Care
Urgent Care 80%* After Deductible $50 Copay
Accidental Injury/First Aid/Medical Emergency/Life
Threatening Emergency 80%* After Deductible $50 Copay
Ambulance (Ground) 80%* After Deductible No Charge
Prosthetic Devices and Orthopedic Braces
Purchase, Repair, or Replacement 80%* After Deductible No Charge (Per Medicare Guidelines)
Durable Medical Equipment 80%* After Deductible No Charge (Per Medicare Guidelines)
Medical Supplies 80%* After Deductible No Charge (Per Medicare Guidelines)
Hearing Aids Not Covered No Charge (Per 36 Months)
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Kaiser Permanente Medicare
Plan Summary Plan Name Medicare A&B*
Kaiser Permanente
Medicare Advantange Plan
Payer Medicare Pays First Plan Pays After Medicare A&B
Group Number N/A 7434-16
Network Nationwide MD/DC/NoVA
Home Health Care
Facility 100% No Charge (Per Medicare Guidelines)
Inpatient Hospital/Facility Services
Room & Board (Includes ICU/CCU/Other Special
Care Unites and Ancillary Services)
Days 1-60: 100% After Inpatient Deductible;
Days 61-90: 100% After Per Day deductible;
After Day 90: 100% After Per Day Deducti-
ble (Limit 60 Days Per Lifetime )
$100 Copay (Per Benefit Period)
Extended Care Facility/Skilled Nursing Care Days 1-20: 100%*; Days 21-100: 100%*
After Per Day Deductible No Charge (100 Days Per Benefit Period)
Inpatient Professional/Practitioner Services
Physician Surgical Services 80% After Deductible* No Charge
Anesthesia, Assistant Surgeon 80% After Deductible* No Charge
Consultation & Physician Visits 80% After Deductible* No Charge
Radiation Therapy/Chemotherapy/Renal Dialysis 80% After Deductible* No Charge
Mental Health
Inpatient Hospital/Facility and Professional Services Same as Medical $100 Copay (Per Benefit Period)
Outpatient Facility and Professional Services Same as Medical $15 Copay
Other Services
Outpatient Private Duty Nursing (Preauthorization
Required) 100%* Special Limitations Apply
Cardiac Rehabilitation 80% After Deductible $15 Copay
Hospice Care 100% Except $5 Per Outpatient Prescription
and 5% Inpatient Respite Care No Charge (Medicare Certified Hospice)
Routine Dental Not Covered $30 Copay for Preventive Care
Routine Vision Not Covered $15 Copay Routine Eye Exam
12
Prescription Drug Coverage
Kaiser Permanente Medicare Plan Prescription Drugs Prescription Drug coverage is included when you enroll in the Kaiser Permanente Medicare Advantage
plan. There is no “doughnut hole coverage gap” that applies to this plan.
Diabetic supplies are covered under the prescription plan however, over-the-counter medications, diet
drugs, cosmetic drugs, and drugs prescribed for a condition not approved by the FDA are excluded from
coverage.
Kaiser Permanente
Medical Center
Community Retail
Pharmacy Mail Order
Generic (Tier 1) $15 Copay $25 Copay $10 Copay
Preferred Brand
(Tier 2) $15 Copay $25 Copay $10 Copay
Non-Preferred
Brand (Tier 3) $15 Copay $25 Copay $10 Copay
Cigna Medicare Surround Plan Prescription Drug Coverage Prescription drug coverage is not included in the stand-alone Cigna Medicare Surround plan. If you enroll
in the Cigna Rx Medicare (PDP) Part D plan offered to BCPS retirees, you cannot enroll in an independent
Medicare Part D plan. There is no “doughnut hole coverage gap” that applies to this plan.
Diabetic supplies are covered under the prescription plan however, over-the-counter medications, diet
drugs, cosmetic drugs, and drugs prescribed for a condition not approved by the FDA are excluded from
coverage.
Retail Pharmacy Mail Order
Generic (Tier 1) You pay 20% $20 Copay
Preferred Brand (Tier You pay 20% $40 Copay
Non-Preferred Brand You pay 20% $40 Copay
Cigna Medicare Advantage Plan Prescription Drug Coverage Prescription drug coverage is included when you enroll in the Cigna Medicare Advantage Plan. There is no
“doughnut hole coverage gap” that applies to this plan. Cigna offers a home delivery pharmacy through
Express Scripts. There is a $250 prescription drug deductible.
Diabetic medications and supplies, asthma, blood pressure, blood thinners, cholesterol, and osteoporosis
are the classes covered under the $0 preventive drug listing. Not all medications under these classes are
covered at $0—please contact Labor First to determine if your medications fall under this list. Eligible $0
preventive drugs are not subject to the $250 deductible.
30 Day Retail 90 Day Retail/Mail Order
Generic (Tier 1) $10 $25
Preferred Brand
(Tier 2) 25% coinsurance ($150 max) 25% coinsurance ($375 max)
Non-Preferred
Brand (Tier 3) 30% coinsurance ($150 max) 30% coinsurance ($375 max)
Specialty 20% coinsurance ($150 max) 20% coinsurance ($375 max)
Medicare Part D Notice of
Creditable Coverage Baltimore County Public Schools
must provide a notice of creditable
prescription coverage to Medicare
beneficiaries who are covered by
prescription drug coverage under
the Cigna Medicare Supplement
plan. There are two important
things you need to know about
BCPS and Medicare’s prescription
drug coverage:
1. Medicare prescription drug
coverage (Medicare part D)
became available in 2006 to
everyone with Medicare. All
Medicare 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. BCPS has determined that the
prescription drug coverage
offered by Cigna Rx Medicare
(PDP) and Kaiser Permanente
is, on average for all plan par-
ticipants, expected to pay out
as much as standard Medicare
prescription drug coverage
pays and is therefore consid-
ered Creditable Coverage.
This means that is you are
covered under a BCPS Medi-
care Supplement plan, you
will not pay a higher premium
if you later decide to join a
Medicare part D drug plan
Medicare part D plans have an
annual deductible of $445. Medi-
care part D plans also have a provi-
sion called the “doughnut hole”
that allows the plan to stop paying
toward prescription drugs for an
enrollee after they have incurred
$4,130 in annual prescription drug
costs. The plan resumes paying
when the enrollee spends a total of
$6,550.
There is no deductible or dough-
nut hole in either of BCPS’s pre-
scription drug plans.
13
Medicare
Explanation of Benefits
*Example only, your specific plan EOB may vary
carrier
14
Medicare
Explanation of Benefits
The dollar amount and percentage
insurance paid on the covered amount.
insurance
*Example only, your specific plan EOB may vary
15
Dental Insurance Options
Plan Name CareFirst Regional Dental PPO CareFirst Regional Dental
Traditional
Cigna Dental
Care Access
DHMO
Group Number 7J91 7J91 10013509
Network Nationwide Nationwide Nationwide
Plan Features In-Network Out-of-Network In-Network Out-of-Network In-Network
Only
Calendar Year
Deductible
Individual: $10
Family: $20
Individual: $25
Family: $50
Individual: $10
Family: $25 None
Maximum Benefit Per
Calendar Year $1,000 Per Person $750 Per Person Unlimited
Member Pays Member Pays Member Pays Member Pays Member Pays
Preventive & Diagnostic
Services No Charge 20%** No Charge No Charge** No Charge
Basic Services 20% (AD) 40% (AD)** 20% (AD) 20% (AD)** $0—$220 Copay
Major Services Surgical 20% (AD) 40% (AD)** 20% (AD) 20% (AD)** $15—$335 Copay
Major Services
Restorative 20% (AD) 40% (AD)** 20% (AD) 20% (AD)** $15—$335 Copay
Dentures & Bridges 50% (AD) 70% (AD)** 50% (AD) 50% (AD)** $15—$335 Copay
Orthodontia Lifetime
Maximum Benefit $1,500 Per Person $1,000*** Per Person 24 Months $1,000 Per Person
Orthodontia 50%* 50%* 50%* 50%* See Fee Schedule
This chart is intended for comparison purposes only. If there are any discrepancies, the summary plan document will govern
(AD) After Deductible
*Orthodontia is only available to dependent children up to age 19 if you select one of the CareFirst plans.
**CareFirst payments for Out-of-Network services are based on the Allowable Benefit. Non-participating providers may balance bill for the difference
***See full fee-schedule for exact costs
Prevention First! Make sure you take advantage of your preventive dental visits. Preventive care services are not subject to any deductible and all three plans cover
100% of the cost when you visit an in-network provider.
Need to Locate a Participating Provider? CareFirst
Visit www.Carefirst.com. Click on “Find a Doctor” and then “Continue as guest”. Select “Dental” and then either “Preferred Dental PPO” or
“Traditional Dental”.
• Providers in the Traditional Dental network who do not also participate in the Preferred Dental PPO network, will accept the insurance for
members enrolled in the Regional Dental PPO and the coerage will be paid at the out-of-network level. The Traditional provider however,
may not balance bill.
Cigna
Visit www.Cigna.com/dental. Click on “Find a Dentist” and then “For plans offered through work or school”. Enter your zip code and select “Cigna
Dental Care HMO”.
16
Vision Insurance
This chart is intended for comparison purposes only. If there are any discrepancies, the summary plan document will govern
*Preapproval required
**You are responsible for all charges and services received out-of-network and must file a claim for reimbursement within 12 months of the date of service
Plan Features CareFirst Davis Vision
In-Network Out-of-Network**
Eye Exams (Once Every 12 Months) $20 Copay Covered up to $35
Spectacle Lenses (Once Every 24 Months)
Single Vision $20 Copay Covered up to $25
Lined Bifocal $20 Copay Covered up to $40
Lined Trifocal $20 Copay Covered up to $55
Lenticular $20 Copay Covered up to $80
Frames (Once Every 24 Months)
Tower Collection No Charge Covered up to $35
Non-Tower Frames Covered up to $130 Covered up to $35
Contact Lenses (Once Every 24 Months)
Elective (in Lieu of Lenses and Frames) Covered up to $130 Covered up to $130
Medically Necessary* $20 Copay Covered up to $210
Lens Options (add to spectacle lens prices)
Transition Lenses $65 Copay
Photochromic Lenses $30 Copay
Scratch-Resistant Coating $25 Copay
Anti-Reflective Coating (AR) $35 Copay
Ultraviolet Coating $12 Copay
Premium Progressive Lenses $90 Copay
Example Cost for Glasses (Lenses & Frames)
with Davis Vision Provider
• Tower collection frames with bifocal lenses, including
scratch-resistant coating = $40
• Non-tower frames (retail $185) with single vision premium
progressive lenses = $165
• Non-tower frames (retail $230) with single vision transi-
tion lenses = $185
Additional Information
• Benefits are based on your last date of service. For exam-
ple, if you have your eye exam and purchase glasses on
March 1, 2020, you will not be eligible for another eye
exam until March 2, 2021 even though the plan year re-
news January 1, 2021. you would not be eligible for
glasses until March 2, 2022
Discounted Rates on Special Services Need to Locate a Participating Provider? Changes in your Prescription?
