The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 COBRA COBRA is an acronym for Consolidated Omnibus Budget Reconciliation Act. Under COBRA, employers have an obligation to make available to covered employees and their covered dependents or eligible covered dependents of retirees, the continuation of certain benefits for a period following the termination of the employment relationship or the occurrence of certain other qualifying events, if they result in loss of coverage. Coinsurance A percentage of the cost of a service that you pay for eligible expenses once the deductible has been satisfied. See the “Deductibles, Coinsurance and Maximums” section and in the “Pharmacy Deductibles, Coinsurance and Maximums” section in this SPD for more information. Copayment Copayments are payments you make on a per-service basis for eligible expenses after the deductible has been satisfied. See “Copayments” in the “Deductibles, Coinsurance and Maximums” section and in the “Pharmacy Deductibles, Coinsurance and Maximums” section in this SPD for more information. Covered Service A health service or supply that is eligible for benefits when performed and billed by an eligible provider. You incur a charge on the date you receive a service, order a supply, or purchase a drug. Custodial Care Services for the primary purpose of meeting personal needs. Services can be provided by persons without professional skills or training. Custodial care does not include skilled care. Custodial care includes giving medicine that can usually be taken without help, preparing special foods, or helping someone to walk, get in and out of bed, dress, eat, bathe or use the toilet. The Program does not cover custodial care. Deductible The per plan year amount you must pay toward eligible expenses before you and the health care Program begin to share covered expenses. See “Embedded” and “Non-Embedded” in this glossary and the “Deductibles, Coinsurance and Maximums” section in this SPD for more information. Durable Medical Equipment (DME) Equipment that is medically necessary, able to withstand repeated use, used primarily for a medical purpose, useful only to a person who is ill, appropriate for use in the patient's home and prescribed by a physician. Durable medical equipment does not include such things as hot tubs, whirlpool baths, vehicle lifts, waterbeds, air conditioners or purifiers, heat appliances, dehumidifiers, computers or exercise equipment. East Employee East Employee designates those individuals who were: • employed by Firstar Corporation, Mercantile Bancorporation, Inc. or Star Bank Corporation before February 27, 2001; or • employed before January 1, 2002, and who are classified on the payroll system as East Region employees; or 144
Retiree Health Care SPD Effective January 1, 2012 • covered under a retirement plan sponsored by Firstar Corporation before January 1, 2002. Embedded Something that is enclosed within something else. For example, the per person deductible and out-of-pocket maximum amount is within the family deductible and out-of-pocket maximum amount for the Comprehensive option. This allows each covered family member the opportunity to get his/her eligible expenses covered prior to the entire family amount being met if you elect family coverage. Emergency A critical condition that starts suddenly and requires immediate treatment to preserve or stabilize your life, limb(s), eye(s) or health. Explanation of Benefits (EOB) The statement sent from the medical Claims Administrator following your receipt of a medical service and a subsequent claim being filed. The EOB shows information about the service and the associated charges, any provider reduction, the amount paid by the plan (if any), and the amount that you are responsible to pay (if any). For pharmacy, the statement sent by Medco upon completion of processing a submitted paper claim. When ordering prescriptions through Medco Pharmacy (Medco’s mail order service), a statement is included with the prescription order and is known as the Medco by Mail Pharmacy Statement. Experimental, Investigative or Unproven A drug, device, diagnostic test, medical treatment or procedure will be considered by the Claims Administrator (or any person or third party to whom it delegates authority) to be experimental, investigative or unproven if any of the following are true: • If, at the time the drug, device, diagnostic test, medical treatment, or procedure is furnished or proposed, it has not been approved for use by the appropriate governmental agency (e.g., U.S. Food and Drug Administration) and such approval is required. • If reliable evidence shows that the drug, device, diagnostic test, medical treatment or procedure is not generally or commonly or customarily recognized by the medical profession as appropriate and of scientifically proven value for the diagnosed illness or injury at the particular presenting stage, and/or that further studies or clinical trials are necessary to determine the maximum tolerated dose, toxicity, efficacy, or efficacy as compared with standard means of diagnosis or treatment. • If reliable evidence demonstrates that the drug, device, diagnostic test, medical treatment or procedure is the subject of ongoing Phase I, II, or III clinical trials as follows: − Phase I clinical trials determine the gate dosages of medication for Phase II trials and define acute effects on normal tissue. − Phase II clinical trials determine clinical response in a defined patient setting. If significant activity is observed in any disease during Phase II, further clinical trials usually study a comparison of the experimental treatment with the standard treatment in Phase III trials. − Phase III trials are typically quite large and require many patients to determine if a treatment improves outcomes in a large population of patients. If a drug, device, diagnostic test, medical treatment or procedure is so new, or its use for the patient's condition is so new, that there is no reliable evidence nor published opinions by national medical associations or other medical assessment groups, including, but not limited to, the American Medical Association, the Food and Drug Administration, the Department of Health 145
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