Beginning January 1, 2017, the District will offer a Medicare Supplement plan through The Hartford for retirees and their spouse/domestic partner age 65 and older. The plan includes coverage for medical, prescription, hearing, vision, chiropractic, and acupuncture services. While this is a District sponsored plan, enrollment, billing questions, etc. should be directed to Benistar Admin Services (see "Contact" tab below). In addition, retirees are responsible for 100% of the benefit premium.

In order to be eligible for The Hartford plan, applicants must meet all of the following criteria:

• Age 65 or Older
• Enrolled in Medicare Part A and B
• Currently enrolled in SVUSD's active group health plan, retiree group health plan, or COBRA medical coverage.

Please be advised that applicants are only eligible if moving directly from a SVUSD medical plan to The Hartford. Spouses looking to enroll must meet all the same requirements.

Rates for The Hartford are broken down by age. The rates below include coverage for medical, prescription, hearing, vision, chiropractic, and acupuncture. These rates do not include the cost of Medicare enrollment.

2024 Monthly Rates:

• Age 65-69 $453.49
• Age 70-74 $491.06
• Age 75-79 $528.01
• Age 80+    $540.06

Please note, applicants may only enroll in the full package, and cannot enroll in just prescription or just medical.

The Hartford network consists of all doctors who accept Medicare. Information on covered services, copays, etc. can be found by navigating the tabs below.

Applicants will need to submit a Medical enrollment form and a Prescription enrollment form directly to Benistar at least 30 days prior to your eligibility date. Please contact the Benefits Department for copies of these enrollment forms.

Dependent children are not eligible to enroll in the Hartford. All dependents will be offered the opportunity to enroll in COBRA once their coverage on an SVUSD active or retiree plan ends. SVUSD does not offer any additional coverage options for dependent children, however, they may wish to explore coverage options through the insurance market place by visiting Covered California.

No, all plan participants must be both 65+ and enrolled in Medicare part A and B.

For Enrollment, Eligibility, and Billing, contact:

BENISTAR Admin Services

• 10 Tower Lane, First Floor, Avon, CT 06001
• 800-236-4782, Press 1
• 5:30 am-3:00 pm

For Customer Service/Claims, contact:

The Hartford

• PO Box 1928, Grapevine, TX 76099
• 844-380-4577

For Prescription Drug Customer Service/Claims, contact:

Express Scripts

• Attn: Med-D Accounts, PO BOX 66752, St Louis, MO 63196-6752
• 888-345-2560

For Mail Order Prescription:

Express Scripts

• PO Box 66773, St Louis, MO 63166-6773
• Physician: 888-327-9791
• Fax: 800-357-9577
• Prior Authorization: 800-935-6103

Calendar Year Deductible: $0

Lifetime Maximum: Unlimited

Part A Services - Hospitalization

• Semi-private room and board, general nursing, and miscellaneous services and supplies.

Part A Services - Skilled Nursing Facility Care

• Semi-private room and board, skilled nursing and rehabilitative services and other services and supplies. You must meet Medicare's requirement which includes hospitalization of at least 3 days. You must enter a Medicare-approved facility within 30 days after leaving the hospital.

Part A Services - Blood Deductible - Hospital Confinement and Out-Patient Medical Expenses

• When furnished by a hospital or skilled nursing facility during a covered stay.

Part A Services - Hospice Care

• Pain relief, symptom management and support services for terminally ill.

Part B Services - Out-Patient Medical Expenses

The Policy may cover the following Medicare Pare B Benefits:

• Physician Services benefit
• Specialist Services benefit
• Outpatient Hospital Services and Ambulatory Surgical Care benefit
• Outpatient Diagnostic and Radiology Services benefit
• Outpatient Mental Health and Substance Abuse Services benefit
• Outpatient Rehabilitative and Cardiac Rehabilitative Services benefit
• Emergency Care benefit
• Urgent Care benefit
• Ambulance Services benefit
• Durable Medical Equipment and Prosthetics benefit

All Medicare Part B Benefits are based on per visit, except Ambulance Services Benefit, which is based on per trip, and Durable Medical Equipment and Prosthetics Benefit, which is based on per device.

Preventive Medical Care & Cancer Screenings

• Coverage for expenses incurred by a covered person for physical exams, preventative screening tests and services, cancer screenings, and any other tests or preventive measures determined to be appropriate by the attending Physician. Refer to your Medicare and You handbook for more information on Preventive services.

Foreign Travel Emergency

• Medically necessary emergency care services

Private Duty Nursing

• Service provided to a person while covered under this benefit and charged directly to the covered person by the nurse and not the hospital.

Hearing Services

Vision Services

Chiropractic Services

Acupuncture Services

Annual Physical Exam

Limitations & Exclusions: The Hartford's Insurance Plan does not cover any expense that is not a Medicare Eligible Expense or beyond the limits imposed by Medicare for such expenses or excluded by name or specific description by Medicare, except as specifically provided in the policy. The plan does not cover: Any part of a covered expense to the extent paid by Medicare; benefits payable under one benefit of the policy to the extent covered under another benefit of the policy; or expense incurred after coverage terminates, except as stated in the Extension-of-Benefits provision of the policy.

You do not pay a yearly deductible.

Initial Coverage Stage:

• You will pay the following until your total yearly drug costs (what you and the plan pay) reach $3,700

Not all drugs are available at a 90-day supply, and not all retail pharmacies offer a 90-day supply.

You may receive up to a 90-day supply of certain maintenance drugs (medications taken on a long-term basis) through home delivery from Express Scripts Pharmacy. There is no charge for standard shipping.

Additional Coverage Stages: