You should have a medical ID card from Aetna and a pharmacy ID card from Optum Rx. If you elected the DVA plan you will also have a dental ID card from Delta Dental/Moda and a vision card from Aetna. You can use your ID cards when visiting your health care providers or pharmacy.

Aetna

Delta Dental

Optum Rx

You can download a digital copy of your ID card online:

• Optum Rx
• Aetna Navigator
• Delta Dental

To request a new physical ID card via phone, visit our Partner Contacts page.

The definition of retiree dependents limiting coverage to age 19 (or age 23 if a full-time student) comes directly from Alaska statute.

Expanding dependent coverage to age 26 is one of the provisions in the Federal Patient Protection and Affordable Health Care Act (PPACA) and the Health Care and Education Reconciliation Act (HCERA) that became effective March 2010. This provision affects employee plans and retiree-only health plans differently.

On June 14, 2010, the U.S. Departments of Health and Human Services, Labor, and Treasury issued regulations on Grandfathered Health Plans under PPACA. In the preamble to the Interim Final Rule, the Secretaries clarify that it is not their intent to apply the PPACA coverage to retiree-only health plans. This means the retiree medical plan, is not subject to the expanded dependent coverage provisions of PPACA.

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Recognized charge means the negotiated charge contained in an agreement the claims administrator has with the provider either directly or through a third party. If there is no such agreement, the recognized charge is determined in accordance with the provisions of this section. Except for charges related to involuntary out-of-network services, an out-of-network provider has the right to bill the difference between the recognized charge and the actual charge. This difference will be the covered person’s responsibility.

Medical Expenses: As to medical services or supplies, the recognized charge for each service or supply is the lesser of:

• What the provider bills or submits for that service or supply;
• Or the 90th percentile of the prevailing charge rate; for the geographic area where the service is furnished as determined by Aetna in accordance with Aetna reimbursement policies.

For more information on recognized charge in the Retiree Plan, see the Retiree Insurance Information Booklet , section 3.1.4 Recognized Charge.

Using "network" providers can provide substantial benefits to members through the elimination of what's known as "balance billing." It can also generate substantial savings to members through negotiated provider discounts.

To find a network provider:

• Call Aetna's Health Concierge at or select the "Find a Doctor" button on our website, AlaskaCare.gov.
• Call Moda/Delta Dental at or select the "Find a Dentist" button on our website
• Call Optum Rx at or select the "Find a Pharmacist" button on our website.

The AlaskaCare plans limit payment of covered services to the recognized charge. The recognized charge is the maximum amount the AlaskaCare plans will pay for a covered service. Aetna and Moda/Delta Dental, and their respective network providers (sometimes referred to as participating providers), agree to a set of discounted negotiated rates for services provided. The recognized charge for network providers is the negotiated rate. For an explanation of how the recognized charge is calculated for out-of-network providers, please see the recognized charge questions under the Network and Dental sections.

An out-of-network provider has the right to bill you for the difference between the recognized charge and the actual charge. This is often referred to as balance billing. Network providers have agreed to accept, as payment in full, the negotiated charge. Therefore, you are not subject to balance billing when you use a network provider.

You may find that not all providers at a "network" facility are part of the Aetna network. For example, if you have a surgical procedure performed at a network hospital, you may find that the hospital and surgeon are in the network, but the anesthesiologist is out-of-network. When you get your bill, you'll see that it reflects the negotiated network rates for your hospital and surgeon. The anesthesiologist, however, may charge what they choose since they have no negotiated contract with Aetna. If the anesthesiologist claim exceeds the recognized charge, you may receive a bill for the balance.

You may prevent balance billing by verifying all medical providers are in the Aetna network and making sure your AlaskaCare Plan covers the services you need. For example, if you're having x-rays, MRIs, CT scans, or PET scans, make sure both the imaging facility and the radiologist who will read your scan are in the network. If you're planning surgery, ask whether the anesthesiologists are in the network. If available, the facility should accommodate your request to use a network provider for your services.

Similarly, for AlaskaCare covered dental services, you may prevent balance billing by verifying the provider is in the Moda/Delta Dental network.

If your provider is not a network provider, you may ask for an estimate of charges, the codes that will be used use for billing, and the provider's zip code. When you receive this information, contact the Aetna Concierge at or Moda/Delta Dental at . A member of the Aetna Concierge or Moda Customer Service team can review the estimated charges and will advise you if the charges fall within the recognized charge for your area. If the estimated charges exceed the recognized charge, you may request that your provider accept that amount and not balance bill you, or you may request payment arrangements with their office.

If your current provider is not listed as a network provider, you can ask your provider to contact Aetna at or Moda at for a participation application. Members are also encouraged to nominate their out-of-network providers to join the network. Contact the Aetna Concierge or Moda Customer Service to find out how.

In some cases, unfortunately, there will not be a network provider for the service you need in your area. The Division, Aetna and Moda/Delta Dental are working diligently to improve network access, but please understand that we cannot force providers into the network.

Yes, there is a network of providers for durable medical equipment. For assistance finding a network provider call the Aetna Concierge at or search online using the Aetna DocFind tool .

The AlaskaCare Retiree health plan was created by statute to provide health coverage to eligible retirees and their dependents in 1975. Alaska Statute Sec. 39.35.535(b) requires that the retiree health plan become supplemental to federal old age benefits available at age 65. This statute has been in effect since 1975. The Retiree Insurance Information Booklet section titled, "Effect of Medicare", states: "If you do not enroll in Medicare coverage the estimated amount Medicare would have paid will be deducted from your claim before processing by this plan."

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If you are currently eligible for Medicare, or when you become eligible for Medicare, you will be automatically enrolled in the AlaskaCare EGWP plan (a group Medicare Part D plan) by the Division of Retirement and Benefits. You do not need to enroll in an individual Medicare Part D plan.

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You are not required to take part in Medicare part C. Part C plans are Medicare Advantage plans provided by private insurers for members who live outside the State of Alaska. They cover the same services as Medicare Part A and B combined as well as some supplemental benefits. The AlaskaCare plan acts as a supplemental plan for Medicare eligible retirees.

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Most people are eligible for premium-free Part A. After members apply for Medicare Part A & B, they will receive a decision letter from Social Security notifying them if they qualify for premium-free Part A. Members who do not qualify for premium-free Medicare Part A, should not enroll in Part A, they must provide a copy of the Social Security letter to the AlaskaCare health claims administrator and the Division of Retirement & Benefits, and AlaskaCare will continue to pay as your primary plan for Part A services.

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Preventive care was not part of the original benefits covered by the AlaskaCare Retiree plan when it was created in 1975. Effective January 1, 2022, the Division of Retirement and Benefits is expanding preventive care coverage to the Retiree Defined Benefit health plan.

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Preventive care coverage includes, but is not limited to vaccinations, wellness visits, colorectal cancer screenings, mammograms, pap smears, prostate cancer screenings, and lung cancer screenings. Like other health plans, services covered by the Plan are based on those recommended by the US Preventive Services Task Force (USPSTF) and other governmental advisory groups and may include additional services as outlined in the Third-Party Administrator’s guidelines. These guidelines will change over time as they are updated to reflect the most current research and evidence.

After January 1, 2022, when you visit an in-network provider for preventive services, your AlaskaCare plan will pay 100% coinsurance and your deductible will not apply.

For preventive care received from out-of-network providers, you will first have to meet the $150 deductible, and then the plan would pay 80% coinsurance (up to the recognized charge) for covered services. Your AlaskaCare out-of-pocket maximum will not apply to preventive care services received from out-of-network providers. If you do not have access to an Aetna network provider in your area, you may contact Aetna to pre-certify use of an out-of-network provider, and those services will be paid as though they were received in-network.

Many retiree plan members have other health coverage, such as Medicare, or additional coverage through their spouse. The AlaskaCare plan will continue to coordinate with other plans the way it does today when determining payment for covered services.

Yes, colorectal cancer screenings including colonoscopies and at-home stool tests (such as Cologuard) will be covered in accordance with the standards outlined by the US Preventive Task Force and current clinical guidelines and frequency limitations outlined by the Third-Party Administrator’s (currently Aetna) clinical policy bulletins.

In alignment with the Plan booklet, Section 3.3.1 Medically Necessary Services and Supplies, and mainstream commercial health insurance practices, the Plan will utilize the current Third-Party Administrator’s (currently Aetna) clinical coverage standards for purposes of determining coverage of preventive services under the Plan. These standards must include, at a minimum, those services with an “A” or “B” recommendation by the USPTF but may include additional services or screenings. Clinical coverage standards regarding preventive care are subject to change and are updated periodically based the most current clinical evidence.

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Yes. Common vaccines included in the proposed preventive care coverage are hepatitis A & B, HPV, influenza (flu shot), measles-mumps-rubella (MMR), meningitis, pneumococcal (pneumonia shot), tetanus, diphtheria, pertussis, polio, chickenpox, rabies, and shingles.

Beginning January 1, 2019, all retirees have access to the shingles vaccine, which is covered by AlaskaCare when administered at a pharmacy. The addition of preventive care services means effective January 1, 2022 you can also receive the shingles vaccine at your doctor’s office.

No, Silver Sneakers is only available to people who are covered by a participating Medicare Advantage or Medicare Supplement Insurance plan. The Division is working to evaluate if any similar programs could be offered to retirees in the future.

Prior authorization is a pre-approval process guided by rigorous clinical standards for intensive, high-cost medical procedures. Prior authorization for specialty medications:

• Ensures the therapy meets FDA guidelines for the condition being treated.
• Ensures providers follow nationally recognized care criteria when prescribing medication.
• Requires the prescriber to provide documentation in support of the clinical criteria specific to that medication prior to the medication being dispensed.

Prior authorization for specialty drugs is a pharmacy management process that reviews certain medications against clinical, evidence-based standards including those established by the FDA to promote safe and effective use of those medications.

A specialty medication has at least one of the following characteristics:

• High Priced: can cost more than $1,000 for a 30-day supply.
• Complex: drug imitates compounds found in the body or is part of a specialty drug class.
• High-Touch: special shipping or handling requirements like refrigeration, special steps to follow as you take it, needs a pharmacist or doctor to measure how well it works for you.

Only about 1% of covered prescriptions are specialty medications. You can review the Optum Rx Specialty Pharmacy Drug List (Effective January, 1 2024) to see if any of your current medications are specialty drugs that may require a prior authorization. If your drug appears on this list, you need to obtain a prior authorization prior to filling your prescription after January 1, 2024 If any of your medications require a prior authorization after January 1, 2024, you will receive a notification letter with detailed information. Please note this list may change over time and is for informational purposes only. If you have any questions, contact Optum Rx at .

While it is not necessary to obtain a prior authorization for your specialty medication prescription before January 1, 2022, you may call Optum Rx at and the customer service agents can help you to submit all of the required pieces of information ahead of time. If you do so, Optum Rx will initiate your specialty medication prior authorization on your behalf after January 1, 2022.

Yes. Members will receive a notification letter advising their medication requires prior authorization review. Once you have an approved prior authorization in place, when it nears expiration, Optum Rx will proactively initiate outreach to your prescriber to obtain the information necessary to extend or renew the authorization.

Providers may submit prior authorization requests electronically, over the phone, or by mail. The prior authorization process is designed with expediency in mind. Most prior authorizations are completed within 72 hours. Physicians can use an electronic platform called Pre-Check my script for real-time information and authorizations.

Yes. This is common in health plans and physicians are already familiar with the prior authorization process. Providers may submit prior authorization requests electronically, over the phone, or by mail.

Some medications should be reviewed for coverage because:

• They’re only approved for, and effective in, treating specific illnesses.
• They may be inappropriately prescribed for conditions for which effectiveness has not been demonstrated.
• They may have dispensing and prescribing requirements specific to a patient’s age, gender, other medication usage, or clinical condition.

Benefits of prior authorization include ensuring the right drug is dispensed at the right time and safety and efficacy standards are adhered to. Members may experience improved quality care when evidence-based criteria are reviewed to promote appropriate use of certain specialty medications.

Prior authorization approvals are typically valid for 3-36 months, depending on the medication. Optum Rx identifies approved prior authorizations for prescriptions expiring within 30 days and will proactively reach out to the prescriber to request any information needed to extend the prior authorization.

Specialty medications are a relatively new type of treatment that has grown substantially over the last few years. In 2020, specialty medications accounted for about 1% of all prescriptions covered by the AlaskaCare retiree plan but cost $110 million in covered plan expenses. A single prescription can cost as much as $160K or more annually.

Similar to how the Plan requires precertification for certain intensive, complex, and high-cost medical services, prior authorization is a common tool used by pharmacy plans to ensure appropriate use.

Growth of specialty medication is expected to continue as new medications are developed and the conditions they are used to treat expand. Implementing a prior authorization process for the medications ensures that they are being used for indications approved by the FDA and align with guidelines established by national clinical specialist groups.

There is no change to coverage for prescription medications that are prescribed under the terms outlined in the Plan booklet. The plan will continue to cover medically necessary and clinically appropriate prescription drugs. There is no change to member copayments which will remain $8 for brand medications, $4 for generic medications, and $0 for medications filled through mail order.

