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As a Pattonville School District Retiree, you can continue your current medical, dental and/or vision coverage. Once you become eligible for Medicare, you have additional options for your medical coverage that are designed to work with Medicare. This guide will help address common questions.

Pattonville School District

2023-2024 RETIREE BENEFIT OPTIONS

Marsh & McLennan Agency LLC

Open Enrollment 2023

August 23- September 6

Pattonville Retiree

Please review and return a completed form to the Benefits Office no than later than

September 6, 2023- the end of Open Enrollment. Please be aware of several premium

changes this year. Important note: New Retirees have up to 1 year from the date of their

retirement to select health coverage through Pattonville. If you have not enrolled within

your first year you are no longer eligible.

Premiums are paid by Direct Debit. Your monthly debit will be the sum of premiums you

choose. Circle all that apply.

UMR Health

Plan ^Retiree

Retiree +

Spouse

Retiree +

1 Child

Retiree +

Children ^{Retiree + Family}

Platinum

HRA ^{$858 $818 $548 $643 $1,327}

Gold HDHP ^{$820 $751 $460 $535 $1,254}

​

HRA ^{$779 $668 $390 $476 $1,146}

The following plans are associated with Medicare. If you are choosing not to enroll in one

of the traditional health plans offered by Pattonville and are age 65 but want to remain

part of the Pattonville group, you may elect one of these plans. IMPORTANT: Making

your Medicare selection on this form does not enroll you in either of these plans. This is

for administrative use to ensure your place in the Pattonville Group.

o This is a Medicare Replacement Plan

o Also known as MediGap coverage

For information about either of these plans or to enroll, please contact our partners at

Marsh McLennan Agency. Kevin Guss- 314-594-2717 / Kevin.Guss@MarshMMA.com.

​

Note: Most people sign up for both Part A (Hospital Insurance) and Part B (Medical Insurance) when they are first eligible (when they turn 65). Generally, there are risks to signing up later, like a gap in your coverage or having to pay a penalty.

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Delta Dental Retiree ^{Retiree +}

^Spouse

Retiree +

1 Child

Retiree +

Children ^{Retiree + Family}

Premier PPO $48 $44 $71 $77 $117

EPO/PPO $24 $16 $20 $22 $41

UHC

Vision

Retiree ^{Retiree +}

Family

UHCV $5.56 $16.09

The

Hartford ^Retiree

Life

$15000 ^$39.30

Only for summer 1995 retirees and after. Not

available unless currently enrolled.

Signature Phone Date

_______________________________________

Print Name

_______________________________________

Email

All retirees must return this form even if you are not making changes to existing coverage.

Pattonville School District

Benefits Coordinator

11097 St Charles Rock Rd

St. Ann, MO 63074

314-213-8035 benefits@psdr3.org

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Delta Dental gives you the freedom to visit the dentist of your choice and to select any dentist on a treatment by treatment

basis. It is important to remember your out-of-pocket costs may vary depending on your choice. You have three options and

the information below describes what you can expect depending on whether you receive services from a Delta Dental PPO

dentist, a Delta Dental Premier dentist or a non-participating dentist.

In PPO Network

1. Delta Dental PPO Network

Comprised of a select panel of dentists, over 287,389 dental offices participate in the Delta Dental PPO program. Delta Dental

will provide the highest level of benefits (see benefit highlights) for covered services when care is received from a Delta Dental

PPO dentist. These dentists agree to:

∙ Accept payment based on the applicable PPO Maximum Plan Allowance – reducing your out-of-pocket expenses.

∙ Submit dental claims for members and abide by Delta’s policies.

∙ Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta

Dental pays the dentist directly.

Your out-of-pocket expenses will be lowest when you see a Delta Dental PPO dentist.

In Premier Network

2. Delta Dental Premier Network

Comprised of over 363,417 participating dental offices, Delta Dental Premier offers you greater access to dentists while still

offering the advantages of a network. These dentists have participating agreements with Delta Dental which require them to:

∙ Accept payment based on the applicable Premier Maximum Plan Allowance – which means no balance billing on any charges

that exceed Delta’s contracted amount.

∙ Submit dental claims for members and abide by Delta’s policies.

∙ Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta

Dental pays the dentist directly.

If your dentist is not a Delta Dental PPO dentist but is a Delta Dental Premier dentist, your benefit will be based on the

Premier benefit level; however, you will receive the cost control and claims filing advantages noted above.

Non-Participating Dentist

3. Non-participating Dentist

If you receive services from a non-participating dentist (does not participate in either Delta Dental network) benefits for covered

services are based on the applicable Maximum Plan Allowance for non-participating dentists :

∙ You will be responsible for filing your own claim forms.

∙ Delta Dental’s benefit payment will be made directly to you.

∙ Benefit payments will be based on Delta’s maximum plan allowance.

∙ You will be responsible for the difference between the dentist’s charge and Delta’ maximum plan allowance.

Your out-of-pocket expenses may be more when you use a non-participating dentist.

