Northwest Retiree Benefit Trust 2015 Benefits Guide
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Northwest Retiree Benefit Trust 2015 Benefits Guide
Welcome to the
2015 Northwest Retiree Benefit Trust Plans
This guide includes detailed information regarding the benefit options available to you
through the Northwest Retiree Benefit Trust.
In this guide, you will find information on the following:
2015 Northwest Retiree Benefit Trust Medical Plan—Page 2
This plan is being offered through Transamerica Premier Life Insurance Company
(nationwide)/ Transamerica Financial Life Insurance Company (New York residents).
2015 Prescription Drug Plan—Page 6
This plan is being offered through Medicare GenerationRx™ (Employer PDP) and is
underwritten by Stonebridge Life Insurance Company.
2015 Dental Plan—Page 9
This plan is being offered through MetLife Dental PPO.
2015 Vision Plan—Page 10
This plan is being offered through Superior Vision.
Important Notes
If you have any questions or need assistance as you review your information, please
contact us. The Retiree Service Center customer care representatives are available
between the hours of 7:00 a.m. and 7:00 p.m. CT to assist you. Our dedicated toll-free
customer care phone number is 1-844-413-2843.
You will now have access to a Care Advocate specialist at Gilsbar to assist you with
understanding your benefits, what they cover, claims medical billing and coordination of your
healthcare needs.
You may enroll in the prescription drug plan unless you currently participate in a
government-sponsored plan, such as VA or TRICARE.
You must enroll in the medical plan to be eligible for the vision plan.
US Airways Retirees and their extended families can get discounted services for
hearing diagnostics, evaluations, and hearing aids through EPIC Discount Hearing
Services. This is a FREE service; there are no enrollment forms to complete. Simply
call EPIC at 1-866-956-5400.
For more information on the benefit plans available,
Visit our website at www.gilsbar.com/nwretireebenefits65
1 25845597
68723 B10134 (10/13)2015 Retiree Medical Plan
Underwritten by Transamerica Premier Life Insurance Company, a Transamerica
Company
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD*
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after
you have been out of the hospital and have not received skilled care in any other facility for 60 days in a
MEDICARE
SERVICES PLAN PAYS YOU PAY
PAYS
HOSPITALIZATION*
Semiprivate room and board, general nurs-
ing and miscellaneous services and sup-
plies:
First 60 days All but the Medicare 100% of the Medicare $0
Part A deductible Part A deductible
61st thru 90th day 75% of the Medicare 25% of the Medicare $0
Part A deductible Part A deductible
91st day and after: 50% of the Medicare 50% of the Medicare $0
While using 60 lifetime reserve days Part A deductible Part A deductible
Once lifetime reserve days are used:
Additional 365 days $0 100% of Medicare $0
Eligible Expenses
Beyond the additional 365 days $0 $0 All costs
SKILLED NURSING FACILITY CARE* You
must meet Medicare’s requirements,
including having been in a hospital for at
least 3 days and entered a Medicare-
approved facility within 30 days after leaving
the hospital:
First 20 days All approved amounts $0 $0
21st thru 100th day 87 1/2% of Medicare 12 1/2% of Medicare $0
Part A deductible Part A deductible
101st day and after $0 $0 All costs
BLOOD
First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
HOSPICE CARE All but very limited
Available as long as your doctor certifies you coinsurance for out- $0 Balance
are terminally ill and you elect to receive patient drugs and
these services. inpatient respite care
Benefits will not be paid for any expenses which are not determined to be Medicare Eligible Expenses by the Federal Medicare Program or its
administrators, except as otherwise specified. For complete details please see the Master Policy. This policy's renewability, cancel ability and
termination provisions are at the option of the group policy holder except in cases of non-payment of premium.
25845597
2MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR*
*Once you have been billed the applicable Medicare-Approved amounts for covered services (which are noted
with an asterisk), your Medicare Part B Deductible will have been met for the calendar year.
MEDICARE
SERVICES PLAN PAYS YOU PAY
PAYS
MEDICAL EXPENSES—In or Out of the Hospital and
Outpatient Hospital Treatment, such as Physician’s
services, inpatient and outpatient medical and surgical
services and supplies, physical and speech therapy,
diagnostic tests, durable medical equipment:
First Medicare Approved Amounts* $0 $0 100% of Part B
deductible
Next Medicare Eligible expenses up to an annual Generally 80% Generally 10% 10% up to $2,000
out-of-pocket totaling $2,000 (includes Part B
deductible).
