2021 bcps retiree guide

2021 BCPS

Retiree

Guide

Effective January 1, 2021—December 31, 2021

2

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

2

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.

3

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.

4

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

5

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

6

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


Family $106.69

Cigna Dental Care Access DHMO

Individual $46.57


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

7

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.

8

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

9

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


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

10

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)

11

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


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







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







0.50 diopter sphere



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:


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



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


Family $88.05

CareFirst Regional Dental Traditional

Individual $31.63


Family $106.69

Cigna Dental Care Access DHMO

Individual $46.57


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




Retiree % Share 31.4/38.4* 34.7/41.7* 38.0/45.0* 40.9/47.5*


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


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


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



Retiree % Share 43.8/50.0* 46.7/52.5* 49.6/55.0* 52.5/57.5*


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


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


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-





Retiree % Share 55.0/60.0* 57.5/62.5* 60.0/65.0* 62.5/67.5*


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


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


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



Retiree % Share 65.0/70.0* 67.5/72.5* 70.0/75.0* 72.5/77.5*


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


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


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







0.50 diopter sphere



least one eye


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


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


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


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


25

If

your

lens

pre-




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*


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


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


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



Retiree % Share 31.4/37.4* 34.7/40.7* 38.0/44.0* 40.9/46.5*


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


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


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-





Retiree % Share 43.8/49.0* 46.7/51.5* 49.6/54.0* 52.5/56.5*


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


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


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



Retiree % Share 55.0/59.0* 57.5/61.5* 60.0/64.0* 62.5/66.5*


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


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


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-





Retiree % Share 65.0/69.0* 67.5/71.5* 70.0/74.0* 72.5/76.5*


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


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


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


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


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


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


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-





Retiree % Share 15.0/22.0* 20.0/25.5* 24.8/28.8* 28.1/32.1*


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


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


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



Retiree % Share 31.4/35.4* 34.7/38.7* 38.0/42.0* 40.9/44.5*


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


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


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-





Retiree % Share 43.8/47.0* 46.7/49.5* 49.6/52.0* 52.5/54.5*


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


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


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



Retiree % Share 55.0/57.0* 57.5/59.5* 60.0/62.0* 62.5/64.5*


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


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


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-





Retiree % Share 65.0/67.0* 67.5/69.5* 70.0/72.0* 72.5/74.5*


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


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


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



Retiree % Share 75.0/77.0* 100.0 100.0 100.0


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


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


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-





Retiree % Share 15.0/20.0* 20.0/23.5* 24.8/26.8* 28.1/30.1*


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


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


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



Retiree % Share 31.4/33.4* 34.7/36.7* 38.0/40.0* 40.9/42.5*


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


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


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-





Retiree % Share 43.8/45.0* 46.7/47.5* 49.6/50.0* 52.5


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


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


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



Retiree % Share 55.0 57.5 60.0 62.5


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


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


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-





Retiree % Share 65.0 67.5 70.0 72.5


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


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


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



Retiree % Share 75.0 100.0 100.0 100.0


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


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


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-





Retiree % Share 15.0/20.0* 20.0/23.5* 24.8/26.8* 28.1/30.1*


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


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


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



Retiree % Share 31.4/33.4* 34.7/36.7* 38.0/40.0* 40.9/42.5*


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


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


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-





Retiree % Share 43.8/45.0* 46.7/47.5* 49.6/50.0* 52.5


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


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


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



Retiree % Share 55.0 57.5 60.0 62.5


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


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


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-





Retiree % Share 65.0 67.5 70.0 72.5


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


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


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



Retiree % Share 75.0 100.0 100.0 100.0


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


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


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-





Retiree % Share 14.0/19.0* 20.0/23.5* 24.8/26.8* 28.1/30.1*


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


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


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



Retiree % Share 31.4/33.4* 34.7/36.7* 38.0/40.0* 40.9/42.5*


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


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


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-




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


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


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


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



Retiree % Share 60.0 62.5 65.0 67.5


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


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


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







0.50 diopter sphere



least one eye


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


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


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


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


40

If

your

lens

pre-





Retiree % Share 13.0/17.0* 20.0/23.5* 24.8/26.8* 28.1/30.1*


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


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


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


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


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


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


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-





Retiree % Share 55.0 57.5 60.0 62.5


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


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


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



Retiree % Share 65.0 100.0 100.0 100.0


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


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


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-





Retiree % Share 12.0/15.0* 20.0/23.5* 24.0/26.8* 26.0/30.1*


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


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


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


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


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


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


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







0.50 diopter sphere



least one eye



Retiree % Share 60.0 100.0 100.0 100.0


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


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


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


44

If

your

lens

pre-





Retiree % Share 11.0/12.0* 20.0/23.5* 23.0/26.8* 25.0/26.8*


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


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


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


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


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


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


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







0.50 diopter sphere



least one eye


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


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


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


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


46







0.50 diopter sphere



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







0.50 diopter sphere



least one eye


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


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


Abortion—Inpatient $100 Copay Based Upon Place of


48







0.50 diopter sphere



least one eye


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


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


Men’s Surgical Sterilization—Inpatient $100 Copay Based Upon Place of


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



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


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







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.

51







0.50 diopter sphere



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

2021 bcps retiree guide

Documents