Locating a Participating Dentist…

To determine if your dentist participates with Delta Dental or to select a participating dentist in your area:

∙ Ask your dentist if he or she participates in the Delta Dental PPO or Delta Dental Premier program

∙ Search on-line at www.deltadentalmo.com, or

∙ Call Delta Dental Customer Service at 1-800-335-8266

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Delta Dental gives you the freedom to visit the dentist of your choice and to select any dentist on a treatment by treatment

basis. It is important to remember your out-of-pocket costs may vary depending on your choice. You have three options and

the information below describes what you can expect depending on whether you receive services from a Delta Dental PPO

dentist, a Delta Dental Premier dentist or a non-participating dentist.

In PPO Network

1. Delta Dental PPO Network

Comprised of a select panel of dentists, over 287,389 dental offices participate in the Delta Dental PPO program. Delta Dental

will provide the highest level of benefits (see benefit highlights) for covered services when care is received from a Delta Dental

PPO dentist. These dentists agree to:

∙ Accept payment based on the applicable PPO Maximum Plan Allowance – reducing your out-of-pocket expenses.

∙ Submit dental claims for members and abide by Delta’s policies.

∙ Charge members only their deductible, co-insurance, and costs for non-covered services at the time of visit because Delta

Dental pays the dentist directly.

Your out-of-pocket expenses will be lowest when you see a Delta Dental PPO dentist.

Locating a Participating Dentist…

To determine if your dentist participates with Delta Dental or to select a participating dentist in your area:

∙ Ask your dentist if he or she participates in the Delta Dental PPO or Delta Dental Premier program

∙ Search on-line at www.deltadentalmo.com, or

∙ Call Delta Dental Customer Service at 1-800-335-8266

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United Healthcare Medicare Advantage Plan, Pages 12-37

The UHC Group Medicare Advantage is a Medicare Advantage PPO Plan with a Medicare contract. To join this plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in the defined Service Area list in the full benefit summary. You have the “choice” to visit any doctor within the Medicare Complete Network without referrals. However, this option also includes coverage for out of network benefits. The chart included provides summary information. Please contact UHC for complete details.

The following plan options are associated with Medicare and are only available to those eligible for Medicare. Included are the Benefit Summaries from UHC and Transamerica along with their enrollment forms. Once enrolled in the below plan(s), changes in plan election will not be allowed until the following open enrollment period

Transamerica Medicare Supplement Plan, Pages 38-44

The Transamerica Medicare Supplement Plan is another option for Retirees. Premiums are based on age and billed directly to you. When you contact Transamerica to enroll you will need to inform them that you are with the Pattonville School District. If you choose to enroll in this plan, please consider also enrolling in a Part D Prescription Drug Plan.

Medicare Options

Blue MedicareRx (PDP) Pages 45-53

The Anthem Blue MedicareRx Plan is another option for Retirees. Monthlypremiums are billed directly to you. When you contact the First Impressions team to enroll you will need to inform them that you are with the Pattonville School District. This is a Part D Prescription Drug Plan.

​

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Prescription Drugs

Your Cost

Initial Coverage Stage Network Pharmacy

(30-day retail supply)

Mail Service Pharmacy

(90-day supply)

Tier 1: Preferred Generic $15 copay $30 copay

Tier 2: Generic $15 copay $30 copay

Tier 3: Preferred Brand $47 copay $94 copay

Tier 4: Non-preferred Drug $100 copay $200 copay

Tier 5: Specialty Tier ^{$100 copay $200 copay}

Coverage gap stage After your total drug costs reach $4,430, you pay 25% of the

price (plus the dispensing fee) for brand name drugs and

25% of the price for generic drugs

Catastrophic coverage stage After your total out-of-pocket costs reach $7,050, you will pay

the greater of $3.95 copay for generic (including brand

drugs treated as generic), $9.85 copay for all other drugs, or

5% coinsurance

Retiree plan prospects must meet the eligibility requirements to enroll for group coverage. This information is not a

complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may

apply. Benefits, premium and/or copayments/coinsurance may change each plan year.

The Drug List (Formulary), pharmacy network, and/or provider network may change at any time. You will receive

notice when necessary.

Y0066_GRMABH_2022_M UHEX22PP4965023_000

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Medicare Part A

Hospital

+

Medicare Part B

Doctor and outpatient

+

Medicare Part D

Prescription drugs

+

Extra programs

Beyond Original Medicare

Your former employer or plan sponsor has chosen a

UnitedHealthcare Group Medicare Advantage plan. The

word “Group” means this is a plan designed just for a former

employer or plan sponsor like yours. Only eligible retirees of

your former employer or plan sponsor can enroll in this plan.

“Medicare Advantage” is also known as Medicare Part C.

These plans have all the benefits of Medicare Part A

(hospital coverage) and Medicare Part B (doctor and

outpatient care) plus extra programs that go beyond Original

Medicare (Medicare Parts A and B).

