Includes PERACare forms: PERACare Enrollment/Change Form Medicare Coverage Medicare Card Submission Form

TURN

ING

65 2021How PERACare Works With Medicare

PERACare Plan Contact Information/ResourcesAnthem Blue Cross and Blue ShieldGroup #COEGR000 Pre-Enrollment: 1-833-244-3887 Post Enrollment: 1-833-244-3888 www.anthem.com/peracare

Centers for Medicare and Medicaid Services (CMS) 1-800-MEDICARE (633-4227) www.medicare.gov

Cigna DentalDental HMO–Group #10080104 Dental PPO–Group #3171792 1-877-635-PERA (7372) www.cigna.com

Delta DentalGroup #11869 1-800-610-0201 www.deltadentalco.com

Kaiser Permanente Group #1804303-338-3800 or 1-800-632-9700www.kp.org

SilverScript® (affiliated with CVS Caremark®)Group #RXCVSD 1-844-345-4162 BIN: 004336 PCN: MEDDADV www.caremark.com

SilverSneakers1-888-423-4632 www.silversneakers.com

Social Security Administration1-800-772-1213 www.ssa.gov

VSPGroup #121446261-800-877-7195www.vsp.com

Colorado PERA Contact InformationMailing AddressColorado PERAPO Box 5800Denver, CO 80217-5800Phone/Website/Email 1-800-759-7372 (PERA) 303-863-3727 (Fax) www.copera.org (email via the “Contact Us” link on the PERA home page)Customer Service Center Phone Hours (Mountain time) 7:00 a.m.–5:30 p.m. Monday–Thursday 7:00 a.m.–4:30 p.m. Friday

Denver Main Office (Office Closed—Drop Box Available) 1301 Pennsylvania StreetDenver, CO 80203-5011Lone Tree Office(Office Closed—NO Drop Box) 10457 Park Meadows Drive, Suite 102Lone Tree, CO 80124Westminster Office (Office Closed—Drop Box Available) 1120 W. 122nd Avenue Westminster, CO 80234

ContentsTurning Age 65

Medicare Health Plans ...................................................................................................................................................................................1

Medicare Frequently Asked Questions Eligibility and Enrollment ...............................................................................................................................................................................1Applying for Medicare Online .....................................................................................................................................................................2Medicare Premiums .......................................................................................................................................................................................2Benefits Under Medicare ..............................................................................................................................................................................2Medicare Quick Reference Chart ...............................................................................................................................................................3Choosing a PERACare Medicare Plan .......................................................................................................................................................4

Plan Benefit InformationOnline Provider Directories ..........................................................................................................................................................................4SilverSneakers .................................................................................................................................................................................................4Moving................................................................................................................................................................................................................4Traveling ............................................................................................................................................................................................................4Cancellation of Coverage ..............................................................................................................................................................................4Prescription Drug Coverage ........................................................................................................................................................................5

PERACare and Medicare Meetings ................................................................................................................................................ 6

Enrolling in PERACare......................................................................................................................................................................... 6

Accessing Your Account .................................................................................................................................................................... 6

2020 Medicare Star Ratings ............................................................................................................................................................. 7

Disclosure Notice for Anthem Medicare Advantage Plans and SilverScript Prescription Drug PlanEnrollment Requirements ............................................................................................................................................................................8SilverScript Plan Rules and Limitations ....................................................................................................................................................8Extra Help Program .......................................................................................................................................................................................8Income Related Monthly Adjustment Amount (IRMAA) ...................................................................................................................8Understanding the Anthem Benefits and Important Rules .................................................................................................................9Release of Information ...................................................................................................................................................................................9

Plan DescriptionsAnthem Medicare Preferred (PPO) Plans Benefit Highlights ..........................................................................................................10Kaiser Permanente Senior Advantage (HMO) Plan Benefit Highlights ........................................................................................12

PremiumsPremium Information .................................................................................................................................................................................. 13Subsidy Chart for PERA Benefit Structure Retirees and DPS Structure Retirees With Medicare Part A ........................... 13Calculating Your Health Care Premium ............................................................................................................................................... 13Anthem/SilverScript Monthly Premiums ............................................................................................................................................. 14Kaiser Monthly Premiums ......................................................................................................................................................................... 14Monthly Premiums for Retirees Under the DPS Benefit Structure Without Medicare Part A ................................................ 14Subsidy Chart for Retirees Under the DPS Benefit Structure Without Medicare Part A ........................................................ 14

PERACare Enrollment/Change Form Medicare Coverage—2021 ............................................................................................................................15

Medicare Card Submission Form ................................................................................................................................................................................. 17

Glossary of Key Terms ...................................................................................................................................................................... 19

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Turning Age 65As you approach your 65th birthday, you may have questions about transitioning to Medicare. This booklet answers many questions about enrolling in Medicare and selecting a PERACare Medicare plan and includes the forms you will need.There are four simple steps to enrolling in a PERACare Medicare plan: Enroll in Medicare Part B. Also enroll in Medicare Part A

if you are eligible to receive it at no cost. Ensure that Social Security has your correct name and address as this information will be used for your enrollment into a PERACare Medicare plan.

Review the plans and premiums on the following pages and choose a plan. Be sure to confirm with your doctors which types of Medicare plans they accept.

Submit a PERACare Enrollment/Change Form to PERA. This form must be signed prior to the requested effective date, but no more than 90 days in advance. If you are not already enrolled in PERACare, you will also need to complete a Certification of Previous Health Care Coverage form to show you had coverage immediately prior to your Medicare eligibility.

Submit a Medicare Card Submission Form to PERA once you have received your Medicare card.

Medicare Health PlansPERACare offers three Medicare plans for retirees, benefit recipients, and their dependents who are enrolled in Medicare. These Medicare plans combine all of the benefits of Medicare Parts A and B plus Part D prescription coverage into one comprehensive plan with easy-to-understand out-of-pocket costs. PERACare’s health care partners are Anthem Blue Cross and Blue Shield (Anthem) and Kaiser Permanente (Kaiser). The Anthem Medicare Preferred (PPO) Medicare Advantage (MA) plans are available if you reside within the United States and its territories. The Kaiser Senior Advantage HMO plan is available only if you reside in the service area described on page 12.

Anthem MAWith an Anthem MA plan, you’ll enjoy the freedom to see any provider—doctors, specialists, and hospitals— who is in the Anthem Medicare Preferred (PPO) network or who accepts Medicare; no referrals needed. Your share of the cost is the same whether the doctor is in- or out-of-network. You just need to see a doctor who accepts Medicare. The plans cover emergency and urgent care worldwide, and are designed with easy-to-understand out-of-pocket costs. Prescription drugs for these plans are managed by SilverScript (affiliated with CVS/Caremark). See the Anthem Medicare Preferred (PPO) Plans Benefit Highlights chart on pages 10 and 11 for more information.