In addition to your standard eye glass
coverage, you will also have access to
various discounts including up to 35% off
the usual and customary charge for Laser
Vision correction when using a Davis Vi-
sion Laser provider
The Davis Vision network now includes many
national and retail stores including Wal-Mart,
Target Optical, Sears Optical, Pearle Vision,
and Doctor’s Visionworks.
Remember, if you choose an eye care profes-
sional that is not part of the Davis Vision net-
work, you will be expected to pay the entire
cost for services up front. You may then seek
reimbursement up to the allowed amounts by
filing a claim form with CareFirst Davis Vision
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
17
Life Insurance
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
Enrollment A personalized life insurance election form will be provided to you by the Office of Benefits, Leaves, and Retirement. Continuation is optional. If
you do no elect to continue this benefit at the time of retirement, you will forefeet your eligibility indefinitely. The election form must be completed
and returned within thirty days of the effect date of your retirement.
Benefit Amount & Reduction Schedule Retirees may not elect to continue more than $50,000 in coverage. This includes $15,000 of Basic Term Life Insurance and up to $35,000 in Sup-
plemental Life Insurance.
Reduction Schedule Supplemental Life Insurance coverage immediately reduces by 10% on the date of retirement. Therefore, the maximum amount of total Life
Insurance on the date of retirement is $46,500. Following retirement, the Supplemental Life Insurance will be reduced by the same dollar
amount on each of the following four anniversaries of your retirement date. The cost of Life Insurance is paid entirely by the retiree. Premiums are
deducted from your pension check. Coverage terminated for non-payment of premium cannot be reinstated.
See example below:
Date
Supplemental
Coverage Basic Coverage Total Coverage
Active June 1, 2021 $65,000 $15,000 $80,000
Retired July 1, 2021 $31,500 $15,000 $46,500*
1st Year July 1, 2022 $28,000 $15,000 $43,000
2nd Year July 1, 2023 $24,500 $15,000 $39,500
3rd Year July 1, 2024 $21,000 $15,000 $36,000
4th Year July 1, 2025 $17,500 $15,000 $32,500
Cost of Coverage Employees who retire at age 65 who elect to continue the Basic Term Life and the maximum amount of Supplemental Life Insurance will pay
$58.61 per month for $46,5000 in total benefit.
Monthly Cost for Basic Term Life Insurance
Retired Prior to 1/1/2005 $9.15 (for $7,380 of coverage)
Retired After 1/1/2005 $18.60 (for $15,000 of coverage)
Monthly Rate per $1,000 of Supplemental Life Insurance
Age 50-54 55-59 60-64 65-69* 70+
Rate .23 .43 .66 1.27 2.06
Ages 25-49 contact the Office of Benefits, Leaves, and Retirement for rates
Don’t Forget to Designate a Beneficiary! Choosing who will receive your Life Insurance benefit is an important decision. Please make sure your beneficiary is up to date.
Cancelling Life Insurance Retirees may cancel their Basic Term Life and/or Supplemental Life Insurance Coverage at any time. Coverage which has been cancelled cannot
be reinstated.
18
Cancer, Catastrophic, and
Other Insurances
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
Cancer Insurance Retirees who were enrolled in cancer insurance at the time of retirement could elect to continue to pay the premoums to keep the coverage. Pre-
miums are deducted from pension checks in combination with the cost of health insurance. Thus, a retiree with cancer insurance will see a deduc-
tion from the pension check that combines the cost of both programs.
Retirees wishing to cancel this insurance must notify the Office of Benefits, Leaves, and Retirement for BCPS in writing. Coverage that is canceled
cannot be reinstated.
This policy is through Washington National Insurance Co. (Conseco) (877) 372-5916.
Catastrophic Insurance The insurance coverage has been billed by CareFirst BlueCross BlueShield for many years. Any billing or coverage questions should be addressed
to CareFirst directly (410) 581-3404.
Accidental Death & Dismemberment (AD&D) Insurance Retirees who were enrolled in AD&D at the time of retirement are able to continue the policy by contacting Prudential at (800) 778-3827 and con-
verting the policy into an individual policy. Preiums will be paid directly to Prudential. Conversion must happen within thirty days immediately
following retirement.
Plans Available Through MRSPA Retiree dental, vision, and long-term care insurance plans are available to purchase through the Maryland Retired School Personnel Association.
Contact the MRSPA directly at (410) 551-1517 or online at www.mrspa.org for more details about eligibility guidelines and costs for these plans.
19
Non-Medicare Cigna Resources
If your
lens
pre-
scription
changes before you are eligible for new
lenses and that prescription meets one of
the following criteria, lenses and frames
Cigna One Guide® The myCigna app now includes a Cigna One Guide® service upgrade with even more tools and support.
With One Guide you cang et tips and reminder to help you stay on track with appointments and preven-
tive care, sign up for messages that can guide you to savings, access support quickly and more. Go to the
myCigna.com website or launch the myCigna App and select “Register Now.” You can chat online with
a personal guide who can answer your questions and help you make the most of your plan and wellness
resources.
Preventive Care
Covered at 100% Prevention is the best medicine
and Cigna offers a wide range of
preventive services including annu-
al routine physicals, well-child care,
immunizations, PAP tests, mammo-
grams, prostate screenings and
other services required by the Af-
fordable Care Act. These services
are provided at no cost to you
when you visit a participating pro-
vider.
Need to Locate a
Participating Provider? Visit a www.Cigna.com. Click on
“Find a Doctor” and then “For plans
offered through work or school.”
Enter your zip code and select
“Open Access Plus, OA Plus,
Choice Fund OA Plus.”
Summary of Benefits
Coverage Choosing a health coverage option
is an important decision. To help
you make an informed choice, a
Summary of Benefits Coverage
(SBC), which summarizes important
information in a standard format, is
available for review. The SBC is
located on the Benefits, Leaves,
and Retirement web page in the
Forms Repository. A paper copy is
also available free of charge by
contacting the Benefits Office.
Coverage Notice Our current employer-sponsored
health plans meet or exceed the
Minimum Essential coverage and
the Affordable and Minimum Val-
ues requirements under the ACA,
so employees will generally not be
subsidy eligible in the Marketplace.
If you have questions about your
specific circumstances, you should
contact your tax advisor or visit
www.healthcare.gov.
24/7/365 Medical Advice with Cigna Virtual Care With virtual care, you get the care and attention you’d expect from an in-office visit, wherever and when-
ever is most convenient for you. Virtual care options let you talk privately with a licensed coun-selor psy-
chiatrist, or board-certified doctor via video or phone. Wellness screenings are also availa-ble through
MDLive. Simply make your appointment online and go for a quick visit to a lab for your blood work and
biometrics. The rest is completed online and via video or phone, wherever it’s most convenient for you.
You’ll receive a summary of your screening results for your records.
You can also receive care through Cigna’s network of behavioral health providers. Cigna Behavioral
health provides access to virtual counseling through its own network of providers. To find a Cigna Behav-
ioral Health network provider: visit myCigna. com, go to “Find Care & Costs” and enter “Virtual counse-
lor” under Doctor by Type. To schedule an appointment online, go to myCigna.com or call MDLIVE di-
rectly at 888.726.3171.
Virtual care is designed to handle minor, nonemergency medical issues. You should NOT use tele-health
if you are experiencing a medical emergency. If you have a medical emergency, you should dial 911
immediately or visit the nearest hospital.
Nurse Line The Health Information Line has trained nurses available to provide health and medical information and
direction to the most appropriate resource. You can also call and listen to hundreds of topics contained
in the audio library or listen via live stream at myCigna.com. Call (866) 494-2111.
Confidential Health Assessment At BCPS, your health matters! When you complete the health assessment on your personal myCigna
account, you answer simple questions and the result is a personalized report of your overall health. Hav-
ing this information gives you more control, so you can start making simple changes to improve your
health.
• Log in to myCigna.com (if you haven’t already registered, click the Register Now button to set up
your account)
• go to the “Wellness” tab
• Click on Health Assessment
• Get started
20
If your
lens pre-
scription
changes
before
you are
eligible
for new lenses and that prescription
meets one of the following criteria, lenses
and frames will be replaced as a 12
month frequency:
• Differs from the original by at least
0.50 diopter sphere
Kaiser Permanente Mobile App Manage you health online with kp.org or by downloading the Kaiser Permanente app to your smartphone.
You can email your doctor, make or change appointments, order prescription refills, print vaccination
records, and more.
Non-Medicare Kaiser Permanente
Resources Preventive Care
Covered at 100% Prevention is the best medicine
and Kaiser Permanente offers a
wide range of preventive services
including annual routine physicals,
well-child care, immunizations, PAP
tests, mammograms, prostate
screenings and other services re-
quired by the Affordable Care Act.
These services are provided at no
cost to you when you visit a partici-
pating provider.
Need to Locate a
Participating Provider? Visit kp.org. Click on “Doctors and
Locations” and make sure you have
selected “Maryland/Virginia/
Washington D.C.” for the region.
Choose “Search our affiliated and
net-work physicians” and scroll
down to choose “Kaiser
Permanente Select HMO” as the
plan name.
Summary of Benefits
Coverage Choosing a health coverage option
is an important decision. To help
you make an informed choice, a
Summary of Benefits and Coverage
(SBC), which summarizes the im-
portant information in a standard
format, is available for review. The
SBC is located on the Benefits,
Leaves, and Retirement web page
in the Forms Repository. A paper
copy is available free of charge, by
contacting the benefits office.
Benefits Coverage Our current employer-sponsored
health plans meet or exceed the
Minimum Essential coverage and
the Affordable and Minimum Val-
ues requirements under the ACA,
so employees will generally not be
subsidy eligible in the Marketplace.
If you have questions about your
specific circumstances, you should
contact your tax advisor or visit
www.healthcare.gov.
Video Visits PCP/Specialist
Did you know that you can schedule a video appointment with your doctor? Save time and money! Unlike
when you visit in person, there is no copay for the visit and no need to take time off work, pay for gas,
parking or cab fare. Appointments can be booked online or by calling the KP appointment line.
After-Hours Care
Connect with a KP emergency medicine physician 24/7/365 if care is needed for a wide range of minor
conditions.
Follow-Up Care
During your video visit, the doctor can make follow-up appointments, order lab tests, and prescribe
medicine. Your video visit is an extension of the care you receive at KP facilities.
Where to Go for Care? KP’s unique all-in-one model of health care combines practitioners, pharmacy, lab, and X-ray services
combined in their state-of-the-art medical centers located around the region. Every facility is connected to
your electronic health record, which keeps your care team informed and ready to give the right care at the
right time.
KP facilities can be found in Towson, Downtown Baltimore, Woodlawn, White Marsh, Halethorpe, Glen Bur-
nie, Abingdon, Columbia, and Annapolis as well as many other locations in MD/DC/VA. For a list of
medical center locations, visit kp.org/facilities.
Away From Home Care Emergency Care
Emergencies are medical or psychiatric conditions, including severe pain, which require immediate
attention to prevent serious jeopardy to your health; examples include chest pain or pressure, severe
shortness of breath, or decrease or loss of consciousness. You do not have to get prior approval for
emergency care. Once your condition is stable, call or have your treating physician call KP. If you still need
care after your condition has been stabilized, you’ll need to get approval for follow-up care.
