Seattle Fire Fighters HealthCare Trust

…for Fire Fighters by Fire Fighters…

Retiree Plans
Annual Benefits Enrollment Guide

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PLAN YEAR | 2011
Welcome to
Your 2011
Annual Benefits
Enrollment Guide!
The Board of Trustees for the Seattle Fire Fighters HealthCare Trust presents to
you the 2011 Annual Benefits Enrollment Guide.

As Trustees, we strive to offer our members valued, comprehensive,

sustainable and affordable health plans that are here for all of us –
from Recruit through Retirement – and to our families.

We encourage you to take the time to educate

yourselves about your benefit options
and choose the best coverage
for you and your family.

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A Word about this Annual Benefits Enrollment Guide
The Seattle Fire Fighters HealthCare Trust prides itself in offering benefits to all members,
from Recruit through Retirement. In this Annual Benefits Enrollment Guide, you will find
information regarding benefits available to our honored and retired members:

• Section One: Plan B – Retiree Medical and Prescription Drug Plan

• Section Two: Medicare Supplemental Plan and Medicare Part D

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SECTION ONE
Plan B – Retiree Medical and Prescription Drug Plan
Who is Eligible?
An individual must meet the following three requirements in order to be an
Eligible Participant:
1. The individual must have retired from the Seattle Fire Department as a
member in good standing of Local 27 and is not enrolled in Medicare Part
A and Part B;
2. The individual must either:
a. Have been a participant in the Seattle Fire Fighters HealthCare Plan
since its inception on January 1, 2008; or
b. Have been a participant in the Seattle Fire Fighters HealthCare Plan
for a minimum of 10 years; or
c. Have applied for a LEOFF system disability pension and have
exhausted his or her COBRA rights under the Seattle Fire Fighters
HealthCare Plan.
3. The individual must either:
a. Be receiving a LEOFF system pension check; or
b. Have a combination of years of service as a Local 27 Member PLUS
his or her age at separation from employment that equal to at least 70
(“Rule of 70”).

Important Eligibility Note: Participants enrolled in Plan B for the 2010 Plan Year continue to
be Eligible Participants without meeting the above-listed requirements as long as they maintain
continuous enrollment in Plan B.

Eligible Family Members* include:

• Your legal spouse or domestic partner (registered with the City of
Seattle or State of Washington), who is not enrolled in Medicare Part A
and Part B and who is not himself and herself a LEOFF 1 fire fighter

• Your children under the age of 26

• Surviving spouse/domestic partner and children of deceased eligible:

retired fire fighter, retired LEOFF 1 fire fighter, or active fire fighter

*Eligible Family Member is more fully described on the back of the enclosed Enrollment
Application and full eligibility rules are included in the Retiree Plan B Benefit Booklet.

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When to Enroll
When you meet the Definition of Eligible Participant (see “Who is
Eligible?” section on page 4), you may enroll in Plan B. Any benefit
selections you make at this time for you and your family will be
binding throughout the Plan Year until the next open enrollment
period, unless you experience a qualified change in status (see “How
to Make Changes” section below).
If you meet the Definition of Eligible Participant, but wish to defer
your enrollment in Plan B you may do so only if you and any eligible
dependents remain covered under another group insurance plan until
such time as you wish to enroll in Plan B. Individual insurance plans
do not qualify you for deferred enrollment. You may only defer
enrollment at the time you first meet the Definition of Eligible
Participant.

How to Enroll
Newly retired Eligible Participants: You must complete and submit
the Enrollment Application to the Trust Office within 30 days of your
retirement date. The Trust Office Information may be found in the
“Helpful Information” section on page 15 of this Guide.
Late Entrant Retiree: If you did not enroll in this Plan at your initial
eligibility (that is, you deferred your enrollment in Plan B), but would
like to enter the Plan at some future date, you must have creditable
group coverage during the time you were not enrolled on this Plan
(individual insurance plans do not qualify you for deferred
enrollment). To enroll, you must complete and submit the Enrollment
Application and proof of other group insurance to the Trust Office
within 30 days of the expiration of your other group insurance. The
Trust Office Information may be found in the “Helpful Information”
section on page 15 of this Guide.

