The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 • Outpatient mental health facilities • Outpatient substance abuse facilities Note: Although a facility may be considered eligible, services provided by the facility may not be eligible under your option. Please see the “What the Options Cover” and the “General Exclusions” sections in this SPD. In addition, there may be other types of facilities that are eligible, but not listed. If you have any questions regarding eligible facilities, call the BCBS customer service department at the number listed in the “Important Resources” section in this SPD. Examples of facilities not eligible under the Program are retirement homes, nursing homes, spas and health clubs. General Exclusions Although the U.S. Bank Retiree Health Care Program options cover most medically necessary services, there are some expenses that are not covered. Some of the services not covered are listed in the coverage charts and in the “Mental Health and Substance Abuse Coverage” section in this SPD. BCBS has the discretion to determine whether a service/procedure is medically necessary. If you have a question about whether an expense is covered, please call BCBS. The following services are specifically not covered: 1. Any treatment, service or supply that is not medically necessary. (See “Medically Necessary” in the “Glossary of Terms” section in this SPD for more detailed information.) 2. Any treatment, service or supply that is not generally accepted and usual for the treatment of an illness, in accordance with the terms of the U.S. Bank plan document and the BCBS medical staff. 3. Preventive care or any treatment, service or supply that is educational, developmental, experimental, investigative or unproven in nature. This includes health services that are considered experimental or investigative, performed for the purpose of research, or unproven procedures, in accordance with the terms of the U.S. Bank plan document and the BCBS medical staff. (See “Experimental, Investigative or Unproven” in the section “Glossary of Terms” in this SPD for a more detailed definition.) 4. Health services eligible for payment under any workers' compensation or employer's liability law or similar law or act, or covered under any no-fault insurance policy to the extent that the no-fault policy covers services eligible under this Program, or any expenses that would otherwise be the responsibility of a third party. (See the section “When You Have Other Coverage – BCBS” in this SPD.) 5. The portion of eligible services and supplies paid or payable under Medicare. (See the section “When You Have Other Coverage – BCBS” in this SPD.) 6. Charges that are eligible, paid or payable, under any medical payment, personal injury protection, automobile or other coverage that is payable without regard to fault, including charges that are applied toward any deductible, copayment or coinsurance requirement of such a policy. 102
Retiree Health Care SPD Effective January 1, 2012 7. Services for or related to treatment of illness or injury which occurs while on military duty and that are recognized by the Veteran's Administration as services related to serviceconnected injuries. 8. Health services needed because the patient committed or attempted to commit a felony, or engaged in an illegal occupation. 9. Services that are prohibited by law or regulation. 10. Examinations or treatment ordered by a court in connection with legal proceedings unless such examinations or treatment is otherwise covered under the terms of this Program. 11. Services or confinements ordered by a court or law enforcement officer that are not medically necessary. Services that are not considered medically necessary include, but are not limited to the following: custody evaluation, parenting assessment, education classes for DUI offenses, competency evaluations, adoption home status, parental competency and domestic violence programs. 12. Court-ordered mental health services unless otherwise specified as covered under the Program. (Refer to the “Mental Health and Substance Abuse Coverage” section in this SPD.) 13. Services received before you or your dependents are covered under the Program. 14. Services received after you or your dependent loses coverage under the Program. 15. Services received by your dependent if your dependent is a U.S. Bank employee with his/her own coverage. 16. Expenses incurred after the Program or plan terminates, except when the patient was confined in a hospital on the date of termination. The Program would be responsible for eligible charges until the patient was discharged. 17. Services, supplies, medical care or treatment given by you or by your or your spouse's immediate family, spouse, child, brother, sister, parent or grandparent. 18. Services given by volunteers or persons who do not normally charge for their services. 19. Services given by a pastoral counselor. 20. Services that are not within the scope, licensure, or certification of a provider. 21. Telephone consultation. 22. Charges for failure to keep scheduled visits. 23. Charges for furnishing medical records or reports. 24. Charges for the completion of claim forms. 103
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The eligibility and enrollment rules for the U

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