1 2025 ACTIVE MEMBER DECISION GUIDE

MY 2025
S HBP ACTI VE D ECI SI O N GU I D E

MY S H BPGA.AD P.COM

SHBP ACTIVE MEMBER DECISION GUIDE

OCTOBER 15 - NOVEMBER 8, 2024
 1 STATE HEALTH BENEFIT PLAN RESOURCES/CONTACT INFORMATION
Anthem Blue Cross and Blue Shield (Anthem)
855-641-4862
Member Services: Monday - Friday, 8 a.m. - 8 p.m. ET
(TTY 711)
anthem.com/shbp
NurseLine (24 hours per day/7 days per week) 866-787-6361
Fraud Hotline: Monday - Friday, 8 a.m. - 8 p.m. ET 855-641-4862

Kaiser Permanente (KP)

855-512-5997
Member Services: Monday - Friday, 7 a.m. - 7 p.m. ET
(TTY 711)
Nurse Advice and Appointment Scheduling
404-365-0966
(24 hours per day/7 days per week)
Prescription Help: Monday - Friday, 7 a.m. - 9 p.m. ET, Saturday my.kp.org/shbp
404-365-0966
and Sunday, 9 a.m. - 6 p.m. ET
Wellness Program Customer Service: Monday - Friday
866-300-9867
(except holidays), 11 a.m. - 8 p.m. ET
Fraud Hotline: Monday - Friday, 7 a.m. - 7 p.m. ET 855-512-5997
Kaiser Permanente Rollover Account (KPRA) Customer Service
877-761-3399 kp.org/healthpayment
Monday - Friday (except holidays), 11 a.m. - 8 p.m. ET

UnitedHealthcare
Member Services: Monday - Friday, 8 a.m. - 8 p.m. ET 888-364-6352
(24 hours per day/7 days per week for Nurseline support) (TTY 711) whyuhc.com/shbp
Fraud Hotline: Monday - Friday, 8 a.m. - 8 p.m. ET 888-364-6352

Wellness Program Administrator

Sharecare 888-616-6411
Member Services: Monday - Friday, 8 a.m. - 8 p.m. ET (TTY 711)
bewellshbp.com
Corporate Compliance Hotline: 844-401-0005
24 hours per day/7 days per week (TTY 711)

Pharmacy Administrator
CVS Caremark®
844-345-3241
Member Services: 24 hours per day/7 days per week
info.caremark.com/shbp
Teletype (TTY) Line 800-231-4403
Fraud Hotline: 24 hours per day/7 days per week 877-287-2040

SHBP
SHBP Member Services
Open Enrollment: Monday - Friday, 8:30 a.m. - 7:30 p.m. ET,
800-610-1863 mySHBPga.adp.com
Saturday, 8:30 a.m. - 5 p.m.;
Regular Business Hours: Monday - Friday, 8:30 a.m. - 5 p.m. ET

Additional Information
TRICARE Supplement 866-637-9911 info.selmanco.com/ga_shbp
Social Security Administration 800-772-1213 ssa.gov

Centers for Medicare & Medicaid Services (CMS)

800-633-4227
24 hours a day/7 days per week medicare.gov
TTY 877-486-2048
The material in this Decision Guide is for informational purposes only and is not a contract. It is intended only to highlight principal benefits of the
SHBP Plan Options. Every effort has been made to be as accurate as possible; however, should there be a difference between this information
and the Plan Documents, the Plan Documents govern. It is the responsibility of each member, active and retired, to read all Plan materials
provided to fully understand the provisions of the option chosen. Availability of SHBP Options may change based on federal or state law changes
or as approved by the Board of Community Health. Premiums for SHBP Options are established by the Board of Community Health and may be
changed at any time by Board Resolution, subject to advance notice.
2 2025 ACTIVE MEMBER DECISION GUIDE

2024 Open Enrollment for Plan Year 2025

Welcome to the State Health Benefit Plan’s (SHBP) Open Enrollment (OE) for
the 2025 Plan Year. OE gives you the opportunity to review your Plan Options
and make changes to your coverage based on your needs. Please read this
document carefully to ensure you are choosing the option that best meets you
and your covered dependents’ healthcare needs.

CONTENTS
HEALTH CARE
ACRONYMS KEY
ANTHEM BLUE CROSS
ANTHEM
1 Resources/Contact Information (Inside Front Cover) AND BLUE SHIELD
CENTERS FOR MEDICARE
CMS & MEDICAID SERVICES
3 Commissioner’s Welcome Letter
DEPARTMENT OF
DCH COMMUNITY HEALTH
4 Welcome to Open Enrollment FLEXIBLE SPENDING
FSA ACCOUNT
5 2025 Medical Claims Administrators and Plan Options HIGH DEDUCTIBLE HEALTH
HDHP PLAN
6 Wellness Incentives At-A-Glance HEALTH INCENTIVE
HIA ACCOUNT
7 Important Plan Reminders HMO
HEALTH MAINTENANCE
ORGANIZATION

10 Annuitant Subsidy Policies HRA

HEALTH REIMBURSEMENT
ARRANGEMENT

11 Open Enrollment and Your Responsibilities HSA HEALTH SAVINGS ACCOUNT

KP KAISER PERMANENTE
12 Making Your Health Benefit Election for 2025 KAISER PERMANENTE
KPRA ROLLOVER ACCOUNT
17 New Hires MEDICARE ADVANTAGE
MAPD WITH PRESCRIPTION DRUGS
18 2025 SHBP Commercial Plan Options MIA MYINCENTIVE ACCOUNT

PCP PRIMARY CARE PHYSICIAN

19 Understanding Your Plan Options for 2025
PREFERRED PROVIDER
PPO ORGANIZATION
23 Benefits Comparison Summary: SHBP Commercial
QE QUALIFYING EVENT
Plan Options RETIREE REIMBURSEMENT
RRA ACCOUNT
34 Alternative Coverage RETIREE OPTION CHANGE
ROCP PERIOD
35 2025 Wellness SHBP STATE HEALTH BENEFIT PLAN

SPC SPECIALIST
41 If You Are Retiring
SUMMARY PLAN
SPD DESCRIPTION
43 Legal Notices
UHC UNITEDHEALTHCARE
 3 2025 ACTIVE MEMBER DECISION GUIDE

Brian P. Kemp, Governor Russel Carlson, Commissioner

2 Martin Luther King Jr. Drive SE, East Tower | Atlanta, GA 30334 | 404-656-4507 | www.dch.georgia.gov

Dear State Health Benefit Plan Member,

Welcome to the State Health Benefit Plan (SHBP) 2025 Open Enrollment through the Georgia Department
of Community Health! I’m thrilled to assist you as we strive to provide Georgians with access to
affordable, quality healthcare.

For the upcoming 2025 Plan Year, I’m delighted to announce that SHBP will once again offer a
comprehensive benefit package for both active and pre-65 retired members. Active members and pre-
65 retired members will have access to the same high-quality plan designs as offered in Plan Year 2024,
including:
• Gold, Silver, and Bronze Health Reimbursement Arrangement (HRA) Plan Options by Anthem Blue
Cross and Blue Shield (Anthem)
• High Deductible Health Plan (HDHP) Option by UnitedHealthcare
• Statewide Health Maintenance Organization (HMO) Plan Options by Anthem and
UnitedHealthcare
• Regional HMO Plan Option by Kaiser Permanente

Furthermore, CVS Caremark® will continue to administer pharmacy benefits for most plan options, and
Sharecare will administer the Be Well SHBP® well-being program. Visit bewellshbp.com for wellness
incentives or my.kp.org/shbp for Kaiser Permanente wellness program details.

You have two convenient ways to make your elections during Open Enrollment, from Tuesday, October
15, 2024, midnight ET through Friday, November 8, 2024, 11:59 p.m. ET:

1. Online via the SHBP enrollment portal at mySHBPga.adp.com

2. By contacting SHBP member services at 800-610-1863 during extended hours: Monday - Friday
from 8:30 a.m. to 7:30 p.m. ET.

Take full advantage of the flexibility offered by the SHBP enrollment portal, with 24-hour access, seven
days a week, for your convenience during Open Enrollment.

Before I conclude, I’d like to extend appreciation to Anthem, UnitedHealthcare, Kaiser Permanente, CVS
Caremark®, Sharecare, and our dedicated healthcare professionals for their ongoing commitment to
Shaping the Future of A Healthy Georgia. Your efforts are truly valued.

Looking forward to a successful Open Enrollment period!

Warm regards,

Russel Carlson
DCH Commissioner

Healthcare Facility Regulation | Medical Assistance Plans | State Health Benefit Plan | Health Planning
Equal Opportunity Employer
4 2025 ACTIVE MEMBER DECISION GUIDE

WELCOME TO OPEN ENROLLMENT

Greetings,

Let me welcome you to the Georgia Department of Community Health (DCH) State Health Benefit
Plan 2025 Open Enrollment (OE) Period. Thank you for the service that you, public school and
state employees, provide to so many Georgians.

Starting on Tuesday, October 15, at midnight, ET through Friday, November 8, 2024, at

11:59 p.m. ET, you will have the opportunity to enroll in a Plan Option that best fits your needs and
those in your family.

You may view the 2025 plan documents and other useful information regarding SHBP on our
website at shbp.georgia.gov.

This 2025 Active Member Decision Guide is a vital resource to assist in your decision-making. It
outlines your choices including Plan Option details, comparison charts, and important information
that will become effective January 1, 2025, and continue through December 31, 2025.

On behalf of Governor Brian Kemp, DCH Commissioner, Russel Carlson, the Board of Community
Health and the entire SHBP family, I encourage you to explore and carefully choose the Plan
Option that will meet your unique needs in 2025.

I look forward to supporting you as we continue Shaping the Future of A Healthy Georgia by
providing access to quality healthcare benefits for SHBP members.

Sincerely,

Louis A. Amis
Executive Director, SHBP
5 2025 ACTIVE MEMBER DECISION GUIDE

2025
Medical Claims Administrators
and Plan Options
Medical Claims Administrators
Anthem Blue Cross and Blue Shield (Anthem), Kaiser Permanente (KP) and
UnitedHealthcare will continue to offer State Health Benefit Plan (SHBP) members
the Commercial (active non-MA) Plan Options listed below for 2025.

Plan Options

Health Maintenance Organization (HMO)

• Anthem
• KP (Metro Atlanta Service Area In-Network only)
• UnitedHealthcare

High Deductible Health Plan (HDHP) with an option to open a Health Savings
Account (HSA)
• UnitedHealthcare

Health Reimbursement Arrangement (HRA) without co-pays

• Anthem: Gold, Silver and Bronze
 6 2025 ACTIVE MEMBER DECISION GUIDE

WELLNESS
INCENTIVES
2025 WELLNESS INCENTIVES AT-A-GLANCE
See 2025 Wellness section for details (pg. 35)
Anthem Health UnitedHealthcare UnitedHealthcare
Anthem HMO Kaiser
Reimbursement HMO Health HDHP Health
Plan Option MyIncentive Permanente (KP)
Arrangement Incentive Account Incentive Account
Account (MIA) Regional HMO
(HRA) (HIA) (HIA)

Up to Up to Up to Up to

Member 480 480 $500 Reward Card 480 480

Covered Spouse 480 480 $500 Reward Card 480 480

UnitedHealthcare
$250 Reward Card $250 Reward Card
Reward Card for
(member) (member)
enrolled member n/a n/a n/a
$250 Reward Card $250 Reward Card
and covered
(covered spouse) (covered spouse)
spouse

Potential Total 960 960 $1,000 1,460 1,460

Anthem HRA: Members enrolled in an Anthem HRA Plan Option will receive SHBP-funded base credits at the
beginning of the Plan Year. The amount funded will be based on the member’s elected coverage tier. If a
member enrolls in an HRA during the Plan Year, these credits will be prorated based on the elected coverage
tier and the months remaining in the current Plan Year. In addition, members and their covered spouses can
earn points for participating in the Be Well SHBP® well-being program.

KP: Members enrolled in the KP Regional HMO Plan Option and their covered spouses will each receive a $500
reward card after they each satisfy KP’s Wellness Program requirements.

UnitedHealthcare: Members and their covered spouses enrolled in a UnitedHealthcare Commercial (active
non-MA) Plan Option will each receive a $250 UnitedHealthcare Reward Card after satisfying all Be Well
SHBP® well-being program requirements and redeeming their points for either well-being incentive credits or
a $150 Visa Prepaid Card through the Sharecare Redemption Center.
 7 2025 ACTIVE MEMBER DECISION GUIDE

New Identification Cards

IMPORTANT PLAN REMINDERS
All UnitedHealthcare members, all Anthem members, and new Kaiser Permanente active and pre-65
retiree (non-MA) members will receive new identification cards before January 1.

Social Security Number (SSN) or other

Taxpayer Identification Number (TIN)
All members must provide SHBP with their Taxpayer Identification Number (TIN) for themselves and
their enrolled dependents upon enrolling in SHBP coverage. The most common type of TIN is a Social
Security Number (SSN), but for individuals who are not eligible for a SSN, members may submit
an Individual Taxpayer Identification Number (ITIN) or Adoption Taxpayer Identification Number
(ATIN). Failure to submit a TIN will result in a loss of coverage and no refund will be issued. For more
information, please visit and review the Invalid/No Social Security Number (SSN) FAQs on the SHBP
website: shbp.georgia.gov.

The requirement to provide an SSN or other TIN is a separate process from Dependent Verification.
Dependents whose coverage is terminated due to providing an invalid SSN or no SSN are not eligible
for coverage even if they passed the Dependent Verification process as they have failed to provide a
valid SSN to SHBP.

Members should provide their dependent(s) SSN by entering it directly into the SHBP Enrollment Portal
at mySHBPga.adp.com or by calling SHBP Member Services at 800-610-1863.