How to Make Changes

Unless you have a qualified change in status, you cannot make
changes to the benefits you select until the next Open Enrollment
period. Qualified changes in status include: marriage, divorce, legal
separation, domestic partnership status change, birth or adoption of a
child, change in child’s dependent status, death of spouse, death of
domestic partner, death of child or other qualified dependent, change
in residence due to an employment transfer for you, your spouse or
domestic partner, commencement or termination of adoption
proceedings, loss of other coverage due to a change in your
spouse’s or domestic partner’s employment status, or a loss of other
coverage due to your spouse’s or domestic partner’s employer
ceasing to make contributions toward their coverage. Loss of other
coverage due to a failure to timely pay premiums or termination of
coverage for cause is not a qualified change in status. Should you
wish to make an enrollment change, you must complete and submit
the Enrollment Application to the Trust Office within 30 days of
adding a new family member and within 60 days of loss of other
group coverage.
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How Plan B Works…
Plan B offers coverage for both medical and prescription drugs. Regence BlueShield, the
claims administrator, also provides the network of providers and an array of services and
programs that complement the medical and prescription drug coverage through this Plan.

Provider Access
To receive the benefits summarized below, you may select any Regence Provider. To search
for a provider, or confirm that your provider is in the Regence network, you may:

• Call Regence for assistance in searching for a provider:

Customer Service: (800) 458-3523

Or

• You can use their on-line provider search engine:

www.wa.regence.com

Other Regence Services and Programs available to you at no additional cost:

• Disease Management - assistance from health professionals in managing
chronic conditions and/or diseases (such as Coronary Artery Disease,
Diabetes, etc.)

• Case Management - assistance from a health professional in managing

complex conditions and/or procedures (such as hip replacement surgery or
other extensive surgeries)

• myRegence.com - online services which allow you to view your own

personal claims and prescription drug history, access health information and
even chat online with other members and Regence professionals.

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Trust Plan B Medical and Prescription Drug Plan Summary
Benefit Plan B
Provider Access Regence Network of
Preferred, Participating, and
Non-Participating Providers
Calendar Year Deductible $750 per person / $2,250 per family
Coinsurance 80%
Out of Pocket Maximum $3,000 per person /
$9,000 per family
Professional Services
Outpatient Subject to deductible and
(Up to 15 visits per calendar year) then plan pays 80%
Inpatient Subject to deductible and
then plan pays 80%
Preventive Care
Routine Exam Covered in Full
(Including well baby exams, adult
physicals, and women’s health exams and
immunizations)
Preventive Care
Mammograms/ Covered in Full
Routine Prostate Screenings

Diagnostic Labs and Imaging

Outpatient Subject to deductible and
then plan pays 80%

Inpatient Subject to deductible and

then plan pays 80%

Hospital Services
Outpatient Subject to deductible
then plan pays 80%
Inpatient Subject to deductible
(Provider must notify Regence prior to any then plan pays 80%
admission except for emergencies)
ER Services $150 copay
(Copay waived if admitted, still subject to Subject to deductible
deductible and coinsurance) then plan pays 80%
Ambulance Service Subject to deductible
then plan pays 80% up to $500 per incident
when medically necessary
Acupuncture Up to 1 exam per calendar year
Up to 10 visits per calendar year
Subject to deductible
then plan pays 80%
This is a summary of benefit plans and is not intended to be relied upon as a contract. If a discrepancy occurs between this Enrollment
Guide and the benefit booklet, the language in the benefit booklet will prevail.

