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M A K I N GY O U RD E C I S I O N SH E A LT HO P E NE N R O L L M E N TC O U N T Y O F S A N TA C L A R ARetirees2021- 2022R E T I R E M E N TA N N U A LR E Q U I R E DN O T I C E S
Welcome to Open Enrollment Thank you for your service to the County of Santa Clara. The EmployeeBenefits Department is pleased to support you through OpenEnrollment for Retiree medical insurance during the month of May. Rest assured — your County medical benefits are not changingand will continue to provide high-quality, affordable coverage foryou and your family. Open Enrollment for Retiree medical insurance runs fromMay 1-31, 2021. Your medical plan elections will take effect July 1, 2021. Please note that in order to keep you and our employees safe, ourlobby is closed to in-person customer service. We encourage youto reach us by phone or email if you have any questions or want tomake a change to your medical plan.
What you need to know for 2021-2022 You’ll see slight changes to premium rates for medical coverage, but almost allmedical plans and features remain unchanged.– Health Net has a new telemedicine provider with Babylon All medical plans include coverage enhancements in response to COVID-19,including:– No cost for COVID-19 testing, diagnosis, and treatment– Coverage for telemedicine (virtual visits), including mental health support We recommend you review your current benefit selections and covereddependents to make sure your benefits continue to meet your needs. No action is needed unless you want or need to:– Change your medical plan– Enroll in a County-sponsored plan if you previously waived coverage– Add or drop coverage for dependents. If you want to make a change, submit your enrollment form to your EmployeeService Center by May 31, 2021.
YOUR COUNTYBENEFITS
Your medical plan optionsYou have a choice of medical plan options that depends on your ageand eligibility for Medicare coverage.HMOHMOPOSSenior Advantage(Medicare)HMO (Classic Network):Under 65Select POS: Under 65Under 65 HMOHMO (Classic Network):Medicare HMO (Preferred Network):Under 65 HMO (Preferred Network):Medicare Select PPO: Under 65 Out-of-State PPO: Under 65 Flex Net: Medicare Select POS: Medicare PPO: Medicare Seniority Plus: Medicare
Medical plans at a glance The charts on the following pages offer an overview of some of theretiree medical plans’ features. Find more detailed plan information on the County’s Retiree Benefits website,including your 2021-2022 Retiree Benefits Guide.
Medical plans at a glanceK A I S E R P E R M A N E N T E H M O : S E N I O R A D VA N TA G EKAISER PERMANENTE HMO: UNDER 65Kaiser Permanente HMO:Senior Advantage (Medicare)Kaiser Permanente HMO:Under 65In-NetworkIn-NetworkNoneNoneIndividual / Family 1,500/ 3,000 1,500/ 3,000Physician Office Visit 10 10Specialist Copay 10 10Preventive CareNo ChargeNo ChargeRx Copay Out-of-Pocket maximumCombined with MedicalCombined with MedicalRetail: 30-day supply 5/ 10 5/ 10Mail Order: up to 100-day supply 10/ 20 10/ 20Calendar Year DeductibleIndividual / FamilyAnnual Out-of-Pocket MaximumPrescription Drugs—Generic/Brand
Medical plans at a glanceH E A LT H N E T S E L E C T P O S : U N D E R 6 5Health Net Select POS: Under 65HMO NetworkPPO NetworkOut-of-NetworkNoneNone 200/ 600Individual / Family 1,500/ 4,500 2,000/ 6,000 3,000/ 9,000Physician Office Visit 15 2030%Specialist Copay 15 2030%Preventive CareNo ChargeNo ChargeNot CoveredCalendar Year DeductibleIndividual / FamilyAnnual Out-of-Pocket MaximumPrescription Drugs—Generic/Brand/Non-FormularyRx Copay Out-of-Pocket maximumRetail: 30-day supplyMail Order: up to 100-day supply 2,000 (member) / 4,000 (family) 5/ 15/ 30/ 0 self-injectable 10/ 30/ 60
Medical plans at a glanceH E A LT H N E T S E L E C T P P O : U N D E R 6 5Health Net Select PPO: Under 65In-NetworkOut-of-NetworkNone 200/MemberIndividual / Family 2,000/Member 4,000/MemberPhysician Office Visit 2030%Specialist Copay 2030%Preventive CareNo Charge30%Calendar Year DeductibleIndividual / FamilyAnnual Out-of-Pocket MaximumPrescription Drugs—Generic/Brand/Non-FormularyRx Copay Out-of-Pocket maximum 2,000 (member) / 4,000 (family)Retail: 30-day supply 5/ 15/ 30/ 20 self-injectable 5/ 15/ 30 50%Mail Order: up to 100-day supply 10/ 30/ 60 10/ 30/ 60 50%