Dependent Verification
Certain Qualifying Events (QE) are opportunities for eligible employees employed with SHBP
Employing Entities to enroll themselves and/or add eligible dependents to their coverage. SHBP
requires documentation to confirm the eligibility of newly added dependents to be covered under
the Plan. Please see the Eligibility & Enrollment Provisions at shbp.georgia.gov for the acceptable
documentation. If you elect to cover dependents, generally, they will be placed in a pending status
until: 1) the required documentation confirming eligibility for coverage is submitted within 45 days
after you declare the QE and the documentation is approved, or 2) until the deadline to provide the
documentation has passed and the QE is automatically canceled; whichever occurs first.

There’s Still Time to Earn 2024 Wellness Incentives

Anthem Blue Cross and Blue Shield (Anthem) Commercial (active non-MA) and UnitedHealthcare
Commercial (active non-MA) Plan Options: Members and their covered spouses currently enrolled in
Anthem and UnitedHealthcare Commercial (active non-MA) Plan Options who have not completed
the required health actions or have not taken any actions have until December 2, 2024, to:

• Complete all required actions;

• Submit the 2024 Physician Screening Form to earn the 2024 points; and
• All submissions must be received by Sharecare no later than December 2, 2024.

If you have questions or need help getting started, visit BeWellSHBP.com or contact Sharecare
at 888-616-6411.
 8 2025 ACTIVE MEMBER DECISION GUIDE
( C O N T I N U E D )

Kaiser Permanente: Members and their covered spouses currently enrolled in the KP Regional HMO
Plan Option have until December 2, 2024 to complete all four wellness activities to receive a $500
reward card. Visit KP’s website at my.kp.org/shbp or contact KP’s wellness program customer
service at 866-300-9867 for details and if you have questions or need help getting started.

2024 Rollover Credits for Commercial (active non-MA) Plan Options: Regardless of what Plan
Option you select, all unused well-being incentive credits earned in 2024 will automatically roll over
to the 2025 Plan Option you choose during Open Enrollment. SHBP will deposit your unused credits
in the incentive account associated with your 2024 plan selection in April 2025. If you remain with
the same Medical Claims Administrator and in the same Plan Option in which you were enrolled in
2024, rollover credits will be available immediately.

Telemedicine/Virtual Visits

Telemedicine/virtual visits are a benefit that is available to SHBP members under all Plan Options.
Telemedicine allows healthcare professionals to evaluate, diagnose and treat patients using
telecommunication technology. Through your Plan’s participating telemedicine/virtual visit
providers, you will be able to see and/or talk to a participating provider from your mobile device,
tablet or computer with a webcam while at home, work or on the go. Please see the Benefits
Comparison Charts in this Decision Guide or contact the Medical Claims Administrators if you have
questions.

Summary of Benefits and Coverage (SBC) for Commercial (active

non-MA) Plan Options
SHBP provides Summary of Benefits and Coverage (SBC) for the following Commercial Plan
Options: Health Maintenance Organization (HMO), Health Reimbursement Arrangement (HRA)
and High Deductible Health Plan (HDHP). SBCs include standard information that help you to
understand, evaluate and compare the Plan Options as you make decisions about which Plan
Option to choose.

The SBCs are available online at shbp.georgia.gov/plan-documents/other-documents and

SHBP members can request electronic copies or paper copies of the SBCs on the website at
shbp.georgia.gov/sbc-request.
9 2025 ACTIVE MEMBER DECISION GUIDE

If you or your enrolled dependent(s) experience a Qualifying Event (QE) during

the Plan Year that results in coverage under a new identification (ID) number
or a change in Plan Option and/or vendor, your well-being incentives will be
forfeited. The deductible and out-of-pocket maximum will not be transferred. For
members enrolled in a Health Reimbursement Arrangement (HRA) Plan Option,
if moving to a new HRA ID number and/or HRA Plan Option, the HRA base funding
will be prorated based on the elected coverage tier and the months remaining in
the current Plan Year. Deductibles, out-of-pocket maximums and any well-being
incentive balances are not prorated nor transferrable. For additional information,
please reference the Eligibility & Enrollment Provisions at shbp.georgia.gov.
 10 2025 ACTIVE MEMBER DECISION GUIDE

The State Health Benefit Plan (SHBP) has two subsidy policies that determine the
ANNUITANT amount of subsidy Annuitants (Retirees) will receive from the SHBP to cover the cost
SUBSIDY POLICIES of their premiums. The amount of subsidy a Retiree receives from SHBP lowers the
monthly premium amount Retirees pay for their SHBP coverage.

Annuitant Basic Subsidy Policy (Basic Policy) Annuitant Years of Service Subsidy Policy (YOS Policy)
Under the Annuitant Basic Subsidy Policy, the Under the Annuitant YOS Policy, the monthly premium
monthly premium amount a Retiree pays for SHBP amount a Retiree pays for SHBP coverage depends on
coverage is the same across all Plan Options but the the number of years of service reported to SHBP from
percentage varies as the costs of Plan Options vary. the retirement system (ERS or TRS) in which the Retiree is
eligible to receive an annuity.
You are subject to the Annuitant Basic Subsidy
Policy if: You are subject to the Annuitant YOS Subsidy Policy if on
January 1, 2012, you did not have five years of service in
1. You were not an active employee on January the State retirement system from where you will receive
1, 2012, but were an Annuitant receiving a an annuity. The subsidy percentage for each member
retirement check from a State retirement system increases with every year of service beginning at 10 years
– ERS or TRS and enrolled in SHBP retirement through 30 or more years. Members with 0-9 years of
coverage on January 1, 2012; or service (i.e., less than 10 years of service) will receive no
subsidy.
2. You were not an active State employee
on January 1, 2012, but were a former State • For members, the subsidy range is a minimum of
employee with eight years of service and 15% for 10 years of service (i.e., 10 years of service =
enrolled in state extended SHBP coverage 15% subsidy), and a maximum of 75% for 30 or more
on January 1, 2012; or you were not an active years of service (i.e., 30 or more years of service = 75%;
Teacher or Public School employee on January but cannot be greater than the subsidy for an Active
1, 2012, but were a former Teacher or Public Employee)
School employee with eight years of service in
a State retirement system but could not retire The subsidy amount for each dependent increases with
due to age and enrolled in State extended SHBP every year of service for the member beginning at 10 years
coverage on January 1, 2012; or through 30 or more years.

3. You were an active employee who on • For dependents, the subsidy range is a minimum of 15%
January 1, 2012 had five years of service in the for a dependent if the member has 10 years of service,
State retirement system from where you will and a maximum of 55% if the member has 30 or more
receive an annuity (ERS or TRS). years of service but cannot be greater than the subsidy
for an Active Employee’s dependent minus 20%
Years of Service Reporting to SHBP
When a member retires, the applicable State retirement system (ERS or TRS) will provide SHBP information which
indicates whether or not a member had five years of service as of January 1, 2012. For members subject to the
YOS policy (i.e., did not have five years of service on January 1, 2012), each applicable State retirement system will
also provide SHBP the number of years of service that a member had upon their retirement. Years of service are
determined by the State retirement systems and not by SHBP. For calculation purposes, years of service are only
considered from the applicable State retirement system(s) from which a member actually retires.
Additional Information
SHBP rate calculators are available online at shbp.georgia.gov to assist Retirees with estimating their premiums
during the 2024 Plan Year. For questions regarding the YOS Policy, please contact SHBP Member Services at
800-610-1863.

The Board of Community Health sets all member premiums by resolution and in accordance with the law and
applicable revenue and expense projections. Any subsidy policy adopted by the Board may be changed at any
time by Board resolution and does not constitute a contract or promise of any amount of subsidy.
11 2025 ACTIVE MEMBER DECISION GUIDE

OPEN ENROLLMENT (OE)

AND YOUR RESPONSIBILITIES
The SHBP Enrollment Portal for OE available from October 15, 2024 at midnight through
November 8, 2024 at 11:59 p.m. ET.

Your Responsibilities as a State Health Benefit Plan (SHBP) Member

• Make your elections online at • Provide your Medicare Part B information
mySHBPga.adp.com no later than directly to SHBP at least one month prior to
November 8, 2024 by 11:59 p.m. ET. your retirement if you and/or your covered
• Make sure you read and understand the dependent, as applicable, are age 65 or
plan materials posted at shbp.georgia.gov older.
and take the required actions.
• Check your payroll deduction to verify that Note: Failure to do so will result in you and/
the correct deduction amount has been or your covered dependent(s) remaining
submitted. If you are not being charged the enrolled in a SHBP Commercial (active
correct amount, immediately contact your non-MA) Plan Option and you will pay
HR department. 100% of the unsubsidized premium, which
• Update any changes in contact information is substantially higher than the SHBP
(i.e., address, email, phone number) by Medicare Advantage Plan Options.
notifying your HR department.
• Notify SHBP whenever you have a change During OE, you may:
in covered dependents within 31 days of a • Elect SHBP coverage
Qualifying Event (QE) by visiting the SHBP • Change to any Plan Option and/or vendor
Enrollment Portal at mySHBPga.adp.com for which you are eligible
24 hours a day/7 days per week or • Enroll eligible dependents
contacting SHBP Member Services at • Drop covered dependents
800-610-1863 for assistance. • Decrease/increase coverage tier
• Discontinue SHBP coverage

IMPORTANT NOTE:
• The election made during OE will be the coverage you have for the entire 2025 Plan Year
unless you have a QE that allows a change to your coverage.
• Enrolling or discontinuing coverage from individual coverage offered through the Health
Insurance Marketplace (exchange) is NOT a QE.
12 2025 ACTIVE MEMBER DECISION GUIDE

MAKING YOUR HEALTH BENEFIT

ELECTION FOR 2025
Open Enrollment (OE) begins October 15, 2024, midnight ET and ends
November 8, 2024, 11:59 p.m. ET
Before making your selection, we urge you to review the Plan Options described in this guide, discuss
them with your family, and choose a Plan Option that is best for you and your covered dependents,
if applicable. Due to expected heavy call volume and online traffic, we strongly encourage all
members to: 1) confirm your access to the enrollment portal in advance of the Open Enrollment
(OE) election start date, and 2) make your election early.

Unable to Make Elections Online or Need Technical Assistance?

If you are unable to make your election(s) online or need technical assistance, please call SHBP
Member Services at 800-610-1863 prior to the last day of OE. Also, confirm that your email address
is correct in the enrollment portal.

How to Reset Your Password

Go to the Enrollment Portal: mySHBPga.adp.com

Step 1: Enter Your User ID

Step 2: Click Forgot Your Password
Step 3: Follow the instructions to answer a series of security questions (case sensitivity does apply)
Step 4: Create a new Password
Step 5: Click Continue

Note: If you do not know the answers to the security questions, contact SHBP Member Services at
800-610-1863 to assist you with the password reset process.

If you answer the security questions wrong or spell the answer incorrectly (case sensitivity does
apply), you will have two more tries before you are locked out and must begin the process again.

What if I Do Not Take Any Action?

If SHBP does not receive an election from you through the website, or by contacting SHBP Member
Services, you have made a decision to take the default coverage below:

• Currently Enrolled in a SHBP Commercial (active Non-MA) Plan Option in 2024: If you are
enrolled in a Commercial (active non-MA) Plan Option in 2024, you will remain in your current
Plan Option and tier with your current Medical Claims Administrator for the 2025 Plan Year.

• Currently Enrolled in TRICARE Supplement in 2024: If you are enrolled in the TRICARE
Supplement in 2024, you will remain enrolled in the TRICARE Supplement for the 2025 Plan Year.

NOTE: If you paid a Tobacco Surcharge in 2024, it will continue to apply. If you did not pay a
Tobacco Surcharge in 2024, you will not pay one if you take the default coverage. Remember,
it is your responsibility to notify SHBP immediately if you and/or your covered dependent(s) no
longer qualify for the Tobacco Surcharge. Also, it is your responsibility to contact SHBP if you and/
or your covered dependent(s) resumes his/her tobacco use. You must notify SHBP if your answer
to the Tobacco Surcharge question changes. If you are enrolled in a MA Plan option, the Tobacco
Surcharge does not apply to you.
13 2025 ACTIVE MEMBER DECISION GUIDE

How to Make Your 2025 Health Benefit Election Online

Go to the SHBP Enrollment Portal: mySHBPga.adp.com

Step 1: Log on to the SHBP Enrollment Portal.

• If you are a first-time user, you must first register using the registration code SHBP-GA and
set up a password before making your 2025 election.
• If you are a returning user but have not accessed the website in 45 days, you must first
reset your password before making your 2025 election.

Step 2: Under the Open Enrollment window, click on Enroll Now to proceed with your 2025 Plan
Year enrollment.

Step 3: If you have not provided a Tobacco Surcharge response in the past, you must first answer
the Tobacco Surcharge questions before going to Review Your Benefits.

Step 4: Click on Review Your Info (if applicable). Verify that each dependent has a valid Social
Security Number (SSN) or other Taxpayer Identification Number (TIN).

Step 5: To start your Election Process, click on Enroll in Benefits tab.

Step 6: Select Change. After you select Change, the Decision Support box will display.

Step 7: Click on Health Coverage or Dependent Health Coverage to choose your medical claims
administrator(s), your plan option(s), and coverage tier(s).

Step 8: Make Your Elections.

NOTE: When adding a dependent, scroll down and check the “Include in Coverage” box located
next to your newly added dependent. For existing dependents, confirm that all dependents
requiring benefits have a check in the “Include in Coverage” box.

If you choose NOT to enroll in a Plan Option you must click the radio option for No Coverage.
A pop-up box will then display Reason for Waive. You will need to use the drop-down box of
populated responses to select a reason for waiving. The Reason for Waive must be populated to
move to the next step.

Step 9: Click on Save and Return to All Benefits. “Your Elections” will display on the screen and
show the elections you made. You should carefully review your elections before confirming.