Kaiser Senior Advantage (HMO)With the Kaiser plan, you are required to use providers—doctors, specialists, and hospitals—in Kaiser’s network and generally have no coverage if you see an out-of-network provider. However, emergency and urgent care are covered worldwide. See the Kaiser Permanente Senior Advantage (HMO) Plan Benefit Highlights chart on page 12 for more information.

Medicare Frequently Asked Questions Eligibility and EnrollmentWho can get Medicare?You are eligible to enroll in Medicare when you turn age 65. People with certain disabilities may also be able to enroll prior to turning age 65. Unless you have employer-sponsored health care coverage, you should enroll in Medicare as soon as you are eligible.

Do I have to enroll in Medicare or is it automatic?Automatic enrollment in Medicare will happen only if you are already receiving a Social Security benefit when you turn age 65. For anyone who is not receiving a Social Security benefit prior to age 65, enrollment requires action on your part. If you want to be in a PERACare health care plan once you turn age 65, you need to contact Social Security and enroll in Medicare no more than three months before the month of your 65th birthday.Based on Medicare’s enrollment rules, if you wait to enroll during your birthday month or later, your Medicare coverage will be delayed and you could be without any health care coverage. If you do not enroll in Medicare when first eligible, you may have a late enrollment penalty when you do enroll later.

Even though I’m turning 65, I can still be covered in my spouse’s employer’s plan. Do I need to enroll in Medicare now or can I wait?As long as you will be covered in an employer group health plan based on your spouse’s (or your own) current employment throughout your Initial Enrollment Period, you can wait to enroll in Medicare. You can sign up for Medicare during a Special Enrollment Period when employer coverage ends. Be sure to confirm with the employer plan that you can continue being covered in their plan.

I like my pre-Medicare PERACare plan. Can I keep it, rather than get Medicare?No, once you turn age 65, your PERACare pre-Medicare coverage will terminate and you must move to a Medicare plan.

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I’m turning age 65, but I also want to keep covering my spouse who is under age 65. Can I do that?

Yes, you can enroll in what we call “combination coverage.” To enroll in combination coverage, you choose the carrier and a Medicare plan, then the individual(s) not eligible for Medicare would choose a pre-Medicare plan with the same carrier. See the PERACare Enrollment/Change Form—Combination Pre‑Medicare and Medicare Coverage, available from PERA, for premiums and more information.

Applying for Medicare OnlineUse the online application to sign up for Medicare —it takes less than 10 minutes. Social Security will process your application and contact you if they need more information. You’ll receive your Medicare card in the mail.You can apply for Medicare online if you: » Are at least 64 years and 9 months old; » Are eligible for Part A at no cost; » Want to sign up for Medicare, but do not currently have

ANY Medicare coverage; » Do not want to start receiving Social Security benefits at

this time; and » Are not currently receiving Social Security retirement,

disability, or survivor benefits.Please refer to the following steps below to apply for Medicare online:

1 Go to www.medicare.gov and click “Apply for Medicare online” under the “Sign Up/Change Plans” drop-down menu.

2 Click on the blue “Apply for Medicare Only” button.3 Click on “Start a New Application.”4 Continue through the application by entering all of the

necessary personal information. 5 Review the question about whether you are covered

under a Group Health Plan and answer “No” if you are, or will be, covered under PERACare. PERACare is a retiree health plan, not a group health plan. Answer “Yes” if you will continue coverage under an employer group health plan beyond age 65.

6 Answer “Yes” to “Want to enroll in Medicare Part B” to enroll in any PERACare plan and to avoid any potential late enrollment penalties imposed by Medicare.

Printing Your Medicare CardSign into your MyMedicare.gov account to print an official copy of your Medicare card. If you do not have an account, visit MyMedicare.gov to create one.

Medicare PremiumsDoes Medicare charge premiums?Yes, once you turn age 65 and have Medicare, you will generally be paying some premium for your Medicare coverage. Most individuals pay a monthly premium for Medicare Part B. (You will also have a separate PERACare plan premium. See PERACare Premiums on pages 13 and 14.) If your modified adjusted gross income as reported on your IRS tax return from two years ago is above a certain amount, you may pay an Income-Related Monthly Adjustment Amount (IRMAA) for Medicare Parts B and D. Because the IRMAA applies only to higher-income individuals, it affects less than 5% of people with Medicare. You will have a separate IRMAA for your Medicare Part B and Part D.Social Security determines your Medicare Part B premium and IRMAA, if any. They are based upon when you enroll and your earnings. The standard monthly Part B premium in 2020 is $144.60. How do I pay my premiums to Medicare?See the “Medicare Quick Reference Chart” on page 3 for details.

Benefits Under MedicareHow can I find out what Medicare covers?Medicare publishes its comprehensive handbook, Medicare & You, annually. You will receive a copy each October once you are enrolled in Medicare. You can request a copy by calling Medicare or you can view a copy on Medicare’s website. You can also view other Medicare information and publications on their website or you can call Medicare’s toll-free number with specific questions. Generally, Medicare covers doctors’ visits, hospital stays, and other services that are determined to be medically necessary and/or are provided for in federal legislation. Medicare operates much like health plans available to individuals before they turn age 65.

For questions about PERACare eligibility, plans, and premiums, contact PERA at 1-800-759-7372 or visit www.copera.org.

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Medicare Quick Reference ChartThe chart below lists the different parts of Medicare, relevant enrollment guidelines, and costs as they relate to PERACare Medicare plans. For more detailed information about Medicare, see “Medicare and Social Security Resources” on page 4.If you are new to Medicare and plan to enroll in a PERACare Medicare plan, you must enroll in Medicare Part B three months before your Medicare effective date.

MEDICARE PART WHAT DO I NEED TO KNOW ABOUT ENROLLING AND WHAT WILL MEDICARE COST?

Medicare Part A—Hospital Insurance » Enroll in Part A if you are eligible at no cost. (You are eligible if you paid the Medicare tax for 40 quarters. You may also be eligible based upon your spouse or former spouse’s eligibility.)

» If you are not eligible for free Part A, you do not need to enroll. Replacement Part A benefits are included in all PERACare Medicare plans.

Medicare Part B—Medical Insurance (Doctors and Outpatient Services)

» You must first enroll in Part B to enroll in a PERACare Medicare plan.

» Standard Part B premium is $144.60 per month in 2020. » Premium is deducted from your Social Security benefit. If you do

not receive a Social Security benefit, you must pay Medicare directly. Medicare will bill you quarterly. You also may contact Medicare to sign up for Medicare Easy Pay to have your Part B premium withdrawn from your bank account on a monthly basis.