Make sure you know what parts of

Medicare you have

You must be entitled to Medicare Part A and

enrolled in Medicare Part B to enroll in this plan.

• If you’re not sure if you are enrolled in

Medicare Part B, check with Social Security

• Visit www.ssa.gov/locator or call

1-800-772-1213, TTY 1-800-325-0778,

8 a.m.–7 p.m., Monday–Friday, or call your

local office

• You must continue paying your Medicare

Part B premium to be eligible for coverage

under this group-sponsored plan

• If you stop paying your Medicare Part B

premium, you may be disenrolled from

this plan

Plan details

H2001_SPRJ61969_061021_M

Medicare Advantage

coverage:

UnitedHealthcare® Group

Medicare Advantage (PPO)

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How your Group Medicare Advantage plan works

Medicare has rules about what types of coverage you can add or combine with a group-sponsored

Medicare Advantage plan.

One plan at a time

• You may be enrolled in only 1 Medicare Advantage plan and 1 Medicare Part D

prescription drug plan at a time.

• The plan you enroll in last is the plan that Centers for Medicare & Medicaid Services

(CMS) considers to be your final decision.

• If you enroll in another Medicare Advantage plan or a stand-alone Medicare Part D

prescription drug plan after your enrollment in this group-sponsored plan, you will be

disenrolled from these plan(s).

• Any eligible family members may also be disenrolled from their group-sponsored plan.

This means that you and your family may not have hospital/medical or drug coverage

through your former employer or plan sponsor.

Remember: If you drop or are disenrolled from your group-sponsored retiree

coverage, you may not be able to re-enroll. Limitations and restrictions vary by

former employer or plan sponsor.

UHEX22PP4962768_001 SPRJ62014

Call toll-free , TTY ,

Questions? We’re here to help.

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www.UHCRetiree.com ^{Call toll-free 1-877-714-0178, TTY 711,}

8 a.m. - 8 p.m. local time, 7 days a week

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How your medical coverage works

Your plan is a Preferred Provider Organization (PPO) plan

This type of plan generally provides more flexibility to let you choose your doctors and hospitals.

You are typically not required to have a referral to see a specialist, and you can see doctors outside

the network without having to pay the entire cost yourself as long as they accept the plan and have

not opted out of or been excluded or precluded from the Medicare Program.

In-network Out-of-network

Can I continue to see my

doctor/specialist? ^Yes

Yes, as long as they participate

in Medicare and accept the plan¹

What is my copay or

coinsurance?

Copays and coinsurance

vary by service²

You may pay a larger share of

the cost for services²

Do I need to choose a primary

care provider (PCP)? ^{No, but recommended No, but recommended}

Do I need a referral to

see a specialist? ^{No No}

Can I go to any hospital? Yes _i^{Yes, as long as they participate}

n Medicare and accept the plan¹

Are emergency and urgently

needed services covered? ^{Yes Yes}

Do I have to pay the

full cost for all doctor or

hospital services?

You will pay your standard

copay or coinsurance for the

services you get²

You will pay your standard

copay or coinsurance for the

services you get (though the

amount may be higher)²

Is there a limit on how much

I can spend on medical

services each year?

Yes² Yes²

Are there any situations when

a doctor will balance bill me?

Under this plan, you are not responsible for any balance billing

when seeing health care providers who have not opted out of or

been excluded or precluded from the Medicare Program

1_{This means that the provider or hospital agrees to treat you and be paid according to UnitedHealthcare’s payment}

schedule. With this plan, we pay the same as Medicare and follow Medicare’s rules. Emergencies would be covered

even if out-of-network.

2_{Refer to the Summary of Benefits or Benefit Highlights in this guide for more information.}

Once you receive your UnitedHealthcare member ID card, you can create your secure online

account at:

You’ll be able to view plan documents, find a provider and access lifestyle and learning articles,

recipes, educational videos and more.

View your plan information online

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Plan information

www.UHCRetiree.com

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How your prescription drug coverage works

Your Medicare Part D prescription drug coverage includes thousands of brand-name and generic

prescription drugs. Check your plan’s drug list to see if your drugs are covered.

Here are answers to common questions:

What pharmacies can I use?

You can choose from thousands of national chain, regional and independent local retail pharmacies.

What is a drug-cost tier?

Drugs are divided into different cost levels, or tiers. In general, the lower the tier, the less you pay.

What will I pay for my prescription drugs?

What you pay will depend on the coverage your former employer or plan sponsor has arranged and

on what drug-cost tier your prescription falls into. Your cost may also change during the year based

on the total cost of the prescriptions you have filled.¹

Can I have more than 1 prescription drug plan?

No. You can only have 1 Medicare plan that includes prescription drug coverage at a time. If you

enroll in another Medicare Part D prescription drug plan OR a Medicare Advantage plan that

includes prescription drug coverage, you will be disenrolled from this plan.

1_{To learn more about your coverage, please refer to your Benefit Highlights or your Summary of Benefits.}

Questions? We’re here to help.