After payment of the standard Part B deductible Generally 80% Generally 20% $0
plan pays 10% Medicare eligible expenses up to
an annual out-of-pocket totaling $2,000 (includes
Part B deductible); thereafter plan pays 20%
Medicare eligible expenses.
Part B Excess Charges (above Medicare approved $0 100% $0
amounts)
BLOOD
First 3 pints $0 All costs $0
Next Medicare Approved Amounts* $0 $0 100% of Part B
deductible
Next Medicare Eligible expenses up to an annual 80% 10% 10% up to $2,000
out-of-pocket totaling $2,000 (includes Part B
deductible).
After payment of the standard Part B deductible 80% 20% $0
plan pays 10% Medicare eligible expenses up to
an annual out-of-pocket totaling $2,000 (includes
Part B deductible); thereafter plan pays 20%
Medicare eligible expenses.
CLINICAL LABORATORY SERVICES
Blood tests for Diagnostic Services 100% $0 $0
HOME HEALTH CARE
Medicare Approved Services: medically necessary 100% $0 $0
skilled care services and medical supplies
Durable medical equipment: First Medicare $0 $0 100% of Part B
Approved Amounts* deductible
Next Medicare Eligible expenses up to an annual 80% 10% 10% up to $2,000
out-of-pocket totaling $2,000 (includes Part B
deductible).
After payment of the standard Part B deductible 80% 20% $0
plan pays 10% Medicare eligible expenses up to
an annual out-of-pocket totaling $2,000 (includes
Part B deductible); thereafter plan pays 20%
Medicare eligible expenses.
FOREIGN TRAVEL
Medically necessary emergency services beginning during
the first 60 days of each trip outside the USA:
First $250 each calendar year $0 $0 $250
Remainder of charges $0 80% to a lifetime 20% and amounts
max of $100,000 over $100,000
lifetime max
3 25845592015 Prescription Drug Plan
Medicare GenerationRx™ (Employer PDP) is a Medicare-approved Part D sponsor
that is offered nationally in all 50 states except NY and the District of Columbia. This
prescription drug plan is a group plan underwritten by a Transamerica affiliated
company, Stonebridge Life Insurance Company (Rutland, VT).
Whether you are looking for the local service of a neighborhood pharmacy, the
convenience of prescriptions by mail or the clinical support of a specialty pharmacy,
Medicare GenerationRx™ has options to match your preferences.
Community Pharmacies
Medicare GenerationRx™ has more than 60,000 community pharmacies for
your use, including most chain drug stores and many independents. For your
convenience, you may also receive an extended day supply at many of our retail
pharmacies under our Choice90Rx® program.
Mail Order Pharmacy
Ordering prescriptions by mail is like having a pharmacy at your door. It can
save you trips to the pharmacy while providing confidentiality in your prescription
needs. You’ll also reap copayment savings. Up to a 90-day supply of your
prescriptions can be delivered to your mailbox for what you would normally pay
for a 60-day supply at your community pharmacy. Ordering prescriptions by
mail lowers your drug cost by 33%!
Specialty Pharmacy Prescriptions
If you are currently taking a medication that is on the specialty tier of your
prescription benefit, you may wish to take advantage of Medicare
GenerationRx™’s preferred specialty pharmacy, Diplomat Specialty Pharmacy.
Diplomat uses pharmacists and nurses to provide specialized Patient Care
Programs. These clinical management programs are designed by pharmacists
and physicians to be a resource to you in managing and understanding your
drug therapy and disease.
Only you know what pharmacy options best suit you. Medicare GenerationRx™ is
pleased to offer you the choice of local pharmacies, prescriptions by mail and a
specialty pharmacy that supports you and your specific needs. If you have questions
on any of these pharmacy options or your Medicare GenerationRx™ plan, our member
services staff is here to help you at 1-877-633-7943 or by visiting
www.MedicareGenerationRx.com/usretirees.