» If you don’t sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty (LEP).

Medicare Part B IRMAA (Income-Related Monthly Adjustment Amount)

» Medicare requires individuals with incomes greater than $85,000 single/$170,000 couple per year to pay an additional amount for Part B coverage.

» Social Security will notify you if this applies to you. » Part B IRMAA is deducted from your Social Security benefit.

If you do not receive a Social Security benefit, you must pay Medicare directly. Medicare will bill you quarterly. You also may contact Medicare to sign up for Medicare Easy Pay to have your Part B premium withdrawn from your bank account on a monthly basis.

Medicare Part C—Medicare Advantage Plans » Plans offered by private companies approved by Medicare. » All PERACare Medicare plans are Part C plans. » Do not enroll in an individual Part C plan if you want to be

enrolled in PERACare.Medicare Part D—Prescription Drug Coverage » All PERACare Medicare plans include Part D coverage as part of

the PERACare plan. » Do not enroll in an individual Part D plan if you want to enroll in

a PERACare Medicare plan. (Medicare does not allow you to have multiple Part D plans.) Your PERACare premium covers your Part D benefit. (There is no separate Part D premium.)

Medicare Part D IRMAA (Income-Related Monthly Adjustment Amount)

» Medicare requires individuals with incomes greater than $85,000 single/$170,000 couple per year to pay an additional amount for Part D coverage.

» Social Security will notify you if this applies to you. » Part D IRMAA is deducted from your Social Security benefit. If

you do not receive a Social Security benefit, you must pay Medicare directly.

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Choosing a PERACare Medicare PlanOnce I have Medicare, do I also need a plan from PERACare?Many individuals have both Medicare and another plan like PERACare, but many others have only Medicare. Since you have options available through PERACare, you should consider them carefully. As with any type of insurance purchase, you are deciding whether you want to pay monthly premiums for more insurance, or have less insurance and have higher costs if/when you are sick or need services.How should I decide on a plan?You can find the right plan for yourself by looking at four factors:Location—The Anthem MA plans are available to all retirees living in the United States. Front Range metro area residents have the additional option of Kaiser. Your doctor—Anthem MA plans provide the freedom to see any provider who is in the Anthem Medicare Preferred (PPO) network or who accepts Medicare. There are no referrals needed in this nationwide network. Even if your provider is not in the Anthem network, you can still see your doctor at the same copay as long as he/she accepts Medicare. Kaiser plans provide the convenience of having most or all of your providers under the same roof in one of several counties along Colorado’s Front Range (see page 12).Services—Once you have narrowed your choices based upon your doctor and the plans available where you live, you’ll want to think about the kinds of health care services that you are likely to use. All of the PERACare plans cover the same types of services and have benefits that meet or exceed the coverage in Original Medicare.Cost—You might want to list the services you use, and then compare the copayments and/or coinsurance among the different plan options for those services. See pages 10 through 12 for detailed information about benefits and costs and you can estimate your total out-of-pocket costs for the year. You would then add that to the various plan premiums for the year to get a comparison of your options. By comparing the benefits and costs of the plans available to you, you can make an informed decision about the best choice for you.

Some plans advertised elsewhere seem less expensive than PERACare’s plans. Why would I choose a PERACare plan?PERACare’s plans generally have better benefits and cover more costs than the individual plans that you see advertised. Compare the benefits and cost-share between your plan options “line-by-line,” consider your health care needs and the services that you use, and make the best decision for your needs. Depending upon the services that you expect to use, you might find that a lower premium, less comprehensive private plan is a good choice for you now. If your situation changes, you can choose PERACare any year during the annual open enrollment.

Plan Benefit InformationOnline Provider DirectoriesProvider directories for all PERACare health plans are available online through PERA’s website. These directories can help you find physicians and other providers who contract with the plans offered in PERACare. Visit www.copera.org and click on “PERACare for Retirees—Carriers” under the “PERACare” drop-down menu. If you do not have internet access, call the plan directly for assistance or to request a printed directory. Phone numbers and plan group numbers for each of the plans are listed on the inside front cover of this booklet.

SilverSneakersAll of PERA’s plans include membership in the SilverSneakers® Fitness Program. With SilverSneakers, you receive a free basic fitness center membership to over 14,000 participating locations nationwide. You also have access to SilverSneakers classes, online workouts and nutrition videos with SilverSneakers On-Demand, Senior AdvisorsSM, health education, and social activities. For more information, call 1-888-423-4632.

MEDICARE AND SOCIAL SECURITY RESOURCES » Call Social Security toll-free at 1-800-772-1213. » Visit the Social Security website at www.ssa.gov. » Call Medicare toll-free at 1-800-MEDICARE

(1-800-633-4227). TTY users should call 1-877-486-2048.

» Visit the Medicare website at www.medicare.gov. » Call the State Health Insurance Assistance Program

(SHIP) at 1-888-696-7213.

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MovingIf you move, please notify PERA of your new address so PERA can advise your health care, dental, and/or vision carriers. You should also contact Social Security to update your address with them and Medicare.

TravelingIf you are traveling and have a medical emergency while you are outside of your plan’s service area (either within the United States or in a foreign country), all of the PERACare Medicare plans cover your emergency and urgent care. In most cases, you would need to pay the bill yourself, and then file your claims with your plan for reimbursement. The PERACare Medicare plans do not cover non-emergency care (routine care) when you are traveling outside of the plan’s service area.

Cancellation of CoverageYou may cancel coverage for yourself and/or any dependent with 30-days advance written notice to PERA. Be sure to sign and date your cancellation request.PERA may cancel coverage if you and/or any dependents are no longer eligible to participate in PERACare or if your premium payments are not current.

Prescription Drug Coverage All of the Medicare health plans offered through PERACare include Medicare Part D prescription drug coverage at no additional charge. The role of a Part D plan is to process and pay for prescription drug claims, develop a formulary and clinical coverage reviews that comply with Medicare requirements, and contract with retail pharmacies. While the benefits, copayments, deductibles, and coverage levels vary among plans, all have these components in common: » A formulary is the list of drugs that are covered by

your plan. The formulary for each Medicare plan is available at www.copera.org by clicking on “PERACare for Retirees—Carriers” under the “PERACare” drop-down menu.

» Prior Authorization (PA) ensures appropriate use of a medication by requesting medical information from your physician. This process will be repeated each time your physician writes a new prescription for the medication (typically once a year).

» Step Therapy (ST) encourages the use of the most cost-effective medication. The plan will use history in their system, or from your physician, to determine if the use of a less expensive, but clinically equivalent, medication might be appropriate.