Call toll-free , TTY ,

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www.UHCRetiree.com ^{Call toll-free 1-877-714-0178, TTY 711,}

8 a.m. - 8 p.m. local time, 7 days a week

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Ways to save on your prescription drugs

You may save on the medications you take regularly

If you prefer the convenience of mail order, you could save time and money by receiving

your maintenance medications through OptumRx® Home Delivery. You’ll get automatic refill

reminders and access to licensed pharmacists if you have questions.

Get a 3-month¹ supply at retail pharmacies

In addition to OptumRx® Home Delivery, most retail pharmacies offer 3-month supplies for

some prescription drugs.

Ask your doctor about trial supplies

A trial supply allows you to fill a prescription for less than 30 days. This way, you can pay a

reduced copay or coinsurance and make sure the medication works for you before getting a

full month’s supply.

Explore lower-cost options

Each covered drug in your drug list is assigned to a drug-cost tier. Generally, the lower the

tier, the less you pay. If you’re taking a higher-tier drug, you may want to ask your doctor if

there’s a lower-tier drug you could take instead.

Have an annual medication review

Take some time during your Annual Wellness Visit to make sure you are only taking the

drugs you need.

The UnitedHealthcare Savings Promise

UnitedHealthcare is committed to keeping your prescription drug costs down. As a

UnitedHealthcare member, you have our Savings Promise that you’ll get the lowest price

available. That low price may be your plan copay, the pharmacy’s retail price or our

contracted price with the pharmacy.

1 _{Your former employer or plan sponsor may provide coverage beyond 3 months. Please refer to the Benefit Highlights}

or Summary of Benefits for more information.

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What is IRMAA?

The Income-Related Monthly Adjustment Amount (IRMAA) is an amount Social Security

determines you may need to pay in addition to your monthly plan premium if your

modified adjusted gross income on your IRS tax return from 2 years ago is above a

certain limit. This extra amount is paid directly to Social Security, not to your plan.

Social Security will contact you if you have to pay IRMAA.

Call Social Security to see if you qualify for Extra Help

If you have a limited income, you may be able to get Extra Help to pay for your

prescription drug costs. If you qualify, Extra Help could pay up to 75% or more of

your drug costs. Many people qualify and don’t know it. There’s no penalty for applying,

and you can re-apply every year.

Call toll-free 1-800-772-1213, TTY 1-800-325-0778, 8 a.m.–7 p.m., Monday–Friday, or

call your local office.

What is a Medicare Part D Late Enrollment Penalty (LEP)?

If, at any time after you first become eligible for Medicare Part D, there’s a period of

at least 63 days in a row when you don’t have Medicare Part D or other creditable

prescription drug coverage, a penalty may apply. Creditable coverage is prescription

drug coverage that is at least as good as or better than what Medicare requires.

The LEP is an amount added to your monthly Medicare premium and billed to you

separately by UnitedHealthcare.

When you become a member, your former employer or plan sponsor will be asked

to confirm that you have had continuous Medicare Part D coverage. If your former

employer or plan sponsor asks for information about your prescription drug coverage

history, please respond as quickly as possible to avoid an unnecessary penalty.

Once you become a member, more information will be available in your Evidence

of Coverage (EOC). Your Quick Start Guide will include details on how to access

your EOC.

Questions? We’re here to help.

Call toll-free , TTY ,

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www.UHCRetiree.com ^{Call toll-free 1-877-714-0178, TTY 711,}

8 a.m. - 8 p.m. local time, 7 days a week

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Your care begins with your doctor

• With this plan, you have the flexibility to see doctors inside or outside the UnitedHealthcare

network

• Even though it’s not required, it’s important to have a primary care provider

• You may pay a larger share of the cost when you see an out-of-network health care provider

• With your UnitedHealthcare Group Medicare Advantage plan, you’re connected to programs,

resources, tools and people that can help you live a healthier life

Finding a doctor is easy

If you need help finding a doctor or specialist, just give us a call. We can even help schedule that

first appointment.

Why use a UnitedHealthcare network doctor?

A network doctor or health care provider is one who contracts with us to provide services to

our members. We work closely with our network of doctors to give them access to resources and

tools that can help them work with you to make better health care decisions. You pay your copay or

coinsurance according to your plan benefits. Your provider will bill us for the rest.

An out-of-network provider does not have a contract with us. With the UnitedHealthcare Group

Medicare Advantage (PPO) plan, you can see any out-of-network provider as long as they accept the

plan and have not opted out of or been excluded or precluded from the Medicare Program. We will

pay for the rest of the cost of your covered service(s), including any charges up to the limit set by

Medicare. If your provider won’t accept the plan, we will contact them on your behalf.

If a provider refuses to directly bill us, they may ask that you pay the full allowable amount upfront.

In that case, you can pay the doctor and then submit a claim to us. You’ll be reimbursed for the cost

of the claim minus your cost share.