Urgent Care
Urgent care need requires prompt attention, usually within 24-48 hours, but is not an emergency; examples
include upper-respiratory symptoms, severe cough or sore throat, ear-aches, or minor burns or cuts. You
can visit an urgent care or retail clinic and you will be covered as long as it can’t wait until you return home.
21
If
your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
Non-Medicare Monthly Benefit Costs
A retiree’s monthly premium for selected
health insurance coverage depends on the
following factors:
1. Years of service employed with BCPS at
the time of retirement. Eligible military
service may be added to your BCPS years.
BCPS years do no include contractual,
temporary, or substitute assignments
2. The health plan chosen. The Board of
Education’s contribution to the cost of
coverage may differ between plans.
3. The level of coverage selected (ex. Indi-
vidual, Family, etc.)
Monthly premium for dental and vision cov-
erage depends on:
1. The plan chosen. The Board of Education
does not contribute to the cost of these
coverages. Retirees are responsible for
the full cost at the COBRA equivalent rate.
2. The level of coverage selected.
Years of Service Total Premium ($) 30 years 29 Years 28 Years 27 Years
Retiree % Share 15.0/25.0* 20.0/28.5* 24.8/31.8* 28.1/35.1*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $111.68 $148.90 $184.64 $209.21
Parent/Child(ren) $1,475.13 $221.27 $295.03 $365.83 $414.51
Two Adults $1,776.72 $266.51 $355.34 $440.63 $499.26
Family $2,008.68 $301.30 $401.74 $498.15 $564.44
Kaiser Permanente HMO
Individual $796.03 $119.40 $159.21 $197.42 $223.68
Parent/Child(ren) $1,577.10 $236.57 $315.42 $391.12 $443.17
Two Adults $1,899.58 $284.94 $379.92 $471.10 $533.78
Family $2,141.73 $321.26 $428.35 $531.15 $601.83
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $211.28 $240.85 $268.74 $296.63
Parent/Child(ren) $1,674.36 $418.59 $477.19 $532.45 $587.70
Two Adults $2,016.69 $504.17 $574.76 $641.31 $707.86
Family $2,273.74 $568.44 $648.02 $723.05 $798.08
Retired January 1, 2021—December 31, 2021
CareFirst Regional Dental PPO
Individual $27.80
Parent/Child or Two Adults $58.08
Family $88.05
CareFirst Regional Dental Traditional
Individual $31.63
Parent/Child or Two Adults $63.51
Family $106.69
Cigna Dental Care Access DHMO
Individual $46.57
Parent/Child or Two Adults $89.28
Family $134.21
CareFirst Davis Vision
Individual $2.04
Parent/Child, Two Adults, or Family $7.82
All BCPS Pre-Medicare Retirees retiring in 2021 hired on or after January 1, 2011 with at least 10
years of service will receive monthly flat dollar subsidies towards their healthcare premium costs.
Pre-Medicare Retiree Only Pre-Medicare Retiree + Dependent(s)
$180.97 $271.45
22
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 26 years 25 Years 24 Years 23 Years
Retiree % Share 31.4/38.4* 34.7/41.7* 38.0/45.0* 40.9/47.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $233.78 $258.35 $282.92 $304.51
Parent/Child(ren) $1,475.13 $463.19 $511.87 $560.55 $603.33
Two Adults $1,776.72 $557.89 $616.52 $675.15 $726.68
Family $2,008.68 $630.73 $697.01 $763.30 $821.55
Kaiser Permanente HMO
Individual $796.03 $249.95 $276.22 $302.49 $325.58
Parent/Child(ren) $1,577.10 $495.21 $547.25 $599.30 $645.03
Two Adults $1,899.58 $596.47 $659.15 $721.84 $776.93
Family $2,141.73 $672.50 $743.18 $813.86 $875.97
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $324.52 $352.41 $380.30 $401.42
Parent/Child(ren) $1,674.36 $642.95 $698.21 $753.46 $795.32
Two Adults $2,016.69 $774.41 $840.96 $907.51 $957.93
Family $2,273.74 $873.12 $948.15 $1,023.18 $1,080.03
Retired January 1, 2021—December 31, 2021
Years of Service Total Premium ($) 22 years 21 Years 20 Years 19 Years
Retiree % Share 43.8/50.0* 46.7/52.5* 49.6/55.0* 52.5/57.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $326.10 $347.69 $369.28 $390.87
Parent/Child(ren) $1,475.13 $646.11 $688.89 $731.66 $774.44
Two Adults $1,776.72 $778.20 $829.73 $881.25 $932.78
Family $2,008.68 $879.80 $938.05 $996.31 $1,054.56
Kaiser Permanente HMO
Individual $796.03 $348.66 $371.75 $394.83 $417.92
Parent/Child(ren) $1,577.10 $690.77 $736.51 $782.24 $827.98
Two Adults $1,899.58 $832.02 $887.10 $942.19 $997.28
Family $2,141.73 $938.08 $1,000.19 $1,062.30 $1,124.41
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $422.55 $443.68 $464.81 $485.93
Parent/Child(ren) $1,674.36 $837.18 $879.04 $920.90 $962.76
Two Adults $2,016.69 $1,008.35 $1,058.76 $1,109.18 $1,159.60
Family $2,273.74 $1,136.87 $1,193.71 $1,250.56 $1,307.40
23
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 18 years 17 Years 16 Years 15 Years
Retiree % Share 55.0/60.0* 57.5/62.5* 60.0/65.0* 62.5/67.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $409.49 $428.10 $446.71 $465.33
Parent/Child(ren) $1,475.13 $811.32 $848.20 $885.08 $921.96
Two Adults $1,776.72 $977.20 $1,021.61 $1,066.03 $1,110.45
Family $2,008.68 $1104.77 $1,154.99 $1,205.21 $1,255.43
Kaiser Permanente HMO
Individual $796.03 $437.832 $457.72 $477.62 $497.52
Parent/Child(ren) $1,577.10 $867.41 $906.83 $946.26 $985.69
Two Adults $1,899.58 $1,044.77 $1,092.26 $1,139.75 $1,187.24
Family $2,141.73 $1,177.95 $1,231.49 $1,285.04 $1,338.58
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $507.06 $528.19 $549.31 $570.44
Parent/Child(ren) $1,674.36 $1,004.62 $1,046.48 $1,088.33 $1,130.19
Two Adults $2,016.69 $1,210.01 $1,260.43 $1,310.85 $1,361.27
Family $2,273.74 $1,364.24 $1,421.09 $1,477.93 $1,534.77
Retired January 1, 2021—December 31, 2021
Years of Service Total Premium ($) 14 years 13 Years 12 Years 11 Years
Retiree % Share 65.0/70.0* 67.5/72.5* 70.0/75.0* 72.5/77.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $483.94 $502.55 $521.16 $539.78
Parent/Child(ren) $1,475.13 $958.83 $995.71 $1,032.59 $1,069.47
Two Adults $1,776.72 $1,154.87 $1,199.29 $1,243.70 $1,288.12
Family $2,008.68 $1,305.64 $1,355.86 $1,406.08 $1,456.29
Kaiser Permanente HMO
Individual $796.03 $517.42 $537.32 $557.22 $577.12
Parent/Child(ren) $1,577.10 $1,025.12 $1,064.54 $1,103.97 $1,143.40
Two Adults $1,899.58 $1,234.73 $1,282.22 $1,329.71 $1,377.20
Family $2,141.73 $1,392.12 $1,445.67 $1,499.21 $1,552.75
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $591.57 $612.70 $633.83 $654.95
Parent/Child(ren) $1,674.36 $1,172.05 $1,213.91 $1,255.77 $1,297.63
Two Adults $2,016.69 $1,411.68 $1,462.10 $1,512.52 $1,562.93
Family $2,273.74 $1,591.62 $1,648.46 $1,705.31 $1,762.15
24
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 10 years 9 Years 8 Years 0-7 Years
Retiree % Share 75.0/80.0* 100.0 100.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $558.39 $744.52 $744.52 $744.52
Parent/Child(ren) $1,475.13 $1,106.35 $1,475.13 $1,475.13 $1,475.13
Two Adults $1,776.72 $1,332.54 $1,776.72 $1,776.72 $1,776.72
Family $2,008.68 $1,506.51 $2,008.68 $2,008.68 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $597.02 $796.03 $796.03 $796.03
Parent/Child(ren) $1,577.10 $1,182.83 $1,577.10 $1,577.10 $1,577.10
Two Adults $1,899.58 $1,424.69 $1,899.58 $1,899.58 $1,899.58
Family $2,141.73 $1,606.30 $2,141.73 $2,141.73 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $676.08 $845.10 $845.10 $845.10
Parent/Child(ren) $1,674.36 $1,339.49 $1,674.36 $1,674.36 $1,674.36
Two Adults $2,016.69 $1,613.35 $2,016.69 $2,016.69 $2,016.69
Family $2,273.74 $1,818.99 $2,273.74 $2,273.74 $2,273.74
Retired January 1, 2021—December 31, 2021
25
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 29 Years 28 Years 27 Years
Retiree % Share 15.0/24.0* 20.0/27.5* 24.8/30.8* 28.1/34.1*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $111.68 $148.90 $184.64 $209.21
Parent/Child(ren) $1,475.13 $221.27 $295.03 $365.83 $414.51
Two Adults $1,776.72 $266.51 $355.34 $440.63 $499.26
Family $2,008.68 $301.30 $401.74 $498.15 $564.44
Kaiser Permanente HMO
Individual $796.03 $119.40 $159.21 $197.42 $223.68
Parent/Child(ren) $1,577.10 $236.57 $315.42 $391.12 $443.17
Two Adults $1,899.58 $284.94 $379.92 $471.10 $533.78
Family $2,141.73 $321.26 $428.35 $531.15 $601.83
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $202.82 $232.40 $260.29 $288.18
Parent/Child(ren) $1,674.36 $401.85 $460.45 $515.70 $570.96
Two Adults $2,016.69 $484.01 $554.59 $621.14 $687.69
Family $2,273.74 $545.70 $625.28 $700.31 $775.35
Retired January 1, 2020—December 31, 2020
Years of Service Total Premium ($) 26 Years 25 Years 24 Years 23 Years
Retiree % Share 31.4/37.4* 34.7/40.7* 38.0/44.0* 40.9/46.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $233.78 $258.35 $282.92 $304.51
Parent/Child(ren) $1,475.13 $463.19 $511.87 $560.55 $603.33
Two Adults $1,776.72 $557.89 $616.52 $675.15 $726.68
Family $2,008.68 $630.73 $697.01 $763.30 $821.55
Kaiser Permanente HMO
Individual $796.03 $249.95 $276.22 $302.49 $325.58
Parent/Child(ren) $1,577.10 $495.21 $547.25 $599.30 $645.03
Two Adults $1,899.58 $596.47 $659.15 $721.84 $776.93
Family $2,141.73 $672.50 $743.18 $813.86 $875.97
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $316.07 $343.96 $371.84 $392.97
Parent/Child(ren) $1,674.36 $626.21 $681.46 $736.72 $778.58
Two Adults $2,016.69 $754.24 $820.79 $887.34 $937.76
Family $2,273.74 $850.38 $925.41 $1,000.45 $1,057.29
26
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 22 Years 21 Years 20 Years 19 Years