At Optum Rx, prior authorization criteria are reviewed and approved by the Optum Rx Pharmacy & Therapeutics (P&T) Committee. The P&T Committee is an independent, multi-specialty and nationally represented group of physicians and pharmacists. The P&T Committee evaluates medications based on scientific evidence to find their place in therapy. Quarterly meetings are held to evaluate, review, and make clinical recommendations. Industry, clinical, and company standards govern the P&T Committee’s review, consideration, and recommendation processes. The committee considers:

• U.S. Food and Drug Administration (FDA) approved indications
• Manufacturer’s package labeling instructions
• Well-accepted and/or published clinical recommendations (ex: American Hospital Formulary Service Drug Information; DRUGDEX; National Comprehensive Cancer Network Drugs and Biologics Compendium; Clinical Pharmacology; major peer reviewed medical journals such as the American Journal of Medicine)

Based on this information, the P&T Committee evaluates whether a drug has a unique therapeutic benefit, comparable safety and efficacy, or whether risk of harm outweighs the benefits. The P&T Committee complies with national quality standards including those provided by the Centers for Medicare & Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), and the Utilization Review Accreditation Commission (URAC®). After thorough clinical review of prior authorization guidelines is complete, the P&T Committee approves the utilization management criteria.

No. Prior Authorizations are not step therapy. Step therapy is focused on cost and, has not been implemented in the retiree plan. Prior authorization focuses on clinical indicators, and ensures that a prescription drug is medically necessary, appropriately prescribed, and meets FDA and other clinical guidelines for the condition being treated.

The AlaskaCare Retiree Pharmacy Plan provides members with the right to appeal the pharmacy claims and prior authorizations that have been denied by the pharmacy claims administrator, Optum Rx. If a claim or prior authorizations is denied, in whole or in part, your letter from Optum Rx will explain the reason for the denial. Please refer to your Retiree Insurance Information Booklet located at AlaskaCare.gov for coverage information and if necessary, call Optum Rx toll-free at for further clarification.

The Division of Retirement and Benefit has been working with the Retiree Health Plan Advisory Board (RHPAB) to review proposed updates to the AlaskaCare Defined Benefit Retiree Health Plan (Plan). These updates will add modern coverage provisions to the Plan, including highly desired coverage for preventive care service and prior authorizations for specialty medications.

The Plan Administrator (the Commissioner of Administration) has adopted the proposed updates, and the Plan will be changed to include the expanded coverage beginning on January 1, 2022.

The proposed changes will take effect on January 1, 2022. This means that the expanded coverage will apply to any dates of service on or after January 1, 2022.

No, the Retiree Plan monthly premiums for 2022 are not changing.

As a retiree-only plan, the Plan is exempt from the ACA provisions mandating coverage for preventive care. Though the additional benefits offered do align with the ACA’s preventive care provisions, these provisions do not impact the retiree plan.

In alignment with the Plan booklet, Section 3.3.1 Medically Necessary Services and Supplies, and mainstream commercial health insurance practices, the Plan will utilize the current Third-Party Administrator’s (TPA) clinical coverage standards for purposes of determining coverage of preventive services under the Plan.

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Members of the Defined Contribution Retirement plan (Public Employees’ Retirement System Tier IV and Teachers’ Retirement System Tier III) and their eligible dependents can participate. To be eligible for medical coverage you must have:

• 10 years of service and be Medicare age eligible, or
• Be any age with 25 years of service for peace officers/firefighters or;
• Be any age with 30 years of service for all others.
• Must have worked the prior 12 months and retire directly from the system.

Specific information on your individual tier status can be obtained through the Division of Retirement and Benefits Member Services Contact Center at or by calling in Juneau or toll-free Monday through Thursday from 8:30 a.m. to 4 p.m. or Friday from 8:30 a.m. to 3 p.m.

In general, if you are a member of the Public Employees’ Retirement System (PERS) and first entered service after June 30, 2006, you are Tier IV. If you are a member of the Teachers’ Retirement System (TRS) and first entered the system after June 30, 2006, you are a Tier III.

• Your spouse. You may be legally separated but not divorced.
• Your children from birth (exclusive of hospital nursery charges at birth and newborn care) up to 23 years of age only if they are:
• your natural children, stepchildren, foster children placed through a State foster child program, legally adopted children, children in your physical custody and for whom bona fide adoption proceedings are underway, or children for whom you are legal, court-appointed guardian (if child is not your natural-born child);
• unmarried and chiefly dependent upon you for support; AND
• living with you in a normal parent-child relationship.
  • This provision is waived for natural/adopted children of the benefit recipient who are living with a divorced spouse, assuming all other criteria is met. Stepchildren must live with the retiree 50% or more of the time to be covered under this plan.
• In addition, if they are between the ages of 19 and 23, they must be attending school regularly on a full-time basis.

Children incapable of employment because of a mental or physical incapacity are covered even if they are past age 23. However, the incapacity must have existed before age 23 and the children must continue to be unmarried, rely chiefly on you for support and living with you in a normal parent-child relationship. You must furnish the claims administrator evidence of the incapacity, proof that the incapacity existed before age 19, and proof of financial dependency. Children are covered as long as the incapacity exists and they meet the definition of children, except for age. Periodic proof of the continued incapacity may be required.

The definition of retiree dependents limiting coverage to age 19 (or age 23 if a full-time student) comes directly from Alaska statute.

Expanding dependent coverage to age 26 is one of the provisions in the Federal Patient Protection and Affordable Health Care Act (PPACA) and the Health Care and Education Reconciliation Act (HCERA) that became effective March 2010. This provision affects employee plans and retiree-only health plans differently.

On June 14, 2010, the U.S. Departments of Health and Human Services, Labor, and Treasury issued regulations on Grandfathered Health Plans under PPACA. In the preamble to the Interim Final Rule, the Secretaries clarify that it is not their intent to apply the PPACA coverage to retiree-only health plans. This means the retiree medical plan, is not subject to the expanded dependent coverage provisions of PPACA.

You should have a medical ID card from Aetna and a pharmacy ID card from Optum Rx. If you elected the DVA plan you will also have a dental ID card from Delta Dental/Moda and a vision card from Aetna. You can use your ID cards when visiting your health care providers or pharmacy.

Aetna

Delta Dental

Optum Rx

Medical/Rx ID Card
If your ID card hasn't arrived, you can view and print your Medical/Prescription ID card or download the mobile app that displays the ID card on your smartphone. Note: Aetna Navigator registration required.

You can use your Social Security number to register or call the Aetna health concierge at for assistance. Aetna

Dental ID Card
To print your Moda Health/Delta Dental of Alaska ID card or download the MyModa mobile app, register on the MyModa website or call Moda at .

Delta Dental

Employees do not contribute to the DCR health trust while they are actively working.

When the employee retires, the DCR medical plan requires Medicare-eligible participants to pay a percentage of the monthly premium. Prior to Medicare eligibility, retirees pay 100 percent of the DCR medical plan cost. After Medicare eligibility, retirees pay a percentage of the plan cost based on years of service:

Years of Service	Retiree Contribution Percentage
10-14	30%
15-19	25%
20-24	20%
25-29	15%
30+	10%

Using network providers can provide substantial benefits to members and their dependent(s) who are not yet Medicare age eligible through the elimination of what's known as "balance billing." It can also generate substantial savings to members through negotiated provider discounts. To find out whether your doctor is a member of the Aetna network, call Aetna's Health Concierge at . To find out whether your dentist is a member of the Moda/Delta Dental network call Moda/Delta Dental at .

Yes, as long as the service is provided (billed) by a preferred hospital or facility. However, you may find that not all providers at a preferred hospital or facility are part of the network. For example, if you have a surgical procedure performed at a preferred hospital, you may find that the hospital and surgeon are in the network, but the anesthesiologist is out-of-network. When you receive your bill, you'll see that it reflects the negotiated network rates for your hospital and surgeon. The anesthesiologist, however, may charge what they chooses since they have no negotiated network contract. If the anesthesiologist claim exceeds the recognized charge, you may receive a bill for the balance. It is wise to talk to your providers before incurring any expenses to see if they are covered in the network. You can also call the Aetna Concierge for additional information at prior to receiving services.

No. The 20% coinsurance differential that applies to out-of-network facilities only applies to the facility services or supplies, and not to the professional services billed by the provider. Similarly, the increased annual out-of-pocket maximum, and out-of-network facility recognized charge calculation do not apply to the professional services billed by the provider.

If you receive care at an out-of-network hospital or other facility either in the Anchorage area or outside of Alaska, including surgery centers, birthing centers, rehabilitative centers, and residential treatment centers, you may be subject to higher out-of-pocket costs. These include a 20% reduction in the coinsurance that the plan pays; and an increase in the individual out-of-pocket maximum. Additionally, the maximum allowable rate for out-of-network facility charges is the lesser of what the facility bills or submits for that service or supply, or the percentage of Medicare that most closely reflects the aggregate contracted rate with the preferred hospital or facility (currently 185% of Medicare).

To avoid incurring a penalty, be sure to use the preferred hospital or facility in your area. There may not be a preferred hospital or facility in some parts of Alaska, and in those instances, members will not incur a penalty. However, it is recommended you contact the Aetna Concierge for additional information at prior to receiving services.

The DCR medical plan only penalizes use of out-of-network providers for the following services: hospital and facility services, preventive care, and limited circumstances such as transplants or inpatient mental health treatment. If you require these types of services, it is important to contact the Aetna concierge team. They can help you find a network provider or facility in your area, or discuss options with you. The DCR medical plan does provide travel coverage for treatment not provided locally or for surgery or diagnostic procedures that can be obtained more cheaply in another geographic region and members may explore these options with the Aetna Concierge team at prior to receiving services.

Aetna does have a DME national provider listing on their DocFind website. To see the current listing, go to AlaskaCare.gov and select the Find a Doctor tool. In DocFind type “durable medical equipment” in the "Search for:" box and enter the appropriate zip code and plan.

The DME national provider list can be found at the top of the generated list, followed by local DME providers, if any. There is no penalty for using an out of network durable medical equipment provider; but you may save money by using a network provider and a non-network provider may bill you for charges above the allowable.

You are not required to enroll in Medicare Parts A and B, but the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees will estimate the portion that Medicare would have covered before paying benefits regardless of your enrollment status. Therefore not enrolling in Medicare Part A & B as soon as you become age eligible may have very significant negative financial impacts for you. Members are strongly urged to consider enrolling in Medicare Part A & B three months prior to their 65th birthday.

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For many people, Medicare Part A is premium-free. However, if you are not eligible for premium-free Part A, you may need to pay a monthly premium. Everyone must pay a monthly premium for Medicare Part B.

For information on how you may be reimbursed for Medicare premiums from your Health Reimbursement Arrangement Account, see section 4, Health Reimbursement Arrangement (HRA) of the plan booklet.

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Currently, you are not required to enroll in Medicare Part D as the drug coverage benefits you have through your AlaskaCare Retiree plan are at least as good as the required benefits offered under Medicare Part D. By not enrolling in Part D, you can avoid unnecessary premiums and coordination between Medicare and AlaskaCare for your prescription drugs. When the plan incorporates the Employer Group Waiver Program, this will change and you will receive additional instruction and communication in advance of this change.

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You are not required, but may opt to take part in Medicare part C. Part C plans are Medicare Advantage plans provided by private insurers for members who live outside the State of Alaska. They cover the same services as Medicare Part A and B combined as well as some supplemental benefits. The AlaskaCare plan acts as a supplemental plan for Medicare eligible retirees, but you may elect to take part in Medicare part C in lieu of the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees.

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Medical necessity is one factor the AlaskaCare health plans consider in determining whether to provide coverage for a service or supply. The AlaskaCare health plans do not pay for services or supplies that are not medically necessary, such as cosmetic procedures.

When Medicare or another plan is primary to the AlaskaCare Retiree Benefit Plan for DCR Plan Retirees, AlaskaCare will defer to the primary payers determination of medical necessity unless it is a service or supply that is specifically excluded under the plan.

When the AlaskaCare medical plan is primary, the plan uses Aetna's current Medical and Pharmacy Clinical Policy Bulletins to determine medical necessity. The Aetna clinical policy bulletins are available to the public here.

Determinations of medical necessity for dental procedures are made by Moda Health.

Aetna's clinical policy bulletins are based on:

• Reports in published, peer-reviewed medical literature
• Studies on a particular topic
• Evidence-based consensus statements
• Expert opinions of health care professionals
• Guidelines published by nationally recognized health care organizations that include supporting scientific data

Under the AlaskaCare plans, services or supplies are never considered medically necessary if they:

• Do not require the technical skills of health care professionals who are acting within the scope of their license
• Are provided mainly for the personal comfort or convenience of you, your family, anyone who cares for you, a health care provider, or a health care facility
• Are provided only because you are in the hospital on a day when you could safely and adequately be diagnosed or treated elsewhere, or
• Are provided only because of where you are receiving the service or supply, if it can be provided in a doctor's or dentist's office or other less costly place.

No, not all medically necessary services or supplies are covered by a health plan. For example, a medically necessary service or supply is not covered by the AlaskaCare plans when:

• It is specifically excluded, or
• The duration of the medically necessary service reaches a plan limitation (for example, some benefits are limited to a certain number of days, services, service per time period, expenses or visits).

The number of medically necessary procedures and unique circumstances of their application are virtually limitless, and as science progresses and the medical field changes, services that were once considered necessary may be recognized as unsafe or even harmful, or new services may be discovered that are more effective. The Third-Party Administrator (TPA) employs dozens, if not hundreds, of clinical experts who specialize in crafting medical necessity guidelines for multiple plans covering millions of lives across the United States. These guidelines are updated continuously to reflect changes and advances in research and technology.

The Division of Retirement and Benefits has historically relied on the TPA to provide this service as it has never have the breadth of medical personnel, expertise, or experience to establish, maintain, and update clinical guidelines; and determinations of medical necessity are part of the claims processing function. Because AlaskaCare contracts with a TPA to perform this function, it is the TPA who makes determinations of medical necessity as part of the claims processing function.