PRESCRIPTION BENEFIT CONTACT INFORMATIONFor questions about the prescription benefit, you may call the following carriers directly:

» Kaiser Permanente 303-338-3800 or 1-800-632-9700

» SilverScript (for those enrolled in PERA’s Anthem Medicare plans only) 1-844-345-4162

PERA’s group numbers with each of the carriers are listed on the inside front cover.

» Quantity Limits are a maximum quantity that can be dispensed for a drug and are in place to prevent overuse. Limits also increase compliance and reduce cost by suggesting that providers consider prescribing higher doses less frequently (for example, dosing once a day versus twice a day).

» Plans may also initiate a change request with your physician to determine if a lower cost, more effective, or safer alternative can be prescribed in place of the one initially prescribed. This process can be started with any medication, but the prescription will only be changed with your physician’s approval.

If you enroll in an Anthem MA plan, your prescription drug benefit will be through SilverScript, a national pharmacy benefit manager affiliated with CVS Caremark. You may get your prescriptions filled at local retail pharmacies and through the CVS Caremark mail-service pharmacy. If you have questions about prescription benefits, call SilverScript at 1-844-345-4162. You will receive an Anthem card to submit to your medical provider and a SilverScript card to submit for prescriptions. If you enroll in Kaiser, you can get your prescriptions filled at Kaiser facilities or through Kaiser’s home-delivery service. If you live in Southern or Northern Colorado and are enrolled in Kaiser, you may also use certain local retail pharmacies to fill your prescriptions.

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Three Ways to Submit Your PERACare Enrollment/Change Form:

MAIL Send your completed form to PERA at PO Box 5800, Denver, CO 80217.

ONLINE Go to www.copera.org and log in with your User ID and password.

FAX Fax your completed form to PERA at 303-863-3727.

Enrolling in PERACareComplete and submit the included PERACare Enrollment/Change Form and the Medicare Card Submission Form to enroll in a PERACare plan. You may also download both forms from PERA’s website.

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The PERACare and Medicare meeting is designed for retirees who will be turning 65 within the next year. At this meeting, PERA staff provides an overview of Medicare enrollment and premiums, as well as a detailed review of the PERACare Medicare Advantage plans with plenty of time for questions and answers.

Due to the COVID-19 pandemic and the high risk it poses for our member population, we have made the difficult decision to temporarily suspend all in-person meetings until further notice. Visit www.copera.org for updates.

» Attend a live meeting online: To register:• Go to www.copera.org/members/webinars and select

“Interested in retiree health care” to view the PERACare webinar schedule.

• Scroll to “Health care webinars for retirees and/or dependents over 65, or about the turn age 65.”

• Click the day and time that works for your schedule. » View a video:

If you are unable to attend a webinar, you may view a video about turning 65. Go to www.copera.org and click on “PERACare for Retirees—2021” under the “PERACare” drop-down menu. Then select the “Turning 65—How PERACare works with Medicare” video.

PERACare and Medicare MeetingsLearn About Enrolling in Medicare and the PERACare Medicare Health Care Plans

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Accessing Your PERA AccountYou can access your PERA account online by logging in with your User ID and password. If you do not have a User ID and password, you will first need to create an online user profile.To create an online user profile, click the “Member/Retiree Login” button on www.copera.org, then click “Register as a new user.” You will enter your personal information, verify your identity, and set up your User ID and password.

CONTRACT IDs WITH MEDICARE » Anthem Blue Cross and Blue Shield: H4036 » Kaiser Permanente: H0630 » SilverScript: S5601

The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare Star Ratings* help you to know how good a job the plan is doing. You can use these Star Ratings to compare the plan’s performance to other plans. The two main types of Star Ratings are:1. An Overall Star Rating that combines all of the

plan’s scores.2. Summary Star Rating that focuses on the plan’s medical

or prescription drug services.

Some of the areas Medicare reviews for these ratings include: » How the plan’s members rate plan services and care; » How well the plan’s doctors detect illnesses and keep

members healthy; and » How well the plan helps members use recommended

and safe prescription medications.

For 2020, Anthem Blue Cross and Blue Shield received the following Overall Star Rating from Medicare for health plan services:

For 2020, Kaiser Permanente received the following Overall Star Rating from Medicare for health/drug plan services:

For 2020, SilverScript received the following Overall Star Rating from Medicare for drug plan services:

The number of stars shows how well the plan performs.★★★★★ 5 stars—excellent★★★★ 4 stars—above average★★★ 3 stars—average★★ 2 stars—below average★ 1 star—poor

* Star Ratings are based on five stars. Star Ratings are assessed each year and may change from one year to the next.

2020 Medicare Star Ratings

★★★★4 Stars

★★★★★5 Stars

★★★★4 Stars

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If you are in an Anthem PERACare Medicare Advantage plan, your prescription drug coverage is provided through SilverScript® Insurance Company, which contracts with the federal government/Medicare. This coverage is in addition to your coverage under Medicare Parts A and B. You must enroll in Medicare Part B in order to qualify for this plan. You should enroll in Medicare Part A if you are eligible to receive it at no cost. In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium.

Enrollment Requirements You can enroll in and be covered by only one Medicare Advantage and Part D prescription drug plan at a time. Therefore, if you enroll in a PERACare Medicare Advantage plan, you should not enroll in any other Medicare Advantage or Part D plan. You must be a U.S. citizen or lawfully present in the U.S. to participate in this PERACare plan. If your address changes during the year, it is your responsibility to inform PERA of your address change.Your enrollment period with Medicare starts three months before the month you turn 65. You need to complete a PERACare Enrollment/Change Form—Medicare Coverage and return it to PERA in advance of your Medicare effective date. You will also need to provide PERA a copy of your Medicare card or entitlement letter once you receive it. If you enroll in a PERACare plan and then decide to disenroll from this plan, and you fail to have other creditable prescription drug coverage (that is, coverage that is at least as good as Medicare coverage) for 63 days or more, you may have to pay a late enrollment penalty in addition to your premium for Medicare prescription drug coverage in the future.If you decide not to participate in a PERACare plan, you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, for assistance with selecting another Part D plan. TTY users should call 1-877-486-2048.

SilverScript Plan Rules and Limitations The SilverScript plan has a network of pharmacies. You may get your prescriptions at network retail pharmacies and the SilverScript mail-service pharmacy. Network pharmacies must generally be used except in cases of an emergency. SilverScript will send you the list of network retail pharmacies, or you can find this list on the “PERACare for Retirees—Carriers” page of PERA’s website at www.copera.org.

