Patrick K. Ryan, County Executivewww.ulstercountyny.gov/personnel/

Benefit Open Enrollment

November 1—November 29

Benefit Plan Year

January 1—December 31, 2020

2020 Non-Medicare Eligible

Retiree Benefit Guide

Benefits Offered

Medical | Prescription Drugs | Dental | Vision

ULSTER COUNTY PERSONNEL DEPARTMENT244 Fa ir Stre e t , PO Box 1 800, King st o n , N e w York 12 402-18 00

Ma in: (8 45)340c3550

Exa m Hotline: (84 5) 334-5454

Fa x : ,(8 45) 340-3592

PATRICK K. RYAN

County Executive ",\ .· r,

,

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· ( n , ·

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SHEREECROSS

Person n el Officer

JAMES FARINA

Director of Em p lo ye eRelations

TO:

FR OM:

DATE:

RE:

Ulster Cou11ty Retfree Hea lth Insura nc e Pa rtic ip a nt

Sh e ree Cro ss, Pe rso nn e l O ffi c e r

Oct ob er 28, 2020

2020 He a lth Insura nc e Ra t e s a n d lm p m t a nt C h a ng e s Fo r

Non-M ed ic are Eligible Re t1ire e s

In 2020,i he County will c onilinu e to o ffer Em p ire Blu e Cross / Blu e Sh i e ld PPO - now PPO .20 and Dire ct

POS -now POS20 m ed ic al pro gram s as pro vid ed in 2019. How eve, r w e a re happy to announce the

ad difion of a third option - the PPO25. Includ ed on page 4 of this letter is the cha rt th at show;s th e

c ov era ge a n d c o st diUere nce.s Tn th e p l ans. You m e enc ourag ed to review the PPO 2 5, esp e cia lly if

y o u li v eoutsid e o f the Hud son Valley and are current ly p aying fo:r th e m or e exp ensive PPO plan. Th e

EPO p lan oHered in 2019 ' willNOT b e o ffe re d in 2020.

EVIERYO INEI MUST IRIESPOND TO THIS LETTIER IBY COMIPILIETIING TIHIE FORM ON THE BO TTOM OF PAGE

4 AND REiTURNING IT IDIIRIEC TlY iTO THIIE !BEN EFITS O IFH CIEIBYNOVIEM BERI 29, 20119'

Th e n e w premium amount for 2020 vvill b e gin w ith you r Decemb er 1,5 2019 p:remium p a yment

withdra wal. Fai lure to provide funding for your premium will resu lt in can cella tion.

M edic al! and Pre scription Benefit II[) Cards - All Em p ir e IBC BS c ards and Exp ress Scr ip t s c ar d s will

continue to be valid fo:r 2020.If you c hoose the new PPO25 you will rec eive new ca rdiS.

M edic all 8 e n e i h - Covera:g e d e scr ip tions, and b en e fit c ompariso ns a re a v dila b le on the Personn e l

Departmen t websi te art:hflp:/ / ulste1cor.mfyny..gov/ perso nnel/new-c cmenf-employees/be nefits-manage menl

fcl ic k on ' 2020 No n-M e dic ar:e Elig'ibl e Re tiree Heal'fh fnsura nc e Be n e f,it ntorrn a tio n, } or from the Bene

fits Office.

We st ron g ly enc ourage you to review the informartio n pro vi d ed. . We enc oura:g e you io visit the

e, mpi1ebJue.c om website t o see w ha t program s y o u r d oct ors may p a rilici p a te in, so you may malke

th e b es t p la n c hoi c e fo:r you an d your fam ily. l he new PPO25 plain m ay setrve your nee ds w ell and

p:rovid e you a nd your f.a m ily a c onsid e rarble sa vings. I f y ou d e,sire t o make cov era ge c hangies,

p lea se inform the Be n e fits O ffice in wrTting o f you r new p lan c hoice...