The clinical policy bulletins provided by Aetna set guidelines that are readily available on-line and transparent to members and their physicians, and clearly show the medical evidence relied upon to make the determination. The evidence basis of the policy bulletins are reviewed regularly and the bulletins are updated as necessary. Medical providers can also request peer-to-peer review with a TPA medical director to present additional medical evidence for consideration.

The National Institute of Health estimates that nearly 30% of all medical procedures or services performed in the United States are either unnecessary and provide no benefit to the patient, or even worse, are harmful. Additionally, a growing body of research indicates it can take as long as 17 years for medical evidence to move from research reccomendations to clincial practice. In a field driven by constantly evolving research and data, it can be difficult for providers to stay on top of the latest body of evidence for a particular procedure or episode of care. Aetna's clinical policy bulletins rely on carefully reviewed medical evidence to make decisions about coverage that are weighed against clinically accepted standards of medical practice.

We encourage you to have your doctor review the clinical policy bulletins used to guide coverage decisions related to medical necessity. After your provider completes this review, and if they disagree, your provider may request a pre-determination of coverage and present additional medical evidence for consideration during the pre-determination review.

To review your doctor's recommended treatment plan, and verify whether the services or supplies fit the definition of medical necessity, contact Moda Health at for services covered under the dental plan, or contact the Aetna Concierge at for services covered under the medical plan.

If there continues to be a difference in opinion, you or your provider are encouraged to appeal the coverage decision.

If a claim is denied based on a medical necessity, you may request an explanation of the scientific or clinical judgment for the determination, free of charge.

If you believe it's warranted, you may also initiate a written appeal to the plan. The AlaskaCare Retiree Benefits Plan for DCR Plan Retirees describe the process and timeline required for submitting an appeal.

The appeals process used by AlaskaCare allows for the use of Independent Review Organizations (IRO) at level 2 of the appeals process. Use of an IRO allows for an impartial review by a third-party medical expert when there is disagreement regarding medical necessity.

The Health Reimbursement Arrangement (HRA) is an IRS approved individual savings account, funded by employer contributions, used to reimburse eligible DCR participants tax-free for qualified out-of-pocket medical expenses and individual health insurance premiums.

You or your dependent’s qualified medical expenses that are payable from your HRA include the following:

• Amounts paid for health insurance premiums.
• Copays, coinsurance, deductible, services, etc. not covered under AlaskaCare or another health plan.
• Amounts paid for prescription medication, but not over-the-counter drugs unless prescribed by a licensed health care provider.

To be eligible you must have retired directly from the DCR plan OR be eligible for Medicare and have a minimum of 10 years of service. For purposes of the HRA, to be considered retired directly from the plan, you must:

• Have at least 30 years of service (other than peace officers and firefighters); or
• Have at least 25 years of service if you are a peace officer or firefighter; or
• Be a surviving spouse of a participant who had retired or who was eligible for retirement and medical benefits at the time of the participant’s death; or
• Be an eligible dependent of a surviving spouse.

Upon retirement, AlaskaCare retirees may choose to participate in a voluntary Dental-Vision-Audio (DVA) plan to provide coverage for themselves and their eligible dependents. Unlike the medical and pharmacy plans, the DVA plan benefits are funded entirely by member-paid premiums.

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The DVA open enrollment is the period during which you can make changes to your DVA benefits. Beginning in 2025, there is a difference in both the vision and dental benefits between plans.

If you have questions about this enrollment period please contact the Division at , or email to learn about your options. You will be able to change your DVA plan each year during an open enrollment period for as long as the State offers two DVA plans.

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Offering two DVA plans provides maximum benefit and choice to all members. Beginning in 2025, each DVA plan has different dental and vision coverage provisions and different monthly premium rates. The audio coverage does not vary between the two DVA plans. Some dental procedures fall into different service classes, depending on which plan you elect.

If you would like to know how a specific service would be covered under each Plan’s dental benefit, call Delta Dental of Alaska at .

If you would like to know how a specific service would be covered under the Standard Plan’s vision benefit, call VSP at , and for the Legacy Plan’s vision benefits, contact Aetna Concierge at .

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You can find information about the two DVA plans online, including the following: DVA Benefit Enrollment Guide and DVA Benefit Comparison .

If you have questions about your options, please contact the Member Education Center or the following claims administrators by benefit:

• Dental Delta Dental of Alaska
• Vision Standard Plan: VSP
• Vision Legacy Plan: Aetna

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You can refer to your dental insurance ID cards to verify which DVA plan you are currently enrolled in. You may also contact Delta Dental of Alaska at or the Division’s Member Education Center at , or email .

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Standard Plan – Vision

• The vision benefit has been updated to implement the Vision Service Plan (VSP) provider network. The VSP network provides enhanced vision benefits with reduced copays for comprehensive eye exams, lenses, and frames. Members would only be responsible for copayments and charges for options that exceed the plan benefit.
• Custom and premium progressive lens enhancements are covered, and discounts are available for photochromic, tints, and other lens enhancements received from a VSP network provider.
• Network providers would determine the member cost share, file a claim with VSP, and only bill the member for their appropriate portion.
• Members who obtain vision care from an out-of-network provider will be responsible for an increased share of the costs under the Standard Plan than they would under the Legacy Plan.
• For members who do not have access to a VSP provider within 25 miles, you can contact VSP ahead of time at to verify provider availability and request pre-approval for in-network benefits.

Legacy Plan – Vision

• The vision benefit under the Legacy Plan is unchanged. The primary difference is that there is no vision provider network under the Legacy Plan. As such, there are no network discounts, and members typically pay out-of-pocket for vision services at the time they are received and submit manual claims for reimbursement. There is also a fixed cost arrangement under the Legacy Plan’s vision benefit, and no reduced coinsurance for certain services. For a more complete comparison of benefits, see the DVA Benefit Comparison .

Standard Plan – Dental

• The annual dental benefit maximum is $3,000.
• Delta Dental’s Preventive First program, which covers preventive dental services at 100% coinsurance, and any eligible preventive services paid by the Standard Plan would not count toward a member’s maximum annual allowance for dental services.
• Features an additional dental network, Delta Dental's PPO network, with deeper discounts that save you more money when you use a network dentist. This allows you to receive coverage for more services before you reach your annual benefit maximum. Standard Plan members can also access lower rates from dentists who participate in Delta Dental’s broader Premier dental network.
• Supports evidence-based coverage limitations, including those developed by the American Dental Association, such as frequency and age limitations for exams, cleanings, and periodontal maintenance.
• Pays less if you visit an out-of-network dentist.

Legacy Plan – Dental

• The annual dental benefit maximum is $2,000.
• Preventive services count toward annual dental benefit maximum.
• Does not have pre-determined frequency or age limitations on most services.
• Features a wide dental network, Delta Dental's Premier dental network, that saves you money when you use a network dentist.
• Pays out-of-network dentists at a higher rate.

Some dental procedures fall into different service classes, depending on which plan you elect. If you would like to know how a specific service would be covered under each plan, call Delta Dental of Alaska at (855) 718-1768.

Please consult the DVA Benefit Comparison for more details about the differences between the plans. The Defined Benefit Retiree Insurance Information Booklet and Defined Contribution Retiree Insurance Information Booklet will contain the complete benefit provisions for both the Standard and Legacy Plans.

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• Both plans provide coverage for dental preventive, restorative, and prosthetic services.
• Both plans have the same dental coinsurance levels:
  • Class I (Preventive): 100%
  • Class II (Restorative): 80%
  • Class III (Prosthetic): 50%
  • Both plans have the same annual dental deductible: $50 per individual (Class II and III Services).
  • Both plans are fully funded by member premiums.
  • Both plans have no deductible for vision services.
  • Both plans allow coverage for one eye exam and pair of lenses per year and frames every other year.
  • Audio benefits are the same under each plan.

  Please consult the 2025 DVA Benefit Comparison for more details about the differences between the plans. The Defined Benefit Retiree Insurance Information Booklet and Defined Contribution Retiree Insurance Information Booklet will contain the complete benefit provisions for both the Standard and Legacy Plans.

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The plan booklets are available on the AlaskaCare webpage.

• Defined Benefit Retiree Insurance Information Booklet
• Defined Contribution Retiree Insurance Information Booklet

You can also call the Division's Member Education Center to request a paper copy.

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Yes, both the Standard and Legacy Plans let you see any licensed dentist or vision provider you want. Both plans give you access to the wide Premier network of dental providers that will save you money. If you choose the Legacy Plan and see an out-of-network provider, the plan will cover a greater portion of the charges so you may pay less for out-of-network services. If you choose the Standard Plan, you have access to an additional PPO network of dental providers, and VSP vision network providers who offer deeper discounts, saving you more money, but you may pay more if you use out-of-network dentists or vision providers.

Remember, if you use an out-of-network dentist or vision provider, you may receive additional bills for charges that the plan will not cover.

Standard Plan members looking to find a vision provider in the VSP network can call VSP at , or use VSP’s online network provider search tool .

Find a Provider

Providers may receive incorrect information when verifying your vision benefits through Aetna's self-service tool. While Aetna continues to update its systems, you can call the Aetna Concierge at to verify your vision benefits.

Standard Plan

For members utilizing a VSP provider, your provider will submit your claims on your behalf. If you choose to access an out-of-network vision provider, you will be responsible for submitting your vision claims to VSP for processing. Your provider may be willing to file the claim for you, but it is your responsibility.

Legacy Plan

No, you are responsible for submitting your vision claims to Aetna for processing. Your provider may be willing to file the claim for you, but it is the member's responsibility.

Each year the Division will host an open enrollment period that allows members to change their DVA plan elections for the upcoming plan year. You will find the enrollment link at AlaskaCare.gov/DVA. If you have questions about the enrollment period please contact the Member Education Center at , or email . While the Division offers multiple plans, you will have an annual opportunity to select the plan that works best for you. You will only be able to make changes to your plan selection during an open enrollment period unless you have a qualifying status change. You can cancel your DVA election at any time by contacting the Division.

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If you updated your plan due to a qualifying status change, you can expect new cards in the mail within 10 to 14 days from when you submitted the change.

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Standard Plan (Vision)

VSP does not issue physical ID cards – you can simply provide your name and date of birth to your VSP provider at your appointment. However, if you would like to view and print your member ID card, you may do so through your VSP account. (You must sign up for an account if you don't already have one.)

Legacy Plan (Dental, Vision, and Audio) and Standard Plan (Dental and Audio)

For the AlaskaCare Retiree Legacy Plan’s Vision benefits and the Standard and Legacy Plan’s Audio benefits, you may print an ID card that includes your name and Aetna ID number by logging on to Aetna's online Navigator tool and clicking "Get an ID Card." If you are not registered for Aetna Navigator, you may call Aetna Concierge at to obtain your Aetna ID number to give your provider.

For the AlaskaCare Retiree Standard and Legacy Dental Plans, Moda Health/Delta Dental will send you an ID card for your dental services. If you need assistance with your dental cards, please contact their Customer Service Center at .

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You may have heard about a lawsuit related to the AlaskaCare Dental-Vision-Audio (DVA) plan. In 2014, in an effort to protect you from rising premiums and to preserve the value of your benefits, the Division updated the dental portion of the DVA plan to align with best dental practices and reduce the cost of services through an expanded dental network. This sought to preserve the plan’s value while maintaining members’ access to care and averting premium increases.

In January 2016, a lawsuit was filed contesting the Division’s efforts. In April 2019, the Alaska Superior Court ruled in favor of the plaintiff. This decision resulted in two DVA plans being offered, the Standard DVA plan and the Legacy DVA plan. This decision was appealed to the Alaska Supreme Court.

On January 21, 2022, the Alaska Supreme Court vacated the Superior Court’s judgement. The Division is evaluating the decision. There will be no immediate changes to the AlaskaCare Retiree Dental-Vision-Audio benefits.

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Yes, you may decrease your DVA level of coverage at any time. To decrease your coverage, submit a written request to the Division stating the level of coverage you would like.

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Yes. If you have a second retirement (you retire from TRS and then from PERS, for example), you may elect DVA coverage under both retirements. However, you are not able to elect the Standard Plan under one retirement and the Legacy Plan under the other. If you are covered by your spouse’s plan, you may elect to have a second plan for yourself or yourself and your eligible dependents.

The benefit to having two dental plans is they coordinate to pay 100% of covered expenses. For example, a filling is covered at 80% under one plan and the second plan pays the remaining 20%. In addition, if you have two dental plans, any annual dollar limits are doubled. For example, if you were covered by the Standard Plan under your retirement, which has a $3,000 annual maximum dental benefit, and by the Legacy Plan under your spouse’s retirement, which has a $2,000 annual maximum benefit, you would have a total annual maximum benefit of $5,000. However, any dental services that are limited to a maximum number of services in a year are not doubled.

For further information and details on coordination of benefits, please see the AlaskaCare Retiree Insurance Information Booklet. It is your responsibility to report the existence of benefits payable under any plan, and to file for those benefits.

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Yes. Regardless of which plan each of you selects, your coverage will continue to coordinate.

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No. A retiree may only select one plan for themselves and any covered dependents. However, if you and your spouse each have a separate AlaskaCare DVA policy, you may select different plans and cover each other as dependents.

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The plans have different dental coverage provisions and different monthly premium rates. The Retiree DVA Benefit Comparison may help you compare the plans and decide which is a better fit for you and your family. The AlaskaCare Retiree Insurance Information Booklets will contain the complete benefit provisions for both the Standard and Legacy Plans.