Step 10: Click I Agree and Confirm Elections. If I Agree and Confirm Elections is NOT clicked, your
enrollment process has not been completed, which means you have decided to make no
changes for 2025.
14 2025 ACTIVE MEMBER DECISION GUIDE

Take Advantage of Decision Support Tools to Help You Select the Healthcare
Option that Best Meets Your Personal and Financial Needs!

To help you with your enrollment choices, the State Health Benefit Plan (SHBP) has included
Decision Support Tools as part of the Enrollment Portal; using them, you will be provided with
personalized, easy-to-understand information to assist you in making educated healthcare
decisions. Decision Support Tools will help you choose the Plan Option that best meets your
personal needs and circumstances.

NOTE: The TRICARE Supplement is not supported by Decision Support Tool.

Newly added dependents, generally, will be placed in a pending status until: 1) the required
documentation is submitted within 45 days of your election proving they are eligible for
coverage, or 2) the deadline to provide the documentation has passed, whichever occurs first.

OPEN ENROLLMENT (OE) CHECKLIST

 Verify all desired dependents are listed on the Confirmation Page and have a
valid Social Security Number or other Taxpayer Identification Number;

 Verify your coverage tier (you only, you + spouse,

you + child(ren) or you + family);

 Confirm that the Plan Option selected shown on the confirmation page is
correct;

 Confirm you have answered the Tobacco Surcharge question appropriately

(applicable to active non-MA plan options only);

 Confirm that you have clicked Finish; and

 Print the confirmation page and save for your records.

NOTE: You may go online multiple times; however, the last option confirmed at the
close of OE will be your option for 2025 unless you experience a Qualifying Event (QE)
that allows you to make a change.
15 2025 ACTIVE MEMBER DECISION GUIDE

SHBP does not provide Flexible Benefits (e.g., dental, vision). If you are eligible to
Flexible make flexible benefit elections through your Employer, please contact your HR
Benefits
Department, or the Flexible Benefits Program administered by the Department of
Program
Administrative Services (DOAS) by visiting GABreeze.ga.gov or call 877-342-7339.

Making Changes During the Plan Year When You Experience a Qualifying Event (QE)
Consider your benefit needs carefully and make the appropriate selection. The election made
during 2024 Open Enrollment (OE) will be the coverage you have for the entire 2025 Plan Year,
unless you have a Qualifying Event (QE) that allows a change in your coverage. You only have
31 days after a QE to add a dependent (90 days to add a newly eligible dependent child). For a
complete description of QEs, see the Eligibility & Enrollment Provisions document available online
at shbp.georgia.gov.

You may also contact SHBP Member Services for assistance at 800-610-1863.

QEs include, but are not limited to: Eligible Dependents*

• Birth, adoption of a child, or child due The State Health Benefit Plan (SHBP)covers
to legal guardianship eligible dependents who meet SHBP guidelines.
• Death of a currently enrolled spouse or Eligible dependents include:
enrolled child • Spouse
• Your spouse’s or eligible dependent’s • Dependent child(ren), including:
loss of eligibility for other group health - Natural child
coverage - Adopted child
• Marriage or divorce - Stepchild
• Medicare eligibility - Child due to Guardianship
• Loss of Medicaid eligibility (excluding
*Visit the Eligibility and Enrollment Provisions
voluntary discontinuation of coverage/
document at shbp.georgia.gov for more
non-compliance/ failure to make
information on continuation of coverage for
payment)
covered dependents disabled prior to age 26.

How to Declare a Qualifying Event

To declare a Qualifying Event, you must log on to the SHBP Enrollment Portal at mySHBPga.adp.com
or contact SHBP Member Services at 800-610-1863.

Note: You can declare a Qualifying Event (QE) in the SHBP Enrollment Portal on the day of, but no earlier
than, the date on which the event actually occurs. For example, if your spouse loses his/her coverage
with his/her current employer on November 30, 2024, you cannot declare the QE in the Enrollment Portal
until November 30, 2024 (i.e., date of the event). If you do not declare the QE in the Enrollment Portal
within 31 days of November 30, 2024 (i.e., date of the event), you will not be able to make your QE in the
Enrollment Portal on a later date. When entering the QE in the portal, you must ensure that you enter the
correct date of the event as this calculates the effective date of the change resulting from the QE. You
may also call SHBP Member Services within the 31 days of the QE and the representatives will make the
necessary changes for you.

If you elect to cover dependents, generally, they will be placed in a pending status until: 1) the required
documentation confirming eligibility for coverage is submitted within 45 days after you declare the QE
and the documentation is approved, or 2) until the deadline to provide the documentation has passed
and the QE is automatically canceled, whichever occurs first.
16 2025 ACTIVE MEMBER DECISION GUIDE

If you are having a baby, you MUST contact SHBP Member Services at 800-610-1863 to add your
newborn child within 90 days of the birth in order for the baby to be covered as a dependent by
SHBP. You may also have to change Plan Tiers. For additional information, please see SHBP’s
Eligibility & Enrollment Provisions document available online at shbp.georgia.gov.
17 2025 ACTIVE MEMBER DECISION GUIDE

New Hires
New Hires Must Make their Election Directly with SHBP
within 31 Days of their Hire Date
SHBP requires that new hires make their elections directly in the SHBP Enrollment Portal at
mySHBPga.adp.com or by contacting SHBP Member Services at 800-610-1863 within 31 days of
their hire date. Making your election with your employer or through any other process does not
satisfy this requirement. If you fail to enroll in SHBP coverage as a new hire, your next opportunity
to enroll in SHBP coverage will be during the next Open Enrollment period, unless you have a
Qualifying Event that allows a change to your coverage.

For more information on how to make your election, please see the section: Making Your Health
Benefit Election for 2025.

Rehires and Transfers

Rehires and Transfers with a break in SHBP coverage of 30
days or less are not considered new hires. Therefore, they will
retain the same coverage or waiver of coverage status prior
to the rehire or transfer occurring.

Effective Date of Coverage

The effective date of coverage for new hires is the first of the
month following one full calendar month of employment
with an SHBP Employing Entity (e.g., State Agencies and
Public School Systems), unless the hire date is concurrent
with the first day of the month. If the hire date is concurrent
with the first day of the month, then coverage is effective the
first day of the month following the hire date.*

Examples:

• If hired October 15, 2024, one full calendar month

following October is November 1, 2024 – November
30, 2024, and coverage would begin the first day
of the month following November, which would be
December 1, 2024.
• If hired November 1, 2024, since the hire date is
concurrent with the first day of the month, coverage
would begin the first day of the following month,
which would be December 1, 2024.
• If hired January 31, 2025, one full calendar month
following January is February 1, 2025 – February 28,
2025, and coverage would begin the first day of the
month following February, which would be March 1,
2025.

*Note: If the first day of the month falls on a weekend or

holiday, the next business day is considered the first day of
the month for SHBP purposes.
18 2025 ACTIVE MEMBER DECISION GUIDE

2025 SHBP COMMERCIAL

(ACTIVE NON-MA)
PLAN OPTIONS
SHBP Members may elect a Commercial (active non-MA) Plan Option, which
includes the following:

Anthem Blue Cross and Blue Shield (Anthem)

• Health Reimbursement Arrangement (HRA) without co-pays

- Gold
- Silver
- Bronze
• Statewide Health Maintenance Organization (HMO)

UnitedHealthcare

• High Deductible Health Plan (HDHP) with an option to open an HSA

• Statewide Health Maintenance Organization (HMO)

Kaiser Permanente (KP)

The KP Regional HMO (Metro Atlanta Service Area only) offers medical,
wellness and pharmacy benefits. You must live or work in one of the below 31
counties within the Metro Atlanta Service Area to be eligible to enroll in KP:
Barrow Clark DeKalb Gwinnett Madison Paulding Walton
Bartow Clayton Douglas Haralson Meriwether Pickens
Butts Cobb Fayette Heard Newton Pike
Carroll Coweta Forsyth Henry Oconee Rockdale
Cherokee Dawson Fulton Lamar Oglethorpe Spalding

Additional Option
The TRICARE Supplement will continue to be available for those members enrolled in TRICARE. See
“Alternative Coverage” section for additional information.

CVS Caremark® Sharecare/Be Well SHBP®

Administers the pharmacy benefits for members who Provides comprehensive well-being
enroll in Anthem and UnitedHealthcare Commercial resources and incentive programs for
(active non-MA) Plan Options. CVS Caremark will provide members who enroll in Anthem and
benefits for retail prescription drug products, mail order, UnitedHealthcare Commercial (active
and specialty pharmacy services. non-MA) Plan Options. Sharecare
will also administer the 2025 action-
NOTE: Members do not have to go to a CVS pharmacy based health incentives that will
location for their prescriptions. CVS Caremark has a allow these SHBP members and their
broad pharmacy network. Use CVS Caremark’s pharmacy covered spouses to earn additional
locator tool to find a network pharmacy near you: points.
info.caremark.com/shbp
 19 2025 ACTIVE MEMBER DECISION GUIDE

Understanding Your
Plan Options For 2025
How the Health Reimbursement Arrangement (HRA) with Anthem Blue
Cross and Blue Shield (Anthem) Works
The HRA is a Consumer-Driven Health Plan (CDHP) NOTE: There is a date limitation to how the 2024
Option that includes a State Health Benefit Plan rollover credits can be used for reimbursement.
(SHBP) - funded HRA account that provides first- Only eligible medical and pharmacy expenses
dollar coverage for eligible medical and pharmacy incurred after the rollover in April 2025 will qualify
expenses. The HRA Plan Options offer access to a for reimbursement using the 2024 rollover credits.
statewide and national network of providers. Eligible medical and pharmacy expenses incurred
between January and March 2025 are not eligible
It is important to note that when you go to the for reimbursement using 2024 rollover credits,
doctor, you do not pay a co-pay. Instead, you pay unless you elect to remain in an HRA. If you stay
the applicable deductible or co-insurance. in an HRA, rollover credits will be available by the
end of January 2025. However, until your unused
SHBP contributes HRA credits to your HRA account 2024 credits roll over, your 2025 HRA credits funded
based on the HRA Plan Option and tier in which you by SHBP and any well-being incentive credits
are enrolled. If you have unused credits in your HRA earned in 2025 (and available at the time claims
account from 2024, those credits will roll over to the are received), will be used to offset those eligible
next Plan Year as long as you remain enrolled in an medical and pharmacy expenses incurred during
SHBP Plan Option, excluding TRICARE Supplement. If this time period.
you were previously a member of another SHBP Plan
Option, all unused 2024 well-being incentive credits
will roll over to your 2025 HRA plan, or any other
Plan Option, in April 2025.
PLAN FEATURES

• There are separate in-network and • Certain drug costs are waived if SHBP is
out-of-network deductibles and out-of-pocket primary and you actively participate in one of
maximums. the Disease Management (DM) Programs for
• After you meet your annual deductible, you pay diabetes, asthma, coronary artery disease, and/
a percentage of the cost of your eligible medical or medications for addiction treatment.
expenses, called co-insurance. • If you enroll in the HRA Plan Option after the
• You do not have to obtain a referral to see a first of the year, your SHBP-funded base
Specialist (SPC); however, we encourage you to credits deposited into your HRA account will be
select a PCP to help coordinate your care. prorated. However, your deductible and
• The credits in your HRA account are used to help co-insurance will not be prorated.
meet your deductible and your out-of-pocket • The Plan pays 100% of covered services provided
maximums. by in-network providers that are properly coded
• There are no co-pays. as “preventive care” within the meaning of the
• The medical and pharmacy out-of-pocket Affordable Care Act (ACA).
maximums are combined. NOTE: In-network diagnostic colonoscopies and
• Pharmacy expenses are not subject to the mammograms/breast services are covered at
deductible; instead, you pay co-insurance. If you 100%. Dilated retinal eye exams are covered at
have available HRA credits, these credits will be 100% once per calendar year.
used to pay your co-insurance at the point of
• Telemedicine/virtual visits for certain medical
sale. Once the credits in your HRA account are
and behavioral health services are available.
exhausted, you are responsible for paying the
co-insurance amount at the point of sale.
 20 2025 ACTIVE MEMBER DECISION GUIDE

How the High Deductible Health Plan (HDHP) with UnitedHealthcare Works
The HDHP offers in-network and out-of-network benefits and provides access to one of the largest
network of providers statewide and on a national basis. In addition to the HDHP’s low monthly
premium, an important benefit of the HDHP is you are able to open a Health Savings Account (HSA)
that allows you to save money tax deferred to help offset your plan costs.

For members and their covered spouses enrolled in a UnitedHealthcare Plan Option, please see
the 2024 Wellness section for more information about the additional $250 Reward Card offered
through UnitedHealthcare. Credits earned by participating in the Be Well SHBP® well-being
program are added to your HIA once the points have been redeemed through the Sharecare
Redemption Center. Any remaining credits will rollover to the next plan year.

The You coverage tier (single) deductible and out-of-pocket maximum will apply to each
individual family member regardless of whether you cover more than one dependent or have
family coverage. This means if your coverage tier is You + spouse, You + child(ren) or You + family,
an individual family member only needs to meet the You coverage tier deductible and
out-of-pocket maximum and his/her eligible medical and pharmacy expenses will be paid
regardless of whether the family deductible has been satisfied. Furthermore, once the You
coverage tier (single) out-of-pocket maximum has been satisfied for that individual family
member, all eligible medical and pharmacy expenses will be paid at 100% for the Plan Year for that
family member.

For example:
An individual who is covered under a family coverage tier, regardless of how many family
members are in that tier, will have a maximum individual in-network deductible of $3,500 and a
maximum individual in-network out-of-pocket of $6,450. The individual out-of-network deductible
maximum will not exceed $7,000 and the individual out-of-network out-of-pocket maximum will
not exceed $12,900. Additionally, an individual family member may not contribute more than their
own individual deductible or out-of-pocket maximum to the overall family deductible and
out-of-pocket maximum.