6 25845597Benefit Category Outpatient Prescription Drugs
General This plan uses a formulary. The plan will send you a formulary. You can also
see the formulary at www.MedicareGenerationRx.com/usretirees.
You must go to certain pharmacies for a limited number of drugs, due to
special handling, provider coordination, or patient education requirements
that cannot be met by most pharmacies in your network. These drugs are
listed on the plan’s website, formulary and printed materials. If the actual
cost of a drug is less than the normal cost-sharing amount for that drug, you
will pay the actual cost, not the higher cost-sharing amount.
Yearly Deductible Your annual deductible is $0.
Initial Coverage Because you have no deductible, you pay the following until your total
yearly drug costs reach $2,850.
Retail Pharmacy— Tier 1: Generic Drugs
Up to 31 day supply $15 copayment for a 31-day supply of drugs in this tier
Tier 2: Preferred Brand Drugs
$25 copayment for a 31-day supply of drugs in this tier
Tier 3: Non-Preferred Brand Drugs
$55 copayment for a 31-day supply of drugs in this tier
Tier 4: Specialty Tier Drugs
33% coinsurance for a 31-day supply of drugs in this tier
Mail Order— Tier 1: Generic Drugs
84-90 day supply $30 copayment for a 90-day supply of drugs in this tier
Tier 2: Preferred Brand Drugs
$50 copayment for a 90-day supply of drugs in this tier
Tier 3: Non-Preferred Brand Drugs
$110 copayment for a 90-day supply of drugs in this tier
Tier 4: Specialty Tier Drugs
33% coinsurance for a 90-day supply of drugs in this tier
Retail— Tier 1: Generic Drugs
84-90 day supply $45 copayment for a 90-day supply of drugs in this tier
Tier 2: Preferred Brand Drugs
$75 copayment for a 90-day supply of drugs in this tier
Tier 3: Non-Preferred Brand Drugs
$165 copayment for a 90-day supply of drugs in this tier
Tier 4: Specialty Tier Drugs
33% coinsurance for a 90-day supply of drugs in this tier
After your Initial Coverage Limit Level drug costs reach $2,850, you receive a discount on brand
name drugs and pay 72% of the plan's costs for all generic drugs until your yearly True-Out-Of-
Pocket drug costs reach $4,550, which is needed to enter catastrophic coverage. A 52.5% discount
on the negotiated price will be available for those brand name drugs from manufacturer's that have
agreed to pay the discount.
7 25845597Notice about the
Coverage Gap (Donut Hole)
During the INITIAL COVERAGE LIMIT your co-pays for the Choice Plan will be: $15
Generic, $25 Preferred Brand, $55 Non-Preferred Brand, and 33% Specialty. When
the shared costs (what your co-pays and what the Medicare GenerationRx™ Plan
actually pays) for your drugs exceed $2,850 you leave the Initial Coverage Phase and
enter the Donut Hole. Please note: the cost-sharing is for a 31-day supply.
EXAMPLE OF HOW YOU COULD GET IN THE DONUT HOLE:
Assume that during the calendar year in the Initial Coverage Phase, Medicare
GenerationRx™ has paid $2,200 in drug costs and you have paid $770 in
co-pays.
$2,200 + $770 = $2,850
(You have reached the Initial Coverage Limit)
Please note: this is only an illustration of how the $2,850 Initial Coverage Limit
can be reached; it could be a different combination of shared costs between
you and Medicare GenerationRx™, depending on how your co-pays add up
and how much the Medicare GenerationRx™ Plan pays for the drugs, but the
total limit is $2,850.
WHAT HAPPENS WHEN I AM IN THE DONUT HOLE?
For the 2014 Choice Plan in the Donut Hole:
PREFERRED BRAND & NON-PREFERRED BRAND DRUGS: You pay
47.5% of the cost; the pharmaceutical companies have committed through
healthcare reform to pay the other 52.5%.
GENERIC DRUGS: You pay 72% of the cost of Generics.
CATASTROPHIC COVERAGE LIMIT
In 2014, the limit is $4,550. Because of healthcare reform, what you pay and
some of the payments made by the Medicare Coverage Gap Discount Program
are included as out-of-pocket spending and help you to get out of the coverage
gap. Prior to healthcare reform, it was only your costs that counted. After the
drug costs have exceeded $4,550, the costs of your drugs will be the greater of:
5% or $2.55 for generic/preferred multi-source drugs, and the greatest of 5% or
$6.35 for all other drugs.