• Defined Benefit Retiree Insurance Information Booklet
• Defined Contribution Retiree Insurance Information Booklet

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Effective January 1, 2025, the Standard Plan and Legacy Plan will have different vision benefits. The Standard Plan has been updated to include the VSP provider network, which includes benefit enhancements for certain services. The benefits under the Legacy Plan are remaining the same. The Retiree DVA Benefit Comparison may help you compare the plans and decide which is a better fit for you and your family. The AlaskaCare Retiree Insurance Information Booklets will contain the complete benefit provisions for both the Standard and Legacy Plans.

• Defined Benefit Retiree Insurance Information Booklet
• Defined Contribution Retiree Insurance Information Booklet

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No. The audio benefits are not affected by which DVA plan you choose.

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The standard and legacy plan monthly premiums are set to reflect the overall value of each plan across all enrolled members. The value of each plan varies based on differences in benefit design, network access, and how much the plan pays out-of-network providers. The rates are not impacted by how many people elect one plan or the other.

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To find a network dental provider, call Delta Dental of Alaska at or use the Find a Dentist search tool. When you need dental care, selecting a provider that is in-network can save both you and the plan money.

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Standard Plan

When you need vision care, selecting an in-network provider can save both you and the plan money. To find a VSP network provider, members enrolled in the Standard Plan can call VSP at , or use VSP’s online network provider search tool . A step-by-step guide on how to use VSP’s provider search can be found here .

Legacy Plan

For members enrolled in the Legacy Plan, there is no network for vision services. For questions regarding vision benefits under the Legacy Plan, contact Aetna Concierge at .

Visiting a dental provider who participates in Delta Dental’s network is one of the best ways to get the most value out of your dental coverage. Network dentists have agreed to provide you services at a discounted rate and will file all claim forms for you.

The Premier network is a broad network of providers who offer savings to members. Both AlaskaCare standard and legacy dental plan members have access to the Premier network and associated discounts.

The PPO network is a narrower network of providers who offer deeper discounts and savings to members. In addition to the Premier network, AlaskaCare standard plan members have access to the PPO network and associated discounts. The PPO network is like a “network within a network” that helps you receive the best prices for the dental care you need.

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If you do not make a plan selection, you will remain in the plan you are currently enrolled in.

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Only members who currently have DVA coverage are eligible to participate in open enrollment.

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Yes, you will have an opportunity to change your DVA plan selection during the open enrollment period. Outside of the open enrollment period, you will not be able to make changes to your elections unless you have a qualifying status change.

If you miss the open enrollment window and have questions about your next opportunity to make a DVA plan selection, please contact the Division of Retirement and Benefits.

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You will not be able to make changes to your plan outside the open enrollment period unless you have a qualifying status change. You can change DVA plans during any qualified status change, such as marriage, birth or adoption of a child, or divorce.

If you missed open enrollment and have questions about your next opportunity to make a DVA plan selection, please contact the Division of Retirement and Benefits.

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No. The level of DVA coverage elected during this Open Enrollment period must be no greater than the level of medical coverage you are electing for the first time during this open enrollment. However, you have a choice between two dental plans. Please visit AlaskaCare.gov/DVA to learn more about the dental choices and how to participate in this year’s DVA Open Enrollment.

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Yes.

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No. Long-Term Care could only be elected when you retired and may not be increased later.

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You can find the Retiree Insurance Information Booklet, as well as other information regarding the health plan, on the Retiree Health Plan page.

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CHCS Services, Inc. is the claims administrator. You may contact them at to initiate a claim.

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Your receipts for expenses may be submitted to:

CHCS Services, Inc.
P.O. Box 13431
Pensacola, FL 32591-3431

Fax: (866) 383-5821

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Yes, CHCS has made a portal available where members may view which plan they are in enrolled in, review plan documents, and obtain a claim submission packet. Members can also use the portal to view claims and receive messages from their case manager.

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Long-term care benefits are not payable for any covered program of care provided or begun prior to the effective date of your coverage, or during the first 12 months of coverage caused by a pre-existing condition. Pre-existing conditions are conditions for which you received diagnosis, test, or treatment (including taking medication) during the three consecutive months before the most recent day you became covered under this plan.
To summarize:

• A pre-existing condition is any that was diagnosed or treated during the 3 months before coverage started.
• If you need care in the first 12 months of coverage due to a pre-existing condition, no benefits will be paid for that period of care.
• After 12 months of coverage, you may apply for benefits with a pre-existing condition and benefits can be paid as normal.
• If you need care in the first 12 months of coverage due to something other than a pre-existing condition, benefits are paid as normal.

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To qualify for benefits, the Bronze plan requires that you are incapable of performing two of the following five Activities of Daily Living (ADLs):

• Eating – your ability to feed yourself
• Dressing – your ability to put on or take of your clothes, fasten buttons or zippers
• Toileting – your ability to get safely to and from the toilet and perform basic personal hygiene
• Transferring – your ability to move in and out of a bed or chair
• Walking – your ability to walk without someone's assistance

The Silver, Gold and Platinum plans require that you be incapable of performing two of the following six ADLs:

• Eating – your ability to feed yourself
• Dressing – your ability to put on or take of your clothes, fasten buttons or zippers
• Toileting – your ability to get safely to and from the toilet and perform basic personal hygiene
• Transferring – your ability to move in and out of a bed or chair
• Continence – your ability to maintain control of bowel and bladder functions or if unable, the ability to perform associated personal hygiene (i.e., caring for a catheter or colostomy bag)
• Bathing – your ability to wash yourself in a tub, shower or by sponge bath

The Silver, Gold, and Platinum plans also provide benefits for cognitive impairment (such as Alzheimer’s), which requires that you be supervised in order to perform the ADLs. Certification of medical necessity from a physician is required under all plans. Prior inpatient care is not required.

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The plans cover licensed nursing care facilities, in-home care provided by a licensed home health care agency, and adult day care. The Silver, Gold and Platinum plans also cover assisted living facilities and respite care. Care provided by family members or outside of the United States is not covered.

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The deductible period is 90 days under all plans. You must receive 90 days of covered care before benefits are paid. You may be in any level of care or multiple levels of care to satisfy the 90 days. For example, you may be in home health care for 60 days and in a nursing home for another 30 days to meet the deductible period.

You do not need to receive care every day during the 90-day period. If you receive care only certain days of the week, you still receive credit for the full week of care toward the 90-day deductible.

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The plans do not cover long-term care required due to:

• Alcohol or drug addiction
• Acts of war, declared or undeclared
• Suicide, attempted suicide or intentionally self-inflicted injuries
• Mental or nervous disorders without demonstrative organic disease
• Confinement in a government institution unless required to pay
• Services provided when you are hospitalized
• Services provided by someone who lives with you, is a member of your family, or who does not normally charge for services
• Services covered by the retiree medical plan, Medicare or any law or government program, except Medicaid
• Services provided outside the United States Services because of past or present service in a government armed forces

Note that Alzheimer’s and other forms of dementia are covered.

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The Bronze and Silver plans have no inflation protection. The Gold plan has 5% simple inflation protection and the Platinum plan has 5% compound inflation protection. Inflation protection is automatic and associated benefit maximums (both daily and lifetime) will be adjusted annually on the date of your enrollment.

Inflation protection stops at age 85. The lifetime and daily benefit amounts reached by that date are locked in for the life of the policy.

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A simple health questionnaire asking for information about current health status will be required initially. Based on the questionnaire, you will either be approved or asked to provide more information in writing or in person or have a medical examination.

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No. Premiums are based on your age at retirement and while all premiums may increase, your premium will always be based on your age on the date you retired. If you elect coverage for your spouse, you pay a separate premium based on their age at your retirement.

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Premiums are subject to review annually and may increase at any time the fund is insufficient to pay the expected claim costs. Premiums have not changed since the inception of the plan.

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The plans are insured by the retirement systems and claims are paid by the third party administrator.

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Medicare covers some costs but the coverage is limited and approved only for short term periods. Neither Medicare nor the retiree medical plan cover lengthy nursing home stays or home care services for personal care needs.

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You may decrease your coverage, from Platinum to Gold for example, or drop coverage for your spouse at any time. You may never increase your level of coverage. You may apply for coverage for a new spouse within 120 days of the date of marriage.

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Periodically, the Division competitively bids these contracts through a Request for Proposal (RFP). This gives us an opportunity to seek better service at lower cost for members and the plan.

Effective January 1, 2019, the AlaskaCare plan uses Optum Rx as the PBM to administer pharmacy benefits.

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Optum Rx will process claims according to the AlaskaCare plan document. Compounds will continue to be covered under the Defined Benefit Retiree Health plan.

Coverage of compounds differs for the active employee and defined contribution retiree health plans. The AlaskaCare Employee Health Plan and AlaskaCare DCR Benefit Plan only cover compound drugs if:

1. the product contains at least one prescription ingredient;
2. the active ingredient(s) is approved by the FDA for medicinal use in the United States;
3. the product is not a copy of a commercially available FDA approved drug; and
4. the safety and effectiveness for the intended use is supported by FDA approval, or adequate medical and scientific evidence in the medical literature.

Optum Rx maintains a National Compound Credentialing Program (NCCP) to ensure the best compounded medication quality and effectiveness for the patients who need personalized medications. You must fill your compounded medication prescription at a pharmacy which has been credentialed with the Optum Rx National Compound Credentialing Program (NCCP).

Using an NCCP pharmacy ensures that you will not be charged up front for your prescription (and required to submit your own claim for reimbursement), you will not be charged for molding or other non-covered charges, and you will not be charged for shipping if the pharmacy mails your compounded medication to you. You can find a list of NCCP-credentialed pharmacies here. You can also call Optum Rx at (TTY 711) to get help locating NCCP-credentialed pharmacies.

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The pharmacy benefit for AlaskaCare retirees remains the same, and Optum Rx will manage all pharmacy benefits. Medicare-eligible retirees and dependents will be enrolled in the AlaskaCare enhanced EGWP. After you enroll in Medicare, you need to provide the Division your Medicare Beneficiary Identifier (MBI - your Medicare Number). You do not need to enroll in an individual Medicare Part D plan.

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If you need to fill prescriptions before your Optum RX pharmacy ID card arrives in the mail, you can contact the Division and we can print or email a temporary card. You can also get a printable ID card from the Optum Rx online portal, or view your ID card in the Optum Rx mobile app.

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Please select the scenario that best describes you:

• I am covered under a single AlaskaCare plan, and…
  • I am an active employee:
    ID cards are issued in packs of two to active employees. If you have an eligible dependent, you can share the extra card with your dependent. If you have more than one eligible dependent, you can request additional cards through Optum Rx at (855) 409-6999. Starting January 1, 2019, you can also print a temporary card from the Optum Rx portal, or use the Optum Rx mobile app.
  • I am a retiree that is not eligible for Medicare:
    ID cards are issued in packs of two to retirees that are not eligible for Medicare. If you have an eligible dependent, you can share the extra card with your dependent. If you have more than one eligible dependent, you can request additional cards through Optum Rx at (855) 409-6999. Starting January 1, 2019, you can also print a temporary card from the Optum Rx portal, or use the Optum Rx mobile app.
  • I am a Medicare-eligible retiree who is not covered under the enhanced Employer Group Waiver Program (EGWP):
    ID cards are issued in packs of two to retirees that are not enrolled in the AlaskaCare enhanced Employer Group Waiver Program (EGWP). If you have an eligible dependent, you can share the extra card with your dependent. If you have more than one eligible dependent, you can request additional cards through Optum Rx at (855) 409-6999. Starting January 1st,1, 2019, you can also print a temporary card from the Optum Rx portal, or use the Optum Rx mobile app.
  • I am a retiree covered under the enhanced Employer Group Waiver Program (EGWP):
    You should have received only a single ID card with the MedicareRx logo in the lower right corner (see example below). Please contact the Division or Optum Rx for additional information on why you may have received a second card.
• I am covered under my own plan and under my spouse’s AlaskaCare plan, and…
  • Both my spouse and I are either an active employee or a retiree not yet eligible for Medicare:
    You will both receive a two-pack of ID cards with your own name and ID number. You may share one copy of your ID card with your spouse, however, you or your dependents only need to present one of these ID cards to the pharmacy. Optum Rx coordinates your coverage behind the scenes.
  • Both my spouse and I are are retirees and eligible for Medicare:
    If you are both eligible for Medicare and are enrolled in the enhanced Employer Group Waiver Program (EGWP), you should each receive a single ID card that has the MedicareRx logo in the lower right (see example below). Each card will have an individual name and ID number. Although you receive only one card, when you present the card at the pharmacy you will receive the benefit of your double coverage under the plan. This means you will not be required to pay a copay at the pharmacy counter.
  • One of us is a Medicare-eligible retiree enrolled in the enhanced Employer Group Waiver Program (EGWP) and the other is either an active employee or a retiree not enrolled in EGWP:
    The retiree who is Medicare-eligible and is enrolled in the enhanced Employer Group Waiver Program (EGWP) will receive a single ID card that has the MedicareRx logo in the lower right (see example below). The card will have their individual name and ID number. Although they receive only one card, when they present the card at the pharmacy, they will receive the benefit of having double coverage under the plan. This means they will not be required to pay a copay at the pharmacy counter.
    
    The spouse who is not enrolled in the EGWP will receive an ID card two-pack in their own name for each layer of coverage they have (their own coverage and their dependent coverage as the spouse of a Medicare-eligible retiree). The only difference between the two packs of ID cards will be the ID number. The ID number that matches the Medicare-eligible retiree’s MedicareRx ID card will be the dependent coverage card.
• I am covered under more than one of my own AlaskaCare plans, and…
  • I am eligible for Medicare:
    If you are eligible for Medicare and are enrolled in the enhanced Employer Group Waiver Program (EGWP), you should receive a single ID card that has the MedicareRx logo in the lower right (see example below). Although you receive only one card, when you present the card at the pharmacy you will receive the benefit of your double coverage under the plan. This means you will not be required to pay a copay at the pharmacy counter.
  • I am not eligible for Medicare:
    You will receive an ID card two-pack for each layer of coverage you have. The only difference between the different packs of ID cards will be the ID number. However, you only need to present one of these ID cards to the pharmacy. Optum Rx coordinates the coverage behind the scenes.