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Trust Plan B Medical and Prescription Drug Plan Summary (continued)
Benefit Plan B
Spinal Manipulations Up to 1 exam per calendar year
Up to 10 visits per calendar year
Subject to deductible
then plan pays 80%
Rehabilitation Services
Outpatient Up to $2,000 per calendar year
(Includes physical/massage/speech
and occupational therapy)
Subject to deductible
then plan pays 80%
Inpatient Up to $30,000 per calendar year
(Includes physical/massage/speech Subject to deductible
and occupational therapy) then plan pays 80%
Home Health Care Up to 10 visits per calendar year
Subject to deductible
then plan pays 80%
Hospice Up to $10,000 per year
Subject to deductible
then plan pays 80%
Skilled Nursing Facility Up to $10,000 per calendar year
Subject to deductible
then plan pays 80%
Chemical Dependency Treatment
Outpatient Subject to deductible
then plan pays 80%
Inpatient Subject to deductible
then plan pays 80%
Medical Supplies Subject to deductible
then plan pays 80%
Mental Health Care
Outpatient Subject to deductible
then plan pays 80%
Inpatient Subject to deductible
then plan pays 80%
Medical Supplies Up to $7,500 per calendar year
Subject to deductible
then plan pays 80%
Vision
Routine Eye Exam $25 copay
One every calendar year
Lenses and Frames Up to $120
One pair every calendar year
This is a summary of benefit plans and is not intended to be relied upon as a contract. If a discrepancy occurs between this Enrollment
Guide and the benefit booklet, the language in the benefit booklet will prevail.

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Trust Plan B Medical and Prescription Drug Plan Summary (continued)
Benefit Plan B
Prescription Drugs
Retail Generic 30% (with a $15 minimum)
Brand 50% (with a $30 minimum)
Non-preferred Brand 50% (with a $30 minimum)
Mail Order
Generic $ 45
Brand $ 90
Non-preferred Brand $ 90
This is a summary of benefit plans and is not intended to be relied upon as a contract. If a discrepancy occurs between this Enrollment
Guide and the benefit booklet, the language in the Retiree Plan B Benefit Booklet will prevail.

How Much Does Plan B Cost?

The costs to enroll in this Plan B Medical and Prescription Drug Plan are illustrated below.

Any changes as a result of enrollment changes (e.g., adding a spouse or deleting a spouse)
will reflect in your December 2010 checks for coverage that will become effective January 1,
2011. Otherwise Note: There were no changes to contribution rates for 2011!

LEOFF II – Contributions are illustrated on a monthly basis

Level of Coverage PLAN B

Fire Fighter Only $ 778.40

Fire Fighter + Spouse2/DP $ 1,556.80

Fire Fighter + Spouse/DP + Ch(ren) $ 1,849.40

Fire Fighter + Ch(ren) $ 1,071.00

LEOFF I – Contributions are illustrated on a monthly basis

Level of Coverage PLAN B

LEOFF I Fire Fighter Only1 N/A

LEOFF I Spouse2/DP Only $ 778.40

LEOFF I Spouse/DP + Ch(ren) $ 1,071.0

1
LEOFF I Fire Fighters are not eligible to participate in this Plan.
2
Spouses who are themselves LEOFF I fire fighters are not eligible to participate in this Plan.

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SECTION TWO
Medicare Supplemental Plan
Who is Eligible?
An individual must meet the following four requirements in order to be an
Eligible Participant:
1. The individual must have retired from the Seattle Fire Department as a
member in good standing of Local 27;
2. The individual is enrolled in Medicare Part A and Part B
3. The individual must either:
a. Have been a participant in the Seattle Fire Fighters HealthCare Plan
since its inception on January 1, 2008; or
b. Have been a participant in the Seattle Fire Fighters HealthCare Plan
for a minimum of 10 years; or
c. Have applied for a LEOFF system disability pension and have
exhausted his or her COBRA rights under the Seattle Fire Fighters
HealthCare Plan; or
d. Has been a participant in Plan B with no lapse in coverage from Plan
B.
4. The individual must either:
a. Be receiving a LEOFF system pension check; or
b. Have a combination of years of service as a Local 27 Member PLUS
his or her age at separation from service equal to 70 years (“Rule of
70”).

Important Eligibility Note: Participants enrolled in this Medicare Supplemental Plan for the
2010 Plan Year continue to be Eligible Participants without meeting the above-listed
requirements as long as they maintain continuous enrollment in this Medicare Supplemental
Plan.
If you are an eligible participant under Plan B or the Medicare Supplemental
Plan, Eligible Family Members include:
• Legal spouse or domestic partner (registered with the City of Seattle or State
of Washington) who is enrolled in Medicare Part A and Part B

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 When to Enroll
When you meet the Definition of Eligible Participant (see “Who
is Eligible?” section on page 10), you may enroll in the Medicare
Supplemental Plan. Any benefit selections you make at this time
will be binding throughout the Plan Year until the next Open
Enrollment period, unless you experience a qualified change in
status (see “How to Make Changes” section below).