De1111tall Co verage Ch an ge - Our dental c ov era ge is still provided by Met Li'fe Den tal... lhe covera ges

are id entical to the 2019 c ov erages.

lea se lbe reminded that the County offers a M ed icare supp lem ent health plan or a Medicare buyout

o retireeswh

en they become Medicare eligible. It is mandatory for re tire es aind dependents to

Vision Coverage - Our vision c o vera g es rema in wi th Davis Vision. No chonges h a v e b e e n m a d e a nd you r c

urrent c ard willl c ontin ue to b e valid..

P1

t 1

sw1i tch , to0 1M ed i c are plan immediately when sa i d pl la n is a va il,ab lle to them. Please notify theEmp lo yee IBe :ne fits Offic e •three months p:rioir to Medicare eHgibiliity so that a smooth transition can be

accomplished. Foi lure to notify tihe Benefit sDep artment of Medicare eligibllity will result in rep ayment

of any claims p a yments m ad e du e t o this e rr or. Ple ase c oll Kev in Ro a c h, Em p '.loy ee Bene fits

Admini st ra1t or ; 1845) 340-3545 to disc u ss y o u r plan choices.

Urgen t Care Out of !Network Rem inder - Our Urgent Caire Cop ay, b oth in and out of netw ork, is

$20/$25 for PPO 25.. If you or a covere d fami ly member c annot loca te an in-netvvo k urgen t c are

center, you may go to an out of netw ork center and pay the $20/$25 PPO25 c opa1y. Thisis

a d vant a g e o us sin c e th e c ost o f goi ng to th e eme rgenc y room includes a co pa y of $100/ $200 for

PPO2 5. Thi s c a n be es p e c ia 1lly use ful w h e n you ore traveling aw ay from hom e..

Prescr ip tion Drug Coverage - Presc rip t1io n c overa ge is provided by Rx Be n e fits fo r Exp re ss Scrip ts, Inc .

Th.e c o-pays for presc rip tions for 2020 are the same as 2019. The formula ry is a vailable at t hewebsit e list

edabove.Thecopays are: PPO- $10/$25/$40 POS- $5/ $20/$40 PPO25 - $10/$25/ $40

Ulster Scr ip ts Ze:ro Co-pay MaHI Ord erBrand Nlame Drug Program - For 2020, our non-Medic are eligible

retirees may continue to purc hase brand-na me maintenanc e medli ca t ionsthrough a maill order

program withou t p aying a1ny co-p ay. Thein format ion and forms, inc:lud ing th e list o f a vaila b le

medic a tion s for tihe Ulst e r Sc rip ts p rogram, are available on the Pe rso n ne :I De p artmen t w eb sit e in the

aforeme ntioned Ben e fi ts! Book or at the Bene fits O ffice. The Ulst e r Scripts !Ce rtain Bra nd Nam e Drugs

For Free) program isavaila1ble to all retirees covered by the Empire Blue C ross BlueShie ld pllans. There have

been chan ges totheclassifi cat io nof somedrug.s,so p le ase chec k the formu la ry..

I.Jive Health Online - Live He a lt h On lin e is now a c ov e red !b ene fit und er our Hea llth Pla n. With a

c om puter and web ca m, or ap plic ablle sm artp hone ap p, you c an tolk to a medic ol profe ssional!24/7,

365 da ys01ye ar. Yo u c a n b e a t h o m e , a t w o k, or out of t o w n (th ou g h no t a ll se rvic es may b e

a vai la b lle in all loc a tio ns.) No app ointment is n e c essa ry to sp e a k with Liv e Hea lth Online. Th is b e n efitsa v e s ti m e a nd costs the sa m e 0 1s a p rima ry c are o ffic e visit. To ac tiva te your account, go to

livehe althonlline.c om on yo ur c omputer or download the approp rila t e a p p lic a tio n from your

sm a rt p h.on e ' s st ore.