Sample card:

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Optum Rx coordinates all the layers of coverage for you and your dependents behind the scenes, so in many cases you and your dependents can use each other’s cards at the pharmacy. However, a non-EGWP dependent should not use the card that has a MedicareRx logo in the lower right corner. This card would only work if the pharmacist uses the correct person code (to identify them as a dependent rather than the policy holder). To avoid any confusion at the pharmacy, we recommend you and your dependents only use a card that has your name on it.

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You can tell the difference between the cards by looking at the logo on the card. One will say AlaskaCare Employee Pharmacy Plan, and the other will say AlaskaCare Retiree Pharmacy Plan. Your employee plan will typically be the primary payer.

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You can contact Optum Rx at , TTY711 if you have questions about your prescriptions or any correspondence you have received from them.

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The Optum Rx home delivery unit reaches out to members to assist with setting up their home delivery accounts and to verify the prescriptions they want delivered. If you receive a call to this effect, it is not a scam. However, if you are unsure if the call is legitimate, you can always decline the call and then contact Optum Rx at to ensure the call is genuine.

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You received this letter because the Centers for Medicare & Medicaid Services (CMS or Medicare) indicated that you have alternative prescription drug coverage under another plan that may be receiving subsidies from Medicare for providing that coverage. We encourage members to confirm enrollment in the AlaskaCare Retiree Medicare Prescription Drug Plan by calling Optum Rx at . If you do not confirm your enrollment or choose not to participate in the AlaskaCare Retiree Medicare Prescription Drug Plan, you will be placed into the opt-out prescription drug program. This is highly discouraged, as it will result in higher costs for you and for the health plan.

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Yes, members may transfer prescriptions from their local pharmacy to Optum Rx Home Delivery or from Optum Rx Home Delivery to their local pharmacy:

1. Members may call their pharmacy and request they transfer prescriptions from the pharmacy to Optum Rx Home Delivery. Optum Rx can also request the transfer request on your behalf. To start home delivery, log in to Optum Rx.com , use the Optum Rx app, or call .
2. Members may call Optum Rx at and request Home Delivery prescriptions be transferred to their local pharmacy.

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Moving to an EGWP had minimal impact to the membership and existing plan, while making pharmacy benefits more affordable and sustainable for the health trust and the State. EGWP is estimated to save the health plan approximately $20 million per year and between $40 to $60 million more annually to the State with no diminishment and minimal impact to the membership and existing plan.

EGWP is one method offered by the federal government to provide subsidies to the State of Alaska retiree health trusts. The subsidies help the State keep the health plan funding healthy without impacting most members. We already have a federal reimbursement plan in place called a Retiree Drug Subsidy program (RDS), but EGWP provides greater returns.

Many large employers have made the move from RDS to EGWP because of the significant cost savings and the ability to match existing benefits. Implementing an EGWP means that retirees and beneficiaries who are eligible for Medicare will have the same level and access to pharmacy benefits as they do now, while making more federal funds available to cover those costs. The savings helps the State fulfill its promise to provide retirement benefits to our AlaskaCare retirees.

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An enhanced EGWP, like the AlaskaCare EGWP, is a plan that includes medications covered under Medicare Part D, as well as any medications currently covered under the AlaskaCare retiree health plan that are not typically covered under Medicare. This ensures that all prescription drugs which are covered under the AlaskaCare plan today will be covered under the AlaskaCare EGWP. This enhanced coverage is also called a “wrap.”

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Much the same way the plan works today. When a member goes to a pharmacy, they will present their AlaskaCare pharmacy ID card. The pharmacy will submit the claim. If the prescription is covered by Medicare, it will be covered by EGWP. Members will pay their normal copay ($0 home delivery; $4 generic; $8 brand-name) and collect their medication. If the prescription is not covered by Medicare, it will automatically bill to the “wrap” plan. The member will pay their same copay and collect their medication. Either way, the member shouldn’t notice a difference.

In the beginning, members may need to get prior authorizations for certain medications. A list of those medications is available on the AlaskaCare Optum Rx information web page. If you are currently taking a medication that requires prior authorization, your doctor will need to complete some information requested by Optum Rx.

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If you are currently eligible for Medicare, or when you first enroll in Medicare, you need to provide the Division your Medicare Beneficiary Identifier (MBI – your Medicare Number). You do not need to enroll in an individual Medicare Part D plan.

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Periodically, the Division competitively bids these contracts through a Request for Proposal (RFP). This gives the Division an opportunity to seek better service at lower cost for members and the plan. The previous procurement process resulted in Optum Rx being selected to provide Pharmacy Benefit Management (PBM) services beginning January 1, 2019.

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No. There is one Pharmacy Benefit Manager (PBM) for all AlaskaCare prescription drug plans, including the AlaskaCare EGWP, Optum Rx.

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Alaska law already requires that for Alaska retirees and beneficiaries, Medicare become the primary coverage for major benefits once they are Medicare-eligible. As a Medicare Part D plan, an EGWP would follow this same statutory requirement. By implementing an enhanced EGWP, like the proposed AlaskaCare EGWP (which covers some medications that are not currently covered under Medicare Part D), the benefits will remain the same as those in place today.

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Yes, beginning January 1, 2019. As a group Medicare Part D plan, the AlaskaCare EGWP covers most vaccines if they are administered at a pharmacy. They may also be covered when received in a doctor’s office, but only if the doctor’s office coordinates with a pharmacy to bill the plan for the entire cost of the vaccination, including the injection of the vaccine. This coverage will extend to all retirees as of that date, including retirees who are not Medicare-eligible and are therefore not enrolled in the enhanced EGWP.

Generally, Medicare Part D covers all commercially-available shots needed to prevent illness. Common vaccines include shingles, diphtheria, tetanus, measles-mumps-rubella, polio, hepatitis A & B, and HPV. Please note that flu and pneumococcal shots are typically covered by Medicare Part B, and therefore will not be covered by the AlaskaCare plan. You can find a complete list of covered vaccines in the formulary on the AlaskaCare Optum Rx information web page. Each vaccine is listed in the formulary as “viral vaccine” under the therapeutic drug class.

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Yes. AlaskaCare is extending these same benefits to non-Medicare eligible retiree and dependents.

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No! As an AlaskaCare member, your health benefits are protected, and it’s the Division’s job to ensure those benefits remain protected and sustained. Although the EGWP is not protected under Alaska’’s constitution, your retiree benefits are. Using an enhanced EGWP and covering additional medications that are not covered by a standalone EGWP will ensure that you continue to receive the same level of benefits consistent with the protections in the Alaska Constitution.

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Yes. The Division will be closely monitoring the program and will evaluate whether it is in Alaska’s best interest to continue using this type of program. If the Division determines that it is not meeting the needs of our members or the State, the Division can disenroll.

Like all Medicare programs, EGWP could change if federal laws and regulations change. Regardless of what happens in the future, Alaska has an obligation to provide pharmacy benefits and will continue to do so.

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The Centers for Medicare and Medicaid Services (CMS) is interested in preserving pharmacy benefits for retirees and in providing an incentive to states or other large employers to continue providing these benefits to retirees. While Alaska will not discontinue retiree pharmacy benefits, this is a concern in many other states and for other large employers with retiree health plans. If retiree drug plans are discontinued, more people will enroll in Medicare Part D, which would mean the federal government shoulders more of the cost. Subsidizing state and employer plans encourages those plans to provide retiree drug benefits and is in everyone’s interest.

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No, the prescription drugs covered under the current plan and the AlaskaCare EGWP will be the same.

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Although these are terms you may hear associated with an EGWP, these stages will not impact your benefits. They are different stages defined by Medicare based on your total drug costs. The “donut hole” policy for coverage of pharmacy benefits is a feature of some Medicare Part D plans, but the design of the AlaskaCare enhanced EGWP ensure that you will not be directly impacted by a coverage gap, because the State covers the pharmacy costs not covered under Medicare Part D. This extra coverage ensures your out-of-pocket costs for drugs will not change.

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Because the AlaskaCare enhanced EGWP is a group Medicare Part D plan, if you have multiple retiree prescription drug coverages the AlaskaCare enhanced EGWP will become the primary payer. If your other retiree coverage previously had been the primary payer, it will move into the secondary payer position. Your total coverage levels will not change. Your medications will still be covered at the same benefit level as they were before.

If you add other health coverage and become covered under an active employee health plan, that coverage will become the primary payer.

Please note that you can only receive home delivery prescriptions through your primary prescription drug coverage’s home delivery program. If AlaskaCare is now your primary coverage and you used to receive home delivery prescriptions through an alternate coverage, you will need to enroll in the AlaskaCare prescription home delivery program to continue to receive your medications by mail.

Optum Rx provides the home delivery pharmacy for the AlaskaCare plans. Please visit Optum Rx.com or contact Optum Rx at to enroll in prescription home delivery. If you receive your medication through Optum Rx home delivery, your copay is $0, which may be less than the copay assessed by your other coverage.

Please note that you cannot be enrolled in more than one EGWP at a time. We anticipate that this situation will be rare, but if you are already covered under an EGWP through a non-AlaskaCare plan, please provide the Division with a copy of your ID card from the other EGWP plan. We will disenroll you from the AlaskaCare EGWP but you will continue to receive the standard AlaskaCare pharmacy benefits.

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You can expect to receive information from Medicare three months prior to turning age 65, and though you should enroll in Medicare Part A and B, you do not need to enroll in an individual Medicare Part D plan. After you enroll in Medicare, you need to provide the Division your Medicare Beneficiary Identifier (MBI - your Medicare number).

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In most cases, no. The AlaskaCare retiree plan, through Optum Rx, will enroll eligible retirees into the AlaskaCare EGWP. AlaskaCare will pay a monthly administrative cost to the PBM for each enrolled member, and most retirees and their Medicare-eligible dependents will not be required to pay a premium to Medicare for Part D coverage.

Medicare does require a premium payment (or surcharge) for individuals who are high-wage earners. This premium is referred to as the Income Related Monthly Adjustment Amount (IRMAA). The Division reimburses members who are assessed an IRMAA for Part D coverage.  Learn more about IRMMA here.

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Yes. If your spouse is eligible for Medicare and you are not, he/she will be enrolled in the AlaskaCare EGWP plan, while your coverage will continue to be provided the same way it is today.

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If your dependents are not currently Medicare-eligible, they will continue to receive prescription drug benefits the same way they do today. If one of your dependents becomes eligible for Medicare in the future, he or she would be enrolled in the AlaskaCare EGWP at that time.

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You cannot be enrolled in more than one EGWP at a time. We anticipate that this situation will be rare, but if you are already covered under an EGWP through a non-AlaskaCare plan, please provide the Division with a copy of your ID card from the other EGWP plan. We will disenroll you from the AlaskaCare EGWP but will you will continue to receive standard AlaskaCare pharmacy benefits.

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For most members, the benefit provided through your AlaskaCare retiree plan provides better value than an individual Medicare Part D plan. If you wish to keep your Individual Part D plan, you must opt out of the AlaskaCare EGWP plan. Retirees that opt-out of the AlaskaCare EGWP will be placed in a prescription drug program that is much different than the plan prescription drug benefits offered today. This may result in increased out-of-pocket expenses for you or your Medicare-eligible dependents.

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Please select the scenario that best describes you:

• I am covered under a single AlaskaCare plan, and…
  • I am a retiree that is not eligible for Medicare:

    ID cards are issued in packs of two to retirees that are not eligible for Medicare. If you have an eligible dependent, you can share the extra card with your dependent. If you have more than one eligible dependent, you can request additional cards through Optum Rx at (855) 409-6999. Starting January 1, 2019, you can also print a temporary card from the Optum Rx portal, or use the Optum Rx mobile app.

  • I am a Medicare-eligible retiree who is not covered under the enhanced Employer Group Waiver Program (EGWP):

    ID cards are issued in packs of two to retirees that are not enrolled in the AlaskaCare enhanced Employer Group Waiver Program (EGWP). If you have an eligible dependent, you can share the extra card with your dependent. If you have more than one eligible dependent, you can request additional cards through Optum Rx at (855) 409-6999. Starting January 1st,1, 2019, you can also print a temporary card from the Optum Rx portal, or use the Optum Rx mobile app.

  • I am a retiree covered under the enhanced Employer Group Waiver Program (EGWP):

    You should have received only a single ID card with the MedicareRx logo in the lower right corner (see example below). Please contact the Division or Optum Rx for additional information on why you may have received a second card.

• I am covered under my own plan and under my spouse’s AlaskaCare plan, and…
  • Both my spouse and I are either an active employee or a retiree not yet eligible for Medicare:

    You will both receive a two-pack of ID cards with your own name and ID number. You may share one copy of your ID card with your spouse, however, you or your dependents only need to present one of these ID cards to the pharmacy. Optum Rx coordinates your coverage behind the scenes.

  • Both my spouse and I are are retirees and eligible for Medicare:

    If you are both eligible for Medicare and are enrolled in the enhanced Employer Group Waiver Program (EGWP), you should each receive a single ID card that has the MedicareRx logo in the lower right (see example below). Each card will have an individual name and ID number. Although you receive only one card, when you present the card at the pharmacy you will receive the benefit of your double coverage under the plan. This means you will not be required to pay a copay at the pharmacy counter.