• There are separate in-network and • Certain drug costs are waived if SHBP is
PLAN FEATURES

out-of-network deductibles and out-of-pocket primary and you actively participate in one
maximums. of the Disease Management (DM) Programs
• You pay co-insurance after meeting the for diabetes, asthma, coronary artery disease,
deductible for all eligible medical and and/or medications for addiction treatment.
pharmacy expenses until the out-of-pocket Members must satisfy the deductible threshold
maximum is met. ($1,650 individual; $3,300 other tiers).
• You do not have to obtain a referral to see a • The Plan pays 100% of covered services
Specialist (SPC); however, we encourage you provided by in-network providers that are
to select a PCP to help coordinate your care. properly coded as “preventive care” within the
• There are no co-pays. meaning of the Affordable Care Act (ACA).
• The medical and pharmacy out-of-pocket • Select generics, listed on the Generic
maximums are combined. Maintenance Drug List, can be obtained for
• Before you can use well-being incentive a co-insurance without having to meet the
credits, members must meet the deductible deductible first.
threshold ($1,650 individual; $3,300 other tiers). • Telemedicine/virtual visits for certain medical
services are available.
 21 2025 ACTIVE MEMBER DECISION GUIDE

How the High Deductible Health Plan (HDHP) with UnitedHealthcare Works
(continued)
Health Savings Account (HSA) HSA Features:
An HSA is like a personal savings account with • Must be enrolled in an HDHP
investment options for health care, except it’s all • The HSA cannot be used with an FSA*
tax-free. You may open an HSA with Optum Bank • Only the amount of the actual account balance is
(a subsidiary of UnitedHealthcare), an independent available for reimbursement
bank, or an independent HSA administrator/ • The employee owns the account and keeps the
custodian. account
• Balances roll over each plan year
NOTE: HSA accounts cannot be combined with a • Investment options are available with a minimum
Flexible Spending Account (FSA).* balance and interest accrues on a tax-free basis
• Contributions can start, stop or change anytime
You can open an HSA if you enroll in the State Health • Distributions cover qualified medical expenses
Benefit Plan (SHBP) High Deductible Health Plan as defined under Section 213(d) of the Internal
(HDHP) and do not have other coverage through: Revenue Code and certain other expenses
• Tax form 1099 SA and 5498 are sent to employees
1) Your spouse’s employer’s plan, for filing
2) Medicare, or
3) Medicaid

*May be used with a general, limited purpose FSA. For more details, please contact your FSA administrator.

How the Statewide Health Maintenance Organization (HMO) with Anthem

Blue Cross and Blue Shield (Anthem) and UnitedHealthcare Works
An HMO allows you to receive covered medical services from in-network providers only (except for
emergency care). You are not required to select a Primary Care Physician (PCP) with the Statewide
HMO. Verify your provider is in-network before selecting an HMO Plan Option. When using in-network
providers, request that they use or refer you to other in-network providers. The HMO offers a statewide
and national network of providers.

For members and their covered spouses enrolled in a UnitedHealthcare Plan Option, please see the
2025 Wellness section for more information about the additional $250 Reward Card offered through
UnitedHealthcare. Credits earned by participating in the Be Well SHBP® well-being program are
added to your HIA or MIA once the points have been redeemed through the Sharecare Redemption
Center; any remaining credits will roll over to the next plan year.

• There are co-pays with this plan for certain • Co-pays count toward your out-of-pocket
PLAN FEATURES

services. maximum.
• Certain services are subject to a deductible and • Co-pays do not count toward your deductible.
co-insurance (see the Benefits Comparison • The medical and pharmacy out-of-pocket
Chart). maximums are combined.
• You do not have to obtain a referral to see a • Certain drug costs are waived if SHBP is primary
Specialist (SPC); however, we encourage you to and you actively participate in one of the Disease
select a PCP to help coordinate your care. Management Programs (DM) for diabetes,
• Coverage is only available when using in-network asthma, coronary artery disease, and/or
providers (except for emergency care). medications for addiction treatment.
• The Plan pays 100% of covered services provided • Telemedicine/virtual visits are available.
by in-network providers that are properly coded
as “preventive care” within the meaning of the
Affordable Care Act (ACA).
 22 2025 ACTIVE MEMBER DECISION GUIDE

HOW THE REGIONAL HEALTH

MAINTENANCE ORGANIZATION
WITH KAISER PERMANENTE WORKS
The KP Regional HMO option is available to State Health Benefit Plan (SHBP) members who
live or work in one of the 31 counties within the Metro Atlanta Service Area listed below.

Barrow Clark DeKalb Gwinnett Madison Paulding Walton

Bartow Clayton Douglas Haralson Meriwether Pickens
Butts Cobb Fayette Heard Newton Pike
Carroll Coweta Forsyth Henry Oconee Rockdale
Cherokee Dawson Fulton Lamar Oglethorpe Spalding

Choose your own Primary Care Physician

(PCP) from a network of carefully selected
Kaiser Permanente providers in 25 medical
facilities. You won’t need a referral for
dermatology, behavioral health, OB/GYN,
optometry or ophthalmology. For other
specialties, your PCP can coordinate any
specialty care you might need. To select a
PCP, you can log on to my.kp.org/shbp or
call KP’s Member Services at 855-512-5997.

The KP Regional HMO option pays 100% of

covered services provided by in-network
providers that are properly coded as
“preventive care” within the meaning of the
Affordable Care Act (ACA). KP administers
the benefits for medical, pharmacy and
wellness.
PLAN FEATURES

• This is a co-pay only option

• There are no deductibles or
co-insurance
• The medical and pharmacy
out-of-pocket maximums are
combined
• Telemedicine/virtual visits are
available without co-pays
• You and your covered spouse can
each earn a $500 reward card
for the completion of specific KP
wellness activities
23 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

SHBP Commercial (active non-MA) Plan Options

Please read the Benefits

Comparison Summary charts
in this guide carefully and
look at your medical and
prescription expenses to
make sure you understand
the out-of-pocket costs
under each option. In
addition, you can find
premium rates online at
shbp.georgia.gov.
 24 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HRA Plans | January 1, - December 31, 2025
Anthem Gold Anthem Silver Anthem Bronze
HRA Option HRA Option HRA Option

Out-of- Out-of- Out-of-

In-Network In-Network In-Network
Network Network Network
Covered Services You Pay You Pay You Pay
Deductible
• You $1,500 $3,000 $2,000 $4,000 $2,500 $5,000
• You + Spouse $2,250 $4,500 $3,000 $6,000 $3,750 $7,500
• You + Child(ren) $2,250 $4,500 $3,000 $6,000 $3,750 $7,500
• You + Family $3,000 $6,000 $4,000 $8,000 $5,000 $10,000

HRA credits will reduce ‘You Pay’ amounts

Out-of-Pocket Maximum
• You $4,000 $8,000 $5,000 $10,000 $6,000 $12,000
• You + Spouse $6,000 $12,000 $7,500 $15,000 $9,000 $18,000
• You + Child(ren) $6,000 $12,000 $7,500 $15,000 $9,000 $18,000
• You + Family $8,000 $16,000 $10,000 $20,000 $12,000 $24,000
HRA credits will reduce ‘You Pay’ amounts
HRA Credits The Plan Pays The Plan Pays The Plan Pays
• You $400 $200 $100
• You + Spouse $600 $300 $150
• You + Child(ren) $600 $300 $150
• You + Family $800 $400 $200
Physicians’ Services The Plan Pays The Plan Pays The Plan Pays
Primary Care Physician or 85% 60% 80% 60% 75% 60%
Specialist Office or Clinic coverage; coverage; coverage; coverage; coverage; coverage;
Visits subject to subject to subject to subject to subject to subject to
• Treatment of illness or injury deductible deductible deductible deductible deductible deductible
85% 60% 80% 60% 75% 60%
Maternity Care (non-routine,
coverage; coverage; coverage; coverage; coverage; coverage;
prenatal, delivery, and
subject to subject to subject to subject to subject to subject to
postpartum)
deductible deductible deductible deductible deductible deductible
Primary Care Physician or
Specialist Office or Clinic
100% 100% 100%
Visits for the following:
coverage; Not coverage; Not coverage; Not
• Wellness care/
not subject to covered not subject to covered not subject to covered
preventive health care
deductible deductible deductible
• Prenatal care coded as
preventive
Physician Services Furnished
in a Hospital 85% 60% 80% 60% 75% 60%
• Inpatient Visits, including coverage; coverage; coverage; coverage; coverage; coverage;
charges by surgeon, subject to subject to subject to subject to subject to subject to
anesthesiologist, pathologist deductible deductible deductible deductible deductible deductible
and radiologist
85% 80% 75%
coverage; coverage; coverage;
Telemedicine/Virtual visit Not covered Not covered Not covered
not subject to not subject to not subject to
deductible deductible deductible
 25 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HMO and HDHP Plans | January 1, - December 31, 2025

Anthem /
UnitedHealthcare KP Regional
UnitedHealthcare
HDHP Option HMO Option
Statewide HMO Option

Out-of-
In-Network Only In-Network In-Network Only
Network
Covered Services You Pay You Pay You Pay
Deductible
• You $1,300 $3,500 $7,000 $0
• You + Spouse $1,950 $7,000 $14,000 $0
• You + Child(ren) $1,950 $7,000 $14,000 $0
• You + Family $2,600 $7,000 $14,000 $0
Out-of-Pocket Maximum
• You $4,000 $6,450 $12,900 $6,350
• You + Spouse $6,500 $12,900 $25,800 $12,700
• You + Child(ren) $6,500 $12,900 $25,800 $12,700
• You + Family $9,000 $12,900 $25,800 $12,700
HRA Credits The Plan Pays The Plan Pays The Plan Pays
• You
• You + Spouse
N/A N/A N/A
• You + Child(ren)
• You + Family
Physicians’ Services The Plan Pays The Plan Pays The Plan Pays
70% 50%
Primary Care Physician or 100% coverage after 100% coverage after
coverage; coverage;
Specialist Office or Clinic Visits $35 PCP co-pay $35 PCP co-pay
subject to subject to
• Treatment of illness or injury $45 SPC co-pay $45 SPC co-pay
deductible deductible
70% 50%
Maternity Care (non-routine, 100% coverage after 100% coverage after
coverage; coverage;
prenatal, delivery, and $35 PCP co-pay $35 PCP co-pay
subject to subject to
postpartum) $45 SPC co-pay $45 SPC co-pay
deductible deductible
Primary Care Physician or
Specialist Office or Clinic Visits
100%
for the following: 100% coverage;
coverage; Not
• Wellness care/preventive not subject to deductible, 100% coverage
not subject to covered
health care in-network only
deductible
• Prenatal care coded as
preventive
Physician Services Furnished in
a Hospital 70% 50%
• Inpatient Visits, including 100% coverage; coverage; coverage;
100% coverage
charges by surgeon, subject to deductible subject to subject to
anesthesiologist, pathologist deductible deductible
and radiologist
70%
100% coverage after
coverage;
Telemedicine/Virtual visit $35 PCP co-pay Not covered 100% coverage
subject to
$45 SPC co-pay
deductible
 26 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HRA Plans | January 1, - December 31, 2025

Anthem Gold Anthem Silver Anthem Bronze

HRA Option HRA Option HRA Option

Out-of- Out-of- Out-of-

In-Network In-Network In-Network
Network Network Network

Physicians’ Services The Plan Pays The Plan Pays The Plan Pays

Physician Services for Emergency 85% coverage; 80% coverage; 75% coverage;
Care subject to deductible subject to deductible subject to deductible

85% 60% 80% 60% 75% 60%

coverage; coverage; coverage; coverage; coverage; coverage;
Allergy Shots and Serum
subject to subject to subject to subject to subject to subject to
deductible deductible deductible deductible deductible deductible
85% 60% 80% 60% 75% 60%
Outpatient Surgery/Services coverage; coverage; coverage; coverage; coverage; coverage;
• When billed as an office visit subject to subject to subject to subject to subject to subject to
deductible deductible deductible deductible deductible deductible
Outpatient Surgery/Services
• When billed with an 85% 60% 80% 60% 75% 60%
outpatient surgery at a facility; coverage; coverage; coverage; coverage; coverage; coverage;
including charges by surgeon, subject to subject to subject to subject to subject to subject to
anesthesiologist, pathologist and deductible deductible deductible deductible deductible deductible
radiologist
Hospital Services The Plan Pays The Plan Pays The Plan Pays
Inpatient Services 85% 60% 80% 60% 75% 60%
• Inpatient care, delivery and coverage; coverage; coverage; coverage; coverage; coverage;
inpatient short-term acute subject to subject to subject to subject to subject to subject to
rehabilitation services deductible deductible deductible deductible deductible deductible
85% 60% 80% 60% 75% 60%
Inpatient Services coverage; coverage; coverage; coverage; coverage; coverage;
• Well newborn care subject to subject to subject to subject to subject to subject to
deductible deductible deductible deductible deductible deductible
85% 60% 80% 60% 75% 60%
Outpatient Surgery/Services coverage; coverage; coverage; coverage; coverage; coverage;
• At a hospital or other facility subject to subject to subject to subject to subject to subject to
deductible deductible deductible deductible deductible deductible
Hospital Emergency Room Care
85% coverage; subject to 80% coverage; subject to 75% coverage; subject to
• Treatment of an emergency
in-network deductible in-network deductible in-network deductible
medical condition or injury
Outpatient Testing, Lab, etc. The Plan Pays The Plan Pays The Plan Pays
Non-Routine Laboratory; X-Rays,
Diagnostic Tests; Injections
• Including medications covered
85% 60% 80% 60% 75% 60%
under medical benefits for the
coverage; coverage; coverage; coverage; coverage; coverage;
treatment of an illness or injury
subject to subject to subject to subject to subject to subject to
NOTE: In-network diagnostic
deductible deductible deductible deductible deductible deductible
colonoscopies and mammograms/
diagnostic breast services are
covered at 100%
85% 60% 80% 60% 75% 60%
Complex Radiology Testing MRIs, coverage; coverage; coverage; coverage; coverage; coverage;
CTs, PET and Nuclear Medicine subject to subject to subject to subject to subject to subject to
deductible deductible deductible deductible deductible deductible
 27 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HMO and HDHP Plans | January 1, - December 31, 2025

