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Understanding your health care coverage options is more complex than ever. Delphi Salaried Retirees Association - Benefit Trust (DSRA-BT) is committed to helping you make an informed choice, with tools and resources to guide you in exploring today’s new Medicare health plan options and the savings they can provide.  We have put together a brochure to help you with the basic understanding of Medicare provided below.  

Understanding Medicare Brochure
2023 Medicare Quick Access Links

Becoming Medicare Eligible

You are either coming into Medicare because you are turning 65 and you must do something because you are coming off your regular health insurance or you qualify for Medicare under 65 due to a disability.  

Medicare Plan Information

2023 Understanding Medicare 


What Happens? 

All DSRA Benefit Trust members turning 65 will receive an “Aging Up” packet 90-120 days prior to turning 65.


What do I need to do?  What do I need to know?

Two Months prior to turning 65, enrollees must complete and submit the DSRA BT Enrollment and Change of Status form.  You must complete this in order to remain in the dental &/or vision plans.

Another enrollment form is required at this time if a participant wants to enroll in a Medicare supplement/prescription drug plan or Medicare advantage/prescription drug plan sponsored by the DSRA Benefit Trust.

Once enrolled, Benistar will invoice each participant for Dental +/- Vision premiums as well as any additional plans you are enrolled in through the DSRA Benefit Trust.

All Post-65 premiums including Hartford Medical, BCBSM Medicare Advantage, Prescription Drug, BCBSM Dental and Vision and MetLife Insurance will be paid to Benistar

Any members who wish to continue to pay their insurance premium with Electronic Funds Transfer (EFT) must complete an Electronic Funds Transfer form with Benistar.

All completed DSRA Benefit Trust documents, such as DSRA Benefit Trust Enrollment and change of Status form, BCBSM Dental and Vision, MetLife Insurance and EFT Form should be mailed, faxed or scanned and emailed to Benistar Retiree Service Center:

Mail:  Benistar Retiree Service Center

10 Tower Lane, Suite 100

Avon, CT 06001

Email:            Fax: 1-860-408-7025


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Delphi Salaried Retirees Association - Benefit Trust’s current coverage requires participation in Medicare Parts A and B. Before you look into a Medicare Supplement or Medicare Advantage plan, it’s important to understand what Medicare covers and the costs you may incur when utilizing Medicare services. Simply stated, Medicare is a health insurance program offered by the federal government. It covers:

✦ People 65 and older.

✦ People under 65 with certain disabilities.

✦ People of any age with End Stage Renal Disease (ESRD) requiring kidney dialysis or kidney transplant.

What is it?

The Many PARTS of Medicare (Quick Overview)

Medicare Part A covers inpatient treatment in a variety of settings including hospitals, skilled nursing facilities, hospice, and other inpatient facilities. Medicare Part A involves deductibles and co-pays, * per benefit period, as well as long-term hospital stays over 90 days.


Medicare Part B is health insurance that covers doctor visits, exams, immunizations, checkups, and durable medical equipment. Like Part A, Medicare Part B involves out-of-pocket expenses including a monthly premium, annual deductible and typically 20 percent of the total cost of your care.**


Medicare Part D is prescription drug coverage. These plans reduce your overall health care costs by lowering the cost of your prescriptions. Each plan can vary by cost and drug coverage.

WHAT ARE YOUR MEDICARE OPTIONS? The two main ways to get your Medicare coverage are: Original Medicare or a Medicare Advantage Plan.

Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are offered by private, Medicare-approved companies. A Medicare Advantage plan provides all of your Part A and Part B coverage. Part D prescription drug coverage is sometimes included as well. Each plan can charge different out-of-pocket costs and have different rules for how you get services. 

Medicare Supplement insurance, also called “Medigap,” is a private policy designed to pay some or all of the health care costs that Original Medicare doesn’t cover. It helps with expenses like co-payments, coinsurance and deductibles. Medicare Supplement plans can drastically reduce your financial liability, particularly during a prolonged hospitalization.

* Medicare Part A & B deductibles are set by CMS.
Please check Medicare.Gov for 2023 amounts. ** In addition to the monthly premium associated with a Medicare Advantage Plan, or Medicare Supplement Plan and/or Prescription Drug Plan, you must continue to pay your Medicare Part B premium 


   How they work? 