  • One of us is a Medicare-eligible retiree enrolled in the enhanced Employer Group Waiver Program (EGWP) and the other is either an active employee or a retiree not enrolled in EGWP:

    The retiree who is Medicare-eligible and is enrolled in the enhanced Employer Group Waiver Program (EGWP) will receive a single ID card that has the MedicareRx logo in the lower right (see example below). The card will have their individual name and ID number. Although they receive only one card, when they present the card at the pharmacy they will receive the benefit of having double coverage under the plan. This means they will not be required to pay a copay at the pharmacy counter.

    The spouse who is not enrolled in the EGWP will receive an ID card two-pack in their own name for each layer of coverage they have (their own coverage and their dependent coverage as the spouse of a Medicare-eligible retiree). The only difference between the two packs of ID cards will be the ID number. The ID number that matches the Medicare-eligible retiree’s MedicareRx ID card will be the dependent coverage card. However, the spouse or other non-Medicare eligible dependents only need to present one of these ID cards to the pharmacy. Optum Rx coordinates the coverage behind the scenes.

• I am covered under more than one of my own AlaskaCare plans, and…
  • I am eligible for Medicare:

    If you are eligible for Medicare and are enrolled in the enhanced Employer Group Waiver Program (EGWP), you should receive a single ID card that has the MedicareRx logo in the lower right (see example below). Although you receive only one card, when you present the card at the pharmacy you will receive the benefit of your double coverage under the plan. This means you will not be required to pay a copay at the pharmacy counter.

  • I am not eligible for Medicare:

    You will receive an ID card two-pack for each layer of coverage you have. The only difference between the different packs of ID cards will be the ID number. However, you only need to present one of these ID cards to the pharmacy. Optum Rx coordinates the coverage behind the scenes.

    
    
    Sample card:
    

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Optum Rx coordinates all the layers of coverage for you and your dependents behind the scenes, so in many cases you and your dependents can use each other’s cards at the pharmacy. However, a non-EGWP dependent should not use the card that has a MedicareRx logo in the lower right corner. This card would only work if the pharmacist uses the correct person code (to identify them as a dependent rather than the policy holder). To avoid any confusion at the pharmacy, we recommend you and your dependents only use a card that has your name on it.

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You can tell the difference between the cards by looking at the logo on the card. One will say AlaskaCare Employee Pharmacy Plan, and the other will say AlaskaCare Retiree Pharmacy Plan. Your employee plan will typically be the primary payer.

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You can opt out of the enhanced EGWP, but this is highly discouraged and will result in higher costs for both you and the health plan. Centers for Medicare and Medicaid Services (CMS) require that you be given the opportunity to opt out of EGWP. Retirees that opt out of the AlaskaCare EGWP will be placed in a prescription drug program that is much different than the plan prescription drug benefits offered today. This will result in increased out-of-pocket expenses for you or your Medicare-eligible dependents.

If you are considering opting out because you are covered under another Medicare plan (e.g. Medicare Advantage that includes prescription drug coverage or another EGWP), in lieu of opting out you can provide a copy of your Medicare Advantage or EGWP ID card to the Division and we will remove you from the enhanced EGWP and place you in the AlaskaCare standard pharmacy benefit plan.

You can call the Division Monday through Thursday, 8:30 a.m. to 4 p.m. and Friday from 8:30 a.m. to 3 p.m. AKST toll-free at or in Juneau at , or email at .

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If you are eligible for the enhanced EGWP and do not opt out, or if you are covered under another Medicare plan and contact the Division with evidence of that coverage, you will retain the Standard Benefit with the following provisions:

Standard Benefit
	Generic Up to 90-Day or 100-Unit Supply	Brand Name Up to 90-Day or 100-Unit Supply
Network pharmacy copayment	$4	$8
Mail order copayment	$0	$0
Supply Limit
Depo-Provera (injectable contraceptive)	5 vials per benefit year

If you are eligible for the enhanced EGWP but choose to opt out, you will receive the opt-out benefit with the following provisions:

Opt-Out Benefit
Retail 30-Day at Network Pharmacy
Prescription Tier	Coinsurance	Minimum Covered Person Payment	Maximum Covered Person Payment
Generic prescription drug	80%	$10	$50
Preferred brand-name prescription drug	75%	$25	$75
Non-preferred brand-name prescription drug	65%	$80	$150
Out-of-Network Pharmacy
Coinsurance for all prescription drugs		60%
Mail Order 1- to 90-Day at Network Pharmacy
Prescription Tier		Copayment
Generic prescription drug		$20
Preferred brand-name prescription drug		$50
Non-preferred brand-name prescription drug		$100
Out-of-Pocket-Limit
Annual individual out-of-pocket limit		$1,000
Annual family out-of-pocket limit		$2,000
Special Note:
Coordination of Benefits	The opt-out benefit is exempt from coordination of benefits.

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You may receive letters or a phone call from Optum Rx asking to confirm certain personal information, including: your name, address, residential address, birthday, and Medicare Beneficiary Identifier (your Medicare ID number). Providing this information assists with expedited enrollment and helps avoid any potential issues related to discrepancies or errors between the health plan and Medicare. This is not a scam. If you need to provide updated information, you will receive reminder letters as follows:

• First letter – upon enrollment in EGWP
• Second letter – 30 days after enrollment
• Third letter – 6 months after enrollment
• Fourth letter – 12 months after enrollment. The fourth letter will be the final request to provide updated information.

To provide this information, you can call the toll-free number provided in the letter, (855) 235-1405 (TTY 711), or mail the return form to:

Optum Rx
Attention: Enrollment Services
P.O. Box 269027
Fort Lauderdale, FL 33326

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If you received an errata sheet from Optum Rx, you do not need to take any action; it is intended for informational purposes only. Because the AlaskaCare enhanced EGWP is a Medicare part D prescription drug plan, the Centers for Medicare & Medicaid Services (CMS) requires that we send out errata sheets to inform members of any corrections or clarifications we have made to the plan’s abridged formulary, evidence of coverage, and summary of benefits. If you have any questions about any of the information on the errata sheet, please contact Optum Rx member services at (TTY 711).

Please note that the AlaskaCare enhanced EGWP provides enhanced benefits beyond the Medicare Part D covered prescription drugs. Please refer to your AlaskaCare plan booklet to understand your full plan benefits.

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Members who are enrolled in the enhanced Employer Group Waiver Program (EGWP) will receive a letter stating they have 21 days to opt-out of the EGWP. This is not a hard deadline. Members may elect to opt out of the enhanced EGWP at any time.

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The Centers for Medicare & Medicaid Services (also called CMS or Medicare) requires that you maintain a residential (physical) address within the Medicare service area. A post office box does not qualify. The service area includes the United States, the District of Columbia, Guam, Puerto Rico, the US Virgin Islands, Northern Mariana Islands and America Samoa. We need you to confirm that you live inside the plan’s service area. No mail will be sent to this physical address unless it is the same as your mailing address. It will only be used to verify that you live inside the plan’s service area.

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We apologize for the tone of the letter, Medicare does not allow us to edit their required letters to add clarity. The intent of the statement in the letter is to emphasize that in order for AlaskaCare to continue to receive federal subsidies associated with your enrollment in EGWP, you must provide a residential address. You will not lose your coverage but if we do not receive your physical address, you will be disentrolled in the EGWP and placed in the AlaskaCare opt-out-plan. The opt-out plan may result in increased out-of-pocket expenses for you or your Medicare eligible dependents.       

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You cannot be enrolled in more than one EGWP at a time. If you are already covered under an EGWP through a non-AlaskaCare plan, please contact the Division. We can dis-enroll you from the AlaskaCare EGWP and leave you in the plan available to non-Medicare-eligible members. You will receive a letter from AlaskaCare confirming that you have been removed from the AlaskaCare enhanced EGWP. Please share this letter with your other Medicare prescription drug plan.

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You cannot be enrolled in Medicare Advantage plan that includes prescription drug coverage and a separate EGWP plan at the same time. We anticipate that this situation will be rare, but if you are covered under a Medicare Advantage plan that includes prescription drug coverage, please provide the Division with a letter or copy of your Medicare Advantage card and we will disenroll you from the AlaskaCare EGWP. If you are disenrolled from the AlaskaCare EGWP, you will continue to receive pharmacy benefits through the standard AlaskaCare pharmacy benefit.

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Yes. The Part D surcharge deducted can be reimbursed through the Health Reimbursement Arrangement (HRA) account. Each year, usually in November, Social Security will send you a letter which will state the IRMAA amount you are required to pay for the upcoming calendar year. To receive reimbursement, you have three options to choose from:

• You may register/log in to the Optum Rx member portal;
• You can use the Optum Rx mobile app; or
• You can request a paper form to enroll in the Part D IRMAA Health Reimbursement Arrangement (HRA).

Additional information can be found on our IRMAA webpage. If you have any questions about how to submit your IRMAA documents and the Health Reimbursement Arrangement (HRA), please contact Optum Rx at or email .

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No, you will not need to reapply for the LIS. Your LIS cost sharing/copays will remain the same.

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The Late Enrollment Penalty is an amount added to the Medicare Part D plan premium for a member who meets one or both of the following criteria:

1. The member did not obtain creditable prescription drug (Rx) coverage when they were first eligible for Medicare Part D
2. The member had a break in creditable prescription drug (Rx) coverage of at least 63 consecutive days.

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No, AlaskaCare will pay the Late Enrollment Penalty fee on behalf of the members. You are receiving a LEP letter since you were identified by the Centers for Medicare & Medicaid Services (CMS or Medicare) as having uncovered months prior to their enrollment into the Medicare Part D plan.

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You can remove a LEP in the following ways:

1. You can call Optum Rx at the phone number on the back of your ID card and speak to an agent who will explain the process to remove the LEP.
2. You can complete the "Declaration of Prior Prescription Drug Coverage" form included with the LEP letter and mail it to the following address:
   Attn: Enrollment Services
   P.O. Box 269027
   Fort Lauderdale, FL 33326

There is a limited amount of time to correct a LEP notice if you feel this has been applied in error. You must contact Optum RX no later than 30 days after receiving notification to complete an attestation and have the LEP removed.

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You may have received a check from Optum Rx for a variety of different reasons. To find out what the check was for and what to do next, please contact Optum Rx Member Services at .

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Initial Coverage State is a term used by Medicare and is part of the Medicare mandatory information sent to all Medicare prescription drug plan participants. However, due to the additional benefits provided through the AlaskaCare enhanced EGWP, this does not apply and will not impact your benefits. Your copay will not change.

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The AlaskaCare retiree plan has what is called an “open formulary.” This means the AlaskaCare retiree plan will cover medications, even if those medications would typically not be covered under a Medicare prescription drug plan.

AlaskaCare is required by the federal Center for Medicare and Medicaid Services (CMS) to send a document called an “abridged formulary” to members in the AlaskaCare enhanced EGWP. This formulary provides a list of medications covered under Medicare Part D. Under the AlaskaCare enhanced EGWP, medications that are not typically covered under Medicare Part D will still be covered through the wrap benefit under the AlaskaCare enhanced EGWP. This means that your medication will remain covered even if it is not on the formulary.

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The COB Survey is a notification to a Medicare beneficiary that the Center for Medicare Services (CMS) has other primary or secondary coverage information on file for that member. Part D sponsors are required to notify each beneficiary of other prescription drug coverage information and request that the beneficiary review the information and report back any updates to Optum Rx. You will need to follow the instructions outlined in the COB letter to update the information with CMS by contacting Optum Rx. Members can update their information by contacting Optum Rx Enrollment Services and an enrollment agent will assist with completing the update over the phone.

Optum Rx Enrollment Services .

In the event that other Primary coverage information is not updated timely, your prescription claims may reject at the pharmacy with a message to the pharmacy that there is alternative insurance coverage. To complete the COB survey, members should contact Optum Rx Enrollment Services at .

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If you are Medicare-eligible and are taking a medication that requires prior-authorization, you will receive a copy of the letter below. If you receive a letter referencing prior authorization that does not look like this, you may have received it in error. You can contact Optum Rx at , TTY711 if you have questions about your prescriptions or any correspondence you have received from them.

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Here’s what won’t change:

• Copayments will remain the same at $0 home delivery, $4 generic, $8 brand-name.
• Covered medications will remain the same.
• Filling prescriptions at the pharmacy will remain the same.
• The value of your benefit will remain the same.
• The current plan allows filling a prescription for 90 days or up to 100 units. This will not change.
• The current appeals process will remain the same. You will not be required to use the federal appeals process.

Here’s what will be different:

• You will receive several mandatory mailings from Optum Rx.
• You will receive a separate monthly explanation of benefits of your prescription claims.
• The pharmacy network will change. We don’t believe these changes will substantially impact members, but you will want to check to be sure your preferred pharmacy is in-network.
• Medicare has a list of drugs that require pre-authorization. These required prior authorizations do not include any “step therapy” requirements. (“Step therapy” is when an insurance plan requires a member to try certain lower-cost medications first before covering a more expensive type of medication.) You may have to get a prior authorization for drugs where it was not previously required or seek prior authorization for drugs that have already been pre‐authorized under the current plan.
• If you have multiple medical conditions and high drug-utilization, you may be enrolled in the Medicare Medication Therapy Management Program by the State. Medicare developed this program as a member protection. This program helps you and your doctor make sure that your medications are working to improve your health and provides a comprehensive review that includes: how your medications are working; if they have side effects; and any interactions between drugs you are taking. You can opt out of this program.

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The current appeals process will remain the same. You will not be required to use the federal appeals process.

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Yes. A full list of covered drugs is available on the AlaskaCare Optum Rx web page.

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No. Your provider can prescribe whatever medication they think is most appropriate for you and your co-pay will be $0 for home delivery, $4 for generic medications, and $8 for a brand-name medication. Depending on what your provider prescribes, the medication may require prior authorization. All claims, not just prescription drug claims, must be medically necessary in order to be covered by the health plan. Determinations of medical necessity are part of the claims processing function for all health care plans and can be complex depending on the situation. AlaskaCare relies on our Pharmacy Benefit Manager (PBM) to make evidence-based decisions on medical necessity as part of the pharmacy claims processing function, and this process will continue under an AlaskaCare EGWP.

There may be instances in which a member’s provider will disagree with coverage decisions related to medical necessity. In these cases, we encourage members to utilize the appeal process for reconsideration.

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Certain high-income retirees will have to pay an extra surcharge, consistent with the extra surcharge applied to Medicare Part B today. Generally, if you are an individual earning more than $85,000 per year or a married couple who earns more than $170,000 per year, you will be charged an extra premium for being enrolled in an AlaskaCare EGWP because it is a group Medicare Part D plan. CMS refers to this as Income Related Monthly Adjustment Amounts (IRMAA). If you are charged an IRMAA for your prescription drug coverage, the Division will cover the full cost of the premium. Contact the Division to learn about your options.

Similar to Medicare Part B, the IRMAA premium amount will be deducted directly from your Social Security check if you qualify for Social Security or will otherwise be invoiced to you directly. The Social Security Administration (SSA) will send you a letter with your IRMAA premium amount and the reason for the determination. If you disagree with the IRMAA premium amount or your income has gone down, you should contact Social Security at (800) 772-1213 to resolve the determination.

The Social Security Administration will use your Modified Adjusted Gross Income (MAGI) to determine if the income-related monthly adjustment amount (IRMAA) applies. MAGI is the sum of:

• Adjusted Gross Income (AGI), which can be found on the last line your IRS 1040 tax form (line 37 on form 1040, line 21 on form 1040A, or line 4 on form 1040EZ), plus:
• Any tax-exempt interest income (line 8b on form 1040).

To make this determination, SSA requests income information from the IRS for the tax year that is two years prior to the premium year. For example, Social Security will use your MAGI from 2017 to determine your 2019 IRMAA. IRMAA is automatically re-determined each year as long as you file an income tax return.

The table below shows the anticipated IRMAA for and is for illustrative purposes only. The MAGI and IRMAA are subject to change.

Individual Modified Adjusted Gross Income (MAGI)	Household Modified Adjusted Gross Income (MAGI)	Monthly Part D IRMAA Surcharge
Less than or equal to $91,000	Less than or equal to $182,000	Not assessed a surcharge
Greater than $91,000 and less than or equal to $114,000	Greater than $182,000 and less than or equal to $228,000	$12.40
Greater than $114,000 and less than or equal to $142,000	Greater than $228,000 and less than or equal to $284,000	$32.10
Greater than $142,000 and less than or equal to $170,000	Greater than $284,000 and less than or equal to $340,000	$51.70
Greater than $170,000 and less than or equal to $500,000	Greater than $340,000 and less than or equal to $750,000	$71.30
Greater than $500,000	Greater than $750,000	$77.90

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The Division is prohibited from paying your Medicare Part D IRMAA premium surcharge directly and will instead reimburse you. If you receive notice that you are required to pay the IRMAA surcharge for the enhanced EGWP, follow the steps outlined in question 74 to request reimbursement. The Division will fund a tax advantaged HRA account that can be used to reimburse you the Part D IRMAA surcharge amount by paper check or through electronic funds transfer to a bank account of your choosing.

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If you refuse to pay the extra surcharge, Medicare will cancel your enrollment in the AlaskaCare enhanced EGWP plan. This will be treated as an opt-out under the plan, and you will be placed in a prescription drug program that is much different than the plan prescription drug benefits offered today. This alternative plan may result in increased out-of-pocket expenses for you or your Medicare-eligible dependents. Please contact the Division if you have concerns about this surcharge or would like to understand the options available.

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Each November you should receive a letter from Social Security that outlines your Medicare premiums, including whether you are subject to the Income-Related Monthly Adjustment Amount (IRMAA) surcharge.

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The Division has partnered with Optum Rx and Optum Bank for easy IRMAA reimbursement through your HRA account. Please allow up to 3 weeks for processing. Members are encouraged to set up reimbursement on an automatic reoccurring basis, but may elect to request reimbursement manually. Reimbursement can be made by check or through electronic funds transfer.

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No. The HRA is a tax-advantaged account and is not taxable income.

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The Division has partnered with Optum Rx and Optum Bank for easy IRMAA reimbursements and will handle all your IRMAA needs. Follow these steps to establish your 2021 Part D IRMAA reimbursement account online:

• Register and/or log in to your Optum Rx.com account either online or through the mobile app.
• Navigate to forms by clicking on the "Information Center" tab on the Navigation bar at the top, select "Programs and Forms", then click on “IRMAA HRA Enrollment Form”.
• Complete the online IRMAA HRA Enrollment Form.
• Upload as an attachment a copy or image of your letter from Social Security or a Medicare Bill that shows what your 2021 Part D IRMAA surcharge will be.
• Optum Rx will confirm your eligibility and set up your Health Reimbursement Account (HRA).
• Once your HRA has been created, Optum Bank will send you a Welcome Packet.
• Log in to optumbank.com to view your HRA account status/balance or to sign up for Direct Deposit. Your banking information that may be with Inspira Financial cannot be transferred on your behalf to Optum Bank.

If you have any questions on how to submit your 2021 IRMAA documents online or if you do not have internet access and would like to submit paper documentation, please contact Optum Rx at or email .

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Yes, by submitting the claim form you will receive a monthly ongoing reimbursement in addition to any eligible reimbursement for previous months.

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Yes, your quarterly payment will be broken into monthly reimbursement via check or direct deposit when you submit the paper claim form.

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No, you can set up automatic reimbursement by submitting the paper claim form.

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To receive reimbursement for the Part D IRMAA surcharge, you should submit the HRA claim as soon as possible, but not later than 12 months after the date you incurred the expenses. Retroactive reimbursements will not be issued for claims received beyond 12 months. Example: if you are assessed a Part D IRMAA surcharge in 2020, you will have until December 31, 2021 to file the HRA claim for reimbursement.

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Unclaimed funds will be forfeit and will revert back to the Retiree health trust.

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No. The HRA can only be used to reimburse members for the Part D income related monthly adjustment amount (IRMAA).

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For general questions about how the plan works or how your drugs are covered under the plan, call Optum Rx at .

To find out if you will be subject to an extra surcharge because you earn a high income, you may contact Social Security at .

Income Related Monthly Adjustment Amount (IRMAA) Information Flyer

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In this video, we will review how to enroll and submit for IRMAA reimbursement with a paper claim form.

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Each year, if you are Medicare-eligible, you will be notified by the Social Security Administration about your plan. This includes if you are required to pay an IRMAA and at what amount. The Social Security Administration uses your Modified Adjusted Gross Income (MAGI) to determine if the IRMAA applies to you and, if so, how much you will have to pay. MAGI is the sum of:

• Adjusted Gross Income (AGI), which can be found on the last line your IRS 1040 tax form (line 37 on form 1040, line 21 on form 1040A, or line 4 on form 1040EZ), plus
• Any tax-exempt interest income (line 8b on form 1040).

The Social Security Administration requests income information from the IRS for the tax year that is two years prior to the surcharge year. IRMAA is automatically re-determined each year as long as you file an income tax return.

The below table shows the IRMAA for . The MAGI and IRMAA is subject to change from year to year. Please review the table below to see if your income qualifies you to be assessed an IRMAA surcharge based on your Modified Adjusted Gross Income (MAGI) from the tax year.

Part D IRMAA Amounts
If your filing status and yearly income in was...
Beneficiaries Who File Individual Tax Returns With Modified Adjusted Gross Income (MAGI)	Beneficiaries Who File Joint Tax Returns With Modified Adjusted Gross Income (MAGI)	Income-Related Monthly Adjustment Amount (IRMAA)
Less than or equal to $106,000	Less than or equal to $212,000	Not assessed a surcharge
Greater than $106,000 and less than or equal to $133,000	Greater than $212,000 and less than or equal to $266,000	$13.70
Greater than $133,000 and less than or equal to $167,000	Greater than $266,000 and less than or equal to $334,000	$35.30
Greater than $167,000 and less than or equal to $200,000	Greater than $334,000 and less than or equal to $400,000	$57.00
Greater than $200,000 and less than $500,000	Greater than $400,000 and less than $750,000	$78.60
Greater than or equal to $500,000	Greater than or equal to $750,000	$85.80

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows.

Part D IRMAA Amounts
If your filing status and yearly income in was...
Beneficiaries Who Are Married and Lived With Their Spouses at Any Time During the Year, but File Separate Tax Returns From Their Spouses With Modified Adjusted Gross Income (MAGI)	Income-Related Monthly Adjustment Amount (IRMAA)
Less than or equal to $106,000	Not assessed a surcharge
Greater than $106,000 and less than or equal to $394,000	$78.60
Greater than or equal to $394,000	$85.80

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Optum Rx will handle all your IRMAA needs. Follow these steps to establish your Part D IRMAA reimbursement account online:

1. Register and/or log in to your Optum Rx.com account either online or through the mobile app.
2. Navigate to the AlaskaCare IRMAA Reimbursement Form by taking the following steps:


• On the top of the main page, click the "Information Center" tab.
• Click "Programs and Forms".
• Click on the "AlaskaCare IRMAA Reimbursement" section. There you will find the digital enrollment form as well as the paper version.
3. To submit your reimbursement request digitally (the faster method), click and submit the IRMAA HRA Digital Enrollment Form.
4. Upload as an attachment, a copy or image of your letter from Social Security or a Medicare Bill that shows what your Part D IRMAA surcharge is.
5. Optum Rx will confirm your eligibility and set up your Health Reimbursement Account (HRA) with Optum Bank within 5 to 7 business days of receipt.
6. Once your HRA has been set up with Optum Bank, they will send you a Welcome Packet within 5 to 7 business days, which will include information on signing up for Direct Deposit.
   • If you currently have Direct Deposit set up with Optum Bank, that information does not need to be submitted again.
7. Once you receive your Welcome Packet, log in to OptumBank.com to view your HRA account status/balance or to sign up for Direct Deposit.

Note: If you are using the IRMAA HRA Enrollment Paper Form, you will need to:

• Print the form,
• Fill out the information accurately,
• Include a copy of your letter from Social Security or a Medicare Bill that shows what your Part D IRMAA surcharge is, and
• Mail or email the form to Optum Rx.

The timeline for completion depends on the information provided and when it is received by Optum Rx.

If you have any questions on how to submit your IRMAA documents online or if you do not have internet access and would like to submit paper documentation, please contact Optum Rx at or email .

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If you receive notice that you are required to pay the IRMAA surcharge for the enhanced EGWP, follow the steps listed above to request reimbursement. The Division will fund a tax advantaged HRA account that can be used to reimburse you the Part D IRMAA surcharge amount by paper check or through electronic funds transfer to a bank account of your choosing.

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To receive reimbursement for the Part D IRMAA surcharge, you should submit the HRA claim as soon as possible, but not later than 12 months after the date you incurred the expenses. Retroactive reimbursements will not be issued for claims received beyond 12 months. Example: if you are assessed a Part D IRMAA surcharge in 2023, you will have until December 31, 2024 to file the HRA claim for reimbursement.

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If you refuse to pay the extra surcharge for your Medicare Part D coverage, Medicare will cancel your enrollment in the AlaskaCare enhanced EGWP plan. This will be treated as an opt-out from the plan, and you will be placed in a prescription drug program that is much different than the plan prescription drug benefits offered today. This alternative plan may result in increased out-of-pocket expenses for you or your Medicare-eligible dependents. Please contact the Division if you have concerns about this surcharge or would like assistance with understanding the options available to you.

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For general questions about your pharmacy benefits, contact Optum Rx, the AlaskaCare pharmacy benefits manager at . For questions related to your IRMAA surcharge, you may contact Social Security at . For more information about the HRA account options, contact the Division at or toll-free at .

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For assistance or a status on a claim you already submitted, you may contact Optum Rx by email: .

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Recognized charge means the negotiated charge contained in an agreement the claims administrator has with the provider either directly or through a third party. If there is no such agreement, the recognized charge is determined in accordance with the provisions of this section. Except for charges related to involuntary out-of-network services, an out-of-network provider has the right to bill the difference between the recognized charge and the actual charge. This difference will be the covered person’s responsibility.

Medical Expenses: As to medical services or supplies, the recognized charge for each service or supply is the lesser of:

• What the provider bills or submits for that service or supply;
• Or the 90th percentile of the prevailing charge rate; for the geographic area where the service is furnished as determined by Aetna in accordance with Aetna reimbursement policies.

For more information on recognized charge in the Retiree Plan, see the Retiree Insurance Information Booklet , section 3.1.4 Recognized Charge.

Coordination of Benefits (COB) is a method of paying claims when you or your covered dependent have more than one health coverage plan. The AlaskaCare health plans coordinate benefits with other group health care plans to which you or your covered dependents belong. Coordination of benefits can be very confusing, even for people who work at a physician's office.

With COB, if you are covered by more than one health care plan, the plans work together to provide benefits. One plan is considered "primary," and pays your covered expenses first. The other plan is "secondary," and depending on the plans COB provisions, may pay a portion or may pay any remaining covered expenses up to 100%. In some cases, there may be a third or fourth plan, as well.