Em pire IBlue Cross 181ue Shield IPremi1 ium s - Th e follo wi ng c ho rt shows the ret iree shor e of monthly

premium {inc ludes medical, presc rip tion, dental and vision c overag e ).. For your referenc e, your Ulster

County percentage is printed after your n,am e on your envelope label.

II you have any questions, plea se c all Kevin Roach, Emp loye e Benefits Administra tor at (845) 340-

3:545 or Mary Connolly, Emp loye e !Bene fits Sp ecia lis t, at (845) 340-3546..

Mo:re information about your cov e:ra1g es c an be found at. http,s://ulstercoun:tyny.gov /personnel/index.html

U'C % PPO20 PPO25 ,D &V O N LY

5 0 %

Retiree Onllry

Ret iree & Spouse

Ret iree & l Chilld

Reitiree & ChUdren

Fo m illy

$4 5 4 . 5 6

$932.1 3

$ 8 5 2 . 38

$957.1 5

$ 1,320 .5 2

$650.91

$ 1,334.65

$ 1,217 .60

$ 1,369 .49

$1,889.94

$410 .91

$8 42.6 5

$771.19

$865.48

$1,193.93

$18.04

$37 .27

$40.46

$40.46

$54.61

6 0 %

Retiree Onllry

Ret iree & Spouse

Ret iree & l Chi ld

Ret iree & ChHdren

f amilw

$363.. 64

$745 .70

$681 .90

$765.. 72

$1,056.42

$520.72

$1 ,0 67 .72

$974 .08

$1,095.59

$1,511.95

$328.72

$674.. 12

$616.95

$692.38

$955.. 14

$14 .43

$29.81

$32 .36

$32.36

$43 .69

6 5 %

Retiree Onllry

Ret iree & Spouse

Reif ree & l Chi ld

Ret iree & Chilt:lren

f amilly

$318.19

$652.49

$ 59 6.6 7

$670.00

$92 4.3 6

$455 .63

$934.26

$852.32

$958.64

$ 1,322.95

$287..63

$589..85

$539 .8 3

$ 605 .8 3

$835 .75

$12 .62

$26 .09

$28 .32

$28 .32

$ 38 .23

70%

Retiree Onllry

Ret iree & Spouse

Ret iree & 1 C h illd

Ret iree & Chi l , j ren

Fo m illy

$ 2 7 2..73

$559.28

$51 1 . 43

$574.29

$ 79 2.3 1

$390.54

$800.79

$730.56

$821 .69

$ 1,13 3 .96

$ 246.5 4

$505.59

$462.71

$519.29

$ 7 16 .36

$10 .82

$ 22.36

$24 .27

$24 .27

$32 .77

75%

Retiree Onllry

Ret iree & Spouse

Ret iree & l Chi ld

Ret iree & Chi ldren

f amilirv

$2 2 7 . 28

$466..07

$426.. 19

$ 47 8.5 7

$ 6 6 0 . 26

$ 3 25 . 45

$667 .33

$60 8 .8 0

$684 .74

$ 9 4 4 . 97

$205.. 45

$421.32

$38 5 .60

$432 .74

$ 5 9 6 . 96

$9.02

$18 .63

$20 .23

$20 .23

$27.31

8 0 %

Rehree Only

Ret iree &. Spouse

Re t1i re e & 1 C h ild

Ret iree &. C hilltf re n lf a

m ilv

$181.82

$372 .85

$340 .95

$382.86

$528.21

$260.36

$533.86

$487 .04

$547.79

$755 .97

$164.36

$337.06

$308.48

$346.19

$477.57

$7.21

$ 1 4 .9 1

$16 .18

$16 .18

$21.84

8 5,%

Re iiire e Only

Ret iree & Spouse

Re fiire e & 1 C h ild Re t

ire e & C hiltl re n lf a

m ilv

$136.37

$279.64

$255.71

$287.14

$396.16

$19 5 .2 7

$ 400 .40

$365.28

$410 .8 5

$566 .98

$123.27

$252.79

$231.36

$259.64

$358.18

$5.41

$11 .18

$ 1 2 . 1 4

$ 12.14

$16 .38

9 0 %

$9 0 . 91

$186 .43

$170 .48

$191 .43

$264.10

$ 130 . 18

$266 .93

$243.52