Filling your prescriptions is convenient

UnitedHealthcare has thousands of national chain, regional and independent local retail pharmacies

in our network.¹

1_{2021 Internal Report Data}

Getting the health care coverage you may need

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Take advantage of UnitedHealthcare’s additional support

and programs

Annual Wellness Visit¹ and many preventive services at $0 copay

An Annual Wellness Visit with your doctor is one of the best ways to start your year off

and stay on top of your health. Take control by scheduling your annual physical and

wellness visit early in the year to give you the most time to take action. You and your

doctor can work as a team to create a preventive care plan, review medications and talk

about any health concerns. You may also be eligible to earn a reward for completing

your Annual Wellness Visit through Renew Rewards*.

Enjoy a preventive care visit in the privacy of your own home

With UnitedHealthcare® HouseCalls², you get a yearly in-home visit from one of our

health care practitioners at no extra cost. A HouseCalls visit is designed to support, but

not take the place of, your regular doctor’s care.

Every visit includes tailored recommendations on health care screenings and a

chance to:

• Review current medications

• Receive education, prevention tips, care and resource assistance, if needed

• Get advice and ask questions on how to manage health conditions

• Receive referrals to other health services and more

At the end of the visit, our health care practitioner will leave a personalized checklist and

send a summary to your regular doctor.

Telephonic Nurse Support³

Speak to a registered nurse 24/7 about your medical concerns at no additional cost

to you.

Special programs for people with chronic or complex health needs

UnitedHealthcare offers special programs to help members who are living with a chronic

disease like diabetes or heart disease. You get personal attention and your doctors get

up-to-date information to help them make decisions.

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Virtual Visits

See a doctor or a behavioral health specialist using your computer, tablet or smartphone.

With Virtual Visits, you’re able to live video chat — anytime, day or night. You will first need

to register and then schedule an appointment. On your tablet or smartphone, you can

download the Amwell®, Doctor On Demand™ and Teladoc_® apps.

Virtual doctor visits

You can ask questions, get a diagnosis or even get medication prescribed and have it

sent to your pharmacy. All you need is a strong internet connection. Virtual doctor visits

are good for minor health concerns like:

• Allergies, bronchitis, cold/cough

• Fever, seasonal flu, sore throat

• Migraines/headaches, sinus problems, stomachache

• Bladder/urinary tract infections, rashes

Virtual behavioral health visits

May be best for:

• Initial evaluation

• Medication management

• Addiction

• Depression

• Trauma and loss

• Stress or anxiety

Hear the moments that matter most with custom-programmed

hearing aids

Your hearing health is important to your overall well-being and can help you stay

connected to those around you. With UnitedHealthcare Hearing, you’ll get access to

hundreds of name-brand and private-labeled hearing aids — available in person at any of

our 7,000+ UnitedHealthcare Hearing providers nationwide⁴ or delivered to your doorstep

with Right2You direct delivery and virtual care (select products only) — so you’ll get the

care you need to hear better and live life to the fullest.

And so much more to help you live a healthier life

After you become a member, we will connect you to many programs and tools that may

help you on your wellness journey. You will get information soon after your coverage

becomes effective.

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Tools and resources to help put you in control

Go online for valuable plan information

As a UnitedHealthcare member, you will have access to a safe, secure website where

you’ll be able to:

• Look up your latest claim information

• Review benefit information and plan materials

• Print a temporary ID card and request a new one

• Search for network doctors

• Search for pharmacies

• Look up drugs and how much they cost under your plan

• Learn more about health and wellness topics and sign up for healthy challenges

based on your interests and goals

• Sign up to get your Explanation of Benefits online

UnitedHealthcare fitness program

Renew Active®⁵ is the gold standard in Medicare fitness programs for body and mind,

available at no additional cost. You’ll receive a free gym membership with access to

the largest Medicare fitness network of gyms and fitness locations. This includes

access to many premium gyms, on-demand digital workout videos and live streaming

classes, social activities and access to an online Fitbit® Community for Renew Active

and access to an online brain health program from AARP® Staying Sharp® (no Fitbit

device is needed).

Go beyond the plan benefits to help you live your best life

Explore Renew by UnitedHealthcare,®⁶ our member-only health and wellness experience.

Renew helps inspire you to take charge of your health and wellness every day by

providing a wide variety of useful resources and activities, including:

• Brain games, healthy recipes, fitness activities, learning courses, Rewards*

and more — all at no additional cost

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1_{A copay or coinsurance may apply if you receive services that are not part of the Annual Physical/Wellness Visit.}

2_{HouseCalls may not be available in all areas.}

3 _{The Telephonic Nurse Support should not be used for emergency or urgent care needs. In an emergency, call 911 or}

go to the nearest emergency room. The information provided through this service is for informational purposes only.

The nurses cannot diagnose problems or recommend treatment and are not a substitute for your provider’s care. Your

health information is kept confidential in accordance with the law. Access to this service is subject to terms of use.