This plan has four cost-sharing tiers. Every drug on the plan’s drug list is on one of the four cost sharing tiers. In general, the higher the cost-sharing tier number, the higher your cost for the drug. » Tier 1: Generic » Tier 2: Preferred Brand » Tier 3: Non-Preferred Brand » Tier 4: High Cost

As a Medicare beneficiary, you have the right to file a grievance or appeal plan decisions about payment or services if you disagree. For more information about these processes, call SilverScript Customer Care at 1-844-345-4162, 24 hours a day, 7 days a week. TTY users should call 711.If you would like to know more about the coverage and costs of Original Medicare, review your current Medicare & You handbook. You can also view a copy online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.For more information about the Medicare Part D portion of your plan, please call SilverScript Customer Care and ask for the Evidence of Coverage. Call toll-free at 1-844-345-4162, 24 hours a day, 7 days a week. TTY users should call 711.

Extra Help Program Medicare beneficiaries with low or limited income and resources may be able to get Extra Help to pay for prescription drug premiums and costs, as well as get help with other Medicare costs. To see if you qualify for Extra Help, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Income Related Monthly Adjusted Amount (IRMAA)Some people may have to pay an extra amount for their prescription drug coverage because of their yearly income. If you have to pay an extra amount, the Social Security Administration, not your Medicare plan, will send you a letter telling you what that extra amount will be and how to pay it. If you have any questions about this extra amount, contact the Social Security Administration at 1-800-772-1213 between 7:00 a.m. and 7:00 p.m., Monday through Friday. TTY users should call 1-800-325-0778.

Disclosure Notice for Anthem Medicare Advantage Plans and SilverScript Prescription Drug Plan

Colorado PERA complies with the Notice of HIPAA Privacy Practices regulations. You may access or obtain this notice by: » Viewing the “PERACare for Retirees—2021” page under the “PERACare” drop-down menu on www.copera.org » Contacting PERA’s Customer Service Center at 1-800-759-7372 » Writing to PERA at: PO Box 5800, Denver, CO 80217-5800

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Understanding the Anthem Benefits and Important Rules » Review the full list of benefits found in the Evidence of

Coverage (EOC), especially for those services that you routinely see a doctor. Visit www.anthem.com/peracare or call 1-833-244-3887, TTY: 711 to view a copy of the EOC.

» Our plan allows you to see providers outside of our network (non-contracted providers). However, while we will pay for covered services provided by a non-contracted provider, the provider must agree to treat you. Except in an emergency or in urgent situations, non-contracted providers may deny care.

Release of InformationBy joining this Medicare prescription drug plan, you acknowledge that Anthem and SilverScript will release your information to Medicare and other plans as is necessary for treatment, payment, and health care operations. You also acknowledge that Anthem and SilverScript will release your information, including your prescription drug event data, to Medicare, who may release it for research and other purposes that follow all applicable federal statutes and regulations. If you intentionally provide false information as part of your enrollment, you may be disenrolled from the plan.Learn more about the Anthem and SilverScript plan and how their plans are different from other plans at www.medicare.gov. You may also contact SilverScript Customer Care at 1-844-345-4162, 24 hours a day, 7 days a week or Anthem at 1-833-244-3887 (pre-enrollment) or 1-833-244-3888 (post enrollment), from 6 a.m. to 8 p.m. Mountain time. TTY users should call 711.

Anthem Blue Cross and Blue Shield and SilverScript Insurance Company complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.ATTENTION: If you speak English, language assistance services, free of charge, are available to you. ATENCIÓN: Si usted habla español, tenemos servicios de asistencia lingüística disponibles para usted sin costo alguno. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。

Contact SilverScript for more information. The formulary and/or Pharmacy network may change at any time. You will receive notice when necessary.SilverScript Employer PDP is a prescription drug plan. This plan is offered by SilverScript Insurance Company, which has a Medicare contract. Enrollment depends on contract renewal.Anthem Blue Cross and Blue Shield is an LPPO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal. Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.

Plan Descriptions

Features Anthem MA #1 Anthem MA #2

Annual Deductible None NoneLifetime Maximum Benefit None NoneOut-of-Pocket Annual Maximum $2,000 $6,000 Where Available? (Note: Emergency care is covered worldwide)

All 50 states, Washington D.C., American Samoa, Guam, Northern Mariana Islands, U.S. Virgin Islands, and Puerto Rico

All 50 states, Washington D.C., American Samoa, Guam, Northern Mariana Islands, U.S. Virgin Islands, and Puerto Rico

Out-of-Network Services Covered? Yes, at any Medicare provider at the in-network cost Yes, at any Medicare provider at the in-network cost

BenefitsPreventive Care All Medicare-covered preventive care covered with $0 copay All Medicare-covered preventive care covered with $0 copay

Outpatient Services (per visit or procedure) Primary Care Office Visit

$0 copay

$20 copay

Live Health Online (online physician visit) $0 copay $0 copaySpecialty Care Office Visit $0 copay $30 copayOutpatient Surgery $0 copay $200 copayDiagnostic Lab and X-Ray $0 copay Lab: $0 copay; X-ray: $20 copayMRI, PET, CT $0 copay $100 copay per procedureDurable Medical Equipment $0 copay 20% coinsuranceOxygen $0 copay 20% coinsurancePhysical, Occupational, and Speech Therapy $0 copay $20 copayHome Health Care $0 copay $0 copayHospice Care $0 copay $0 copayVision Care $0 copay for exam (up to $70);

$100 combined materials allowance every 12 months$0 copay for exam (up to $70);

$100 combined materials allowance every 12 monthsHearing Services $20 copay for exam every 12 months;

$500 hearing aid allowance every 36 months$20 copay for exam every 12 months;

$500 hearing aid allowance every 36 monthsChiropractic Care $20 copay; limited to 20 visits per year $20 copay; limited to 12 visits per year

Inpatient CareHospital Care and Professional Visits

$300 per admission; maximum $900 per year

$500 per admission; maximum $1,500 per year

Skilled Nursing Facility Care No copay days 1–20 $65 copay per day days 21–100

No copay days 1–20 $75 copay per day days 21–100

Emergency and Urgent Care Emergency Room Visit (waived if admitted)

$50 copay

$65 copay

Urgent Care $0 copay $30 copayAmbulance Service $75 copay $100 copay

Part D Prescription Drugs, Administered by SilverScriptNot applicable to the Out-of-Pocket Maximum

Retail Copay (up to 31-day supply)

Mail Copay (up to 90-day supply)

High Cost Copay (up to 31-day supply)