$273.90

$377.99

$ 8 2.18

$168 .53

$154.24

$173.10

$238.79

$3 ..61

$7.45

$8.. 09

$8.09

$10 .92

l 00%

Reiiiree Onlly

Ret iree & Spouse

Reiliree & l C hild

Ret iree & C hilltf ren

!Family

Reiliree Only

RetireGt & SpousGt

Rehree & 1 C h ild

Retiree & C hillk:fre n

f a mily

$0.00

$0 .0 0

$0 .0 0

$0 ..00

$0 .00

$0.00

$ 0 . 0 0

$0.00

$0.00

$0 .00

$0.00

$ 0 1. 0 0

$0.00

$0.00

$0 .00

$0..00

$ 0 . 0 0

$0 .00

$0..00

$0 .00

2 0 2 0 Non- M ed 1"c a re El"1a 1"b le

TIER POS20

R efiree Rates

Benefit

FeaturePOS PPO New PPO25

DeductibleIn Network: N/A

OutNetwork: $2,000/$5,000

In Network: N/A

OutNetwork: $500/$1,250

In Network: N/A

OutNetwork: $500/$1,250

Out of Pocket

Maximum

InNetwork: $3,880/$9,700

OutNetwork: $8,000/$20,000

InNetwork: $3,880/$9,700

OutNetwork: $1,000/$2,500

InNetwork: $3,880/$9,700

OutNetwork: $1,000/$2,500

CoInsuranceInNetwork: N/A

OutNetwork: 40%

InNetwork: N/A

OutNetwork: 20%

InNetwork: N/A

OutNetwork: 20%

In Network Copays | Out of Network: Deductible & Coinsurance Apply

Office Visit $20 Copay $20 Copay$25 Copay Primary Care

$40 Copay Specialist Care

OutPatient

Surgery$0 Copay $0 Copay $100 Copay

MRI/CAT/PET

Scans$0 Copay $0 Copay $75 Copay

Urgent Care $20 Copay $20 Copay $25 Copay

Emergency

Room$100 copayment(waived if admitted w/in 24-hrs)

$100 copayment(waived if admitted w/in 24-hrs)

$200 copayment(waived if admitted w/in 24-hrs)

Hospital

Admission$0 Copay $0 Copay $200 Copay

Prescriptions

(30-day Supply)

$5 / $20 / $40 $10 / $25 /$40 $10 / $25 /$40

-------------------------------------------------------------------------------------------------------------------

PLEASE COMPLETE THE FORM BELOW AND RETURN IT BY NOVEMBER 29, 2019 DIRECTLY TO: Kevin Roach,

Ulster County Employee Benefits Office, P.O. Box 1800, Kingston, N.Y. 12402

I am a NON-Medicare eligible retiree/spouse and I have reviewed the three Empire BCBS plans

available. I am requesting coverage in the plan for which I have indicated below. I certify that my

dependents continue to be eligible for coverage by marriage or child dependency. For questions

regarding eligibility, please contact the Benefits Office. Dental & Vision plans are included.

Empire BCBS POS20 Plan

Empire BCBS PPO20 Plan

Empire BCBS PPO25 Plan

Signature Printed Name

Date

Table of Contents

The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the

employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information.

While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of

discrepancy between the Guide and the actual plan documents, the actual plan documents will prevail.

All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996.

If you have any questions about your Guide, contact Employee Benefits.