         Are they right for you?

Medicare Advantage Plan Detail
2023 Medicare Advantage Plans


You must continue to be enrolled, aging up or qualify to enroll in Part A and Part B of Medicare to be eligible to enroll in a Medicare Advantage plan.  In addition, since the BCBSM Medicare Advantage PPO plans offered are group Medicare plans, you have the ability to enroll during open enrollment or at another time during the year when you experience a life event. 

How Medicare Advantage Plans Work

Medicare Part A helps cover an inpatient stay at the hospital, skilled nursing facility or rehabilitation facility. Here are just a few of the costs that are covered through Part A:
• A semi-private hospital room
• Drugs, medical supplies, medical equipment, lab tests, X-rays and radiation treatment as an inpatient
• Operating room and recovery room services
• Some blood transfusions in a hospital or skilled nursing facility
• Rehabilitation services, such as physical therapy through home health care

Medicare Part B goes hand-in-hand with Part A. It covers the cost of doctor visits – including an annual wellness exam — and other medical services. You can count on it for expenses, such as:
• Visits to your doctor and outpatient medical services
• Emergency services
• Clinical laboratory services, such as blood and urine tests

• Preventive care, including flu shots and preventive screenings, such as mammograms, colorectal and prostate cancer screenings
When enrolled in the Medicare Advantage plan, you’ll still need to pay your Part B premium.

Medicare Part C is when private insurance companies contract with the Federal government to administer Original Medicare benefits this is called a Medicare Advantage plan. Medicare Advantage plans combine all Original Medicare benefits, rights and protections with extra benefits. Our Medicare Advantage PPO plan includes benefits you won’t get from Original Medicare including:

• Blue Cross® Coordinated Care

• In-home wellness visit

• 24-Hour Nurse Line

• SilverSneakers® Fitness program

Medicare Part D is prescription drug coverage.

The plans are all-in-one Medicare Advantage plans, that combine Medicare Part A and Part B with additional benefits. Blue Cross (BCBSM) has a contract with Medicare to administer your health care benefits.  Medicare Advantage plans focus on health, not just health care, and can help you attain and maintain better health through coverage for preventive services, as well as care support and disease management programs.

The Trust offers 3 Blue Cross Blue Shield (BCBSM) Medicare Advantage PPO Plus plans with a Blue Cross Blue Shield (BCBSM) Prescription Drug plan.  When enrolling in the Diamond or Emerald BCBSM Medicare Advantage PPO Plus Plan you will be enrolled in the BCBSM High Prescription Drug plan.  If you enroll in the Ruby BCBSM Medicare Advantage PPO Plus Plan you will be enrolled in the Ruby Prescription Drug Plan.  Please visit the Summary of Benefits below to review the plans in detail.  


The Blue Cross Blue Shield (BCBSM) Medicare Advantage PPO Plus plans provide three options for your medical needs with extra benefits to consider that are not available in The Hartford plans we have available.  Please review the information below to determine your needs with the differences between the BCBSM Medicare Advantage PPO Plus Plans and The Hartford Plans available. Diamond and Emerald BCBSM Medicare Advantage PPO Plus plans are bundled with the BCBSM High RX plan and the BCBSM Medicare Advantage PPO Plus Ruby Prescription Drug Plan has slightly different coverage levels.  Please review the Benefits at a Glance located below.  If you would like a BCBSM Prescription Drug Standalone plan to go with a Hartford Plan, please review the High and Low BCBSM Prescription Drug Plans, the choice is yours.

Plan Details

The BCBSM Medicare Advantage PPO Plus plans offered do not have a defined geographic service area and you can visit any physician and/or hospital where Medicare services are offered.

  • Your annual costs will vary depending on the premiums, copayments, coinsurance and benefits of the plan you select.  There are 3 plans offered through the trust.

  • Medicare Advantage PPO Plus plans may have copayments or cost sharing amounts on Medicare covered services that differ from the cost sharing amounts in Original Medicare.


Wellness visits
Your plan covers an annual physical exam and an annual wellness visit at no cost.
• Annual physical exam
Your doctor physically checks your overall health and discusses any symptoms or concerns you currently have.
• Annual wellness visit
Based on your health and risk factors, your doctor creates or updates your personalized prevention plan to help prevent disease or disability (a physical exam isn’t performed).