Anthem /
UnitedHealthcare
UnitedHealthcare KP Regional HMO Option
HDHP Option
Statewide HMO Option

Out-of-
In-Network Only In-Network In-Network Only
Network
Physicians’ Services The Plan Pays The Plan Pays The Plan Pays

Physician Services for Emergency 70% coverage; subject to

100% coverage 100% coverage
Care in-network deductible

70% 50%
Allergy Shots and Serum 100% after 100% after
coverage; coverage;
• Co-pay only applies when $35 PCP co-pay $35 PCP co-pay
subject to subject to
billed with an office visit $45 SPC co-pay $45 SPC co-pay
deductible deductible
70% 50%
100% after 100% after
Outpatient Surgery/Services coverage; coverage;
$35 PCP co-pay $35 PCP co-pay
• When billed as an office visit subject to subject to
$45 SPC co-pay $45 SPC co-pay
deductible deductible
Outpatient Surgery/Services
• When billed with an outpatient 70% 50%
surgery at a facility, including 80% coverage; coverage; coverage; 100% coverage
charges by surgeon, subject to deductible subject to subject to after $100 co-pay
anesthesiologist, pathologist and deductible deductible
radiologist
Hospital Services The Plan Pays The Plan Pays The Plan Pays
Inpatient Services 70% 50%
• Inpatient care, delivery and inpatient 80% coverage; coverage; coverage; 100% coverage after
short-term acute rehabilitation subject to deductible subject to subject to $250 co-pay
services deductible deductible
70% 50%
Inpatient Services coverage; coverage;
100% coverage 100% coverage
• Well newborn care subject to subject to
deductible deductible
70% 50%
Outpatient Surgery/Services 80% coverage; coverage; coverage; 100% coverage after
• At a hospital or other facility subject to deductible subject to subject to $100 co-pay
deductible deductible
Hospital Emergency Room Care 100% coverage after 100% coverage after
70% coverage; subject to
• Treatment of an emergency medical $200 co-pay, if admitted $200 co-pay, if admitted
in-network deductible
condition or injury co-pay waived co-pay waived
Outpatient Testing, Lab, etc. The Plan Pays The Plan Pays The Plan Pays
Non-Routine Laboratory, X-Rays,
Diagnostic Tests, Injections
• Including medications covered
70% 50% 100% coverage at KP or
under medical benefits - for the
80% coverage; coverage; coverage; contracted facility
treatment of an illness or injury
subject to deductible subject to subject to $100 co-pay at outpatient
NOTE: In-network diagnostic
deductible deductible hospital facility
colonoscopies and mammograms
are covered at 100%. For HDHP,
deductible must be met first.
70% 50% $45 co-pay at KP or
Complex Radiology Testing MRIs, CTs, 80% coverage; coverage; coverage; contracted freestanding
PET and Nuclear Medicine subject to deductible subject to subject to imaging center $100 co-pay
deductible deductible at outpatient hospital facility
 28 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HRA Plans | January 1, - December 31, 2025
Anthem Gold HRA Option Anthem Silver HRA Option Anthem Bronze HRA Option

Out-of- Out-of-
In-Network In-Network In-Network Out-of-Network
Network Network

Behavioral Health The Plan Pays The Plan Pays The Plan Pays
Mental Health and
Substance Use Disorder
85% coverage; 60% coverage; 80% coverage; 60% coverage; 75% coverage; 60% coverage;
(MH/SUD) Inpatient Facility
subject to subject to subject to subject to subject to subject to
and Residential Treatment
deductible deductible deductible deductible deductible deductible
Centers
NOTE: Prior approval required
MH/SUD: Group Outpatient
85% coverage; 60% coverage; 80% coverage; 60% coverage; 75% coverage; 60% coverage;
Visits, Intensive Outpatient,
subject to subject to subject to subject to subject to subject to
Partial Day Hospitalization,
deductible deductible deductible deductible deductible deductible
and Methadone Clinics
MH/SUD: Outpatient Visits 85% coverage; 60% coverage; 80% coverage; 60% coverage; 75% coverage; 60% coverage;
Professional and Methadone subject to subject to subject to subject to subject to subject to
Clinics deductible deductible deductible deductible deductible deductible

Other Coverage The Plan Pays The Plan Pays The Plan Pays
Outpatient Acute Short-Term
Rehab Services
• Physical, Speech and
Occupational Therapies
• Other Short-Term Rehab 85% coverage; 60% coverage; 80% coverage; 60% coverage; 75% coverage; 60% coverage;
Services subject to subject to subject to subject to subject to subject to
NOTE: There is a benefit deductible deductible deductible deductible deductible deductible
maximum of 40 visits
(combined in-network and
out-of-network) per therapy
in a benefit year.
Chiropractic Care Coverage 85% coverage; 60% coverage; 80% coverage; 60% coverage; 75% coverage; 60% coverage;
Up to a maximum of 20 visits subject to subject to subject to subject to subject to subject to
per Plan Year deductible deductible deductible deductible deductible deductible
Vision Routine Eye Exam
NOTE:
100% coverage; 100% coverage; 100% coverage;
• Limited to one eye exam
not subject to deductible not subject to deductible not subject to deductible
every 24 months.
Out-of-network Out-of-network Out-of-network
• Dilated retinal eye exam is
eye exam not covered eye exam not covered eye exam not covered
covered at 100% once per
calendar year
Hearing Services
Routine Hearing Exam when 100% coverage Not covered 100% coverage Not covered 100% coverage Not covered
properly coded as preventive
Hearing Services 85% coverage; 60% coverage; 80% coverage; 60% coverage; 75% coverage; 60% coverage;
Non-routine hearing not subject to subject to subject to subject to subject to subject to
performed in an office setting deductible deductible deductible deductible deductible deductible
85% coverage for exam and 80% coverage for exam and 75% coverage for exam and
fittings (subject to deductible); fittings (subject to deductible); fittings (subject to deductible);
Hearing Aid: Adult Fittings $1,500 hearing aid allowance $1,500 hearing aid allowance $1,500 hearing aid allowance
every five years (not subject to every five years (not subject to every five years (not subject to
deductible) deductible) deductible)
80% coverage for exam and 75% coverage for exam and
85% coverage for exam and
fittings (subject to deductible); fittings (subject to deductible);
fittings (subject to deductible);
Hearing Aid: Children $3,000 hearing aid allowance $3,000 hearing aid allowance
$3,000 hearing aid allowance per
(Up to age 19) Fittings per hearing impaired ear every per hearing impaired ear every
hearing impaired ear every four
four years (not subject to four years (not subject to
years (not subject to deductible)
deductible) deductible)
 29 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HMO and HDHP Plans | January 1, - December 31, 2025
Anthem/UnitedHealthcare UnitedHealthcare KP Regional
Statewide HMO Option HDHP Option HMO Option
Out-of-
In-Network Only In-Network In-Network Only
Network

Behavioral Health The Plan Pays The Plan Pays The Plan Pays

Mental Health and Substance Use

70% coverage; 50% coverage; 100% after $250 co-pay
Disorder (MH/SUD) Inpatient Facility 80% coverage;
subject to subject to Contact KP directly
and Residential Treatment Centers. subject to deductible
deductible deductible for benefit coverage
NOTE: Prior approval required.
MH/SUD: Group Outpatient Visits, 100% after $35 SPC per visit.
70% coverage; 50% coverage;
Intensive Outpatient, Partial Day $17 co-pay for group therapy
100% Coverage subject to subject to
Hospitalization, Contact KP directly
deductible deductible
and Methadone Clinics for benefit coverage
100% after $35 PCP co-pay
70% coverage; 50% coverage;
MH/SUD Office Visits: Professional 100% after $35 PCP co-pay $35 SPC co-pay
subject to subject to
and Methadone Clinics $35 SPC co-pay Contact KP directly
deductible deductible
for benefit coverage
Other Coverage The Plan Pays The Plan Pays The Plan Pays
Outpatient Acute Short-Term
Rehab Services
• Physical, Speech and
Occupational Therapies 70% coverage; 50% coverage;
• Other Short-Term Rehab Services 100% after $25 co-pay subject to subject to 100% after $25 co-pay
NOTE: There is a benefit maximum deductible deductible
of 40 visits (combined in-network
and out-of-network) per therapy
in a benefit year.

Chiropractic Care Coverage 70% coverage; 50% coverage;

Up to a maximum of 20 visits per 100% after $45 co-pay subject to subject to 100% after $45 co-pay
Plan Year deductible deductible

Vision Routine Eye Exam

NOTE:
100% coverage;
• Limited to one eye exam every 24 100% coverage; 100% coverage;
not subject to deductible
months. not subject to deductible, not subject to deductible
Out-of-network
• Dilated retinal eye exam is in-network only in-network only
eye exam not covered
covered at 100% once per year
with a diagnosis or diabetes
100%
Hearing Services
coverage;
Routine Hearing Exam when 100% coverage Not covered 100% coverage
not subject to
properly coded as preventive
deductible

Hearing Services 70% coverage; 50% coverage; 100% after $100 co-pay in
80% coverage;
Non-routine hearing not performed subject to subject to outpatient setting or $250
subject to deductible
in an office setting deductible deductible co-pay in inpatient setting

100% for exam and fittings;

70% coverage for exam and
after $35 PCP co-pay 100% coverage for exam
fittings (subject to deductible);
$45 SPC co-pay and fittings;
Hearing Aid: Adults Fittings $1,500 hearing aid allowance
$1,500 hearing aid allowance $1,500 hearing aid allowance
every five years
every five years every five years
(subject to deductible)
(not subject to deductible)

100% for exam and fittings;

70% coverage for exam and 100% coverage for exam and
after $35 PCP co-pay
fittings (subject to deductible); fittings;
$45 SPC co-pay
Hearing Aid: Children $3,000 hearing aid allowance $3,000 hearing aid allowance
$3,000 hearing aid allowance
(Up to age 19) Fittings per hearing impaired ear per hearing impaired ear every
per hearing impaired ear every
every four years (subject to four years (not subject to
four years (not subject to
deductible) deductible)
deductible)
 30 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HRA Plans | January 1, - December 31, 2025

Anthem Gold HRA Option Anthem Silver HRA Option Anthem Bronze HRA Option
Out-of- Out-of- Out-of-
In-Network In-Network In-Network
Network Network Network
Other Coverage The Plan Pays The Plan Pays The Plan Pays
Applied Behavior
Analysis

NOTE: Requires
85% coverage not subject to 80% coverage not subject to 75% coverage not subject to
prior approval;
deductible deductible deductible
only covered for
treatment for
autism spectrum
disorders.
85% 60% 80% 60% 75% 60%
Urgent Care coverage; coverage; coverage; coverage; coverage; coverage;
Services subject to subject to subject to subject to subject to subject to
deductible deductible deductible deductible deductible deductible
Home Health
Care Services 85% 60% 80% 60% 75% 60%
coverage; coverage; coverage; coverage; coverage; coverage;
NOTE: Prior subject to subject to subject to subject to subject to subject to
approval deductible deductible deductible deductible deductible deductible
required.
Skilled Nursing 85% 80% 75%
Facility Services coverage; up coverage; up coverage; up
to 120 days to 120 days to 120 days
Not Covered Not Covered Not Covered
NOTE: Prior per Plan Year; per Plan Year; per Plan Year;
approval subject to subject to subject to
required. deductible deductible deductible
Hospice Care
85% 60% 80% 60% 75% 60%
coverage; coverage; coverage; coverage; coverage; coverage;
NOTE: Prior
subject to subject to subject to subject to subject to subject to
approval
deductible deductible deductible deductible deductible deductible
required.
Durable Medical
Equipment
(DME) - Rental or
85% 60% 80% 60% 75% 60%
purchase
coverage; coverage; coverage; coverage; coverage; coverage;
subject to subject to subject to subject to subject to subject to
NOTE: Prior
deductible deductible deductible deductible deductible deductible
approval
required for
certain DME.
Transplant
Services
Contact the Medical Claim Administrator for coverage details
NOTE: Prior
approval
required.
 31 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HMO and HDHP Plans | January 1, - December 31, 2025

Anthem/
UnitedHealthcare KP Regional
UnitedHealthcare
HDHP Option HMO Option
Statewide HMO Option

Out-of-
In-Network Only In-Network In-Network Only
Network
Other Coverage The Plan Pays The Plan Pays The Plan Pays
Applied Behavior
Analysis
100% after $35 PCP/SPC copay
100% after
NOTE: Requires prior for office place of service. 70% coverage;
$35 PCP co-pay
approval; only 100% coverage for all other subject to deductible
$35 SPC co-pay
covered for places of service
treatment for autism
spectrum disorders.
70% coverage; 50% coverage;
100% after 100% after
Urgent Care Services subject to subject to
$35 co-pay $35 co-pay
deductible deductible
Home Health Care
Services 70% coverage; 50% coverage;
100% coverage subject to subject to 100% coverage
NOTE: Prior approval deductible deductible
required.
Skilled Nursing Facility 70% coverage;
Services up to 120 days
100% coverage up to 100% coverage up to
per Plan Year; Not Covered
120 days per Plan Year 120 days per Plan Year
NOTE: Prior approval subject to
required. deductible
Hospice Care
70% coverage; 50% coverage;
100% coverage subject to subject to 100% coverage
NOTE: Prior approval
deductible deductible
required.
Durable Medical
Equipment (DME) -
Rental or purchase 70% coverage; 50% coverage;
100% coverage subject to subject to 100% coverage
NOTE: Prior approval deductible deductible
required for certain
DME.
Transplant Services
Contact the Medical Claim Administrator for coverage details
NOTE: Prior approval
required.
 32 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HRA Plans | January 1, - December 31, 2025

Anthem Gold HRA Option Anthem Silver HRA Option Anthem Bronze HRA Option

Out-of- Out-of- Out-of-

In-Network In-Network In-Network
Network* Network* Network*
Other Coverage You Pay You Pay You Pay
Tier 1
15% ($20 min/$50 max); 15% ($20 min/$50 max); 15% ($20 min/$50 max);
NOTE: Per 31-day not subject to deductible not subject to deductible not subject to deductible
maximum supply.
Tier 2
25% ($50 min/$80 max); 25% ($50 min/$80 max); 25% ($50 min/$80 max);
NOTE: Per 31-day not subject to deductible not subject to deductible not subject to deductible
maximum supply.
Tier 3
25% ($80 min/$125 max); 25% ($80 min/$125 max); 25% ($80 min/$125 max);
NOTE: Per 31-day not subject to deductible not subject to deductible not subject to deductible
maximum supply.
Participating 90-day
Voluntary Mail Order
OR Tier 1–15% ($50 min/$125 max) Tier 1–15% ($50 min/$125 max) Tier 1–15% ($50 min/$125 max)
Retail 90-day Tier 2–25% ($125 min/$200 max) Tier 2–25% ($125 min/$200 max) Tier 2–25% ($125 min/$200 max)
Network Tier 3–25% ($200 min/$312.50 Tier 3–25% ($200 min/$312.50 Tier 3–25% ($200 min/$312.50
max) max) max)
NOTE: Per 90-day
maximum supply.