Generic $15Preferred Brand $45Non-Preferred Brand $60

Generic $30Preferred Brand $90Non-Preferred Brand $120

High Cost $75

Generic $15Preferred Brand $45Non-Preferred Brand $60

Generic $30Preferred Brand $90Non-Preferred Brand $120

High Cost $75

Anthem Medicare Preferred (PPO) Medicare Advantage Plans Benefit Highlights

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Plan Descriptions

Features Anthem MA #1 Anthem MA #2

Annual Deductible None NoneLifetime Maximum Benefit None NoneOut-of-Pocket Annual Maximum $2,000 $6,000 Where Available? (Note: Emergency care is covered worldwide)

All 50 states, Washington D.C., American Samoa, Guam, Northern Mariana Islands, U.S. Virgin Islands, and Puerto Rico

All 50 states, Washington D.C., American Samoa, Guam, Northern Mariana Islands, U.S. Virgin Islands, and Puerto Rico

Out-of-Network Services Covered? Yes, at any Medicare provider at the in-network cost Yes, at any Medicare provider at the in-network cost

BenefitsPreventive Care All Medicare-covered preventive care covered with $0 copay All Medicare-covered preventive care covered with $0 copay

Outpatient Services (per visit or procedure) Primary Care Office Visit

$0 copay

$20 copay

Live Health Online (online physician visit) $0 copay $0 copaySpecialty Care Office Visit $0 copay $30 copayOutpatient Surgery $0 copay $200 copayDiagnostic Lab and X-Ray $0 copay Lab: $0 copay; X-ray: $20 copayMRI, PET, CT $0 copay $100 copay per procedureDurable Medical Equipment $0 copay 20% coinsuranceOxygen $0 copay 20% coinsurancePhysical, Occupational, and Speech Therapy $0 copay $20 copayHome Health Care $0 copay $0 copayHospice Care $0 copay $0 copayVision Care $0 copay for exam (up to $70);

$100 combined materials allowance every 12 months$0 copay for exam (up to $70);

$100 combined materials allowance every 12 monthsHearing Services $20 copay for exam every 12 months;

$500 hearing aid allowance every 36 months$20 copay for exam every 12 months;

$500 hearing aid allowance every 36 monthsChiropractic Care $20 copay; limited to 20 visits per year $20 copay; limited to 12 visits per year

Inpatient CareHospital Care and Professional Visits

$300 per admission; maximum $900 per year

$500 per admission; maximum $1,500 per year

Skilled Nursing Facility Care No copay days 1–20 $65 copay per day days 21–100

No copay days 1–20 $75 copay per day days 21–100

Emergency and Urgent Care Emergency Room Visit (waived if admitted)

$50 copay

$65 copay

Urgent Care $0 copay $30 copayAmbulance Service $75 copay $100 copay

Part D Prescription Drugs, Administered by SilverScriptNot applicable to the Out-of-Pocket Maximum

Retail Copay (up to 31-day supply)

Mail Copay (up to 90-day supply)

High Cost Copay (up to 31-day supply)

Generic $15Preferred Brand $45Non-Preferred Brand $60

Generic $30Preferred Brand $90Non-Preferred Brand $120

High Cost $75

Generic $15Preferred Brand $45Non-Preferred Brand $60

Generic $30Preferred Brand $90Non-Preferred Brand $120

High Cost $75

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Kaiser Permanente Senior Advantage (HMO) Plan Benefit Highlights

Features Med HMO

Annual Deductible NoneLifetime Maximum Benefit NoneOut-of-Pocket Annual Maximum $4,700 Where Available? (Note: Emergency care is covered worldwide)

Coverage is available in the following Colorado counties: Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, El Paso, Gilpin,

Jefferson, Larimer, Pueblo, and WeldOut-of-Network Services Covered? Only for emergency care

BenefitsPreventive Care All Medicare-covered preventive care covered with $0 copay

Outpatient Services (per visit or procedure)Primary Care Office Visit

$15 copay

Specialty Care Office Visit $30 copayVideo or Phone Visit No chargeAmbulatory Surgery $200 copayDiagnostic Lab and X-Ray No chargeMRI, PET, CT $100 copay per procedureDurable Medical Equipment 20% copayOxygen No chargePhysical, Occupational, and Speech Therapy $20 copayHome Health Care No chargeHospice Care No chargeVision Care $15 copay for exam; $100 credit for frames, lenses, or contacts every

24 months; additional charge for contact lens fittingHearing Services $15 copay for exam every 12 months;

$500 hearing aid allowance every 36 monthsChiropractic Care $15 copay; limited to 20 visits per year

Inpatient CareHospital Care and Professional Visits

$250 per day; maximum $500 per admit

Skilled Nursing Facility Care No copay days 1–20 $75 copay per day days 21–100

Emergency and Urgent Care (covered out-of-network)Emergency Room Visit (waived if admitted)

$75 copay

Urgent Care $30 copayAmbulance Service 20% coinsurance up to $195 per incident

Prescription Drugs Not applicable to the Out-of-Pocket Annual MaximumPharmacy Copay (up to 31-day supply) Preferred Generic $5

Non-Preferred Generic $15 Preferred Brand $40 Non-Preferred Brand $60 Specialty $75

Mail Order Copay (up to 90-day supply) Preferred Generic $10 Non-Preferred Generic $30 Preferred Brand $80 Non-Preferred Brand $120 Specialty $150

12

MEDICARE PART B PREMIUMSYou must maintain Medicare Part B coverage to be enrolled in a PERACare health care plan. If you do not pay your premium, and your Medicare Part B is canceled, you will be canceled from your PERACare health care plan.

13

Subsidy Chart for PERA Benefit Structure Retirees and DPS Structure Retirees With Medicare Part A

YEARS OF SERVICE SUBSIDY YEARS OF

SERVICE SUBSIDY

20+ $115.00 10 $57.5019 109.25 9 51.7518 103.50 8 46.0017 97.75 7 40.2516 92.00 6 34.5015 86.25 5 28.7514 80.50 4 23.0013 74.75 3 17.2512 69.00 2 11.5011 63.25 1 5.75

PremiumsPremium InformationHow does the PERA health care subsidy work?PERA provides a health care subsidy to help offset your health care premium. The subsidy amount is set in state law, and is applied toward your health care premium (by law the subsidy cannot be applied to dental or vision premiums). The subsidy is based upon your years of service credit and is paid for all benefit recipients (retirees, cobeneficiaries, and survivors) under the PERA benefit structure and is paid for retirees only under the DPS benefit structure.

The maximum subsidy is $115 for most Medicare (over age 65) retirees (see chart at right). For Medicare retirees under the DPS benefit structure who do not have Medicare Part A, the maximum subsidy is $230 (see chart on page 14), which was designed to help offset your higher plan premiums.

What will a PERACare Medicare plan cost?Your total monthly cost will be your PERACare premium plus your Medicare Part B premium and any applicable IRMAA (see page 3). You do not pay Part A or Part D premiums when you are in PERACare.