8 258455972015 Dental Plan -
MetLife Dental PPO
In-Network Out-of-Network
Annual deductible None $50 per person
(per person)
Preventive Care No Deductible No Deductible
Exam - (twice per calendar year) The Plan pays The Plan pays 80%
Prophylaxis - (twice per calendar year) 100% of discounted of reasonable and
in-network fees customary (R&C)
charges
Minor Care The Plan pays 80% The Plan pays 50%
Oral surgery of discounted of R&C charges, af-
Extractions in-network ter annual Deductible
Amalgams No Deductible (deductible applies to
Endodontics minor and major care
Periodontics combined)
Major Care The Plan pays 50% The Plan pays 50%
Bridgework of discounted of R&C charges, af-
Dentures In-network fees ter annual Deductible
Crowns No Deductible (deductible applies to
Inlays and onlays minor and major care
Reparation and replacement of bridges, combined)
crowns, inlays, onlays, Dentures
Implants—1. Provided no more than
once for the same tooth position in a 60
month period.
2. Repaired not more than once in a 12
month period.
3. Supported prosthetics but no more
than once for the same tooth position in
a 5 year period.
Annual Benefit Maximum $1,500/person $1,000/person
If you have questions, need additional information, or help in locating a participating MetLife dentist (there
are over 125,000 nationwide) please call MetLife at 866-526-0965 M-F 8am to 11pm EST or the Northwest
Retiree Benefits Trust Service Center at 1-844-413-2843.
*For residents of TX, LA, MS and MT out of network preventive care will be covered at 100% due to state
mandates.
Like most group benefits programs, benefit programs offered by MetLife contain certain exclusions,
exceptions, waiting periods, reductions, limitations, and terms for keeping them in force.
9 258455972015 Vision Plan -
Superior Vision Plan
In-Network Out-of-Network
Copayments $15 Comprehensive Eye Exams; $25 Materials;
$10 Contact Lens Fitting
Comprehensive Eye Exam - Covered in Full Up to $37
Ophthalmologist (MD)
Comprehensive Eye Exam - Covered in Full Up to $28
Optometrist (OD)
Standard Lenses (Per pair):
Single Vision Covered in Full Up to $32
Bifocal Covered in Full Up to $46
Trifocal Covered in Full Up to $57
Lenticular Covered in Full Up to $84
Contact Lenses (Per pair):*
Medically Necessary Covered in Full Up to $210
Elective** $100 Retail Allowance Up to $80
Frames—Standard** $125 Retail Allowance Up to $64
*Contact lenses are in lieu of eyeglass lenses and frames benefit.
**The insured is responsible for paying any charges in excess of this allowance.
Plan Frequency Lens Options and Upgrades Member pays 20%
Comprehensive Exam 12 Months (covered pair of lenses) off retail up to:
Lenses 12 Months Factory scratch coat $13
Frames 24 Months Ultraviolet coat $15
Contact Lenses 12 Months Standard anti-reflective coat $50
High Index 1.6 $55
Materials Discount SVP8-20 Polycarbonate $40
These discounts apply to upgrades on the covered Standard photochromic $80
frame and lenses only. For discounts on additional Glass coloring $35
pairs, please refer to the Discounts on Additional Plastic, tints, solid, or gradients $25
Purchases. Member pays:
Power over 4.00 Sphere, 2.00D 20% discount off retail
Frames 20% off the difference between the Cylinder & 5.00 Prism
covered frame allowance and the Cosmetic finishing, beveling, 20% discount off retail
retail price of the selected frame. edging & mounting
Note: Discounts do not apply when prohibited by Miscellaneous options 20% discount off retail
the manufacturer.
Higher end or brand name lens upgrades are at an
Materials Discounts on Additional Purchases additional expense to you. These upgrades will be
Discounts up to 20% on Materials and 30% on available at a 20% discount off retail.
Additional Purchases are available through Superior
Vision contracted providers identified in the provider View your benefits and provider listing at
directory. www.superiorvision.com
All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance Coverage for your vision plan.
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