PEIP Retiree Health Options

PEIP Retiree Health HealthPartners Freedom Plan Options

January 1, 2010 through December 31, 2010

HealthPartners Freedom Plan with RX HealthPartners Freedom Plan without RX $279.90 monthly $151.80 monthly Prescription Drugs $12 copay for generic drugs; $24 copay for brand drugs. No coverage. (30-day supply) Mail order available (2 copays for 90-day supply) Medicare Must have Parts A & B, or Part B only. Residency Requirements Must reside within the service area (see reverse side). Preventive Care (A routine physical, eye exam, hearing exam, 100% coverage in network. immunizations and cancer screenings) Physician Services $15 copay per visit in network. Extended Absence 100% coverage in network. Extended Absence (Office visit for illness or injury) Option available outside the state of Minnesota and Option available outside the state of Minnesota and within the U.S. within the U.S. 100% coverage at a network hospital. Hospital 80% coverage outside U.S. $50 copay, waived if admitted in U.S. $35 copay, waived if admitted in U.S. Emergency Care 80% coverage outside U.S. 80% coverage outside U.S.  In network, 50% coverage for hearing aids up  In network, $100 credit towards the purchase to a $1,000 maximum payment every 2 years of a hearing aid once every 5 years.  In network preventive dental with a $15 copay.  No coverage for preventive dental. Additional Benefits  Extended Absence Option – allows you to take  Extended Absence Option – allows you to take your benefits with you outside the state of your benefits with you outside the state of Minnesota and within the U.S., for up to 9 Minnesota and within the U.S., for up to 9 months. months.

Billing Options Monthly.

Changes Catastrophic Benefit Level: Once the rx out-of- Catastrophic Benefit Level: Once the rx out-of- HealthPartners Freedom Plan with RX HealthPartners Freedom Plan without RX $279.90 monthly $151.80 monthly pocket reaches $4,550 plan pays greater of $2.50 pocket reaches $4,550 plan pays greater of $2.50 for generic/$6.30 for brand drugs OR 5% of for generic/$6.30 for brand drugs OR 5% of prescription drug cost, whichever prescription drug cost, whichever is greater. is greater.

Service area includes: Aitkin, Anoka, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carlton, Carver, Cass, Chippewa, Chisago, Clay, Clearwater, Cook, Cottonwood, Crow Wing, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Goodhue, Grant, Hennepin, Houston, Hubbard, Isanti, Itasca, Jackson, Kanabec, Kandiyohi, Kittson, Koochiching, Lac qui Parle, Lake, Lake of the Woods, LeSueur, Lincoln, Service Area Lyon, Mahnomen, Marshall, Martin, McLeod, Meeker, Mille Lacs, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Pine, Pipestone, Polk, Pope, Ramsey, Red Lake, Redwood, Renville, Rice, Rock, Roseau, Scott, Sherburne, Sibley, St Louis, Stearns, Steele, Stevens, Swift, Todd, Traverse, Wabasha, Wadena, Waseca, Washington Watonwan, Wilkin, Winona, Wright and Yellow Medicine counties. Please call 952-883-5601 or 1-800-247-7015 for specific information.

This is a brief summary of benefits. Not all covered services, exclusions, and limitations are shown here.