Medical plans at a glanceH E A LT H N E T O U T- O F - S TAT E P P O : U N D E R 6 5Health Net Out-of-State PPO: Under 65In-NetworkOut-of-NetworkNone 200/MemberIndividual / Family 2,000/Member 4,000/MemberPhysician Office Visit 2030%Specialist Copay 2030%Preventive CareNo ChargeNot CoveredCalendar Year DeductibleIndividual / FamilyAnnual Out-of-Pocket MaximumPrescription Drugs—Generic/Brand/Non-FormularyRx Copay Out-of-Pocket maximum2,000 (member) / 4,000 (family)Retail: 30-day supply 5/ 15/ 30/ 20 self-injectable 5/ 15/ 30 50%Mail Order: up to 100-day supply 10/ 30/ 60 10/ 30/ 60 50%
Medical plans at a glanceH E A LT H N E T F L E X N E T: M E D I C A R EHealth Net Flex Net: MedicareIn-NetworkCalendar Year DeductibleIndividual / FamilyNoneAnnual Out-of-Pocket MaximumIndividual / FamilyNonePhysician Office VisitNo chargeSpecialist CopayNo chargePreventive CareNo ChargePrescription Drugs—Generic/BrandRx Copay Out-of-Pocket maximum 1,000 (member) / 2,000 (family)Retail: 30-day supply 5/ 10/ 0 self-injectableMail Order: up to 100-day supply 10/ 20
Medical plans at a glanceH E A LT H N E T S E L E C T P O S : M E D I C A R EHealth Net Select POS: MedicareHMO NetworkPPO NetworkOut-of-NetworkNoneNone 200/ 600Individual / Family 1,500/ 4,500 2,000/ 6,000 3,000/ 9,000Physician Office Visit 15 2030%Specialist Copay 15 2030%Preventive CareNo ChargeNo ChargeNot CoveredCalendar Year DeductibleIndividual / FamilyAnnual Out-of-Pocket MaximumPrescription Drugs—Generic/Brand/Non-FormularyRx Copay Out-of-Pocket maximumRetail: 30-day supplyMail Order: up to 100-day supply 2,000 (member) / 4,000 (family) 5/ 15/ 30/ 0 self-injectable 10/ 30/ 60
Medical plans at a glanceH E A LT H N E T P P O : M E D I C A R EH E A LT H N E T S E N I O R I T Y P L U S : M E D I C A R EHealth Net PPO:MedicareIn-NetworkOut-of-NetworkHealth Net Seniority Plus:MedicareIn-NetworkCalendar Year DeductibleIndividual / Family 0/ 100NoneAnnual Out-of-Pocket MaximumIndividual / Family 2,000/Member 4,000/Member 3,400Physician Office Visit 2030%No ChargeSpecialist Copay 2030%No ChargePreventive CareNo ChargeNot CoveredNo ChargePrescription Drugs—Generic/Brand/Non-FormularyRx Copay Out-of-Pocket maximum 2,000 (member) / 4,000 (family)Combined with MedicalRetail: 30-day supply 5/ 15/ 30/ 20 self-injectable 5/ 15/ 30 50% 3/ 7/ 7/ 0 self-injectableMail Order: up to 100-day supply 10/ 30/ 60 10/ 30/ 60 50% 6/ 14/ 14
Medical plans at a glanceVA L L E Y H E A LT H P L A N H M O C L A S S I C : U N D E R 6 5VA L L E Y H E A LT H P L A N H M O P R E F E R R E D : U N D E R 6 5Valley Health Plan HMO Classic:Under 65Valley Health Plan HMO Preferred:Under 65In-NetworkIn-Network 0 0Individual / Family 1,000/ 2,000 1,000/ 2,000Physician Office Visit 0 0Specialist Copay 0 0Preventive Care 0 0Rx Copay Out-of-Pocket maximumN/AN/ARetail: 30-day supply 0 0Mail Order: up to 90-day supply 0 0Calendar Year DeductibleIndividual / FamilyAnnual Out-of-Pocket MaximumPrescription Drugs—Generic/Brand
Medical plans at a glanceVA L L E Y H E A LT H P L A N H M O C L A S S I C : M E D I C A R EVA L L E Y H E A LT H P L A N H M O P R E F E R R E D : M E D I C A R EValley Health Plan HMO Classic:MedicareValley Health Plan HMO Preferred:MedicareIn-NetworkIn-Network 0 0Individual / Family 1,000/ 2,000 1,000/ 2,000Physician Office Visit 0 0Specialist Copay 0 0Preventive Care 0 0Rx Copay Out-of-Pocket maximumN/AN/ARetail: 30-day supply 0 0Mail Order: up to 90-day supply 0 0Calendar Year DeductibleIndividual / FamilyAnnual Out-of-Pocket MaximumPrescription Drugs—Generic/Brand
VHP HMO Classic vs. PreferredClassic PlanNetwork Providers California IPASan Benito Medical Associates (SBMA)Santa Clara County IPA (SCCIPA)Santa Clara Valley Medical Center (SCVMC)Silicon Valley Medical DevelopmentPalo Alto Medical Foundation (PAMF)Sutter Gould Medical Foundation(select locations)Preferred Plan California IPASan Benito Medical Associates (SBMA)Santa Clara County IPA (SCCIPA)Santa Clara Valley Medical Center (SCVMC)Silicon Valley Medical Development
TelemedicineAll of the County medical plans offer telemedicine at no cost to you.Doctors can diagnose and prescribe medication, just like an in-personoffice visit. Virtual visits are available—by phone or video—with a licenseddoctor or therapist. You can make appointments by web, phone, or mobile app. Appointments are available 24 hours a day, seven days a week. You can use telemedicine as an alternative to expensive ER/urgentcare visit or any non-emergency health concerns. Mental health support is available (depending on the plan).