How to Enroll
Newly enrolled in Medicare Part A and Part B: You must complete
and submit the Enrollment Application to the Trust Office within 30
days of your Medicare enrollment date. The Trust Office Information
may be found in the “Helpful Information” section on page 15 of this
Guide.

If you are interested in enrolling in the SilverScript program, contact

the Trust Office to request an enrollment packet. If you have enrolled
in a Medicare Part D prescription drug plan elsewhere, you may still
be eligible to receive reimbursements for prescription drug through
this Plan. Contact the Trust office with questions regarding Medicare
Part D prescription drug reimbursements.

How to Make Changes

Unless you have a qualified change in status, you cannot make
changes to the benefits you select until the next Open Enrollment
period. Qualified changes in status include: marriage, divorce, legal
separation, domestic partnership status change, death of spouse,
death of domestic partner, or death of other qualified dependent,
change in residence due to an employment transfer for you, your
spouse or domestic partner, loss of other coverage due to a change
in your spouse’s or domestic partner’s employment status, or a loss
of other coverage due to your spouse’s or domestic partner’s
employer ceasing to make contributions toward their coverage. Loss
of other coverage due to a failure to timely pay premiums or
termination of coverage for cause is not a qualified change in status.
Should you wish to make an enrollment change, you must complete
and submit the Enrollment Application to the Trust Office within 30
days of the qualified change in status.

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How the Medicare Supplemental Plan Works…
The Medicare Supplemental Plan offers supplemental coverage for approved Medicare
charges. The summary of eligible reimbursements is listed below:

Medicare Supplemental Plan Summary

Benefit Medicare Supplemental Plan
Medicare Deductibles
Reimbursed at 100%
(Part A and Part B)
Part B Coinsurance
Reimbursed at 100%
(20% paid by member)
Covered Services ƒ Physician Services
ƒ Surgeon & assistant surgeon
ƒ Physician consultation (while hospitalized)
ƒ X-rays
ƒ Laboratory work
ƒ Physical therapy (up to $2,000 per calendar year)
ƒ Radiation Therapy
ƒ Diagnostic Scans
ƒ Chiropractic Charges
ƒ Allergy care
ƒ Alcohol Treatment
ƒ Durable Medical Equipment
Reimbursement Payment Schedule
Hospitalization (Inpatient Part A) Deductible is reimbursed
Hospitalization (Outpatient Part B) Deductible and 20% coinsurance is reimbursed
Rehabilitative Charges 20% coinsurance reimbursed
(Physical, occupational, speech
therapies)

Total Payments from this Medicare Supplemental Plan are not to exceed the original claim
amount.

Non-Trust Medicare Prescription Drug Program – Medicare Part D

reimbursements
If you have enrolled in a Medicare Part D program through another carrier or health plan, you
may also receive reimbursement for your out-of-pocket expenses for Medicare Part D
prescription drug costs. The Medicare Supplemental Plan offers reimbursements for Medicare
Part D deductibles and coinsurance, up to your True Out of Pocket. The cost for this Part D
portion of the Plan is included in the Medicare Supplemental Plan costs illustrated on page 13.

Trust Medicare Prescription Drug Program –

SilverScript Medicare Part D and Part D reimbursement Information
If you have not enrolled in a Medicare Part D program through another carrier or health plan,
the Seattle Fire Fighters HealthCare Trust offers you access to SilverScript Medicare Part D,
which is an approved Medicare Part D prescription drug plan. The cost of the SilverScript
Medicare Part D plan is $38.00 per enrolled member per month. This cost is in addition to the
Medicare Supplemental Plan costs listed on page 13, and will be included in your deduction

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from your pension check (or if you pay the Trust directly, should be included in your monthly
payment).

For information regarding the SilverScript Medicare Part D program and changes for 2011,
please visit:

http://seattlefirefighters.silverscript.com

How Much Does The Medicare Supplemental Plan Cost?

The cost to enroll in this Medicare Supplemental Plan is illustrated below.

This change will reflect in your December 2010 checks for coverage that will become effective
January 1, 2011.

