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This version is for retirees and their eligible survivors
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What to Do…
Benefits at a Glance
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Benefits
Health Care Participation
Medical Coverage
Newwork Access Plan (NAP)
Comprehensive Access Plan (CAP)
Retiree Optional Plan (ROP)
Medicare Supplemental Plan (MSP)
Definitions
Claims and Appeals Process
Non-Medicare HMOs and Kaiser EPO
Medicare HMOs
Mental Health and Substance Abuse Coverage
Prescription Drug Coverage
Life & Accident
Insurance
Retirement
Benefits
Other
Benefits
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Benefits Handbook Home
About This Handbook
Benefits at a Glance
What to Do…
Health Care Benefits
Life & Accident Insurance
Retirement Benefits
Other Benefits
Rules, Regulations & Administrative Information
Contacts
Health Care Benefits
Health Care Participation
Medical Coverage
Mental Health and Substance Abuse Coverage
Prescription Drug Coverage
Medical Coverage
Newwork Access Plan (NAP)
Comprehensive Access Plan (CAP)
Retiree Optional Plan (ROP)
Medicare Supplemental Plan (MSP)
Definitions
Claims and Appeals Process
Non-Medicare HMOs and Kaiser EPO
Medicare HMOs
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Welcome!
About This Handbook
Benefits at a Glance
Medical Coverage at a Glance
NAP Medical at a Glance
CAP Medical at a Glance
In-Area Health Savings Account (HSA) Medical Plan at a Glance
Out-of-Area Health Savings Account (HSA) Medical Plan at a Glance
Retiree Optional Plan (ROP) Medical at a Glance
Blue Shield HMO Medical at a Glance
Health Net HMO Medical at a Glance
Kaiser Permanente EPO Medical at a Glance
Medicare Supplemental Plan (MSP) Medical Coverage at a Glance
Medicare HMOs
Life and Accident Insurance at a Glance
Retirement Plans at a Glance
Life Balance Benefits at a Glance
What to Do.
Age-Related Events
Under Age 65
At Age 62
At Age 65
When Your Spouse or Registered Domestic Partner Turns 65
Family Events
If You Get Married or Establish a Registered Domestic Partnership
If You Have New Children
In the Case of Dissolution of Marriage or Termination of a Registered Domestic Partnership
In Case of Death
What Your Family Needs to Do in the Event of Your Death
If Your Spouse or Another Dependent Dies
Other Events
If You Move
If Your Children Become Ineligible for Coverage
Changing Coverage During the Year (Change-in-Status Events)
Health Care Benefits
Health Care Participation
Eligible Retirees
Eligible Dependents
Qualified Medical Child Support Orders
Disabled Dependents
Ineligible Dependents
Penalties for Covering Ineligible Dependents
Eligible Survivors of Retirees
If a Surviving Dependent Dies
Cost of Coverage
Retiree Medical Employer Contribution (RMEC) Program
Retiree Premium Offset Account (RPOA) for RMEC Retirees
Methods of Payment
Non-Payment of Premium Contribution
Retiree Medical Savings Account (RMSA)
Enrollment and When Coverage Begins
Changing Your Coverage
Open Enrollment
Mid-Year Health Care Enrollment Changes
Cancelling Coverage
Timeline for Enrollment
If You Have Other Coverage
Which Plan Is Primary for You?
Which Plan Is Primary for Your Children?
Coordination with Medicare
Reductions/Exclusions for Duplicate Coverage
Subrogation and Reimbursement
When Coverage Ends
Extended Benefits When Coverage Ends
COBRA and Conversion to an Individual Medical Policy
COBRA Coverage Under the Retiree Medical Plan
Appeals
Conversion to an Individual Medical Policy
HIPAA Conversion Plan
If Eligibility Is Denied
Medical Coverage
The Options Available
PG&E's Plans Administered by Anthem Blue Cross
Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)
Medical Benefits for Members Under 65
Medical Benefits for Medicare-Eligible Members
PG&E's Medicare Plan Options - General Information
Medicare
Medicare Part A
Medicare Part B
Medicare Part D
When You Become Medicare-Eligible
Other Things You Need to Know When You Become Medicare-Eligible
Network Access Plan (NAP)
NAP at a Glance
How the NAP Works
Network Providers
Non-Network Providers
Deductibles
Plan Maximums
Copayments and Benefit Percentages
How Benefits Are Determined
Medical Management Programs
Utilization Review Program
Authorization Program
Medical Necessity Review Process
Personal Case Management (for Non-Medicare Members)
What the NAP Covers
Acupuncture
Ambulance Services
Chiropractic Care
Hearing Aids - Effective January 1, 2014
Home Health Care and Hospice Care
Hospital Care - Inpatient
Hospital Care - Outpatient
Organ and Tissue Transplants
Prescription Drugs
Professional Services
Psychiatric Care and Substance Abuse Treatment
Transportation and Lodging
Skilled Nursing Facility
Other Covered Services and Supplies
What the NAP Doesn't Cover
Third-Party Exclusion
Comprehensive Access Plan (CAP)
CAP at a Glance
How the CAP Works
Deductibles and Maximums
Copayments and Benefit Percentages
How Benefits Are Determined
Medical Management Programs
Utilization Review Program
Authorization Program
Medical Necessity Review Process
Personal Case Management (for Non-Medicare Members)
What the CAP Covers
Acupuncture
Ambulance Services
Chiropractic Care
Hearing Aids - Effective January 1, 2014
Home Health Care and Hospice Care
Hospital Care - Inpatient
Hospital Care - Outpatient
Organ and Tissue Transplants
Prescription Drugs
Professional Services
Psychiatric Care and Substance Abuse Treatment
Skilled Nursing Facility
Transportation and Lodging
Other Covered Services and Supplies
What the CAP Doesn't Cover
Third-Party Exclusion
Retiree Optional Plan (ROP)
ROP at a Glance
How the Retiree Optional Plan (ROP) Works
Deductibles and Maximums
Copayments and Benefit Percentages
How Benefits Are Determined
Medical Management Programs
Utilization Review Program
Authorization Program
Medical Necessity Review Process
Personal Case Management (for Non-Medicare Members)
What the ROP Covers
Acupuncture
Ambulance Services
Chiropractic Care
Hearing Aids - Effective January 1, 2014
Home Health Care and Hospice Care
Hospital Care - Inpatient
Hospital Care - Outpatient
Mental Health Care
Organ and Tissue Transplants
Prescription Drugs
Professional Services
Psychiatric Care and Substance Abuse Treatment
Skilled Nursing Facility
Substance Abuse
Transportation and Lodging
Other Covered Services and Supplies
What the ROP Does Not Cover
Third-Party Exclusion
Medicare Supplemental Plan (MSP)
MSP at a Glance
Eligibility
How the MSP Works
What the MSP Covers
Services and Supplies
Emergency Care
Outpatient Prescription Drug Coverage
Skilled Nursing Facility
Home Health Care
Hospice Care
Mental Health Conditions
What the MSP Does Not Cover
Third-Party Exclusion
Definitions
Claims and Appeals Process
Filing a Claim for Benefits
Required Information
Payment of Benefits for Non-Network Benefits
Benefit Determinations (Before an Appeal Is Filed)
To Resolve a Problem
Appeals
How to Appeal a Claim Decision - Non-Urgent
PG&E's Voluntary Review Process
Non-Medicare Health Maintenance Organizations (HMOs) and the Kaiser Exclusive Provider Organization (EPO)
How HMOs and the Kaiser EPO Work
Primary Care Physicians (PCPs)
Service Areas
Available HMOs/EPOs