*NOTE: For HRA Out-of-Network, please refer to the Health Reimbursement Arrangement (HRA) plan
option Summary Plan Description (SPD).

Additional information
• Amounts you pay go toward the out-of-pocket maximum.

• If you or your physician request a Brand-name Prescription Drug Product in place of the
chemically equivalent Prescription Drug Product (Generic equivalent), you will pay the applicable
Brand co-insurance in addition to the difference between the Brand and Generic Drug costs. This
differential will apply toward your out-of-pocket maximum.

• CVS Caremark® administers the pharmacy benefits for members enrolled in Anthem HRA Plan
Options.

• While the pharmacy co-pay/co-insurance amounts are not changing for 2025, you may want to
check to see if the medications you are taking have changed tiers for 2025.
 33 2025 ACTIVE MEMBER DECISION GUIDE

Benefits Comparison Summary:

HMO and HDHP Plans | January 1, - December 31, 2025

Anthem/UnitedHealthcare UnitedHealthcare KP Regional

Statewide HMO Option HDHP Option HMO Option
Out-of-
In-Network Only In-Network In-Network Only
Network*
Other Coverage You Pay The Plan Pays You Pay
Tier 1
$20 70% coverage; $20
NOTE: Per 31-day
co-pay after deductible is met co-pay
maximum supply.
KP per 30-day max.
Tier 2
$50 70% coverage; $50
NOTE: Per 31-day
co-pay after deductible is met co-pay
maximum supply.
KP per 30-day max.
Tier 3
$90 70% coverage; $80
NOTE: Per 31-day
co-pay after deductible is met co-pay
maximum supply.
KP per 30-day max.
Participating 90-day
Voluntary Mail Order OR
Tier 1–$50 Tier 1–$50
Retail 90-day
Tier 2–$125 70% coverage; Tier 2–$125
Network
Tier 3–$225 after deductible is met Tier 3–$200
co-pays co-pays
NOTE: Per 90-day
maximum supply.

*NOTE: For HDHP Out-of-Network, please refer to the High Deductible Health Plan (HDHP) plan option Summary
Plan Description (SPD).

Additional information
• Co-pay amounts you pay do not go toward the deductible for Anthem or UHC HMO, but do for the UHC
HDHP. Co-pay amounts paid do go toward the out-of-pocket maximum for the Anthem and the UHC
HMO and the HDHP.

• The HDHP Plan now includes a Generic Maintenance Drug List. If you take medications on the Generic
Maintenance Drug List, you do not have to meet the deductible before your co-insurance rate is applied.
You will pay the 30% co-insurance beginning on your first fill of these select medications on the approved
list. If you have questions about the Generic Maintenance Drug List, call Customer Care at
1-844-345-3241 or go to info.caremark.com/shbp.

• For the Anthem and UHC plans, if you or your physician request a Brand-name Prescription Drug Product
in place of the chemically equivalent Prescription Drug Product (Generic equivalent), you will pay the
applicable Brand co-pay/co-insurance in addition to the difference between the Brand and Generic Drug
costs. This differential will apply towards your out-of-pocket maximum.

• CVS Caremark® administers the pharmacy benefits for members enrolled in Anthem HMO and
UnitedHealthcare HMO and HDHP Plan Options. Kaiser Permanente administers the pharmacy benefits for
members enrolled in their Plan Option.

• While the pharmacy co-pay/co-insurance amounts are not changing for 2025, you may want to check
to see if the medications you are taking have changed tiers for 2025.
34 2025 ACTIVE MEMBER DECISION GUIDE

ALTERNATIVE COVERAGE
TRICARE Supplement for Eligible • Retired Reservists between the ages of 60 and
65
Military Members • Retired Reservists under age 60 and enrolled
Are you career retired military or a reservist? in TRICARE Retired Reserve (TRR)
Consider the TRICARE Supplement Plan • Qualified Retired National Guard and Retired
Reserve Members enrolled in TRICARE Reserve
The TRICARE Supplement Plan is an alternative to Select (TRS)
State Health Benefit Plan (SHBP) coverage that • Spouses/surviving spouses of any of the
is offered to members and dependents who are above
eligible for SHBP coverage and enrolled in TRICARE.
The TRICARE Supplement Plan is not sponsored by Points to consider if you elect TRICARE
the SHBP, the Georgia Department of Community Supplement Plan coverage
Health (DCH) or any employer. The TRICARE
Supplement Plan is sponsored by the Government • Effective January 1, 2025, TRICARE will become
Employees Association, Inc. (GEA) and is your primary coverage.
administered by Selman & Company. In general, • TRICARE Supplement Plan will become the
to be eligible, the members and dependents must secondary coverage.
each be under age 65, ineligible for Medicare and • The eligibility rules and benefits described in
registered in the Defense Enrollment Eligibility the TRICARE Supplement Plan will apply:
Reporting System (DEERS). - Unmarried adult children under the age of
26 who are no longer eligible for regular
Who is eligible for enrollment in the TRICARE TRICARE must be enrolled in TRICARE
Supplement Plan? Young Adult (TYA) through TRICARE before
enrolling in the TRICARE Supplement Plan.
Members who are eligible for enrollment in the - Unmarried children under the age of 21
TRICARE Supplement Plan include the following: or 23 if a full-time student who are no
longer eligible for regular TRICARE, must
• Retired military receiving retired, retainer or be enrolled in TYA through TRICARE before
equivalent pay enrolling in the TRICARE Supplement Plan.
• Tobacco Surcharge will not apply.

For complete information about eligibility and benefits, contact 866-637-9911 or visit
info.selmanco.com/ga_shbp. You may also find information at shbp.georgia.gov.
35 2025 ACTIVE MEMBER DECISION GUIDE

2025 WELLNESS
Wellness for Members Enrolled in Anthem Blue Cross and Blue
Shield (Anthem) and UnitedHealthcare Commercial (Active Non-
MA) Plan Options
The State Health Benefit Plan (SHBP) is excited to continue working with our Wellness partner,
Sharecare. If you elect Anthem or UnitedHealthcare coverage, you and your covered spouse have
access to SHBP’s well-being program (administered by Sharecare) called Be Well SHBP®. This
program offers comprehensive well-being resources and incentives to support your goals for
health. If you want to take big steps toward improved well-being or just a small step in the right
direction, Sharecare can help. The program is confidential, voluntary and offered at no additional
cost to you.

The Sharecare team will provide you with the support, tools and lifestyle management information
you need to improve your health and well-being. The types of support you receive include the
Sharecare RealAge® Test that determines your body’s true age, a highly personalized profile,
personalized content to help improve your health habits, access to a personal well-being coach,
a biometric screening, healthy living webinars, monthly rotating challenges that encourage daily
tracking of healthy behaviors, and access to a library of health and wellness content. As a
value-added benefit, Be Well SHBP® members have access to guided programs designed to
foster and encourage relaxation, manage stress and anxiety, promote tobacco cessation, and
encourage healthy eating habits. These programs are designed to evolve to meet the needs of
participants and include:

• Unwinding: Relax and meditate

• Unwinding Anxiety: Manage stress and anxiety
• Craving to Quit: Quit tobacco and vaping
• Eat Right Now: Manage and control food cravings

To learn more about the many features of the current program, visit BeWellSHBP.com
or call 888-616-6411.
 36 2025 ACTIVE MEMBER DECISION GUIDE

2025 Well-Being Incentives for Anthem and UnitedHealthcare Commercial (Active Non-MA) Plan Options*
Members and their covered spouses can each earn 480 points and choose to redeem them in the Sharecare Redemption
Center** for either: 1) a $150 Visa® Prepaid Card (when redeeming all 480 points earned in 2025) OR 2) 480 well-being
incentive credits (to apply toward eligible medical and pharmacy expenses).

If You Complete… You Will Earn…

The RealAge Test 120 points****
Take a confidential, online questionnaire that will take about 10
minutes to complete. It is recommended that you complete the
RealAge Test early in 2025 to allow for completion of action items
below.
A Biometric Screening 120 points****
You have three options to complete your Biometric Screening:
through your physician, or at an SHBP-sponsored screening
event, or at a Quest Diagnostics Patient Service Center (PSC).
Preventive Screening Exams Preventive Screening Exams
• Complete a preventive screening exam (colonoscopy, Earn 60 points for each completed screening exam, up to two
mammogram, pap smear or prostate screening). times.
• Screenings should be completed by August 31, 2025.
• For screenings completed in September, October,
November, and December 1 , members can self-attest by
December 1, 2025.
Well-being Coaching, Online Challenges, or a Combination of Up to 240 points in the following increments****
both
Well-being Coaching Well-being Coaching
Actively engage with a Sharecare well-being coach. • Earn 40 points for each completed coaching call per
calendar month, up to 6 times.
• Maximum of one call in a calendar month qualifies you for
the 40 points.
• Maximum of 240 points.

Online Challenges Online Challenges

Within the Sharecare app or on the online platform, join and Earn 40 points up to 6 times, for a maximum of 240 points
complete a monthly challenge. These challenges cover different by completing the following challenges in the month they’re
wellness areas: physical health, diet & nutrition, mental well-being, offered.
sleep, and overall health. • Physical: January, April, September
• Diet & Nutrition: March, July, October
• Mental Well-being: May, November
• Sleep: February, June
• Overall Health: August

*All actions must be completed and appropriate documentation submitted and received by Sharecare between January 1, 2025
and December 1, 2025. This includes the Biometric Screening through your physician by completing the 2025 Physician Screening
Form, or at an SHBP-sponsored screening event, or at a Quest Diagnostics Patient Service Center (PSC). It is your responsibility to
ensure your information is complete and all documentation is received by Sharecare by December 1, 2025.

**Points are saved in the Sharecare Redemption Center until you choose to redeem them, meaning points will not be sent
automatically to Anthem or UnitedHealthcare. Therefore, members must make their selection on how they choose to redeem their
points through the Sharecare Redemption Center, by visiting BeWellSHBP.com.

***If you elect to redeem your points for well-being incentive credits to apply toward eligible medical and pharmacy expenses,
you may do so in increments of 120 (up to a maximum of 480). Credits will be available within 30 days of redemption and will be
deposited into your HRA, MIA or HIA account. You will not be able to select the Visa Prepaid Card option if you begin redeeming
points for incentive credits. If you elect to redeem all 480 points earned in 2024 for the Visa Prepaid Card, it can be used anywhere
Visa is accepted and will be physically mailed within 8 weeks of redemption. The Visa Prepaid Card will expire 12 months after the
issuance date.

****Note: Points cannot be awarded until completion of the RealAge Test. Biometrics, Well-being Coaching, Online Challenges, and
Preventive Screening Exams can only be applied to points upon RealAge Test completion.

Important Reminder: Remember to redeem points before transferring into a Medicare Advantage Plan as points are not
automatically redeemed and transferred for Medicare Advantage members.

To learn more about how well-being incentives work with your Plan Option, please see the chart on the next page:
“How Your Well-being Incentive Credits Work with Your Plan Option”
 37 2025 ACTIVE MEMBER DECISION GUIDE

How Your Well-Being Incentive Credits Work with Your Plan Option

After you choose to redeem your points in the Sharecare Redemption Center for well-being incentive credits to apply toward
eligible medical and pharmacy expenses (which you may do so in increments of 120, up to a maximum of 480), credits will
be available within 30 days of redemption. Credits will be deposited into your MIA, HRA or HIA account. See 2025 Well-Being
Incentives for Anthem and UnitedHealthcare Commercial (active non-MA) Plan Options chart for details below.

When You Must Redeem Your Points for

Plan Option Account Type How Your Credits Work
Credits
Anthem HMO MyIncentive All points earned in 2025 must be redeemed When you use your benefits, you pay the
Account (MIA) through Sharecare’s Redemption Center member responsibility, including provider/
(points will not be sent automatically to pharmacy co-pay, co-insurance or deductible
your Medical Claims Administrator). as you normally would. Once the claim has
been paid, information is sent to the MIA
program. If you have MIA credits to cover all,
or a portion of the member responsibility that
you’ve paid, Anthem will reimburse you (up to
the amount of MIA credits available) by mailed
check or you can set-up direct deposit along
with a MIA Summary.