TelemedicineTelemedicine is available through the County’s medical plans. You canfind more information in your online Benefits Guide.My Doctor -6168VHP 24/7 Nurse Advice Line866-682-9492
YOURCOSTS FORCOVERAGE
2021-2022 premium rates Monthly retiree plan rates and contributions are included with theletter mailed to your home. The letter also includes your current medical plan coverage and thenew out-of-pocket premium for that coverage. You can also find rates and contributions on the Retiree Benefits website. Your monthly premium rate will automatically change with yourongoing CalPERS deduction, effective July 1, 2021.
COMPLETINGYOURENROLLMENT
Only enroll if you want or need to Change your medical plan Enroll in a County-sponsored plan, if you previously waived coverage Add or drop coverage for eligible dependents
Completing your enrollment If you do not have any changes, no action is required. If you are making changes:– Contact your dedicated Employee Benefits Representative to requestthe forms you need.– Establish your premium deduction authorization through your monthlyCalPERS pension check if you:» Are not currently enrolled in medical coverage, or» Now have a cost for coverage.– Return all required forms to the Employee Benefits Department by May 31, 2021. Return your forms to the Employee Benefits Department by fax or email as shownbelow —do not send any enrollment forms directly to the medical plan carriers.County of Santa Clara, Employee Benefits DepartmentFax: 408-277-0318Email: benefits@esa.sccgov.org
YOURRESOURCES
Your resources Visit the Retiree Benefits webpage for resources such as:– Retiree Benefits Guide– 2021-2022 Retiree Medical Rates– A schedule of special OE webinars and Office Hours hosted byour health plan provider partners Contact your dedicated Employee Benefits representative. Contact Employee Benefits staff at 408-970-2600 or by email atbenefits@esa.sccgov.org.
Contact informationB E N E F I T SC O NTACTSNeed Help With Contact Phone or WebsiteMedical PlansKaiser county/Valley Health Plan888-421-8444www.valleyhealthplan.org/sccHealth tent/iwc/mysites/sc/home.action
Contact informationE M P L O Y E EBE NEFITSREPRESEN TATIV E SFirst Initial ofYour Last NameYour RepresentativeDirect Phone NumberEmailAMelinda Lum408-970-2618Melinda.lum@esa.sccgov.orgB, H, IAllison tal Michele , GLuisa Leticia Bayona408-970-2662Leticia.bayona@esa.sccgov.orgJ, P, T, ZIliana Salazar408-970-2659Iliana.salazar@esa.sccgov.orgK, N, U, V, X, YAngelina rgLRosalinda De La gMKelly Anderson408-970-2600Kelly.anderson@esa.sccgov.orgO , Q , R, WGeneva a Chiprez408-970-2600Angela.chiprez@esa.sccgov.org
County of Santa Clara, Employee Services Agency400 Race Street, Suite 201, San Jose, CA 95126Phone 408-970-2600Email fits
HEALTH NET PPO: MEDICARE HEALTH NET SENIORITY PLUS: MEDICARE Health Net PPO: Medicare Health Net Seniority Plus: Medicare In-Network Out-of-Network In-Network Calendar Year Deductible Individual / Family 0/ 100 None Annual Out-of-Pocket Maximum Individual / Family 2,000/Member