We have plans for everyone.
If a large network of doctors and hospitals is important to you, we’ve got it.
If you want a plan that doesn’t require referrals, we’ve got it.
If a low premium is one of your priorities, we’ve got that too.

The Centers for Medicare and Medicaid Services (CMS) regulate the Medicare Advantage plans and determine the rules by which the contracted insurance carriers, such as BCBSM, are required to follow. Your out-of-pocket costs for benefits or services you receive vary by Medicare Advantage plan.  The three BCBSM Medicare Advantage PPO Plus plans the Trust offer are (1) BCBSM / Diamond Plan PPO with a BCBSM Medicare High Prescription Drug Plan, (2) BCBSM / Emerald Plan PPO with a BCBSM Medicare High Prescription Drug Plan or (3) BCBSM / Ruby Plan PPO with a BCBSM Medicare Ruby Prescription Drug Plan. 

With Medicare Plus Blue PPO you can visit any health care provider you’d like without a referral. With your PPO plan, you can choose any doctor or hospital that accepts Medicare. You’ll get nationwide coverage and low out-of-pocket costs.  


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H9572 (PPO Only) - BCBSM

BCBSM Medicare Advantage Plan Rates

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Copays are the only differences in the High PDP and Ruby PDP Plan.  Please refer to the Benefits at a Glance below to see the difference in RX Copays.  Formulary of ALL BCBSM PDP plans are the same.

H9572 & S5584 (PPO/PDP) - BCBSM

Standalone Prescription Drug Plan Information
Please review details on the benefits for each medicare advantage plan
2023 Standalone Prescription Drug Plans
Standalon RX Plan Information

We continue to provide prescription drug plans offered by the DSRA Benefit Trust through BCBSM. The BCBSM RX Plans are OptumRX plan designs.

Members will need to re-enter payment information and re-confirm auto-refill status for home delivery when converting from Express Scripts to OptumRX.

Members have the opportunity to enroll in stand-alone prescription drug coverage with BCBSM in either the High or Low plan. 

•Your formulary is a list of drugs covered by your plan.

•Out-of-pocket cost is applied based on drug tiers and pharmacy type:

Tier 1= Preferred generic drugs

Tier 2= Generic

Tier 3= Preferred brand drugs

Tier 4= Non-preferred drugs

Tier 5= Specialty drugs

Your plan doesn’t have a coverage gap as with other Part D prescription plans. This means you continue to pay your plan’s copay until you reach the catastrophic phase, where your out-of-pocket cost may be lower but never more than your group plan copay.

You have access to more than 63,700 pharmacies nationwide. including more than 23,000 preferred pharmacies.

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OptumRX. (P) Toll-free: 1-855-810-0007 / TTY: 711

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High RX Plan

$ 91.90

Low RX Plan

$ 72.90

S5584 (PDP Only) - BCBSM
Prescription BlueSM is a PDP plan with a Medicare contract. Enrollment in Prescription Blue depends on contract renewal.

H9572 & S5584 (PPO/PDP) - BCBSM
Medicare Plus BlueSM and Prescription BlueSM are PPO and PDP plans with Medicare contracts. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal.

Mediare Supplement Plan Information
2023 Medicare Supplement Plans

The DSRA BT offers Health, Dental, and Vision insurance for Salaried and Hourly retirees of Delphi.

You will find in this section information on and links to plan coverages available, premium rates, co-pays and annual deductibles, each of which impact your total out of pocket medical services cost. However, you cannot purchase stand alone RX from the Trust.  You will also be able to navigate to guidebooks, enrollment forms, and carrier specific information

Eligibility qualification is administered for the Trust through Benistar, our new Plan Administrator.

  • Health Care- For post-65 retirees, spouses and surviving spouses, Hartford Insurance and Benistar/ESI provide the Trust with a Group Health Care Plan that includes Rx and operates like a Medicare Supplement plan.  Four distinct plans are offered:

    • Elite 

    • Premium 

    • Choice

    • Premium Plus

  • If you purchase a plan from the Hartford, you are not required to purchase the Rx plan from the Trust.  You can now purchase a Rx plan from the carrier of your choice to meet the Medicare requirement.  To enroll in any of the Hartford plans, you are required to complete 2 enrollment forms; 1) the Hartford form and 2) the DSRABT enrollment form.  All forms are provided below in the Forms Section.