Anthem HRA Health Members enrolled in an HRA plan option When you use your benefits, any funds that
Reimbursement receive account-based credits funded by are owed to providers/pharmacies will be
Account (HRA) SHBP, which are available immediately and automatically paid by Anthem out of your HRA
do not require redemption in the Sharecare first. You will not pay anything until all of your
Redemption Center. available HRA credits have been used.

All points earned in 2025 must be redeemed

through Sharecare’s Redemption Center
(points will not be sent automatically to
your Medical Claims Administrator).

UnitedHealthcare Health Incentive Members and their covered spouses When you use your benefits, you pay the
HMO Account (HIA) enrolled in a UnitedHealthcare HMO Plan member responsibility, including provider/
Option are each eligible to receive a $250 pharmacy co-pay, co-insurance or deductible
UnitedHealthcare Reward Card after as you normally would. Once the claim has
satisfying all Be Well SHBP® well-being been paid, information is sent to the HIA
program requirements and redeeming their program. If you have HIA credits to cover all,
points for either well-being incentive credits or a portion of the member responsibility that
or $150 Visa Prepaid Card through the you’ve paid, UnitedHealthcare will mail you a
Sharecare Redemption Center. reimbursement check (up to the amount of HIA
credits available) along with an HIA summary.
All points earned in 2025 must be redeemed
through Sharecare’s Redemption Center
(points will not be sent automatically to
your Medical Claims Administrator).

UnitedHealthcare Health Members and their covered spouses You first pay a portion* of your deductible to
HDHP Incentive enrolled in a UnitedHealthcare HDHP Plan activate your ability to use your HIA credits.
Account (HIA) Option are each eligible to receive a $250 Once that portion of your deductible has been
UnitedHealthcare Reward Card after met, when you use your benefits, any funds
satisfying all Be Well SHBP® well-being owed to providers will be automatically paid
program requirements and redeeming by UnitedHealthcare out of your HIA (up to the
their points for either well-being incentive amount of HIA credits available).
credits or $150 Visa Prepaid Card through
the Sharecare Redemption Center. For pharmacy, you will pay upfront. If you have
enough credits in your HIA to cover all, or a
All points earned in 2025 must be redeemed portion of the expense, UnitedHealthcare will
through Sharecare’s Redemption Center automatically mail you a reimbursement check
(points will not be sent automatically to (up to the amount of HIA credits available).
your Medical Claims Administrator).
*Portion of Your Deductible:
You: $1,650
You + Child(ren): $3,300
You + Spouse: $3,300
You + Family: $3,300
The above amounts reflect a portion of the total
required Deductible.

Note: If you terminate your coverage with SHBP, any unused MIA, HRA or HIA credits will be forfeited.
38 2025 ACTIVE MEMBER DECISION GUIDE

Wellness for Kaiser Permanente

The State Health Benefit Plan (SHBP) is excited to partner again with Kaiser Permanente (KP).
They offer a comprehensive and integrated team approach to wellness. In addition, KP provides
a variety of wellness tools and resources and an incentive program designed to empower you to
take an active role in your own health. You will have access to KP’s tools, activities and services
such as: the Total Health Assessment, biometric screenings, and online and on-site healthy living
classes. To learn more about KP services and programs, visit my.kp.org/shbp.

Kaiser Permanente Rollover Account (KPRA)

The KPRA will be available to members enrolling with KP who were previously enrolled in another
SHBP Plan Option during 2024 that have unused incentive credits earned in SHBP’s Be Well SHBP®
program administered by Sharecare. The balance will roll over in April 2025. With the KPRA,
members will be able to use those unused credits for eligible medical and pharmacy expenses
incurred after April 2025, while insured under the KP Regional HMO plan. If you have questions
regarding your KPRA, contact KPRA customer service after April 2025 at 877-761-3399 or visit
kp.org/healthpayment.

You must first pay your medical co-pay(s) out-of-pocket. Normally, within 15 days of when the
claim is processed, you will be reimbursed your co-pay(s) from the available funds in your KPRA.
Your KPRA comes with a Kaiser Permanente Prescription Drug Card. To maximize your pharmacy
benefits, you should use this card at KP pharmacies to pay your co-pay(s) at the point of sale.
Although the KP prescription card is accepted outside of the KP network, you will have to pay the
full cost of the drug as this is not a covered benefit under your Plan.
 39 2025 ACTIVE MEMBER DECISION GUIDE

2025 Wellness Incentives for Kaiser Permanente

Earn up to $1,000 and feel the benefits of taking care of your health!

Simply sign-up for the KP Wellness Program at my.kp.org/shbp and make sure you are up to date
on all five of the activities listed below. Each member and covered spouse who satisfies the KP
Wellness Program requirements will receive a $500 reward card (up to $1,000 per household). Use
your wellness incentive to further embrace your Total Health.

Getting your reward is easy. To get started, visit kp.org/engage to sign on and accept your
wellness program agreement (required for reward eligibility). From there you can check the status
of your activities which do not have to be completed in any specific order. For details or questions,
visit my.kp.org/shbp or call 866-300-9867.

NOTE: All actions must be completed between January 1, 2025 and December 1, 2025.

What to Do What You Will Earn

Accept your Wellness Program
Agreement: How will YOU use your $500 wellness
incentive reward? Complete all five
Sign on to kp.org/engage to accept your
activities and earn a reward card worth

1.
Wellness Program Agreement - check $500 to spend on anything you choose!
“yes,” then click submit. If you check
“no” or if you don’t complete this step, • Pay for co-pays and prescription
you will not earn credits for your Kaiser medications for the entire year
Permanente Wellness Program activities. • Relieve stress with quarterly massages
• Take a nice weekend hiking trip in the
Take Your Total Health Assessment: mountains
Complete your KP Total Health • Splurge on new work-out clothes or

2. Assessment (THA) online. The

questionnaire is confidential and takes
walking shoes
• Stock up on healthy foods at the grocery
store
about 10 minutes.
Know Your Numbers: Both members and their covered spouses
Complete a Biometric Screening at a are eligible to earn the incentive for a total
of $1,000 per household.
Kaiser Permanente Medical Office, or

3.
by a KP clinician at an SHBP-sponsored
biometric screening event.

NOTE: ONLY those screenings performed

by KP are eligible for the reward.

Get Yourself Screened:

4.
Complete all age and gender
appropriate preventive screenings for
breast, cervical or colorectal cancer.

Make A Lifestyle Change:

Your choice—participate in either

5. Wellness Coaching by Phone or a

mission through the healthy lifestyle
programs.

Note: If you terminate your coverage with SHBP, any unused KPRA credits will be forfeited.
40 2025 ACTIVE MEMBER DECISION GUIDE

TOBACCO POLICIES
Tobacco Cessation
Every attempt to quit tobacco is worth the effort. It takes planning, support and
sometimes, all the will power you’ve got. But quitting for good is absolutely
possible. Both Sharecare and Kaiser Permanente offer comprehensive online
and telephonic tobacco cessation services that provide the tools and support
you need to quit successfully. Both programs are confidential, voluntary and are
at no additional cost to you. To learn more, members enrolled in Anthem and
UnitedHealthcare should visit BeWellSHBP.com and members enrolled in KP
should visit my.kp.org/shbp.

Tobacco Cessation Medications

Prescription and over-the-counter (OTC) tobacco cessation therapies, including
nicotine replacement therapy (NRT), are available. For members enrolled in
Anthem and UnitedHealthcare, please go to info.caremark.com/shbp to learn
more. For members enrolled in KP, please go to my.kp.org/shbp to learn more.

Tobacco Surcharge
Tobacco surcharges are included in all SHBP Plan Options (except for the
Medicare Advantage Plan Options and TRICARE Supplement). These surcharges
are intended to promote tobacco cessation and use of the Tobacco Cessation
Online and Telephonic Coaching Programs. Please go to shbp.georgia.gov to
access the tobacco surcharge removal policies. These policies allow you to have
the tobacco surcharge removed by completing the Tobacco Surcharge Removal
Requirements. The Tobacco Surcharge Removal policies apply to all tobacco
products and Electronic Nicotine Delivery Systems.

Tobacco Surcharge Removal/Refund

In compliance with the Affordable Care Act (ACA) requirements for wellness
programs, SHBP’s covered tobacco users (members and covered dependents)
may qualify for tobacco surcharge refunds or adjustments of premiums paid
in 2025 by completing the Tobacco Surcharge Removal Requirements in the
Tobacco Users Cessation Policies for Anthem, UnitedHealthcare and KP at:
shbp.georgia.gov.
 41 2025 ACTIVE MEMBER DECISION GUIDE

IF YOU ARE RETIRING

Planning to Retire Soon? Here’s What You Need to Know

• Before you transition to retirement, review the • If you are retiring and you or your covered
SHBP Retirement Coverage Presentation on our dependents are age 65 or older (or will be
website at shbp.georgia.gov. turning age 65 at your retirement), you have
• In order to continue your State Health Benefit the option of: 1) enrolling in an active SHBP
Plan (SHBP) coverage as a retiree, you and Medicare Advantage with Prescription Drugs
any dependents you want covered must be (MAPD) Plan Option if you submit your Medicare
enrolled in the Plan while you are an active Part B enrollment information directly to SHBP,
member immediately prior to your retirement. or 2) remaining in a Commercial (active Non-
If you are not enrolled in the SHBP and wish to MA) Plan Option, and you will pay 100% of the
carry coverage as a retiree, you will need to unsubsidized premium, which is substantially
enroll during Open Enrollment the year prior higher than the SHBP Medicare Advantage Plan
to your retirement. This also applies to any Options. Medicare Advantage Plan Options are
dependent(s) you would like to cover as a the only Plan Options subsidized by SHBP for
retiree, which means you will need to enroll Retirees age 65 and older.
your dependent(s) during Open Enrollment the • When you retire, check your annuity deductions
year prior to your retirement while you are still to verify that the correct deduction amount has
an active member if you would like them to be been submitted to SHBP. If SHBP determines
covered when you retire. that you have not submitted your premium
• If you make a change during Open Enrollment payment or your premium payment was a
but retire before the change can become partial payment, or your premium exceeds
effective on January 1, your elections prior to the maximum amount SHBP will deduct from
Open Enrollment, including your Plan Option, your annuity, SHBP will bill you directly and
Tier and covered dependents, will remain the you should submit payment according to
same. your invoice. If you are not being charged the
correct amount, immediately contact SHBP
• If you are retiring and under age 65, and 1) Member Services at 800-610-1863.
fall under the Annuitant Basic Subsidy Policy,
your Plan Options and rates are the same • Once retired, you will have a Retiree Option
as for active members and the Tobacco Change Period (ROCP) that will allow you to
Surcharge question will apply or 2) fall under only change your Plan Option.
the Annuitant Years of Service Subsidy Policy, • You may add dependents only if you have a
your Plan Options are the same as for active qualifying event (QE) because Retirees do not
members but your rates are based on your have an Open Enrollment period.
Years of Service in a State retirement system
(e.g. TRS or ERS) and the Tobacco Surcharge Please refer to the Retiree Decision Guide for
question will apply. additional information regarding your SHBP
coverage and Plan Options as a Retiree
42 2025 ACTIVE MEMBER DECISION GUIDE

HEALTH IS A
STATE OF MIND
WELLNESS IS A
STATE OF BEING.
 43 2025 ACTIVE MEMBER DECISION GUIDE

About the Following Notices Access to Obstetrical and

LEGAL NOTICES
Gynecological (OB/GYN) Care
The following important legal notices are also
posted on the State Health Benefit Plan (SHBP) You do not need prior authorization from the
website at shbp.georgia.gov under Plan Plan or from any other person (including a
Documents: PCP) in order to obtain access to obstetrical
or gynecological care from a health care
Penalties for Misrepresentation professional in the Claims Administrator’s
network who specializes in obstetrics or
If an SHBP participant misrepresents eligibility gynecology. The health care professional,
information when applying for coverage however, may be required to comply with
during change of coverage or when enrolling certain procedures, including obtaining prior
in benefits, the SHBP may take adverse authorization for certain services, following a
action against the participants, including, pre-approved treatment plan, or procedures
but not limited to terminating coverage (for for making referrals. For a list of participating
the participant and his or her dependents) health care professionals who specialize in
or imposing liability to the SHBP for fraud obstetrics or gynecology, call the telephone
indemnify (requiring payment for benefits to number on the back of your Identification Card.
which the participant or his or her beneficiaries
were not entitled). Penalties may include a
HIPAA Special Enrollment Notice
lawsuit, which may result in payment of charges
to the Plan or criminal prosecution in a court of
If you decline enrollment for yourself or your
law.
Dependents (including your spouse) because
of other health insurance or group health plan
To avoid enforcement of the penalties, the
coverage, you may be able to enroll yourself
participant must notify the SHBP immediately
and your Dependents if you or your Dependents
if a dependent is no longer eligible for
lose eligibility for that other coverage (or if the
coverage or if the participant has questions
employer stops contributing towards your or
or reservations about the eligibility of a
your Dependents’ other coverage). However,
dependent. This policy may be enforced to the
you must request enrollment within 31 days
fullest extent of the law.
after your or your Dependents’ other coverage
ends (or after the employer stops contributing
Federal Patient Protection and toward the other coverage).
Affordable Care Act Notices
Choice of Primary Care Physician In addition, if you have a new Dependent as a
result of marriage, birth, adoption, or placement
The Plan generally allows the designation for adoption, you may be able to enroll yourself
of a Primary Care Physician/Provider (PCP). and your new Dependents. However, you must
You have the right to designate any PCP who request enrollment within thirty-one (31) days
participates in the Claims Administrator’s after the marriage or adoption, or placement
network, and who is available to accept you for adoption (or within 90 days for a newly
or your family members. For children, you may eligible dependent child).
also designate a pediatrician as the PCP. For
information on how to select a PCP, and for a Eligible Covered Persons and Dependents may
list of participating PCP’s, call the telephone also enroll under two additional circumstances:
number on the back of your Identification Card. • The Covered Person’s or Dependent’s
Medicaid or Children’s Health Insurance
 44 2025 ACTIVE MEMBER DECISION GUIDE

