The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
GLOSSARY OF TERMS
Admission
Inpatient stay (in bed) that lasts at least one day and night.
Allergy Services
Medical services that involve evaluation and management of immune system disorders.
Allowed Amounts
The amount that is the basis for payment with regard to a given covered service. All benefit
payments under the BCBS administered options are based on the allowed amount. The allowed
amount may vary from one provider to another for the same service. Also, the Claims
Administrator may periodically adjust the allowed amount.
Medco uses the amount a participating pharmacy would charge if you showed your Medco ID
card. The BCBS allowed amount is the negotiated amount of payment that a participating
provider has agreed to accept as payment in full (less deductibles, coinsurance and copayments)
for a covered service at the time your claim is processed. The allowed amount may be based on
an estimated final price (including anticipated adjustments), or it may be based on discounts
from billed charges. See the “Allowed Amounts” section in this SPD for more information about
the determination of allowed amounts by BCBS.
Annual Maximum
The cumulative maximum amount payable by the U.S. Bank Retiree Health Care Program for a
particular covered medical service or prescription drug incurred by you during each plan year or
by each of your covered dependents during the plan year. The maximum does not include
amounts that are your responsibility (deductibles, coinsurance, copayments, penalties and other
amounts). Refer to the “What the Options Cover” section in this SPD for specific annual
maximums on certain medical services. For annual maximums related to prescription drugs, if
any, see the “Pharmacy” section in this SPD.
Average Semiprivate Room Rate
The average rate charged for a room with more than one bed. If the provider has no semiprivate
rooms, the program still uses the average semiprivate room rate for payment of the claim.
Claims Administrator
For the self-funded benefit options, U.S. Bank has delegated authority to several third party
claims administrators ("Claims Administrator") to interpret and construe the terms of the
Program and to determine all factual and legal questions under the Program with respect to all
initial claims for benefits and requests for review of adverse benefit determinations. This
delegated authority includes, but is not limited to, determinations of entitlement to benefits and
the amounts of the benefits to be paid. Your location and the coverage option you choose will
determine your specific Claims Administrator. For a list of Claims Administrators, see the
“Claims Administrator Information” section in this SPD.
143