Click here to view a side-by-side comparison of the four medical plans. 

Retirees Post-65 Group Retiree Insurance Plan 

DSRA-BT offers four medical plan choices to retirees over the age of 65. All four plans are underwritten by The Hartford.  


For complete details about the plans, please refer to the Group Retiree Insurance Plan Summary of Benefits documents here.

Added benefits INCLUDED with your Hartford Plans

Dental Plan Coverge Details

The Elite, Premium, Choice and Premium Plus Retiree Medical Plans are available to ALL DSRA Benefit Trust Members in ALL states except Florida.  Benefits for these plans include the “Silver and Fit” fitness club membership program as well as a yearly $25 copay full physical (up to $500 value).  Members can elect one of two BCBSM prescription drug plans, High or Low to pair with the Hartford medical plan or as a standalone plan.  Members will automatically be enrolled in the BCBSM low prescription drug plan.  If you would like to enroll in the BCBSM High prescription drug plan please contact Benistar.  You do not need to enroll in the Hartford medical plan to enroll in the BCBSM prescription drug plan.

2023 Dental and Vision Plans

Dental- For both pre and post-65 retirees, their dependents and surviving spouses, BCBS of Michigan provides the Trust with dental insurance. Dental insurance may be purchased separately.  All Summaries state Effective Date as of 1/1/2016. They continue to be effective for 2023.

We understand the importance of good dental health. Good oral hygiene is important to your overall health. Regular visits to the dentist can help detect problems like gingivitis and even oral cancer.  Plan on visiting your dentist once every six months. DSRA-BT offers dental coverage through Blue Cross Blue Shield of Michigan (BCBSM).  The dental plan provides a wide variety of covered services – either covered in full or partially by the plan. Members will continue to have the choice to enroll in dental and/or vision which requires an application to be completed.

Click here for plan coverage details or for Guide to Benefits and Premiums.



low dental plan

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high dental plan

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* Differences in Class coverage's for the Low Dental Plan and the High Dental Plan

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Click here for plan coverage details or for Summary of Benefits and Premiums.

Your eyes are your windows to wellness. Routine eye exams each year allows your eye doctor to detect symptoms of serious eye disease – such as cataracts, glaucoma, and macular degeneration – and health conditions – such as diabetes, cardiovascular disease, and high blood pressure. Caught early, many of these diseases are treatable. However, left undetected and untreated, these conditions can result in vision loss, a lower quality of life, and higher overall health care costs. DSRA-BT will continue to offer vision benefits through Blue Cross Blue Shield of Michigan (BCBSM). The vision plan offers you comprehensive coverage – including eye exams and materials – through VSP, the nation’s largest vision care network, with 27,000 doctors and 41,000 locations. Members will continue to have the choice to enroll in vision and/or dental which requires an application to be completed. The table below provides an overview of the vision plan benefit. For specific details about the plan, please refer to the Summary of Benefits.  

To find a VSP doctor, call 1-800- 877-7195 or log on to the VSP website at

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This form is used for Medicare Advantage Plans, Stand Alone RX Plans, Dental & Vision and Hartford Plans.

This form is also required for The Hartford Plans.

2023 Medicare Forms

Complete the forms below for the programs you wish to enroll in for your post 65 needs.  Send completed forms to Benistar Retiree Service Center by mail, email or fax.




VISION Vision Service Plan (VSP)

Medicare Plus BlueSM and Prescription BlueSM are PPO and PDP plans with Medicare contracts. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal.

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“Out-of-network/non- contracted providers are under no obligation to treat Medicare Plus Blue PPO BCBSM Diamond, Medicare Plus Blue PPO BCBSM Emerald and Medicare Plus Blue PPO BCBSM Ruby members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.”

Additional information can be found by clicking on the topics below.

- DSRABT medical/Rx enrollment forms

- BCBSM Dental and Vision Enrollment Form

- BCBSM Rx Formulary

Post 65 Forms
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