Program (CHIP) coverage is terminated as a For more detailed information on the

LEGAL NOTICES
result of loss of eligibility; or mastectomy-related benefits available under
• The Covered Person or Dependent becomes your Plan option, call the telephone number on
eligible for a subsidy (State Premium the back of your Identification Card.
Assistance Program).
Newborns’ and Mothers’ Health
NOTE: The Covered Person or Dependent must
Protection Act of 1996
request Special Enrollment within sixty (60)
days of the loss of Medicaid/CHIP or of the
The Plan complies with the Newborns’ and
eligibility determination. To request Special
Mothers’ Health Protection Act of 1996.
Enrollment or obtain more information, call SHBP
Member Services at 1-800-610-1863 or visit the
Group health plans and health insurance
SHBP Enrollment Portal: mySHBPga.adp.com.
issuers generally may not, under Federal law,
restrict Benefits for any hospital length of stay
Women’s Health and Cancer in connection with childbirth for the mother
Rights Act of 1998 or newborn to less than 48 hours following a
vaginal delivery, or less than 96 hours following
The Plan complies with the Women’s Health a cesarean section. However, federal law
and Cancer Rights Act of 1998. Mastectomy, generally does not prohibit the mother’s or
including reconstructive surgery, is covered the newborn’s attending Provider, after consulting
same as other medical and surgical benefits with the mother, from discharging the mother
under your Plan Option. Following cancer or her newborn earlier than 48 hours (or 96
surgery, the SHBP covers: hours, as applicable). In any case, plans and
issuers may not, under Federal law, require that
• All stages of reconstruction of the breast on a Provider obtain authorization from the Plan or
which the mastectomy has been performed the insurance issuer for prescribing a length of
• Reconstruction of the other breast to stay not in excess of 48 hours (or 96 hours, as
achieve a symmetrical appearance applicable).
• Prostheses and mastectomy bras
• Treatment of physical complications of
mastectomy, including lymphedema

NOTE: Reconstructive surgery requires prior

approval, and all Inpatient admissions require
prior notification.

HEALTH INSURANCE PORTABILITY The purpose of this notice is to

AND ACCOUNTABILITY ACT describe how medical information
NOTICE OF INFORMATION PRIVACY about you, which includes your
PRACTICES personal information, may be used
and disclosed and how you can get
Georgia Department of Community access to this information. Please
Health State Health Benefit Plan Notice of review it carefully.
Information Privacy Practices
 45 2025 ACTIVE MEMBER DECISION GUIDE

The Georgia Department of Community Health Plan “Enrollment Information” and “Claims
LEGAL NOTICES
(DCH) and the State Health Benefit Plan Are Information” are Used in Order to Administer
Committed to Your Privacy. DCH understands the Plan. PHI includes two kinds of information,
that your information is personal and private. “Enrollment Information” and “Claims
Certain DCH employees and companies hired Information”. “Enrollment Information” includes,
by DCH to help administer the Plan (Plan but is not limited to, the following types of
Representatives) use and share your personal information regarding your plan enrollment:
and private information in order to administer (1) your name, address, email address,
the Plan. This information is called “Protected Social Security number and all information
Health Information” (PHI), and includes any that validates you (and/or your Spouse and
information that identifies you or information Dependents) are eligible or enrolled in the
in which there is a reasonable basis to believe Plan; (2) your Plan enrollment choice; (3) how
can be used to identify you and that relates to much you pay for premiums; and (4) other
your past, present, or future physical or mental health insurance you may have in effect. There
health or condition, the provision of health care are certain types of “Enrollment Information”
to you, and payment for those services. This which may be supplied to the Plan by you or
notice tells how your PHI is used and shared your personal representative, your employer,
by DCH and Plan Representatives. DCH follows other Plan vendors or other governmental
the information privacy rules of the Health agencies that may provide other benefits to
Insurance Portability and Accountability Act of you. This “Enrollment Information” is the only
1996 (“HIPAA”). kind of PHI your employer is allowed to obtain.
Your employer is prohibited by law from using
Only Summary Information is Used When this information for any purpose other than
Developing and/or Modifying the Plan. The assisting with Plan enrollment.
Board of Community Health, which is the
governing Board of DCH, the Commissioner “Claims Information” includes information
of DCH and the Executive Director of the Plan your health care providers submit to the Plan.
administer the Plan and make certain decisions For example, claims information may include
about the Plan. During those processes, they medical bills, diagnoses, statements, x-rays or
may review certain reports that explain costs, lab test results. It also includes information you
problems, and needs of the Plan. These reports may submit or communicate directly to the
never include information that identifies any Plan, such as health questionnaires, biometric
individual person. If your employer is allowed screening results, enrollment forms, leave forms,
to leave the Plan entirely, or stop offering the letters and/or telephone calls. Lastly, it includes
Plan to a portion of its workforce, DCH may information about you that may be created by
provide Summary Health Information (as the Plan. For example, it may include payment
defined by federal law) for the applicable statements and/or other financial transactions
portion of the workforce. This Summary Health related to your health care providers.
Information may only be used by your employer
to obtain health insurance quotes from other Your PHI is Protected by HIPAA. Under HIPAA,
sources and make decisions about whether employees of DCH and employees of outside
to continue to offer the Plan. Please note that companies and other vendors hired or
DCH, Plan Representatives, and your employer contracted either directly or indirectly by DCH to
are prohibited by law from using any PHI that administer the Plan are “Plan Representatives,”
includes genetic information for underwriting and therefore must protect your PHI. These
purposes. Plan Representatives may only use PHI and
share it as allowed by HIPAA, and pursuant to
their “Business Associate” agreements with
DCH to ensure compliance with HIPAA and DCH
requirements.
 46 2025 ACTIVE MEMBER DECISION GUIDE

DCH Must Ensure the Plan Complies with

LEGAL NOTICES
Information Technology Companies: Plan
HIPAA. DCH must make sure the Plan complies Representatives maintain and manage
with all applicable laws, including HIPAA. DCH information systems that contain PHI.
and/or the Plan must provide this notice, follow
its terms and update it as needed. Under HIPAA, Enrollment Services Companies: Plan
Plan Representatives may only use and share Representatives may provide the enrollment
PHI as allowed by law. If there is a breach of website and/or provide customer service to
your PHI, DCH must notify you of the breach. help Plan Members with enrollment matters.

Plan Representatives Regularly Use and Share NOTE: Treatment is not provided by the Plan
your PHI in Order to Administer the Plan. Plan but we may use or disclose PHI in arranging or
Representatives may verify your eligibility in approving treatment with providers.
order to make payments to your health care
providers for services rendered. Certain Plan Under HIPAA, all employees of DCH must
Representatives may work for contracted protect PHI and all employees must receive and
companies assisting with the administration comply with DCH HIPAA privacy training. Only
of the Plan. By law, these Plan Representative those DCH employees designated by DCH as
companies also must protect your PHI. Plan Representatives for the SHBP health care
component are allowed to use and share your
HIPAA allows the Plan to use or disclose PHI for PHI.
treatment, payment, or health care operations.
Below are examples of uses and disclosures for DCH and Plan Representatives May Make
treatment, payment and health care operations Uses or Disclosures Permitted by Law in
by Plan Representative Companies and PHI Special Situations. HIPAA includes a list of
data sharing. special situations when the Plan may use or
disclose your PHI without your authorization as
Claims Administrator Companies: Plan permitted by law. The Plan must track these
Representatives process all medical and drug uses or disclosures. Below are some examples
claims; communicate with the Plan Members of special situations where uses or disclosures
and/or their health care providers. for PHI data sharing are permitted by law. These
include, but are not limited to, the following:
Wellness Program Administrator Companies:
Plan Representatives administer Well- Compliance with a Law or to Prevent Serious
Being programs offered under the Plan; and Threats to Health or Safety: The Plan may use or
communicate with the Plan Members and/or share your PHI in order to comply with a law or
their health care providers. to prevent a serious threat to health and safety.

Actuarial, Health Care and /or Benefit Public Health Activities: The Plan may give PHI
Consultant Companies: Plan Representatives to other government agencies that perform
may have access to PHI in order to conduct public health activities.
financial projections, premium and reserve
calculations, and financial impact studies on Information about Eligibility for the Plan and
legislative policy changes affecting the Plan. to Improve Plan Administration: The Plan
may give PHI to other government agencies,
State of Georgia Attorney General’s Office, as applicable, that may provide you or your
Auditing Companies and Outside Law Firms: dependents benefits (such as state retirement
Plan Representatives may provide legal, systems or other state or federal programs)
accounting and/or auditing assistance to the in order to get information about your or your
Plan. dependent’s eligibility for the Plan, to improve
 47 2025 ACTIVE MEMBER DECISION GUIDE

administration of the Plan, or to facilitate your Right to Ask for a Restriction of Uses and
LEGAL NOTICES
receipt of other benefits. Disclosures or for Special Communications:
You have the right to ask for added restrictions
Research Purposes: Your PHI may be given to on uses and disclosures, but the Plan is not
researchers for a research project, when the required to agree to a requested restriction,
research has been approved by an institutional except if the disclosure is for the purpose of
review board. The institutional review board carrying out payment or health care operations,
must review the research project and its rules to is not otherwise required by law, and pertains
ensure the privacy of your information. solely to a health care item or service that you
or someone else on your behalf has paid in full.
Plan Representatives Share Some Payment You also may ask the Plan to communicate with
Information with the Employee. Except as you at a different address or by an alternative
described in this notice, Plan Representatives means of communication in order to protect
are allowed to share your PHI only with you your safety.
and/or with your legal personal representative.
However, the Plan may provide limited Right to a Paper Copy of this Notice and Right
information to the employee about whether the to File a Complaint: You have the right to a
Plan paid or denied a claim for another family paper copy of this notice. Please contact the
member. SHBP Member Services at 1-800-610-1863 or you
may download a copy at shbp.georgia.gov. If
You May Authorize Other Uses of Your PHI. Plan you think your HIPAA privacy rights may have
Representatives may not use or share your been violated, you may file a complaint. You
PHI for any reason that is not described in this may file the complaint with the Plan and/or the
notice without a written authorization by you U.S. Department of Health & Human Services,
or your legal representative. For example, use Office of Civil Rights, Region IV. You will never be
of your PHI for marketing purposes or uses or penalized by the Plan or your employer for filing
disclosures that would constitute a sale of PHI a complaint.
are illegal without this written authorization. If
you give a written authorization, you may revoke Summaries of Benefits and Coverage
it later.
Summaries of benefits and coverage describe
You Have Privacy Rights Related to Plan each Plan Option in the standard format
Enrollment Information and Claims required by the Affordable Care Act. These
Information that Identifies You. documents are posted here: shbp.georgia.gov.
To request a paper copy, please contact SHBP
Right to Inspect and Obtain a Copy of your Member Services at 800-610-1863.
Information, Right to Ask for a Correction: You
have the right to obtain a copy of your PHI that Georgia Law Section 33-30-13 Notice:
is used to make decisions about you. If you think
it is incorrect or incomplete, you may contact SHBP actuaries have determined that the total
the Plan to request a correction. cost of coverage (which includes the cost paid
by the State and the cost paid by members)
Right to Ask for a List of Special Uses and under all options is 0% higher than it would be if
Disclosures: You have the right to ask for a list the Affordable Care Act provisions did not apply.
of all special uses and disclosures.
 48 2025 ACTIVE MEMBER DECISION GUIDE
LEGAL NOTICES
ADDRESSES TO FILE HIPAA COMPLAINTS:
Georgia Department of Community U.S. Department of Health & Human
Health SHBP HIPAA Privacy Unit Services Office for Civil Rights
Region IV
P.O. Box 1990 Atlanta Federal Center
Atlanta, GA 30301
1-800-610-1863 61 Forsyth Street SW Suite 3B70
Atlanta, GA 30303-8909
1-877-696-6775

For more information about these notices, contact

Georgia Department of Community Health

State Health Benefit Plan

P.O. Box 1990

Atlanta, GA 30301
1-800-610-1863
49 2025 ACTIVE MEMBER DECISION GUIDE

Website for Open Enrollment Available October 15, 2024

at midnight through November 8, 2024 at 11:59 p.m. ET
FOR PLAN COVERAGE EFFECTIVE JANUARY 1, 2025 – DECEMBER 31, 2025

The material in this booklet is for

information purposes only and is
not a contract. It is intended only
to highlight principal benefits
of the State Health Benefit Plan
(SHBP) Plan Options. Every
effort has been made to be as
accurate as possible; however,
should there be a difference
between this information and
the Plan Documents, the Plan
Documents govern. For all Plan
Options other than the Medicare
Advantage (MA) options, the
Plan Documents include the SHBP
regulations, the Summary Plan
Descriptions, Evidence of Coverage
documents and reimbursement
guidelines of the vendors. The
Plan Documents for MA are the
Evidence of Coverage (EOC) and
the RX Certificate of Coverage. It is
the responsibility of each member,
active and retired, to read the Plan
Documents to fully understand
how that option pays benefits.
Availability of SHBP options may
change based on federal or state
law changes or as approved by the
Board of Community Health.

Premiums for SHBP Plan Options

are established by the DCH Board
and may be changed at any time
by Board Resolutions subject to
advance notice.
50 2025 ACTIVE MEMBER DECISION GUIDE

NOTES

51 2025 ACTIVE MEMBER DECISION GUIDE

NOTES

52 2025 ACTIVE MEMBER DECISION GUIDE

NOTES

53 2025 ACTIVE MEMBER DECISION GUIDE

NOTES

54 2025 ACTIVE MEMBER DECISION GUIDE

NOTES