Retiree % Share 43.8/49.0* 46.7/51.5* 49.6/54.0* 52.5/56.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $326.10 $347.69 $369.28 $390.87
Parent/Child(ren) $1,475.13 $646.11 $688.89 $731.66 $774.44
Two Adults $1,776.72 $778.20 $829.73 $881.25 $932.78
Family $2,008.68 $879.80 $938.05 $996.31 $1,054.56
Kaiser Permanente HMO
Individual $796.03 $348.66 $371.75 $394.83 $417.92
Parent/Child(ren) $1,577.10 $690.77 $736.51 $782.24 $827.98
Two Adults $1,899.58 $832.02 $887.10 $942.19 $997.28
Family $2,141.73 $938.08 $1,000.19 $1,062.30 $1,124.41
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $414.10 $435.23 $456.35 $477.48
Parent/Child(ren) $1,674.36 $820.44 $862.30 $904.15 $946.01
Two Adults $2,016.69 $988.18 $1,038.60 $1,089.01 $1,139.43
Family $2,273.74 $1,114.13 $1,170.98 $1,227.82 $1,284.66
Retired January 1, 2020—December 31, 2020
Years of Service Total Premium ($) 18 years 17 Years 16 Years 15 Years
Retiree % Share 55.0/59.0* 57.5/61.5* 60.0/64.0* 62.5/66.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $409.49 $428.10 $446.71 $465.33
Parent/Child(ren) $1,475.13 $811.32 $848.21 $885.08 $921.96
Two Adults $1,776.72 $977.20 $1,021.61 $1,066.03 $1,110.45
Family $2,008.68 $1,104.77 $1,154.99 $1,205.21 $1,255.43
Kaiser Permanente HMO
Individual $796.03 $437.82 $457.72 $477.62 $497.52
Parent/Child(ren) $1,577.10 $867.41 $906.83 $946.26 $985.69
Two Adults $1,899.58 $1,044.77 $1,092.26 $1,139.75 $1,187.24
Family $2,141.73 $1,177.95 $1,231.49 $1,285.04 $1,338.58
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $498.61 $519.74 $540.86 $561.99
Parent/Child(ren) $1,674.36 $987.87 $1,029.73 $1,071.59 $1,113.45
Two Adults $2,016.69 $1,189.85 $1,240.26 $1,290.68 $1,341.10
Family $2,273.74 $1,341.51 $1,398.35 $1,455.19 $1,512.04
27
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 14 Years 13 Years 12 Years 11 Years
Retiree % Share 65.0/69.0* 67.5/71.5* 70.0/74.0* 72.5/76.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $483.94 $502.55 $521.16 $539.78
Parent/Child(ren) $1,475.13 $958.83 $995.71 $1,032.59 $1,069.47
Two Adults $1,776.72 $,154.87 $1,199.29 $1,243.70 $1,288.12
Family $2,008.68 $1,305.64 $1,355.86 $1,406.08 $1,456.29
Kaiser Permanente HMO
Individual $796.03 $517.42 $537.32 $557.22 $577.12
Parent/Child(ren) $1,577.10 $1,025.12 $1,064.54 $1,103.97 $1,143.40
Two Adults $1,899.58 $1,234.73 $1,282.22 $1,329.71 $1,377.20
Family $2,141.73 $1,392.12 $1,445.67 $1,499.21 $1,552.75
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $583.12 $604.25 $625.37 $646.50
Parent/Child(ren) $1,674.36 $1,155.31 $1,197.17 $1,239.03 $1,280.89
Two Adults $2,016.69 $1,391.52 $1,441.93 $1,492.35 $1,542.77
Family $2,273.74 $1,568.88 $1,625.72 $1,682.57 $1,739.41
Retired January 1, 2020—December 31, 2020
Years of Service Total Premium ($) 10 Years 9 Years 8 Years 0-7 Years
Retiree % Share 75.0/79.0* 100.0 100.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $558.39 $744.52 $744.52 $744.52
Parent/Child(ren) $1,475.13 $1,106.35 $1,475.13 $1,475.13 $1,475.13
Two Adults $1,776.72 $1,332.54 $1,776.72 $1,776.72 $1,776.72
Family $2,008.68 $1,506.51 $2,008.68 $2,008.68 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $597.02 $796.03 $796.03 $796.03
Parent/Child(ren) $1,577.10 $1,182.83 $1,577.10 $1,577.10 $1,577.10
Two Adults $1,899.58 $1,424.69 $1,899.58 $1,899.58 $1,899.58
Family $2,141.73 $1,606.30 $2,141.73 $2,141.73 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $667.63 $845.10 $845.10 $845.10
Parent/Child(ren) $1,674.36 $1,322.74 $1,674.36 $1,674.36 $1,674.36
Two Adults $2,016.69 $1,593.19 $2,016.69 $2,016.69 $2,016.69
Family $2,273.74 $1,796.25 $2,273.74 $2,273.74 $2,273.74
28
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 29 Years 28 Years 27 Years
Retiree % Share 15.0/22.0* 20.0/25.5* 24.8/28.8* 28.1/32.1*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $111.68 $148.90 $184.64 $209.21
Parent/Child(ren) $1,475.13 $221.27 $295.03 $365.83 $414.51
Two Adults $1,776.72 $266.51 $355.34 $440.63 $499.26
Family $2,008.68 $301.30 $401.74 $498.15 $564.44
Kaiser Permanente HMO
Individual $796.03 $119.40 $159.21 $197.42 $223.68
Parent/Child(ren) $1,577.10 $236.57 $315.42 $391.12 $443.17
Two Adults $1,899.58 $284.94 $379.92 $471.10 $533.78
Family $2,141.73 $321.26 $428.35 $531.15 $601.83
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $185.92 $215.50 $243.39 $271.28
Parent/Child(ren) $1,674.36 $368.36 $426.96 $482.22 $537.47
Two Adults $2,016.69 $443.67 $514.26 $580.81 $647.36
Family $2,273.74 $500.22 $579.80 $654.84 $729.87
Retired January 1, 2019—December 31, 2019
Years of Service Total Premium ($) 26 Years 25 Years 24 Years 23 Years
Retiree % Share 31.4/35.4* 34.7/38.7* 38.0/42.0* 40.9/44.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $233.78 $258.35 $282.92 $304.51
Parent/Child(ren) $1,475.13 $463.19 $511.87 $560.55 $603.33
Two Adults $1,776.72 $557.89 $616.52 $675.15 $726.68
Family $2,008.68 $630.73 $697.01 $763.30 $821.55
Kaiser Permanente HMO
Individual $796.03 $249.95 $276.22 $302.49 $325.58
Parent/Child(ren) $1,577.10 $495.21 $547.25 $599.30 $645.03
Two Adults $1,899.58 $596.47 $659.15 $721.84 $776.93
Family $2,141.73 $672.50 $743.18 $813.86 $875.97
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $299.17 $327.05 $354.94 $376.07
Parent/Child(ren) $1,674.36 $592.72 $647.98 $703.23 $745.09
Two Adults $2,016.69 $713.91 $780.46 $847.01 $897.43
Family $2,273.74 $804.90 $879.94 $954.97 $1,011.81
29
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 22 Years 21 Years 20 Years 19 Years
Retiree % Share 43.8/47.0* 46.7/49.5* 49.6/52.0* 52.5/54.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $326.10 $347.69 $369.28 $390.87
Parent/Child(ren) $1,475.13 $646.11 $688.89 $731.66 $774.44
Two Adults $1,776.72 $778.20 $829.73 $881.25 $932.78
Family $2,008.68 $879.80 $938.05 $996.31 $1,054.56
Kaiser Permanente HMO
Individual $796.03 $348.66 $371.75 $394.83 $417.92
Parent/Child(ren) $1,577.10 $690.77 $736.51 $782.24 $827.98
Two Adults $1,899.58 $832.02 $887.10 $942.19 $997.28
Family $2,141.73 $938.08 $1,000.19 $1,062.30 $1,124.41
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $397.20 $418.32 $439.45 $460.58
Parent/Child(ren) $1,674.36 $786.95 $828.81 $870.67 $912.53
Two Adults $2,016.69 $947.84 $998.26 $1,048.68 $1,099.10
Family $2,273.74 $1,068.66 $1,125.50 $1,182.34 $1,239.19
Retired January 1, 2019—December 31, 2019
Years of Service Total Premium ($) 18 Years 17 Years 16 Years 15 Years
Retiree % Share 55.0/57.0* 57.5/59.5* 60.0/62.0* 62.5/64.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $409.49 $428.10 $446.71 $465.33
Parent/Child(ren) $1,475.13 $811.32 $848.20 $885.08 $921.96
Two Adults $1,776.72 $977.20 $1,021.61 $1,066.03 $1,110.45
Family $2,008.68 $1,104.77 $1,154.99 $1,205.21 $1,255.43
Kaiser Permanente HMO
Individual $796.03 $437.82 $457.72 $477.62 $497.52
Parent/Child(ren) $1,577.10 $867.41 $906.83 $946.26 $985.69
Two Adults $1,899.58 $1,044.77 $1,092.26 $1,139.75 $1,187.24
Family $2,141.73 $1,177.95 $1,231.49 $1,285.04 $1,338.58
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $481.71 $502.83 $523.96 $545.09
Parent/Child(ren) $1,674.36 $954.39 $996.24 $1,038.10 $1,079.96
Two Adults $2,016.69 $1,149.51 $1,199.93 $1,250.35 $1,300.77
Family $2,273.74 $1,296.03 $1,352.88 $1,409.72 $1,466.56
30
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 14 Years 13 Years 12 Years 11 Years
Retiree % Share 65.0/67.0* 67.5/69.5* 70.0/72.0* 72.5/74.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $483.94 $502.55 $521.16 $539.78
Parent/Child(ren) $1,475.13 $958.83 $995.71 $1,032.59 $1,069.47
Two Adults $1,776.72 $1,154.87 $1,199.29 $1,243.70 $1,288.12
Family $2,008.68 $1,305.64 $1,355.86 $1,406.08 $1,456.29
Kaiser Permanente HMO
Individual $796.03 $517.42 $537.32 $557.22 $577.12
Parent/Child(ren) $1,577.10 $1,025.12 $1,064.54 $1,103.97 $1,143.40
Two Adults $1,899.58 $1,234.73 $1,282.22 $1,329.71 $1,377.20
Family $2,141.73 $1,392.12 $1,445.67 $1,499.21 $1,552.75
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $566.22 $587.34 $608.47 $629.60
Parent/Child(ren) $1,674.36 $1,121.82 $1,1263.68 $1,205.54 $1,247.40
Two Adults $2,016.69 $1,351.18 $1,401.60 $1,452.02 $1,502.43
Family $2,273.74 $1,523.41 $1,580.25 $1,637.09 $1,693.94
Retired January 1, 2019—December 31, 2019
Years of Service Total Premium ($) 10 Years 9 Years 8 Years 0-7 Years
Retiree % Share 75.0/77.0* 100.0 100.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $558.39 $744.52 $744.52 $744.52
Parent/Child(ren) $1,475.13 $1,106.35 $1,475.13 $1,475.13 $1,475.13
Two Adults $1,776.72 $1,332.54 $1,776.72 $1,776.72 $1,776.72
Family $2,008.68 $1,506.51 $2,008.68 $2,008.68 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $597.02 $796.03 $796.03 $796.03
Parent/Child(ren) $1,577.10 $1,182.83 $1,577.10 $1,577.10 $1,577.10
Two Adults $1,899.58 $1,424.69 $1,899.58 $1,899.58 $1,899.58
Family $2,141.73 $1,606.30 $2,141.73 $2,141.73 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $650.73 $845.10 $845.10 $845.10
Parent/Child(ren) $1,674.36 $1,289.26 $1,674.36 $1,674.36 $1,674.36
Two Adults $2,016.69 $1,552.85 $2,016.69 $2,016.69 $2,016.69
Family $2,273.74 $1,750.78 $2,273.74 $2,273.74 $2,273.74
31
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 29 Years 28 Years 27 Years