It is important to remember that not all expenses are covered expenses. In addition, each plan may have their own separate deductibles that may have to be satisfied independent of each other. The plans will likely also have independent and different copayments, coinsurance rates and annual out-of-pocket limits.

Here are examples of common COB situations and rules:

If You Are Covered Under…	Here's How the Plans Pay
Active employee plan and retiree plan	Primary: Active employee plan Secondary: Retiree plan
Retiree plan and as dependent under another person's plan through active employment	Primary: Retiree plan Secondary: Other person's plan
Retiree plan and Medicare-eligible	Primary: Medicare Secondary: Retiree plan
Two retiree plans	Primary: Plan in force the longest Secondary: Other plan
Retiree plan, as dependent under another person's plan through active employment, and Medicare-eligible	Primary: Other person's plan Secondary: Medicare Third: Retiree plan
Active employee plan, retiree plan, as dependent under another person's plan through active employment, and Medicare-eligible	Primary: Active employee plan Secondary: Other person's plan Third: Medicare Fourth: Retiree plan

If your dependent children are covered under more than one plan, in most cases, the plan of the parent whose birthday falls earlier in the year (not the oldest) is primary. If both parents have the same birthday, the plan that has covered the children longer is primary. If the parents are separated or divorced, the plans pay as follows:

• Primary: plan of the parent whom the court has established as financially responsible for the child's health care (the claims administrator must be informed of the court decree)
• Secondary: plan of the parent with custody of the child
• Third: plan of the spouse of the parent with custody of the child
• Fourth: plan of the parent who does not have custody of the child

If none of the above rules applies, the plan that has covered the patient the longest is primary.

The AlaskaCare Retiree Dental, Vision, Audio (DVA) Plan for DCR Plan Retirees coordinates benefits differently than the medical plan does when it is secondary to another plan. For DVA services, the amount the plan pays after the deductible is met is figured by subtracting what the primary plan pays from 100% of expenses covered by the AlaskaCare plan on that claim.

Example:

• You obtain a filling from a network dentist who charges $200.
• Both your dental plans pay 80% for class II (restorative) services.
• You have met your deductibles for the year.
• Primary plan pays: $160 (80% of $200)
• Secondary plan pays: $40 (20% of $200)
• Total paid: $200

For medical services, when the AlaskaCare plan is secondary on a claim the plan will reduce the allowable amount by the amount paid by the primary plan, before applying the deductible, copays and/or coinsurance. The allowable amount is the total amount the AlaskaCare plan is responsible for, before any member cost share provision is applied.

Example:

• You are Medicare age eligible and obtain a service from a provider who accepts Medicare. The Medicare allowed rate for the service is $1,500.
• Both Medicare and the AlaskaCare plan pay 80% for the covered service.
• You have not met either your Medicare or AlaskaCare deductible for the year.
• Medicare as primary plan pays: $1,067.20 ($1,500-$166 Medicare deductible = $1,334x80% is $1,067.20)
• AlaskaCare DCR medical plan bases payment on: $432.80 ($1,500-$1,067.20)
• AlaskaCare DCR medical plan pays as secondary: $106.24 ($432.80 - $300 deductible = $132.80x80% is $106.24)
• Total paid by both plans: $1,173.44.
• Unpaid portion ($326.56) applies to the annual individual out-of-pocket maximum.

No. Under the medical plan, the allowable amount on the second AlaskaCare plan will be reduced by the amount paid under the primary plan (see above example). You may also receive a balance bill for the amount over the recognized charge allowed under the primary plan if you receive services from an out-of-network provider.

Example:

• You are not yet Medicare age eligible and obtain a service from an out-of-network provider who charges $500 for a procedure.
• The recognized charge for the procedure is $425.
• Both AlaskaCare plans pay 80% for the covered service.
• You have met your annual deductibles.
• The primary plan pays: $340 ($425x80% is $340)
• The secondary plan bases payment on: $85 ($425-$340 paid by primary plan)
• The plan pays as secondary: $68 ($85x80% is $68)
• Total paid by both plans: $408.
• Unpaid portion that you may be responsible for is $92. This is the difference between the billed amount and the allowable recognized charge ($75), plus your coinsurance ($17). Your coinsurance amount ($17) will apply towards the annual individual out-of-pocket maximum.

You may also receive a balance bill if you use an out-of-network provider for dental services. In this case, the plan will pay up to the recognized charge for this service in your area.

Example:

• You obtain a filling from an out-of-network dentist who charges $250 for a filling.
• The recognized charge for this service in Alaska is $150.
• Both your plans pay 80% for class II (restorative) services.
• You have met your deductibles for the year.
• Primary plan pays: $120 (80% of $150)
• Secondary plan pays: $30 (20% of $150)
• Total paid: $150
• Potential balance bill amount: $100 ($250 - $150)

You may also receive a balance bill if one of your plans has a lower coinsurance rate (the percentage of the cost you pay for covered expenses once you meet any deductible) or excludes coverage for the service.

Example:

• You obtain a filling from a dental network provider who charges $200.
• Your dental plan pays 80% for class II (restorative) services, but your spouse's plan only pays 10%.
• You have met your deductibles for the year.
• Primary plan pays: $160 (80% of $200)
• Secondary plan pays: $20 (10% of $200)
• Total paid: $180
• Potential balance bill amount: $20 ($200 - $180)
For more information on how recognized charges are calculated, see the Recognized Charges FAQs.

If you are covered under two AlaskaCare plans, the annual maximum that the plan pays will double. For example, under the Alaska care retiree dental plan, the annual $2,000 individual maximum would double to $4,000.

No, the maximum frequency of services per year is not increased due to having other coverage. For example, if you have two plans that each cover up to 20 spinal manipulations each year, the plan will coordinate payment on only 20 manipulations. Manipulations in excess of 20 would not be covered under either plan.

If you are covered under AlaskaCare and age eligible for Medicare, your claims will be processed as if Medicare is your primary coverage regardless of whether or not you actually have Medicare coverage. This means that the AlaskaCare plan reduces the allowable amount it will pay by the amount that would have been paid under Medicare Parts A and B, regardless of whether you actually have Medicare. It's your responsibility to enroll in Medicare Parts A and B as soon as you become eligible and to pay applicable Medicare premiums.

Because the AlaskaCare enhanced EGWP is a group Medicare Part D plan, if you have multiple prescription drug coverages the AlaskaCare enhanced EGWP will become the primary payer. If your other coverage previously had been the primary payer, it will move into the secondary payer position. Your total coverage levels will not change. Your medications will still be covered at the same benefit level as they were before.

Please note that you can only receive mail-order prescriptions through your primary prescription drug coverage’s home delivery program. If AlaskaCare is now your primary coverage and you used to receive mail-order prescriptions through an alternate coverage, you will need to enroll in the AlaskaCare prescription home delivery program to continue to receive your medications by mail.

Optum Rx provides the mail-order pharmacy for the AlaskaCare plans. Please visit Optum Rx.com or contact Optum Rx at to enroll in prescription home delivery. If you receive your medication through Optum Rx home delivery, your copay is $0, which may be less than the copay assessed by your other coverage.

Please note that you cannot be enrolled in more than one EGWP at a time. We anticipate that this situation will be rare, but if you are already covered under an EGWP through a non-AlaskaCare plan, please provide the Division with a copy of your ID card from the other EGWP plan. We will disenroll you from the AlaskaCare EGWP but will you will continue to receive standard AlaskaCare pharmacy benefits.

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If you were not married when you retired, you chose one of two options. You chose either a Regular or Level Income Option benefit. The type of retirement you elected is irrevocable.

1. Regular Retirement: All benefits cease at the time of your death, including health insurance.
   • Beneficiary payment: Your beneficary(s) will receive the balance of your member contribution account, if any, or the last pension check. If you die after you have retired, your beneficiary is entitled to the benefit check for the month in which you died, if it was not already paid to you. Any check payable to you dated after you die, will need to be returned to the Division to be reissued in the name of your beneficiary(s).
2. Level Income Option (not available for PERS Tier III): If you chose this option you will receive an increased benefit amount prior to age 65, and a decreased amount beginning at age 65. If you chose this benefit option you must anticipate other retirement resources to commence at age 65 in order to provide approximately the same income. All benefits cease at the death of the member, include health insurance.
   • Beneficiary payment: Beneficiary(s) receive the balance of your contribution account, if any or the last pension check.

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If you were not married at the time of retirement, but marry after appointment to retirement, you cannot change the type of retirement benefit you elected. Payment of your last pension check and the balance of the member contribution account will be paid to the beneficiary(s) as indicated on the most current beneficiary designation on file with the Division of Retirement and Benefits.

While married, you can cover a new spouse for health insurance, but health insurance for your new spouse will stop at the time of your death.

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If you elected a joint and survivor option at retirement, at the time of your death your beneficiary will start receiving that benefit. To receive survivor benefits, your surviving spouse or incapacitated child's representative must submit a certified copy of the death certificate and complete and submit the survivor benefit application.

The benefit amount your survivor will receive depends on the irrevocable survivor election you made at retirement. The elections available to you, as the member, were:

• 50% Joint and Survivor
• 75% Joint and Survivor
• 66-2/3rd Last Survivor (Not available for PERS Tier III)

The survivor percentage chosen applies to the gross benefits, before taxes or deductions for supplemental insurance.

Examples:

Member Chose 50% Joint and Survivor

Example Only

Current Monthly Gross Benefit	Survivor Gross Benefit
$2,000 Base Benefit	$1,000 Base Survivor Benefit
$800 Post Retirement Pension Adjustment	$400 Post Retirement Pension Adjustment
$200 COLA	$100 COLA
$3,000 Total Benefit	$1,500 Total Survivor Benefit

Member Chose 75% Joint and Survivor

Example Only

Current Monthly Gross Benefit	Survivor Gross Benefit
$2,000 Base Benefit	$1,500 Base Survivor Benefit
$800 Post Retirement Pension Adjustment	$600 Post Retirement Pension Adjustment
$200 COLA	$150 COLA
$3,000 Total Benefit	$2,250 Total Survivor Benefit

Member Chose 66-2/3rd Last Survivor Option

Example Only

Current Monthly Gross Benefit	Survivor Gross Benefit
$2,000 Base Benefit	$1,333 Base Survivor Benefit
$800 Post Retirement Pension Adjustment	$533 Post Retirement Pension Adjustment
$200 COLA	$130 COLA
$3,000 Total Benefit	$1,996 Total Survivor Benefit

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If you are divorced after retirement, you will not be able to change your retirement election to a non-survivor option. The retirement election made when you retired is irrevocable. The divorce does not nullify your survivor designation. Upon your death, your spouse at the time of retirement will still be considered the survivor and will receive survivor benefits.

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If you are the member, death of your spouse does not affect the 50% or the 75% Joint and Survivor options. The retirement election made at the time of retirement is irrevocable. You are not able to change your retirement election to a non-survivor option.

If you chose the 66-2/3rd Last Survivor and your spouse dies, your benefit is reduced to the 66-2/3rd level as you are now the last survivor between the pair.

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If you remarry after divorce or the death of your spouse that was named as the survivor at the time of retirement, your new spouse may be added as a dependent to your retiree health insurance. However, your new spouse will have no rights to survivor benefits. Both pension and retiree health insurance will cease at the time of your death. Your last retirement check will be paid out to your named beneficiary.

DISCLAIMER:
The information contained in this informational brochure is based on a summary description of benefits, costs, rates, other calculations, policies or procedures for the pension and benefit plans administered by the Division of Retirement and Benefits, including but not limited to, the Public Employees' Retirement System and the AlaskaCare Retiree Benefit Plan. The Division of Retirement and Benefits has made every effort to ensure, but does not guarantee, that the information provided is accurate and up to date. Where this information conflicts with the relevant Plan Document, the Plan Document controls.

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Form 1095-B is a tax form that reports the type of health insurance coverage you have, any dependents covered by your insurance policy, and the period of coverage for the prior year. This form is used to verify that you and your dependents have at least minimum qualifying health insurance coverage. This form is sent to members with retiree coverage under AlaskaCare.

The Health Care Information Forms for Individuals (Forms 1095-A, 1095-B, and 1095-C) report information regarding an individual’s health insurance to the IRS. 1095 forms are issued by your insurance provider or employer. The version of the form you receive will depend on the type of health insurance you have.

• If you are a retiree covered under the AlaskaCare Retiree Health Plan, you will receive a 1095-B.
• If you are an active employee covered under the AlaskaCare Employee Health Plan, you will receive a 1095-C.
  • Note that if you are an active employee covered under a union health trust, you will receive a 1095 form from your union health trust. Please contact your health trust with any questions.
• If you received coverage under a federal or state Health Insurance Marketplace (also called the “Exchange”), you will receive a 1095-A from the Marketplace. These forms are not issued for any AlaskaCare coverage.

1095-B forms are issued at the beginning of each year in advance of tax filing season. Typically, you will receive your form 1095-B by mid-March. If you are covered under the AlaskaCare Retiree Health Plan and believe you should have received a 1095-B but did not, please contact the Division of Retirement and Benefits.

You will not need to attach the 1095-B to your tax return. However, you should keep this documentation with your other tax records.

It is not necessary to wait for your form 1095-B in order to file your taxes. For more questions and answers about health care information forms for individuals from the IRS, see their FAQ page .

The 1095 forms are sent only to the member, or the “responsible individual” as referred to by the IRS. A copy of the form is not provided to dependents.

Yes, self-insured group health plans for employees, COBRA coverage, and retiree coverage qualify as Minimum Essential Coverage.

If you have additional questions about your 1095, please contact your tax consultant. Visit IRS.gov to learn more.