4_{Please refer to your Summary of Benefits for details regarding your benefit coverage.}

5_{Participation in the Renew Active® program is voluntary. Consult your doctor prior to beginning an exercise program}

or making changes to your lifestyle or health care routine. Renew Active includes standard fitness membership and

other offerings. Fitness membership equipment, classes, personalized fitness plans, caregiver access and events may

vary by location. Certain services, discounts, classes, events and online fitness offerings are provided by affiliates of

UnitedHealthcare Insurance Company or other third parties not affiliated with UnitedHealthcare. Participation in these

third-party services are subject to your acceptance of their respective terms and policies. AARP Staying Sharp is the

registered trademark of AARP. The largest gym network of all Medicare fitness programs is based upon comparison

of competitors’ website data as of March 2021. UnitedHealthcare is not responsible for the services or information

provided by third parties. The information provided through these services is for informational purposes only and is not a

substitute for the advice of a doctor. The Renew Active program varies by plan/area. Access to gym and fitness location

network may vary by location and plan. Renew Active premium gym and fitness location network only available with

certain plans.

6 _{Renew by UnitedHealthcare is not available in all plans. Resources may vary.}

*Renew Rewards is not available in all plans with Renew by UnitedHealthcare.

Benefits, features and/or devices vary by plan/area. Limitations and exclusions apply.

© 2021 United HealthCare Services, Inc. All Rights Reserved.

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What’s next

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Start using your plan on your effective date. Remember to use your UnitedHealthcare

member ID card.

UnitedHealthcare will process your enrollment

Quick Start Guide

and UnitedHealthcare

member ID card

Once you’re enrolled, we will mail you a Quick Start Guide 7–10 days

after your enrollment is approved and a UnitedHealthcare member

ID card. Please note, your member ID card will be attached to the

front cover of your guide.

Website access _w^{After you receive your member ID card, you can register online at the}

ebsite listed below to get access to plan information.

Health assessment

In the first 90 days after your plan’s effective date, we’ll give you a call.

Medicare requires us to call and ask you to complete a short health

survey. You can also go to the website below and take the survey online.

We’re here for you

When you call, be sure to let the Customer Service Advocate know that you’re calling about a

group-sponsored plan. In addition, it will be helpful to have:

Your group number found on the front of this book

Medicare number and Medicare effective date — you can find this information on

your red, white and blue Medicare card

Names and addresses for your doctors, clinics and the name and address of

your pharmacy

If you’re calling about drug coverage, please have a list of your current prescriptions

and dosages ready

H2001_SPRJ61971_052621_M UHEX22PP4961960_000 SPRJ62076

Here’s what you can expect next

Call toll-free , TTY ,

Questions? We’re here to help.

58

Call toll-free 1-877-714-0178, TTY 711

^{www.UHCRetiree.com} 8 a.m. - 8 p.m. local time, 7 days a week

Marsh & McLennan Agency LLC

You can enroll by phone, mail or fax. Simply choose the way that is easiest for you and follow the

Enrollment Request Form checkpoints below.

By phone

By mail

UnitedHealthcare

P.O. Box 30770

Salt Lake City, UT 84130-0770

By fax

Fill out the Enrollment Request Form and fax it to:

888-950-1170

Incomplete information may delay your enrollment.

Y0066_HTE_2022_C UHEX22MP4977604_000

Enrollment Request Form checkpoints

Print your name exactly as it

appears on your red, white and blue

Medicare card

Make sure your permanent address is

complete and accurate

Sign and date your name where indicated

Provide the name of your primary care

provider (PCP)

Confirm the plan sponsor and group

numbers are correct

Include the date you expect your proposed

coverage to begin

How to enroll

59

What’s next

Call toll-free 1-877-714-0178, TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week to

enroll over the phone.

Marsh & McLennan Agency LLC

Page 1 of 4

2022 Enrollment request form

1. Plan information

Plan sponsor

Group number GPS employer ID

GPS branch number

Effective date requested:

(i.e., your proposed effective date, or on what day your coverage should begin)

Plan sponsor use ONLY: Please date stamp this document to indicate when you received the

completed and signed form.

To enroll in the UnitedHealthcare® Group Medicare Advantage (PPO) plan, please provide the

following:

2.

Information about you (Please type or print in black or blue ink.)

Last name First name Middle initial

Birth date _{Sex: ◻ Male ◻ Female}

Home phone number

( ) —

Mobile phone number

( ) —

Medicare number

Permanent residence street address (P.O. Box is not allowed)

City County State ZIP code

Mailing address (Only if it’s different from above. You can give a P.O. Box)

City State ZIP code

Email address (optional)

61

What’s next

Pattonville School District

13762 24819

001

Marsh & McLennan Agency LLC

Page 2 of 4

Last name First name Medicare number

Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal

employee health benefits coverage, VA benefits or State Pharmaceutical Assistance Programs.

Will you have other prescription drug coverage in addition to our plan? Yes No

If “yes”, what is it?