ACH Form for Ulster County Retirees

Empire BCBS Website & LiveHealthOnline.com Instructions

Benefit Enrollment Change Form

(please print)

(Circle elections

and print

information)

(please print)

Express Scripts

Express Scripts Formulary—2020

PPO 20 & PPO 25 Copays (Retail-30-day supply): $10/$25/$40, Mail order 90-day supply= 2-copays

POS 20 Copays (Retail-30-day supply): $5/$20/$40, Mail order 90-day supply= 2-copays

Express Scripts Formulary—2020

PPO 20 & PPO 25 Copays (Retail-30-day supply): $10/$25/$40, Mail order 90-day supply= 2-copays

POS 20 Copays (Retail-30-day supply): $5/$20/$40, Mail order 90-day supply= 2-copays

Express Scripts Exclusion List—2020

Express Scripts Exclusion List—2020

Ulster Scripts Employee Program

Ulster Scripts —Formulary

Ulster Scripts—Employee Enrollment Form

Ulster Scripts—Enrollment Form / Agreement

Dental Plan—MetLife

NEW PROVIDER— SAME BENEFITS | Group ID Number: 217284

PROVIDER: METLIFE

ELIGIBILITY

Primary enrollee, spouse (or domestic partner) and

eligible dependent children to the end of the month

that dependent turns 26

Deductibles $50 per person / $150 per family each calendar year

Waived for Diagnostic

& Preventive & OrthodonticsYes

Maximums $1,500 per person each calendar year

Diagnostic & Preventive counts

toward maximumYes

Benefits & Covered Services*In-Network Providers

Negotiated Fee Schedule

Out-of-Network* Providers

R & C 90th Percentile

Diagnostic & Preventive Services

Exams, cleanings, x-rays, sealants100% 100%

Basic Services-Fillings 80% 80%

Endodontics (root canals) 80 % 80 %

Periodontics (gum treatment) 80 % 80 %

Oral Surgery 80 % 80 %

Major Services-Crowns, inlays, onlays

& cast restorations50% 50%

Prosthodontics-Bridges, dentures,

implants, TMJ50% 50%

Orthodontic Benefits-dependent

children to age 1950% 50%

Orthodontic Maximums $1500 Lifetime $1500 Lifetime

* Out of Network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary (R & C) charge is based on the lowest of

(1) the dentist’s actual charge (the ‘Actual Charge’), (2) the dentist’s usual charge for the same or similar services (the ‘Usual Charge’) or (3) the charge of most dentists in the same

geographic area for the same or similar services as determined by MetLife (the ‘Customary Charge’). Services must be necessary in terms of generally accepted dental standards.

This benefit information is not intended or designed to replace or serve as the plan’s Evidence of

Coverage or Summary Plan Description. If you have specific questions regarding the benefits,

limitations or exclusions for your plan, please consult your company’s benefits representative.

Dental Plan—MetLife / Find a Dental Provider

MetLife Network: Preferred Dentist Plus Network (PDP Plus)

Group ID Number: 217284

Vision Plan—Davis Vision

Local, Regional, & National providers

including Empire Visionworks, Vision Excel,

Kenco, Dr. Joseph Cohen, and Walmart.

For a complete list of providers and more

details about the plan please log onto the

Open Enrollment section of our Member site

at davisvision.com or call

1.877.923.2847 and

Enter Client Code 2769

Vision Plan—Davis Vision

Empire BCBS Summary of Benefits— POS20 Plan

Note for 2020 – Acupuncture will be covered after $20 copayment- medical review after 5 visits – maximum 30 visits per calendar year.

Empire BCBS Summary of Benefits— POS20 Plan

Empire BCBS Summary of Benefits—PPO20 Plan

Note for 2020 – Acupuncture will be covered after $20 copayment- medical review after 5 visits – maximum 30 visits per calendar year.

20

Empire BCBS Summary of Benefits—PPO20 Plan

Empire BCBS Summary of Benefits—PPO25 Plan

County of Ulster PPO25

Empire BCBS Summary of Benefits—PPO25 Plan

Important Notice from Ulster County About Your

Prescription Drug Coverage and Medicare

Effective: January 1 ,2020

Important Notice from Ulster County About Your

Prescription Drug Coverage and Medicare (continued)