Retiree % Share 15.0/20.0* 20.0/23.5* 24.8/26.8* 28.1/30.1*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $111.68 $148.90 $184.64 $209.21
Parent/Child(ren) $1,475.13 $221.27 $295.03 $365.83 $414.51
Two Adults $1,776.72 $266.51 $355.34 $440.63 $499.26
Family $2,008.68 $301.30 $401.74 $498.15 $564.44
Kaiser Permanente HMO
Individual $796.03 $119.40 $159.21 $197.42 $223.68
Parent/Child(ren) $1,577.10 $236.57 $315.42 $391.12 $443.17
Two Adults $1,899.58 $284.94 $379.92 $471.10 $533.78
Family $2,141.73 $321.26 $428.35 $531.15 $601.83
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $169.02 $198.60 $226.49 $254.38
Parent/Child(ren) $1,674.36 $334.87 $393.47 $448.73 $503.98
Two Adults $2,016.69 $403.34 $473.92 $540.47 $607.02
Family $2,273.74 $454.75 $534.33 $609.36 $684.40
Retired January 1, 2018—December 31, 2018
Years of Service Total Premium ($) 26 Years 25 Years 24 Years 23 Years
Retiree % Share 31.4/33.4* 34.7/36.7* 38.0/40.0* 40.9/42.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $233.78 $258.35 $282.92 $304.51
Parent/Child(ren) $1,475.13 $463.19 $511.87 $560.55 $603.33
Two Adults $1,776.72 $557.89 $616.52 $675.15 $726.68
Family $2,008.68 $630.73 $697.01 $763.30 $821.55
Kaiser Permanente HMO
Individual $796.03 $249.95 $276.22 $302.49 $325.58
Parent/Child(ren) $1,577.10 $495.21 $547.25 $599.30 $645.03
Two Adults $1,899.58 $596.47 $659.15 $721.84 $776.93
Family $2,141.73 $672.50 $743.18 $813.86 $875.97
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $282.26 $310.15 $338.04 $359.17
Parent/Child(ren) $1,674.36 $559.24 $614.49 $669.74 $711.60
Two Adults $2,016.69 $673.57 $740.13 $806.68 $857.09
Family $2,273.74 $759.43 $834.46 $909.50 $966.34
32
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 22 Years 21 Years 20 Years 19 Years
Retiree % Share 43.8/45.0* 46.7/47.5* 49.6/50.0* 52.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $326.10 $347.69 $369.28 $390.87
Parent/Child(ren) $1,475.13 $646.11 $688.89 $731.66 $774.44
Two Adults $1,776.72 $778.20 $829.73 $881.25 $932.78
Family $2,008.68 $879.80 $938.05 $996.31 $1,054.56
Kaiser Permanente HMO
Individual $796.03 $348.66 $371.75 $394.83 $417.92
Parent/Child(ren) $1,577.10 $690.77 $736.51 $782.24 $827.98
Two Adults $1,899.58 $832.02 $887.10 $942.19 $997.28
Family $2,141.73 $938.08 $1,000.19 $1,062.30 $1,124.41
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $380.30 $401.42 $422.55 $443.68
Parent/Child(ren) $1,674.36 $753.46 $795.32 $837.18 $879.04
Two Adults $2,016.69 $907.51 $957.93 $1,008.35 $1,058.76
Family $2,273.74 $1,023.18 $1,080.03 $1,136.87 $1,193.71
Retired January 1, 2018—December 31, 2018
Years of Service Total Premium ($) 18 Years 17 Years 16 Years 15 Years
Retiree % Share 55.0 57.5 60.0 62.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $409.49 $428.10 $446.71 $465.33
Parent/Child(ren) $1,475.13 $811.32 $848.20 $885.08 $921.96
Two Adults $1,776.72 $977.20 $1,021.61 $1,066.03 $1,110.45
Family $2,008.68 $1,104.77 $1,154.99 $1,205.21 $1,255.43
Kaiser Permanente HMO
Individual $796.03 $437.82 $457.72 $477.62 $497.52
Parent/Child(ren) $1,577.10 $867.41 $906.83 $946.26 $985.69
Two Adults $1,899.58 $1,044.77 $1,092.26 $1,187.24 $1,187.24
Family $2,141.73 $1,177,95 $1,231.49 $1,388.58 $1,338.58
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $464.81 $485.93 $507.06 $528.19
Parent/Child(ren) $1,674.36 $920.90 $962.76 $1,004.62 $1,046.48
Two Adults $2,016.69 $1,109.18 $1,159.60 $1,210.01 $1,260.43
Family $2,273.74 $1,250.56 $1,307.40 $1,364.24 $1,421.09
33
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 14 Years 13 Years 12 Years 11 Years
Retiree % Share 65.0 67.5 70.0 72.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $483.94 $502.55 $521.16 $539.78
Parent/Child(ren) $1,475.13 $958.83 $995.71 $1,032.59 $1,069.47
Two Adults $1,776.72 $1,154.87 $1,199.29 $1,243.70 $1,288.12
Family $2,008.68 $1,305.64 $1,355.86 $1,406.08 $1,456.29
Kaiser Permanente HMO
Individual $796.03 $517.42 $537.32 $557.22 $577.12
Parent/Child(ren) $1,577.10 $1,025.12 $1,064.54 $1,103.97 $1,143.40
Two Adults $1,899.58 $1,234.73 $1,282.22 $1,329.71 $1,377.20
Family $2,141.73 $1,392.12 $1,445.67 $1,499.21 $1,552.75
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $549.32 $570.44 $591.57 $612.70
Parent/Child(ren) $1,674.36 $1,088.33 $1,130.19 $1,172.05 $1,213.91
Two Adults $2,016.69 $1,310.85 $1,361.19 $1,411.68 $1,462.10
Family $2,273.74 $1,477.93 $1,534.77 $1,591.62 $1,648.46
Retired January 1, 2018—December 31, 2018
Years of Service Total Premium ($) 10 Years 9 Years 8 Years 0-7 Years
Retiree % Share 75.0 100.0 100.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $558.39 $744.52 $744.52 $744.52
Parent/Child(ren) $1,475.13 $1,106.35 $1,475.13 $1,475.13 $1,475.13
Two Adults $1,776.72 $1,332.54 $1,776.72 $1,776.72 $1,776.72
Family $2,008.68 $1,506.51 $2,008.68 $2,008.68 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $597.02 $796.03 $796.03 $796.03
Parent/Child(ren) $1,577.10 $1,182.83 $1,577.10 $1,577.10 $1,577.10
Two Adults $1,899.58 $1,424.69 $1,899.58 $1,899.58 $1,899.58
Family $2,141.73 $1,606.30 $2,141.73 $2,141.73 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $633.83 $845.10 $845.10 $845.10
Parent/Child(ren) $1,674.36 $1,255.77 $1,674.36 $1,674.36 $1,674.36
Two Adults $2,016.69 $1,512.52 $2,016.69 $2,016.69 $2,016.69
Family $2,273.74 $1,705.31 $2,273.74 $2,273.74 $2,273.74
34
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 29 Years 28 Years 27 Years
Retiree % Share 15.0/20.0* 20.0/23.5* 24.8/26.8* 28.1/30.1*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $111.68 $148.90 $184.64 $209.21
Parent/Child(ren) $1,475.13 $221.27 $295.03 $365.83 $414.51
Two Adults $1,776.72 $266.51 $355.34 $440.63 $499.26
Family $2,008.68 $301.30 $401.74 $498.15 $564.44
Kaiser Permanente HMO
Individual $796.03 $119.40 $159.21 $197.42 $223.68
Parent/Child(ren) $1,577.10 $236.57 $315.42 $391.12 $443.17
Two Adults $1,899.58 $284.94 $379.92 $471.10 $533.78
Family $2,141.73 $321.26 $428.35 $531.15 $601.83
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $169.02 $198.60 $226.49 $254.28
Parent/Child(ren) $1,674.36 $334.87 $393.47 $448.73 $503.98
Two Adults $2,016.69 $403.34 $473.92 $540.47 $607.02
Family $2,273.74 $454.75 $534.33 $609.36 $684.40
Retired January 1, 2017—December 31, 2017
Years of Service Total Premium ($) 26 Years 25 Years 24 Years 23 Years
Retiree % Share 31.4/33.4* 34.7/36.7* 38.0/40.0* 40.9/42.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $233.78 $258.35 $282.92 $304.51
Parent/Child(ren) $1,475.13 $463.19 $511.87 $560.55 $603.33
Two Adults $1,776.72 $557.89 $616.52 $675.15 $726.68
Family $2,008.68 $630.73 $697.01 $763.30 $821.55
Kaiser Permanente HMO
Individual $796.03 $249.95 $276.22 $302.49 $325.58
Parent/Child(ren) $1,577.10 $495.21 $547.25 $599.30 $645.03
Two Adults $1,899.58 $59647 $659.15 $721.84 $776.93
Family $2,141.73 $672.50 $743.18 $813.86 $875.97
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $282.26 $310.15 $338.04 $359.17
Parent/Child(ren) $1,674.36 $559.24 $614.49 $669.74 $711.60
Two Adults $2,016.69 $673.57 $740.13 $806.68 $857.09
Family $2,273.74 $759.43 $834.46 $909.50 $966.34
35
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 22 Years 21 Years 20 Years 19 Years
Retiree % Share 43.8/45.0* 46.7/47.5* 49.6/50.0* 52.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $326.10 $347.69 $369.28 $390.87
Parent/Child(ren) $1,475.13 $646.11 $688.89 $731.66 $774.44
Two Adults $1,776.72 $778.20 $829.73 $881.25 $932.78
Family $2,008.68 $879.80 $938.05 $996.31 $1,054.56
Kaiser Permanente HMO
Individual $796.03 $348.66 $371.75 $394.83 $417.92
Parent/Child(ren) $1,577.10 $690.77 $736.51 $782.24 $827.98
Two Adults $1,899.58 $832.02 $887.10 $942.19 $997.28
Family $2,141.73 $938.08 $1,000.19 $1,062.30 $1,124.41
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $380.30 $401.42 $422.55 $443.68
Parent/Child(ren) $1,674.36 $753.46 $795.32 $837.18 $879.04
Two Adults $2,016.69 $907.51 $957.93 $1,008.35 $1,058.76
Family $2,273.74 $1,023.18 $1,080.03 $1,136.87 $1,193.71
Retired January 1, 2017—December 31, 2017
Years of Service Total Premium ($) 18 Years 17 Years 16 Years 15 Years
Retiree % Share 55.0 57.5 60.0 62.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $409.49 $428.10 $446.71 $465.33
Parent/Child(ren) $1,475.13 $811.32 $848.20 $885.08 $921.96
Two Adults $1,776.72 $977.20 $1,021.61 $1,066.03 $1,110.45
Family $2,008.68 $1,104.77 $1,154.99 $1,205.21 $1,255.43
Kaiser Permanente HMO
Individual $796.03 $437.82 $457.72 $477.62 $497.52
Parent/Child(ren) $1,577.10 $867.41 $906.83 $946.26 $985.69
Two Adults $1,899.58 $1,044.77 $1,092.26 $1,139.75 $1,187.24
Family $2,141.73 $1,177.95 $1,231.49 $1,285.04 $1,338.58
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $464.81 $485.93 $507.06 $528.19
Parent/Child(ren) $1,674.36 $920.90 $962.76 $1,004.62 $1,046.48
Two Adults $2,016.69 $1,109.18 $1,159.60 $1,210.01 $1,260.43
Family $2,273.74 $1,250.56 $1,307.40 $1,364.24 $1,421.09
36
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 14 Years 13 Years 12 Years 11 Years
Retiree % Share 65.0 67.5 70.0 72.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $483.94 $502.55 $521.16 $539.78
Parent/Child(ren) $1,475.13 $958.83 $995.71 $1,032.59 $1,069.47
Two Adults $1,776.72 $1,154.87 $1,199.29 $1,243.70 $1,288.12