Name of other insurance

Member number Group number

Rx Bin Rx PCN (optional)

Your answer to the following questions will not keep you from being enrolled in this plan:

3.A few questions to help us manage your plan

1.Would you prefer plan information in another language or an accessible format? Yes No

If “yes”, please select from the following:

Spanish Braille Other

If you don’t see the language or format you want, please call us toll-free at

2.Do you or your spouse work?

If “no”, what was your retirement date?

Yes No

3.

Do you have any health insurance other than Medicare, such as private

insurance, Worker’s Compensation, VA benefits or other employer coverage?

If “yes”, please provide the following:

Yes No

Name of the health insurance

Member number

4.Please give us the name of your primary care provider (PCP), clinic or health center.

Provider or PCP full name

Provider/PCP number (Please enter the number exactly as it appears

on the website or in the Provider Directory. It will

be 10 to 12 digits. Don’t include dashes.)

63

What’s next

1-877-714-0178, (TTY 711) during 8 a.m. - 8 p.m. local time, 7 days a week.

Marsh & McLennan Agency LLC

Page 3 of 4

5. Do you live in a nursing home or long-term care facility?

If “yes”, please give us information on the long-term care facility:

Yes No

Name

Address

City State ZIP code

Date you moved there

4. ATTENTION – please sign and date

I understand that my signature on this enrollment request form means that I have read

and understood the contents of this enrollment request form, including the Statements of

Understanding, and that the information provided by me is accurate and complete. If my plan

includes outpatient prescription drug benefits, I understand that my signature on this enrollment

request form means that I will be automatically enrolled in my plan’s outpatient prescription drug

benefits which includes Part D and supplemental prescription drug coverage. I understand that if I

intentionally provide false information on this form, I will be disenrolled from the plan.

This enrollment request form must be signed, dated and received prior to your desired

effective date. Upon receipt, the plan will process the form according to Medicare guidelines.

Signature of applicant/member/authorized representative Today’s date

5. Authorized representative information

If I sign as an authorized representative, it means I have the legal right under state law to sign.

I can show written proof (power of attorney, guardianship, etc.) of this right if Medicare asks for it.

I understand that I will need to submit written proof of this right, to the plan, if I wish to take action on

behalf of the member beyond this application. After this application has been approved and I have

received my UnitedHealthcare member ID card, I can call Customer Service at the number on my

UnitedHealthcare member ID card to update my authorization information on file.

Signature Today’s date

Last name First name Medicare number

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What’s next

Marsh & McLennan Agency LLC

Page 3 of 4

5. Do you live in a nursing home or long-term care facility?

If “yes”, please give us information on the long-term care facility:

Yes No

Name

Address

City State ZIP code

Date you moved there

4. ATTENTION – please sign and date

I understand that my signature on this enrollment request form means that I have read

and understood the contents of this enrollment request form, including the Statements of

Understanding, and that the information provided by me is accurate and complete. If my plan

includes outpatient prescription drug benefits, I understand that my signature on this enrollment

request form means that I will be automatically enrolled in my plan’s outpatient prescription drug

benefits which includes Part D and supplemental prescription drug coverage. I understand that if I

intentionally provide false information on this form, I will be disenrolled from the plan.

This enrollment request form must be signed, dated and received prior to your desired

effective date. Upon receipt, the plan will process the form according to Medicare guidelines.

Signature of applicant/member/authorized representative Today’s date

5. Authorized representative information

If I sign as an authorized representative, it means I have the legal right under state law to sign.

I can show written proof (power of attorney, guardianship, etc.) of this right if Medicare asks for it.

I understand that I will need to submit written proof of this right, to the plan, if I wish to take action on

behalf of the member beyond this application. After this application has been approved and I have

received my UnitedHealthcare member ID card, I can call Customer Service at the number on my

UnitedHealthcare member ID card to update my authorization information on file.

Signature Today’s date

Last name First name Medicare number

65

What’s next

Marsh & McLennan Agency LLC

Y0066_SOU_2022_C UHEX22MP4977956_000

By enrolling in this plan, I agree to the following:

This is a Medicare Advantage plan and has a contract with the federal government.

This is not a Medicare Supplement plan.

I need to keep my Medicare Part A and Part B, and continue to pay my Medicare Part B and, if

applicable, Part A premiums, if they are not paid for by Medicaid or a third party. To be eligible

for this plan, I must live in the plan’s service area and be a United States citizen or be lawfully

present in the U.S.

This plan covers a specific service area. If I plan to move out of the area, I will call my

plan sponsor or this plan to disenroll and get help finding a new plan in my area.

I may not be covered while out of the country, except for limited coverage near the U.S.

border. However, under this plan, when I am outside of the U.S. I am covered for emergency

or urgently needed care.

I can only have one Medicare Advantage or Prescription Drug plan at a time.

• Enrolling in this plan will automatically disenroll me from any other Medicare health plan.