How do I pay my PERACare premium?PERA will determine your PERACare plan premium, subtract the subsidy amount to which you are entitled, and deduct the balance from your PERA benefit each month. For example, your February premium is deducted from your January 31 benefit.

How do I pay my Medicare Part B premium?If you receive a Social Security benefit, Medicare will deduct your Part B premium and any applicable IRMAA from your Social Security benefit. If you are not receiving a Social Security benefit, you must pay the Medicare Part B premiums, Part B IRMAA, and Part D IRMAA directly to Medicare. Medicare will bill you quarterly for these premiums. You also have the option to contact Medicare to sign up for Medicare Easy Pay to have your premiums withdrawn from your bank account on a monthly basis. Note that if Medicare sends you a bill that shows payment(s) due, you should not ignore the bill or Medicare may cancel your coverage.

Calculating Your Health Care PremiumAfter you have selected a health plan and chosen a level of coverage, you are ready to calculate your premium for that plan.The premiums and subsidy chart on this page and the top of page 14 apply to all benefit recipients except benefit recipients under the DPS benefit structure who do not have Medicare Part A. If you are under the DPS benefit structure and do not have Medicare Part A, see page 14 for the premiums and subsidy chart to calculate your health care premium.

A. Enter the total premium amount (from the premium chart above) $_______________

B. Enter your Medicare Benefit Recipient Subsidy (from the subsidy chart above) $_______________

C. Subtract line B from line A (A – B) $_______________

This is your monthly health care premium.

14

Monthly Premiums for Retirees Under the DPS Benefit Structure Without Medicare Part AIf you are receiving benefits under the DPS benefit structure, and do not have Medicare Part A, see below for your premiums and subsidy. The premiums below show the monthly premiums for coverage, before deduction of the PERA subsidy. 1. Find the right premium—“Retiree only” (single coverage) or “Retiree plus spouse” (couple coverage). 2. Subtract your PERA subsidy from the premium below to get your premium.

Subsidy Chart for DPS Benefit Structure Retirees Without Medicare Part A

YEARS OF SERVICE SUBSIDY YEARS OF SERVICE SUBSIDY

20+ $230.00 10 $115.00

19 218.50 9 103.5018 207.00 8 92.0017 195.50 7 80.5016 184.00 6 69.0015 172.50 5 57.5014 161.00 4 46.0013 149.50 3 34.5012 138.00 2 23.0011 126.50 1 11.50

PREMIUM PAYMENT

Premiums for health, dental, and vision are deducted from your monthly benefit on an after-tax basis. If your monthly benefit is not large enough to accommodate this, please contact PERA to request a PERACare Automatic Payment Authorization form. Coverage will not be set up until the form is received.

Anthem/SilverScript Monthly Premiums Note: See separate premium chart below if you are a retiree under the DPS benefit structure and do not have Medicare Part A. MA #1 MA #2Retiree only $260.00 $169.00Retiree plus spouse 520.00 338.00

Kaiser Monthly PremiumsRetiree only $199.00Retiree plus spouse 398.00

Anthem MA #1 Anthem MA #2 KaiserRetiree only $659.00 $579.00 $596.00Retiree plus spouse 1,318.00 1,158.00 1,192.00

Complete and return this form if you want to enroll in, change, or cancel coverage(s).

PERACare Enrollment/Change Form Medicare Coverage—2021Colorado Public Employees’ Retirement AssociationPO Box 5800, Denver, Colorado 80217-58001-800-759-PERA (7372) • Fax: 303-863-3727 • www.copera.org

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Your SSN

Your Information Name __________________________________________________________________________

Last First MI

Permanent Residence Street Address ____________________________________________________ (PO Box is not allowed)

City _______________________________ State ______________ ZIP Code __________________

Daytime Phone Number ___________________ Email Address _______________________________

Sign up for electronic delivery of PERA information? q Yes q No

( )

Signature Certification

By signing the form, I certify and agree with the following: I am eligible to enroll in the Program, and if I am enrolling my spouse and/or dependents, I certify that they also are eligible to be enrolled. By joining a PERACare Medicare plan, I acknowledge that the Medicare plan will release my information to Medicare and other plans as is necessary for treatment, payment, and health care operations. I authorize Colorado PERA to deduct from my monthly benefit the premium for my coverage. Finally, I agree that, if I wish to cancel this coverage, I must provide PERA with a 30 -day advance written notice.

Your Signature ____________________________________________ Date __________________

Spouse’s Signature _________________________________________ Date __________________(Spouse’s signature only required if enrolling in a Medicare health plan)

Effective Date I would like to request my effective date to enroll in, change, or cancel coverage to be

_______________________1, 2021.* This Enrollment/Change Form must be signed prior to the requested effective date, but cannot be signed more than 90 days in advance.

* If this date is not your retirement effective date, a Certification of Previous Health Care Coverage form may be required. See the PERACare Enrollment Eligibility Chart in the PERACare Health Benefits Program Medicare Coverage booklet.

Dependent Enrollment Information

Complete this section if you are adding coverage(s) for your dependent(s) and be sure that your spouse signs above. If you are adding health plan coverage for a dependent who does not have Medicare, use the PERACare Enrollment/Change Form Combination Pre-Medicare and Medicare Coverage—2021.

_______________________________________________________________________________ Spouse’s Last Name First Name MI Birthdate SSN M/F

_______________________________________________________________________________ Child’s Last Name First Name MI Birthdate SSN M/F

/ /

/ /

(Continued on reverse)

Sign Here è

Sign Here è

15

PERACare Enrollment/Change FormMedicare Coverage—2021 (Page 2)

Your Name ________________________________________________ Your SSN ______________________________

Medicare Information

For health plan enrollment(s) only

Complete this section if you are enrolling in a health plan or changing health plans.Send a photocopy of your Medicare card(s) as soon as you receive it.

My Medicare No. _________________________ q Both Medicare Parts A and B q Part B Only

My Spouse’s Medicare No. _________________________ q Both Medicare Parts A and B q Part B Only

My Child’s Medicare No. _________________________ q Both Medicare Parts A and B q Part B Only

Health Plan Selection

1. What do you want to do? (Check only one box.) q Do not change PERACare health care coverage

q Enroll in or change coverage as indicated below q Cancel current PERACare health care coverage

2. Check yes or no to the following important medical questions for all enrollees:Do any enrollees currently receive dialysis treatment or have End-Stage Renal Disease (ESRD)? q Yes q No

Will any enrollees have additional medical coverage outside of Medicare and PERACare? q Yes q No

Will any enrollees have prescription drug coverage outside of Medicare and PERACare? q Yes q No

3. Select a coverage level, and then 4. Select a health plan:

q Benefit Recipient (BR) Only q Anthem MA #1 q BR+Spouse q Anthem MA #2 q BR+Child(ren) q Kaiser Permanente Med HMO q BR+Spouse+Child(ren)

SilverScript® provides the prescription drug benefit for the Anthem MA plans.