Family $2,008.68 $1,305.64 $1,355.86 $1,406.08 $1,456.29
Kaiser Permanente HMO
Individual $796.03 $517.42 $537.32 $557.22 $577.12
Parent/Child(ren) $1,577.10 $1,025.12 $1,064.54 $1,103.97 $1,143.40
Two Adults $1,899.58 $1,234.73 $1,282.22 $1,329.71 $1,377.20
Family $2,141.73 $1,392.12 $1,445.67 $1,499.21 $1,552.75
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $549.32 $570.44 $591.57 $612.70
Parent/Child(ren) $1,674.36 $1,088.33 $1,130.19 $1,172.05 $1,213.91
Two Adults $2,016.69 $1,310.85 $1,361.27 $1,411.68 $1,462.10
Family $2,273.74 $1,477.93 $1,534.77 $1,591.62 $1,648.46
Retired January 1, 2017—December 31, 2017
Years of Service Total Premium ($) 10 Years 9 Years 8 Years 0-7 Years
Retiree % Share 75.0 100.0 100.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $558.39 $744.52 $744.52 $744.52
Parent/Child(ren) $1,475.13 $1,106.35 $1,475.13 $1,475.13 $1,475.13
Two Adults $1,776.72 $1,332.54 $1,776.72 $1,776.72 $1,776.72
Family $2,008.68 $1,506.51 $2,008.68 $2,008.68 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $597.02 $796.03 $796.03 $796.03
Parent/Child(ren) $1,577.10 $1,182.83 $1,577.10 $1,577.10 $1,577.10
Two Adults $1,899.58 $1,424.69 $1,899.58 $1,899.58 $1,899.58
Family $2,141.73 $1,606.30 $2,141.73 $2,141.73 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $633.83 $845.10 $845.10 $845.10
Parent/Child(ren) $1,674.36 $1,255.77 $1,674.36 $1,674.36 $1,674.36
Two Adults $2,016.69 $1,512.52 $2,016.69 $2,016.69 $2,016.69
Family $2,273.74 $1,705.31 $2,273.74 $2,273.74 $2,273.74
37
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 29 Years 28 Years 27 Years
Retiree % Share 14.0/19.0* 20.0/23.5* 24.8/26.8* 28.1/30.1*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $104.23 $148.90 $184.64 $209.21
Parent/Child(ren) $1,475.13 $206.52 $295.03 $365.83 $414.51
Two Adults $1,776.72 $248.74 $355.34 $440.63 $499.26
Family $2,008.68 $281.22 $401.74 $498.15 $564.44
Kaiser Permanente HMO
Individual $796.03 $111.44 $159.21 $197.42 $223.68
Parent/Child(ren) $1,577.10 $220.79 $315.42 $391.12 $443.17
Two Adults $1,899.58 $265.94 $379.92 $471.10 $533.78
Family $2,141.73 $299.84 $428.35 $531.15 $601.83
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $160.57 $198.60 $226.49 $254.38
Parent/Child(ren) $1,674.36 $318.13 $393.47 $448.73 $503.98
Two Adults $2,016.69 $383.17 $473.92 $540.47 $607.02
Family $2,273.74 $432.01 $534.33 $609.36 $684.40
Retired January 1, 2016—December 31, 2016
Years of Service Total Premium ($) 26 Years 25 Years 24 Years 23 Years
Retiree % Share 31.4/33.4* 34.7/36.7* 38.0/40.0* 40.9/42.5*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $233.78 $258.35 $282.92 $304.51
Parent/Child(ren) $1,475.13 $463.19 $511.87 $560.55 $603.33
Two Adults $1,776.72 $557.89 $616.52 $675.15 $726.68
Family $2,008.68 $630.73 $697.01 $763.30 $821.55
Kaiser Permanente HMO
Individual $796.03 $249.95 $276.22 $302.49 $325.58
Parent/Child(ren) $1,577.10 $495.21 $547.25 $599.30 $645.03
Two Adults $1,899.58 $596.47 $659.15 $721.84 $776.93
Family $2,141.73 $672.50 $743.18 $813.86 $875.97
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $282.26 $310.15 $338.04 $359.17
Parent/Child(ren) $1,674.36 $559.24 $614.49 $669.74 $711.60
Two Adults $2,016.69 $673.57 $740.13 $806.68 $857.09
Family $2,273.74 $759.43 $834.46 $909.50 $966.34
38
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 20-22 Years 19 Years 18 Years 17 Years
Retiree % Share 43.8/45.0* 52.5 55.0 57.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $326.10 $390.87 $409.49 $428.10
Parent/Child(ren) $1,475.13 $646.11 $774.44 $811.32 $848.20
Two Adults $1,776.72 $778.20 $932.78 $977.20 $1,021.61
Family $2,008.68 $879.80 $1,054.56 $1,104.77 $1,154.99
Kaiser Permanente HMO
Individual $796.03 $348.66 $417.92 $437.82 $457.72
Parent/Child(ren) $1,577.10 $690.77 $827.98 $867.41 $906.83
Two Adults $1,899.58 $832.02 $997.28 $1,044.77 $1,092.26
Family $2,141.73 $938.08 $1,124.41 $1,177.95 $1,231.49
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $380.30 $443.68 $464.81 $485.93
Parent/Child(ren) $1,674.36 $753.46 $879.04 $920.90 $962.76
Two Adults $2,016.69 $907.51 $1,058.76 $1,109.18 $1,159.60
Family $2,273.74 $1,023.18 $1,193.71 $1,250.56 $1,307.40
Retired January 1, 2016—December 31, 2016
Years of Service Total Premium ($) 16 Years 15 Years 14 Years 13 Years
Retiree % Share 60.0 62.5 65.0 67.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $446.71 $465.33 $483.94 $502.55
Parent/Child(ren) $1,475.13 $885.08 $921.96 $958.83 $995.71
Two Adults $1,776.72 $1,066.03 $1,110.45 $1,154.87 $1,199.29
Family $2,008.68 $1,205.21 $1,255.43 $1,305.64 $1,355.86
Kaiser Permanente HMO
Individual $796.03 $477.62 $497.52 $517.42 $537.32
Parent/Child(ren) $1,577.10 $946.26 $985.69 $1,025.12 $1,064.54
Two Adults $1,899.58 $1,139.75 $1,187.24 $1,234.73 $1,282.22
Family $2,141.73 $1,285.04 $1,338.58 $1,392.12 $1,445.67
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $507.06 $528.19 $549.32 $570.44
Parent/Child(ren) $1,674.36 $1,004.62 $1,046.48 $1,088.33 $1,130.19
Two Adults $2,016.69 $1,210.01 $1,260.43 $1,310.85 $1,361.27
Family $2,273.74 $1,364.24 $1,421.09 $1,477.93 $1,534.77
39
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 10-12 Years 9 Years 8 Years 0-7 Years
Retiree % Share 70.0 100.0 100.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $521.16 $744.52 $744.52 $744.52
Parent/Child(ren) $1,475.13 $1,032.59 $1,475.13 $1,475.13 $1,475.13
Two Adults $1,776.72 $1,243.70 $1,776.72 $1,776.72 $1,776.72
Family $2,008.68 $1,406.08 $2,008.68 $2,008.68 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $557.22 $796.03 $796.03 $796.03
Parent/Child(ren) $1,577.10 $1,103.97 $1,577.10 $1,577.10 $1,577.10
Two Adults $1,899.58 $1,329.71 $1,899.58 $1,899.58 $1,899.58
Family $2,141.73 $1,499.21 $2,141.73 $2,141.73 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $591.57 $845.10 $845.10 $845.10
Parent/Child(ren) $1,674.36 $1,172.05 $1,674.36 $1,674.36 $1,674.36
Two Adults $2,016.69 $1,411.68 $2,016.69 $2,016.69 $2,016.69
Family $2,273.74 $1,591.62 $2,273.74 $2,273.74 $2,273.74
Retired January 1, 2016—December 31, 2016
40
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 29 Years 28 Years 27 Years
Retiree % Share 13.0/17.0* 20.0/23.5* 24.8/26.8* 28.1/30.1*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $96.79 $148.90 $184.64 $209.21
Parent/Child(ren) $1,475.13 $191.77 $295.03 $365.83 $414.51
Two Adults $1,776.72 $230.97 $355.34 $440.63 $499.26
Family $2,008.68 $261.13 $401.74 $498.15 $564.44
Kaiser Permanente HMO
Individual $796.03 $103.48 $159.21 $197.42 $223.68
Parent/Child(ren) $1,577.10 $205.02 $315.42 $391.12 $443.17
Two Adults $1,899.58 $246.95 $379.92 $471.10 $533.78
Family $2,141.73 $278.42 $428.35 $531.15 $601.83
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $143.67 $198.60 $226.49 $254.38
Parent/Child(ren) $1,674.36 $284.64 $393.47 $448.73 $503.98
Two Adults $2,016.69 $342.84 $473.92 $540.47 $607.02
Family $2,273.74 $386.54 $534.33 $609.36 $684.40
Retired January 1, 2015—December 31, 2015
Years of Service Total Premium ($) 26 Years 25 Years 20-24 Years 19 Years
Retiree % Share 31.4/33.4* 34.7/36.7* 38.0/40.0* 52.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $233.78 $258.35 $282.92 $390.87
Parent/Child(ren) $1,475.13 $463.19 $511.87 $560.55 $774.44
Two Adults $1,776.72 $557.89 $616.52 $675.15 $932.78
Family $2,008.68 $630.73 $697.01 $763.30 $1,054.56
Kaiser Permanente HMO
Individual $796.03 $249.95 $276.22 $302.49 $417.92
Parent/Child(ren) $1,577.10 $495.21 $547.25 $599.30 $827.98
Two Adults $1,899.58 $596.47 $659.15 $721.84 $997.28
Family $2,141.73 $672.50 $743.18 $813.86 $1,124.41
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $282.26 $310.15 $338.04 $443.68
Parent/Child(ren) $1,674.36 $559.24 $614.49 $669.74 $879.04
Two Adults $2,016.69 $673.57 $740.13 $806.68 $1,058.76
Family $2,273.74 $759.43 $834.46 $909.50 $1,193.71
41
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 18 Years 17 Years 16 Years 15 Years
Retiree % Share 55.0 57.5 60.0 62.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $409.49 $428.10 $446.71 $465.33
Parent/Child(ren) $1,475.13 $811.32 $848.20 $885.08 $921.96
Two Adults $1,776.72 $977.20 $1,021.61 $1,066.03 $1,110.45
Family $2,008.68 $1,104.77 $1,154.99 $1,205.21 $1,255.43
Kaiser Permanente HMO
Individual $796.03 $437.82 $457.72 $477.62 $497.52
Parent/Child(ren) $1,577.10 $867.41 $906.83 $946.26 $985.69
Two Adults $1,899.58 $1,044.77 $1,092.26 $1,139.75 $1,187.24
Family $2,141.73 $1,177.95 $1,231.49 $1,285.04 $1,338.58
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $464.81 $485.93 $507.06 $528.19
Parent/Child(ren) $1,674.36 $920.90 $962.76 $1,004.62 $1,046.48
Two Adults $2,016.69 $1,109.18 $1,159.60 $1,210.01 $1,260.43
Family $2,273.74 $1,250.56 $1,307.40 $1,364.24 $1,421.09
Retired January 1, 2015—December 31, 2015
Years of Service Total Premium ($) 10-14 Years 9 Years 8 Years 0-7 Years
Retiree % Share 65.0 100.0 100.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $483.94 $744.52 $744.52 $744.52
Parent/Child(ren) $1,475.13 $958.83 $1,475.13 $1,475.13 $1,475.13
Two Adults $1,776.72 $1,154.87 $1,776.72 $1,776.72 $1,776.72
Family $2,008.68 $1,305.64 $2,008.68 $2,008.68 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $517.42 $796.03 $796.03 $796.03