• If I enroll in a different Medicare Advantage plan or Medicare Part D Prescription Drug

Plan, I will be automatically disenrolled from this plan.

• If I disenroll from this plan, I will be automatically transferred to Original Medicare.

• Enrollment in this plan is for the entire plan year. I may leave this plan only at certain times

of the year or under special conditions.

My information will be released to Medicare and other plans, only as necessary, for

treatment, payment and health care operations.

Medicare may also release my information for research and other purposes that follow all

applicable Federal statutes and regulations.

For members of the Group Medicare Advantage plan.

I understand that when my coverage begins, I must get all of my medical and prescription

drug benefits from the plan. Benefits and services provided by the plan and contained in the

Evidence of Coverage (EOC) document will be covered. Neither Medicare nor the plan will

pay for benefits or services that are not covered.

Statements of understanding

69

What’s next

Marsh & McLennan Agency LLC

38

Pattonville School District

Retiree Medical Insurance

Plan Description

Transamerica

Marsh & McLennan Agency LLC

SERVICES YOU PAY

First 60 days $0

61st - 90th days: $0

91st day and after:

While using 60 lifetime reserve

days

$0

Once lifetime reserve days are

used: Additional 365 days

$0

Beyond the Additional 365 days All Costs

First 20 days $0

21st thru 100th day $0

101st day and after All Costs

First 3 pints $0

Additional amounts $0

BLOOD

$0 3 pints per year

100% $0

All approved amounts $0

All but coinsurance each day 100% of daily coinsurance**

$0 $0

$0 Medicare Eligible Expenses

$0 $0

SKILLED NURSING FACILITY CARE

You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-

approved facility within 30 days after leaving the hospital:

All but Part A coinsurance each

day

Part A coinsurance each day

All but Part A coinsurance each

day

Part A coinsurance each day

MEDICARE PAYS PLAN PAYS

HOSPITALIZATION

Semiprivate room and board, general nursing and miscellaneous services and supplies:

All but Part A Deductible Part A Deductible

of the hospital and have not received skilled care in any other facility for 60 days in a row.

* A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out

Plan Description

Retiree Medical Insurance

Pattonville School District

Underwritten by Transamerica Life Insurance Company, Cedar Rapids, IA

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD*

**Plan pays up to Medicare's daily coinsurance amount. Medicare calculates the Skilled Nursing Facility coinsurance by multiplying the

Medicare Part A deductible by 1/8.

Benefits will not be paid for any expenses which are not determined to be Medicare Eligible Expenses by the Federal

Medicare Program or its administrators, except as otherwise specified. The Plan Description may not include all benefits

available to you. For complete details, please see Certificate. Descriptions and policy details may vary by state. This

policy's renewability, cancellability and termination provisions are at the option of the group policy holder except in cases

of non-payment of premium.

LM1000GPM, LM1000GCM, Form numbers may vary by state.

133292 04/122

Page 1 of 2

Marsh & McLennan Agency LLC

MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR

SERVICES MEDICARE PAYS

Part B Deductible of Medicare

Approved Amounts

$0

Remainder of Medicare Approved

Amounts

Generally 80%

Part B Excess Charges (above

Medicare Approved Amounts)

$0

First 3 pints $0

Part B Deductible of Medicare

Approved Amounts

$0

Remainder of Medicare Approved

Amounts

80%

Blood tests for diagnostic services 100%

Medically necessary skilled care

services and medical supplies

100%

Part B Deductible of Medicare

Approved Amounts

$0

Remainder of Medicare Approved

Amounts

80%

First $250 each calendar year $0

Remainder of charges $0

Benefits will not be paid for any expenses which are not determined to be Medicare Eligible Expenses by the Federal

Medicare Program or its administrators, except as otherwise specified. The Plan Description may not include all benefits

available to you. For complete details, please see Certificate. Descriptions and policy details may vary by state. This

policy's renewability, cancellability and termination provisions are at the option of the group policy holder except in cases

of non-payment of premium.

LM1000GPM, LM1000GCM, Form numbers may vary by state.

80% to a lifetime maximum of

$50,000

20% and amounts over

the $50,000 lifetime

maximum

20% $0

OTHER BENEFITS - IF NOT COVERED BY MEDICARE

FOREIGN TRAVEL

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA:

$0 $250

HOME HEALTH CARE - MEDICARE APPROVED SERVICES:

$0 $0

DURABLE MEDICAL EQUIPMENT

Part B Deductible $0

MEDICARE PARTS A & B

All costs $0

BLOOD

3 pints per year $0

Part B Deductible $0

20% $0

CLINICAL LABORATORY SERVICES

$0 $0

20% $0

PLAN PAYS YOU PAY

MEDICAL EXPENSES -

In or out of the Hospital and Outpatient Hospital Treatment, such as Physician’s services, inpatient and outpatient medical and

surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment:

Part B Deductible $0

Page 2 of 2

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Pattonville School District

Summary of Benefits

BlueMedicareRx

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