Contributions are illustrated on a monthly basis

Level of Coverage MEDICARE SUPPLEMENTAL PLAN

Per Enrolled Individual $ 148.50

If you are enrolled in the SilverScript Medicare Part D and Reimbursement Plan through CVS
Caremark, your 2011 costs are listed below. Please note: This additional cost will be billed
separate from your Medicare Supplemental Plan (above) and your payment should be directed
to the Trust Office.

Contributions are illustrated on a monthly basis and will be added to the Medicare
Supplemental Plan cost illustrated above.
SILVERSCRIPT MEDICARE PART D AND
Level of Coverage
REIMBURSEMENTS

Per Enrolled Individual $ 38.00

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Questions and Answers:
Forms to be completed if making changes to Plan B and/or Medicare
Supplemental Plan:
• Enrollment Application to add or drop eligible family member

To enroll in Plan B:
• If you wish to enroll in Plan B for the first time, you must complete the Enrollment
Application.
• If you are making any enrollment changes to Plan B (e.g., adding a spouse,
dropping an eligible family member), you must complete the Enrollment Application.

To enroll or re-enroll in Medicare Supplemental Plan and/or SilverScript Medicare Part

D:
• If you wish to enroll in the Medicare Supplemental Plan and/or SilverScript Medicare
Part D for the first time, you must complete the Enrollment Application.
• If you are an existing Medicare Supplemental Plan and/or SilverScript member, you
do not complete the Enrollment Application to continue your coverage for 2011.

Where do I find Plan B and Medicare Supplemental Plan forms?

• A 2011 Enrollment Application was included in the Enrollment Packet with this
Guide.
• You may also contact the Trust Office for forms.

When are the Plan B and Medicare Supplemental Plan forms due and where
do I return them?
• All 2011 Enrollment Application forms are due by December 6, 2010 and must
be returned to:
Seattle Fire Fighters HealthCare Trust Office
c/o Suzan Kolb
P.O. Box 6
Mukilteo, WA 98275-0006

Who do I contact with questions about Plan B, Medicare Supplemental

Plan, and/or SilverScript?
• You may contact:

Suzan Kolb, Trust Administrator (206) 859-2600

Nancy Grier, Trust Administrator (206) 859-2693

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Helpful Information:
DESCRIPTION OF INFORMATION CONTACT

TRUST OFFICE
PLAN B, MEDICARE SUPPLEMENTAL PLAN Nancy Grier
CUSTOMER SERVICES
For questions regarding Open Enrollment, request
Benefit Solutions, Inc.
benefits/enrollment forms, eligibility, general (206) 859-2693
benefits questions, Trust Operations

REGENCE BLUESHIELD
For questions regarding claims, pharmacy Customer Service
benefits, requesting new ID cards, finding a Hours: Monday – Friday from 8:00 am to 5:00 pm
provider or pharmacy (800) 458-3523

To find a provider:
www.wa.regence.com

To access your personal information

www.myregence.com

TRUST CONSULTANTS
DiMartino Associates, Inc.
For questions regarding, general benefits
questions, Trust business (206) 623-2430

SILVERSCRIPT MEDICARE PART D

For questions regarding claims, pharmacy Monday through Friday from 8:30 am to 5:00 pm
benefits, requesting new ID cards, finding a (206) 859-2693
provider or pharmacy

Online information:
http://seattlefirefighters.silverscript.com

The information in this Enrollment Guide is presented for illustrative purposes only. The text contained in this Guide was taken
from various sources. While every effort was taken to accurately report your benefits, discrepancies, or errors are always
possible. In case of discrepancy between the Guide and the formal plan documents, which are the Summary Plan Description
and the Benefit Booklet for the Plan in which you are enrolled, the formal plan documents will prevail. All information is
confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996.
If you have any questions about your 2011 Annual Benefits Enrollment Guide, contact the Trust Office.

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Seattle Fire Fighters HealthCare Trust

Board of Trustees
Dallas Baker
Aaron Karls
Jeff Milton
Tim O’Mahony
Chris Robinson
Zach Schade
Kenny Stuart

Trust Administrator
Benefit Solutions, Inc.

Prepared
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