Dental Plan Selection

1. What do you want to do? (Check only one box.) q Do not change PERACare dental coverage

q Enroll in or change coverage as indicated below q Cancel current PERACare dental coverage

2. Select a coverage level, and then 3. Select a dental plan:

q Benefit Recipient (BR) Only q Cigna Dental PPO q BR+Spouse q Cigna Dental HMO* q BR+Child(ren) q Delta Dental PPO q BR+Spouse+Child(ren)

* If you are enrolling in the Cigna Dental HMO, indicate the six-digit DHMO office number(s) below. To obtain this number, call Cigna at 1-877-635-PERA (7372) or visit www.copera.org and click the appropriate “Provider Directory” from the “PERACare for Retirees—Carriers” page in the “PERACare” section.

Cigna Dental HMO Office Number(s): Benefit Recipient Spouse Child(ren)

Complete this section to enroll in,

change, or cancel health care

coverage

Complete this section to enroll in,

change, or cancel dental coverage

1. What do you want to do? (Check only one box.) q Do not change PERACare vision coverage

q Enroll in or change coverage as indicated below q Cancel current PERACare vision coverage

2. Select a coverage level, and then 3. Select a vision plan:

q Benefit Recipient (BR) Only q VSP PPO #1 q BR+Spouse q VSP PPO #2 q BR+Child(ren) q VSP PPO #3 q BR+Spouse+Child(ren)

Note: If you select a coverage level but do not select a plan, you will be enrolled in VSP PPO #1.

Vision Plan Selection

Complete this section to enroll in,

change, or cancel vision coverage

Medicare Advantage (MA)

16

17

Medicare Card Submission FormColorado Public Employees’ Retirement AssociationPO Box 5800, Denver, Colorado 80217-58001-800-759-PERA (7372) • Fax: 303-863-3727 • www.copera.org

Copy of Medicare Card Attach a Legible Photocopy of Your Medicare Card Below.

DO NOT SEND YOUR ORIGINAL MEDICARE CARD.

Extend transparent tape to edges of card. Do not staple or glue.

Member SSN

Complete this form if you are enrolling in a PERACare Medicare plan for the first time. You must submit your PERACare Enrollment/Change Form along with this form for your request to be processed.

Your Information

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Name __________________________________________________________________________ Last First MI

Permanent Residence Street Address ____________________________________________________ (PO Box is not allowed)

City _______________________________ State ______________ ZIP Code __________________

Daytime Phone Number ___________________ Email Address ______________________________

Sign up for electronic delivery of PERA information? q Yes q No

( )

Medicare Information My Medicare No. _________________________ q Both Medicare Parts A and B q Part B Only

My Spouse’s Medicare No. _________________________ q Both Medicare Parts A and B q Part B Only

My Child’s Medicare No. _________________________ q Both Medicare Parts A and B q Part B Only

19

Glossary of Key TermsThe health care terms listed below are used in this booklet, and are defined here in the context of their usage by PERA and are not meant to be comprehensive.

CarrierInsurance company or administrator offering coverage.

Centers for Medicare & Medicaid Services (CMS)This division of the U.S. Department of Health and Human Services that oversees the Medicare and Medicaid programs.

CoinsuranceThe percentage of covered medical expenses that you pay. For example, if your coinsurance for a hospital stay is 20%, you would pay 20% of the charges and the plan would pay the other 80%.

Copay or Copayment The dollar amount that you pay to a provider for a covered service. For example, if your copay for a hospital stay is $500, you would pay $500 and the plan would pay all remaining charges.

FormularyA list of covered drugs you can receive through the plan, including generic, brand-name, high cost, and specialty drugs.

Health Maintenance Organization (HMO)Members receive care from the HMO’s provider network, but do not have access to providers who are outside of the plan’s network.

MedicareMedicare is the federal health insurance program for people age 65 and over, and for some disabled people under age 65.

Medicare CardAfter enrolling, you will receive a card that lists your Medicare claim number and the effective date of your coverage.

Medicare’s Enrollment PeriodsYou are eligible to enroll in Medicare at age 65. Sign up early, within the three months before your birthday month, if you want to have PERACare coverage when you turn 65. If you do not enroll when you are first eligible, you may be eligible to enroll later during a “special enrollment period” based on loss of employer coverage that you have at age 65. You also may enroll during an annual general enrollment period. See CMS’s publication, Enrolling in Medicare Part A and Part B (CMS Product No. 11036), for detailed information.

Medicare Part A CoverageMedicare Part A covers inpatient hospital care, skilled nursing facility care, some home health services, and hospice care.

Medicare Part B CoverageMedicare Part B covers doctors and other outpatient health services.

Medicare Part C Coverage (Medicare Advantage Plans)Medicare Part C provides coverage for everything Medicare covers in Parts A and B. The Part C coverage is provided by a private insurance company approved by Medicare.

Medicare Part D CoverageMedicare Part D covers outpatient prescription drugs. Part D coverage is sold by private insurance companies, subject to government approval and oversight.

Out-of-Pocket CostsThe actual costs you pay when you receive health care services.

Out-of-Pocket MaximumThe most you may have to pay in a calendar year for covered services. Depending on the plan, it may include your deductible, copays, and coinsurance. Once the amount you have paid for your covered services has reached the amount of the Out-of-Pocket Maximum, the plan pays 100% for all of your covered services for the rest of the calendar year. Note that most plans specify that some types of services are not included in the Out-of-Pocket Maximum, for example, your payments for prescription drugs are typically not included in the calculation.

Pharmacy Benefit Manager (PBM)The company that administers a plan’s prescription drug benefit; also called prescription benefit manager.

Primary Care Provider (PCP)The doctor who works with you and other doctors to provide, prescribe, approve, and coordinate your medical care and treatment. An HMO plan may require you to see your PCP before you can see a specialist.

PremiumThe amount you are charged each month for your coverage.

SpecialistA doctor who has advanced education and training in a specific area of medicine, such as a cardiologist or neurologist.

This booklet provides information about PERA’s health benefits program. Your rights, benefits, and obligations as a Colorado PERA member are governed by Title 24, Article 51 of the Colorado Revised Statutes, and the Rules of the Colorado Public Employees’ Retirement Association, which take precedence over any interpretations in this booklet.

Colorado Public Employees’ Retirement Association PO Box 5800 Denver, Colorado 80217-5800 www.copera.org

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