Summaries of Benefits (Non-Medicare)
Blue Shield HMO (Access+)
Health Net HMO
Kaiser Permanente EPO - North and South
Additional Coverage Rules
Claims, Appeals and Complaints
Claims
Appeals
Complaints Process for HMOs
Medicare Health Maintenance Organizations (HMOs)
HMO Plan Summaries of Benefits for Medicare-Eligible Members
Blue Shield Medicare COB HMO
Health Net Medicare COB HMO
Health Net Seniority Plus
Kaiser Senior Advantage - Northern and Southern California
HMO (Medicare) Claims, Appeals and Complaints
Eligibility & Participation
Claims
Mental Health and Substance Abuse Coverage
Eligibility
How Benefits Are Provided
For NAP Members
Coinsurance and Copayments for NAP Members
How the Program Works for NAP Members
What the Program Covers for NAP Members
For CAP Members
Deductibles and Limits for CAP Members
Coinsurance and Copayments for CAP Members
How the Program Works for CAP Members
What the Program Covers for CAP Members
For HMO and Kaiser EPO Members
Deductibles and Limits for HMO and Kaiser EPO Members
Coinsurance and Copayments for HMO and Kaiser EPO Members
How the Program Works for HMO and Kaiser EPO Members
What the Program Covers for HMO and Kaiser EPO Members
For Members of All Medical Plans
Medical Management and Authorization Programs
Medically Necessary
What the Program Does Not Cover
More about the Program
Claims and Appeals Process for ValueOptions (VO)
Prescription Drug Coverage
Plan Benefits
Generic Incentive Provision
Eligibility
How the Plan Works
Retail Pharmacy Service
Express Scripts Mail-Order Pharmacy
What the Plan Covers
What the Plan Does Not Cover
Coordination of Benefits
Claims and Appeals
Claims and Inquiries
Appeals
PG&E's Voluntary Review Process
Postretirement Life and Accident Insurance Plans
Life Insurance
Eligibility, Enrollment, and Cost
Imputed Income from Your Life Insurance Coverage
How Your Benefit Is Paid
Your Beneficiary
Accelerated Benefit Option (ABO)
Assignment of Benefits
When Coverage Ends
Converting Your Supplemental and Dependent Life Insurance Coverage to an Individual Policy
Claims and Appeals
Claims Relating to a Benefit
Claims Relating to Eligibility
Accidental Death & Dismemberment Insurance
Eligibility, Enrollment, and Cost
How Your Benefit Is Paid
Beneficiary Designation
Claims and Appeals
Claims Relating to a Benefit
Claims Relating to Eligibility
State Legal Notices
Retirement Benefits
Retirement Plan
If You Are a Current Employee Thinking About Retirement
Plan Highlights for Retirees and Survivors
Pension Checks
Payment Options
Other Retirement Benefit Provisions
Other Important Plan Information
Claims and Appeals
The Pension Benefit Guaranty Corporation
Retirement Savings Plan
Participating in the Plan
Beneficiary Designation
Investing
PG&E Corporation Stock Fund Dividends
Monitoring and Making Changes to Your Investments
Financial EnginesR
Fidelity Education and Modeling Tools
Distributions After Your Employment Has Ended
What Happens
If You Leave PG&E or Retire
If You Die
If You Get Divorced
If You Get Rehired
Additional Plan Information
Significant Accounting Policies and Investment Disclosure
Fees and Expenses
Plan Administration and the Corporation's Power and Duties
Participant Account Activity and Plan Service Provider
Claims and Appeals Procedures
Borrowing, Pledging, and Assigning Interests in the Plan
Future of the Plan
Qualified Domestic Relations Orders (QDROs)
Facility of Payment
Other Benefits
Retiree Discount
Smoking Cessation Program
Rules, Regulations & Administrative Information
Plan Amendment and Termination
Your Rights Under ERISA
Health Information Privacy and Data Security
Forfeiture of Unclaimed Benefit Payments
Facility of Payment
Administrative Information
The Pacific Gas and Electric Company Health Care Plan for Retirees and Surviving Dependents
The Pacific Gas and Electric Company Postretirement Life Insurance Plan
The Pacific Gas and Electric Company Retirement Plan
Contacts
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