Parent/Child(ren) $1,577.10 $1,025.12 $1,577.10 $1,577.10 $1,577.10
Two Adults $1,899.58 $1,234.73 $1,899.58 $1,899.58 $1,899.58
Family $2,141.73 $1,392.12 $2,141.73 $2,141.73 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $549.32 $845.10 $845.10 $845.10
Parent/Child(ren) $1,674.36 $1,088.33 $1,674.36 $1,674.36 $1,674.36
Two Adults $2,016.69 $1,310.85 $2,016.69 $2,016.69 $2,016.69
Family $2,273.74 $1,477.93 $2,273.74 $2,273.74 $2,273.74
42
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 29 Years 28 Years 27 Years
Retiree % Share 12.0/15.0* 20.0/23.5* 24.0/26.8* 26.0/30.1*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $89.34 $148.90 $178.68 $193.58
Parent/Child(ren) $1,475.13 $177.02 $295.03 $354.03 $383.53
Two Adults $1,776.72 $213.21 $355.34 $426.41 $461.95
Family $2,008.68 $241.04 $401.74 $482.08 $522.26
Kaiser Permanente HMO
Individual $796.03 $95.52 $159.21 $191.05 $206.97
Parent/Child(ren) $1,577.10 $189.25 $315.42 $378.50 $410.05
Two Adults $1,899.58 $227.95 $379.92 $455.90 $493.89
Family $2,141.73 $257.01 $428.35 $514.02 $556.85
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $126.77 $198.60 $226.49 $254.38
Parent/Child(ren) $1,674.36 $251.15 $393.47 $448.73 $503.98
Two Adults $2,016.69 $302.50 $473.92 $540.47 $607.02
Family $2,273.74 $341.06 $534.33 $609.36 $684.40
Retired January 1, 2014—December 31, 2014
Years of Service Total Premium ($) 20-26 Years 19 Years 18 Years 17 Years
Retiree % Share 31.4/33.4* 52.5 55.0 57.5
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $233.78 $390.87 $409.49 $428.10
Parent/Child(ren) $1,475.13 $463.19 $774.44 $811.32 $848.20
Two Adults $1,776.72 $557.89 $932.78 $977.20 $1,021.61
Family $2,008.68 $630.73 $1,054.56 $1,104.77 $1,154.99
Kaiser Permanente HMO
Individual $796.03 $249.95 $417.92 $437.82 $457.72
Parent/Child(ren) $1,577.10 $495.21 $827.98 $867.41 $906.83
Two Adults $1,899.58 $596.47 $997.28 $1,044.77 $1,092.26
Family $2,141.73 $672.50 $1,124.41 $1,177.95 $1,231.49
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $282.26 $443.68 $464.81 $485.93
Parent/Child(ren) $1,674.36 $559.24 $879.04 $920.90 $962.76
Two Adults $2,016.69 $673.57 $1,058.76 $1,109.18 $1,159.60
Family $2,273.74 $759.43 $1,193.71 $1,250.56 $1,307.40
43
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 10-16 Years 9 Years 8 Years 0-7 Years
Retiree % Share 60.0 100.0 100.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $446.71 $744.52 $744.52 $744.52
Parent/Child(ren) $1,475.13 $885.08 $1,475.13 $1,475.13 $1,475.13
Two Adults $1,776.72 $1,066.03 $1,776.72 $1,776.72 $1,776.72
Family $2,008.68 $1,205.21 $2,008.68 $2,008.68 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $477.62 $796.03 $796.03 $796.03
Parent/Child(ren) $1,577.10 $949.26 $1,577.10 $1,577.10 $1,577.10
Two Adults $1,899.58 $1,139.75 $1,899.58 $1,899.58 $1,899.58
Family $2,141.73 $1,285.04 $2,141.73 $2,141.73 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $507.06 $845.10 $845.10 $845.10
Parent/Child(ren) $1,674.36 $1,004.62 $1,674.36 $1,674.36 $1,674.36
Two Adults $2,016.69 $1,210.01 $2,016.69 $2,016.69 $2,016.69
Family $2,273.74 $1,364.24 $2,273.74 $2,273.74 $2,273.74
Retired January 1, 2014—December 31, 2014
44
If
your
lens
pre-
scription changes before you are eligible
for new lenses and that prescription
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 29 Years 28 Years 27 Years
Retiree % Share 11.0/12.0* 20.0/23.5* 23.0/26.8* 25.0/26.8*
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $81.90 $148.90 $171.24 $186.13
Parent/Child(ren) $1,475.13 $162.26 $295.03 $339.28 $368.78
Two Adults $1,776.72 $195.44 $355.34 $408.65 $444.18
Family $2,008.68 $220.95 $401.74 $462.00 $502.17
Kaiser Permanente HMO
Individual $796.03 $87.56 $159.21 $183.09 $199.01
Parent/Child(ren) $1,577.10 $173.48 $315.42 $362.73 $394.28
Two Adults $1,899.58 $208.95 $379.92 $436.90 $474.90
Family $2,141.73 $235.59 $428.35 $492.60 $535.43
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $101.41 $198.60 $226.49 $226.49
Parent/Child(ren) $1,674.36 $200.92 $393.47 $448.73 $448.73
Two Adults $2,016.69 $242.00 $473.92 $540.47 $540.47
Family $2,273.74 $272.85 $534.33 $609.36 $609.36
Retired January 1, 2013—December 31, 2013
Years of Service Total Premium ($) 20-26 Years 19 Years 10-18 Years 0-9 Years
Retiree % Share 26.8 52.5 55.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $199.53 $390.87 $409.49 $744.52
Parent/Child(ren) $1,475.13 $395.33 $774.44 $811.32 $1,475.13
Two Adults $1,776.72 $476.16 $932.78 $977.20 $1,776.72
Family $2,008.68 $538.33 $1,054.56 $1,104.77 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $213.34 $417.92 $437.82 $796.03
Parent/Child(ren) $1,577.10 $422.66 $827.98 $867.41 $1,577.10
Two Adults $1,899.58 $509.09 $997.28 $1,044.77 $1,899.58
Family $2,141.73 $573.98 $1,124.41 $1,177.95 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $226.49 $443.68 $464.81 $845.10
Parent/Child(ren) $1,674.36 $448.73 $879.04 $920.90 $1,674.36
Two Adults $2,016.69 $540.47 $1,058.76 $1,109.18 $2,016.69
Family $2,273.74 $609.36 $1,193.71 $1,250.56 $2,273.74
45
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
Non-Medicare Monthly Benefit Costs
Years of Service Total Premium ($) 30 Years 20-29 Years 10-19 Years 0-9 Years
Retiree % Share 10.0 25.0 50.0 100.0
Cigna Open-Access Plus In-Network (OAPIN)
Individual $744.52 $74.45 $186.13 $372.26 $744.52
Parent/Child(ren) $1,475.13 $147.51 $368.78 $737.57 $1,475.13
Two Adults $1,776.72 $177.67 $444.18 $888.36 $1,776.72
Family $2,008.68 $200.87 $502.17 $1,004.34 $2,008.68
Kaiser Permanente HMO
Individual $796.03 $79.60 $199.01 $398.02 $796.03
Parent/Child(ren) $1,577.10 $157.71 $394.28 $788.55 $1,577.10
Two Adults $1,899.58 $189.96 $474.90 $949.79 $1,899.58
Family $2,141.73 $214.17 $535.43 $1,070.87 $2,141.73
Cigna Open-Access Plus In and Out-of-Network (OAP)*
Individual $845.10 $84.51 $211.28 $422.55 $845.10
Parent/Child(ren) $1,674.36 $167.44 $418.59 $837.18 $1,674.36
Two Adults $2,016.69 $201.67 $504.17 $1,008.35 $2,016.69
Family $2,273.74 $227.37 $568.44 $1,136.87 $2,273.74
Retired January 1, 2012—December 31, 2012
46
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
Non-Medicare Medical Plan Summary
Plan Name
Cigna Open-
Access Plus In-
Network
(OAPIN)
Kaiser
Permanente HMO
Select
Cigna Open-Access Plus In and
Out-of-Network (OAP)
Group Number 3216080 7434-6 3216080
Network Nationwide Regional (MD/DC/
NoVA) Nationwide
Plan Features In-Network Only In-Network Only In-Network Out-of-Network**
Calendar Year Deductible Individual: None
Family: None
Individual: None
Family: None
Individual: $200
Family: $400
Individual: $300
Family: $600
Calendar Year Out-of-Pocket Maximum
(Medical Services)
Individual: $1100
Family: $3600
Individual: $3500
Family: $9400
Individual:
$1000
Family: $2000
Individual: $1500
Family: $3000
Coinsurance 100% (after applicable
Copay)
100% (after applicable
Copay) 85% 75%
PCP Required? No Yes No
Referrals Required for Specialist? No Yes No
Deductible/OOP Max Accrual Embedded Embedded Embedded
Preventive Care Services
Adult Physicals & Well Child Visits No Charge No Charge No Charge 25% (AD)
Immunizations No Charge No Charge No Charge 25% (AD)
Mammogram, PAP, & PSA Tests No Charge No Charge No Charge No Charge
Office Visits, Labs, & Testing
Office Visits PCP: $15 Copay
Specialist: $25 Copay $5 Copay
PCP: $20 Copay
Specialist: $30
Copay
25% (AD)
Laboratory Tests & X-Rays No Charge No Charge No Charge 25% (AD)
Allergy Shots & Testing No Charge $5 Copay No Charge 25% (AD)
Physical/Speech/Occupational Therapy $25 Copay* $5 Copay* $30 Copay* 25% (AD)
Chiropractic Office Visit $25 Copay* Not Covered $30 Copay 25% (AD)
Inpatient Hospital—Facility Services
Semi-Private Room and Board $100 Copay No Charge 15% (AD) 25% (AD)
Inpatient Laboratory Tests & X-Rays No Charge No Charge No Charge 25% (AD)
Inpatient Advanced Imaging (CT, MRI, PET) No Charge No Charge 15% (AD) 25% (AD)
Inpatient Physician/Surgical Services No Charge No Charge 15% (AD) 25% (AD)
47
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
Non-Medicare Medical Plan Summary
Plan Name
Cigna Open-
Access Plus In-
Network
(OAPIN)
Kaiser
Permanente HMO
Select
Cigna Open-Access Plus In
and Out-of-Network (OAP)
Group Number 3216080 7434-6 3216080
Network Nationwide Regional (MD/DC/
NoVA) Nationwide
Inpatient Hospital—Facility Services Continued
Inpatient Anesthesia Services No Charge No Charge 15% (AD) 25% (AD)
Inpatient Skilled Nursing/Rehab Facility Services No Charge No Charge 15% (AD) 25% (AD)
Inpatient Physical/Speech/Occupational Therapy No Charge 100% No Charge No Charge
Inpatient Dialysis/Radiation/Chemotherapy No Charge 100% 15% (AD) 25% (AD)
Home Health Care No Charge No Charge No Charge* 25% (AD)*
Hospice Care No Charge No Charge No Charge No Charge
Emergency Services
Urgent Care $25 Copay $5 Copay $30 Copay
Emergency Room (Waived if Admitted) $100 Copay $35 Copay $100 Copay
Ambulance (Air Ambulance if medically necessary) No Charge No Charge No Charge
Maternity/Infertility Services
Delivery—Facility $100 Copay No Charge 15% (AD) 25% (AD)
Global Maternity Fees Prenatal and Postnatal Visits No Charge 50% of Allowed Benefit 5% (AD) 25% (AD)
Artificial Insemination—Outpatient (requires pre-
authorization) No Charge 50% of Allowed Benefit 15% (AD) 25% (AD)
Artificial Insemination In Vitro Fertilization—Outpatient
(requires pre-authorization) No Charge
Based Upon Place of
Service 15% (AD) 25% (AD)
Abortion—Outpatient No Charge Based Upon Place of
Service 15% (AD) 25% (AD)
Abortion—Inpatient $100 Copay Based Upon Place of
Service 15% (AD) 25% (AD)
48
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
Non-Medicare Medical Plan Summary
Plan Name
Cigna Open-
Access Plus In-
Network
(OAPIN)
Kaiser
Permanente HMO
Select
Cigna Open-Access Plus In
and Out-of-Network (OAP)
Group Number 3216080 7434-6 3216080
Network Nationwide Regional (MD/DC/
NoVA) Nationwide
Family Planning Services
Women’s Surgical Sterilization—Outpatient No Charge Based Upon Place of
Service No Charge 25% (AD)
Women’s Surgical Sterilization—Inpatient No Charge Based Upon Place of
Service No Charge 25% (AD)
Men’s Surgical Sterilization—Outpatient No Charge Based Upon Place of
Service 15% (AD) 25% (AD)
Men’s Surgical Sterilization—Inpatient $100 Copay Based Upon Place of
Service 15% (AD) 25% (AD)
Mental Health and Substance Abuse (10 counseling sessions available at no cost through Employee Assistance Program)
Pre-Authorization Required? Yes Yes Yes
Mental Health Inpatient Services $100 Copay No Charge 15% (AD) 25% (AD)
Mental Health Outpatient Services $25 Copay $5 Copay $30 Copay 25% (AD)
Substance Abuse Inpatient Services $100 Copay No Charge 15% (AD) 25% (AD)
Substance Abuse Outpatient Services $25 Copay $5 Copay $30 Copay 25% (AD)
Other Services
Hearing Aids No Charge (Limit 2 per
3 years)
100% (Limit 1 per ear
per 3 years)
No Charge
(Limit 2 per 3
years)
25% (AD)
Diabetic Supplies No Charge 20% No Charge 25% (AD)
Durable Medical Equipment No Charge 100% of Allowed Benefit No Charge 25% (AD)
Prosthetic Devices No Charge 100% of Allowed Benefit No Charge 25% (AD)
49
If your lens prescription changes before
you are eligible for new lenses and that
Non-Medicare Prescription Drugs
Plan Name
Cigna Open-
Access Plus In-
Network
(OAPIN)
Kaiser
Permanente HMO
Select
Cigna Open-Access Plus In and
Out-of-Network (OAP)
Group Number 3216080 7434-6 3216080
Network Nationwide Regional (MD/DC/
NoVA) Nationwide
Prescription Drug Coverage
Calendar Year Deductible (RX) Individual: None
Family: None
Individual: None
Family: None
Individual: None
Family: None
Calendar Year Out-of-Pocket Maximum (RX) Individual: $5500
Family: $9600 Combined with Medical
Individual: $5600
Family: $11200
OOP Max Accrual Embedded Embedded Embedded
Retail 30 Day Supply
Generic (Tier 1) $10 Copay $5 Copay** $10 Copay
Preferred Brand (Tier 2) $20 Copay $5 Copay** $20 Copay
Non-Preferred Brand (Tier 3) $35 Copay $5 Copay** $35 Copay
Retail 90 Day Supply
Generic (Tier 1) $30 Copay $5 Copay* $30 Copay
Preferred Brand (Tier 2) $60 Copay $5 Copay* $60 Copay
Non-Preferred Brand (Tier 3) $105 Copay $5 Copay* $105 Copay
Mail-Order 90 Day Supply
Generic (Tier 1) $20 Copay $5 Copay* $20 Copay
Preferred Brand (Tier 2) $40 Copay $5 Copay* $40 Copay
Non-Preferred Brand (Tier 3) $70 Copay $5 Copay* $70 Copay
*Cost will be $15 when filled at a participating community pharmacy
**Up to a 60 day supply
Mandatory Generic Substitution If your prescription is written for a brand name drug and a generic equivalent is available, you will automatically be dispensed the generic form. If
you elect to take the brand name:
Cigna: You will pay the non-preferred brand copay plus the difference between the contracted allowable cost of the brand name drug and the
actual cost of the generic drug. Express Scripts Pharmacy will be Cigna’s home delivery pharmacy effective 1/1/2021. As part of the first fill of a
prescription through Express Scripts Pharmacy, members will need to update payment information on mycigna or by phone with a Cigna repre-
sentative. This will ensure data security directly with Express Scripts Pharmacy.
Kaiser Permanente: You will pay the full allowable cost of the brand name drug.
Step Therapy & Prior Authorization In step therapy, you and your doctor follow a series of steps when choosing the most appropriate medications to treat your condition. Some pre-
scription medications require a prior authorization review to verify that a medication is appropriate for the diagnosis, dosage, frequency, and dura-
tion of therapy. Your doctor should contact the insurance company to initiate a request prior to writing a prescription.
50
If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
Frequently Asked Questions
I turn 65 soon, do I need to sign up for Medicare?
If you want to continue your health insurance coverage under BCPS, you must enroll in Medicare parts A&B when you first become eligible. You
do not need to enroll in Medicare part D because all Medicare plans offered through BCPS are bundled with prescription drug coverage. If you
choose cancel your health coverage through BCPS, we must receive notification in writing
How do I change my name/address/phone number?
Personal and/or demographic changes must be received in writing, please use the form in the back of the Guide. We cannot update your infor-
mation over the phone.
Can I make changes to my plan?
Retirees may make plan changes at any time throughout the year by completing the Enrollment/Change Application in the back of the Guide.
Changes will be accepted at any time during the month and will be processed effective the firs of the following month. Please allow 7-10 business
days for processing to be completed and another 10 days for ID cards to arrive to your home.
How do I add my spouse/dependents to my benefits?
Retirees may add a spouse or dependent if there is a qualifying life change event (marriage, adoption, loss of other coverage, etc.) by completing
the Enrollment/Change form in the back of the Guide. Proof of the qualifying event must accompany the form when submitted for processing.
ID cards for medical, prescription, dental, and vision benefits must be requested from the insurance companies directly. Contact numbers can be
found on the Resource page in the front of this Guide. ID cards may also be requested and temporary cards downloaded electronically by setting
up a personal online account on the insurance company’s website.
How do I report the death of a spouse or dependent?
If the spouse or dependent of a retiree passes away had coverage under any of the BCPS benefit plans, please contact the Benefits Office as soon
as possible and forward a copy of the death certificate so they can be removed from coverage.
How do I report the death of the retiree?
If the retiree has coverage under any of the BCPS benefit plans, including life insurance, please contact the Benefits Office as soon as possible and
forward a copy of the death certificate so they can be removed from coverage. If the retiree had any life insurance, BCPS will forward a copy of the
death certificate to Prudential to begin the claims process. If they retired prior to 1/1/2005, they may also have a paid-up MetLife life insurance
policy. MetLife would have to be contacted directly (888) 280-6083.
The death of the retiree must be reported separately to Social Security Administration and their pension system, BCPS does not communicate with
those entities.
Surviving Spouse Benefit: Upon a retiree’s death if they had a spouse or dependents covered under a BCPS health plan, the spouse and depend-
ents have the option to continue coverage. For one year following the retiree’s death coverage may be continued and will include the contribution
from the Board of Education. A surviving spouse may not add any dependents who were not previously covered.
Why is my prescription so expensive?
Retirees who elect the Cigna Rx Medicare (PDP) drug plan may notice an exceptional difference in cost for their prescriptions when they join the
plan. This is because, instead of a copay, retirees will pay a percentage of the total retail cost of the drug at the pharmacy. The cost of drugs can
vary from pharmacy to pharmacy. Retirees are encouraged to price their medication in myCigna.com using the price-a-medication tool or they
may call around to different pharmacies in their area to find the best cost or, if applicable, have their prescriptions filled via mail order. The cost for
mail order is $20 copay for generic and $40 copay for brand name drugs.
How do I get a new insurance ID card?
Who is my beneficiary and how do I change my beneficiary?
Beneficiary information is not held by BCPS and the life insurance companies and pension systems will not disclose this information. If you are
unsure who your beneficiaries are or you would like to change your current designation, you will need to contact the life insurance companies and
the applicable pension system directly.
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If your lens prescription changes before
you are eligible for new lenses and that
prescription meets one of the following
criteria, lenses and frames will be re-
placed as a 12 month frequency:
• Differs from the original by at least
0.50 diopter sphere
• Axis changes by 15 degrees or more
• Change in prism diopter 0.5 in at
least one eye
The Department of Human Resources
Office of Benefits, Leaves and Retirement
6901 N. Charles Street, Building B, Towson, MD 21204
www.bcps.org