The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 and Human Services, the National Institutes of Health, the Council of Medical Specialty Societies and any other association or federal program or agency that has the authority to approve medical testing and treatment, on which to base a scientific opinion of the medical value of the proposed treatment. For purposes of determining whether a drug, device, diagnostic test, medical treatment or procedure is “experimental, investigative or unproven,” reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature, written protocol or protocols used by the treating provider or facility or another provider or other facility studying substantially the same drug, device, diagnostic test, medical treatment or procedure guidelines established by BCBS of MN Medical Policy Committee or the written informed consent used by the treating provider or facility or by another provider or facility studying the same drug, device, diagnostic test, medical treatment or procedure. Family Practice A branch of medicine that involves comprehensive health care for the entire family, including obstetric care and minor surgical procedures. Formulary A list of commonly prescribed brand-name and generic drugs that Medco has designated as “preferred” based on the drug’s clinical effectiveness and opportunities to help contain costs. You receive the highest level of coverage when you use formulary (preferred) drugs. HIPAA HIPAA, which is an acronym for the Health Insurance Portability and Accountability Act, is a federal law that was passed in 1996. HIPAA provides for portability of health care in certain situations, such as by limiting pre-existing condition exclusions and providing for special enrollment rights in group health plans. HIPAA also has provisions to protect the privacy of patient medical records. Home Health Care Agency A provider that is licensed or certified as a home health care agency and sends health professionals and home health aides into a home to provide health services. Home Infusion Therapy Treatment provided in the home by a home health care agency involving the administration of nutrients, antibiotics and other drugs and fluids intravenously. Hospice Care Care for terminally ill patients that are no longer receiving treatment to cure their disease, with the purpose of keeping them comfortable. An interdisciplinary team of professionals directs care, with family members or friends acting as primary caregivers. Hospital A facility licensed or regulated as an acute care facility and staffed by physicians. Hospitals provide inpatient and outpatient care 24 hours a day. 146
Retiree Health Care SPD Effective January 1, 2012 In-Network Provider For the Early Retiree Medical option, a provider who has entered into a service agreement with the medical Claims Administrator for the network associated with your location and health care option. If you receive services from an in-network provider, your expenses are generally covered at a higher level than if you chose an out-of-network provider and you will not be responsible for paying the difference between the billed charge and the allowed amount. Refer to the “Which Network Providers to Use” section of this SPD for more information on the provider networks. Lifetime Maximum The cumulative maximum amount payable by the Program for a particular non-essential covered medical service or prescription drug incurred by you during your lifetime or by each of your covered dependents during the dependent's lifetime under all U.S. Bank Health Care Plans. The maximum does not include amounts that are your responsibility (deductibles, coinsurance, copayments, penalties and other amounts). Exceeding the lifetime maximum does not cause you or your dependents to be eligible for any conversion right provided by the program. Refer to the “What the Options Cover” section in this SPD for specific lifetime maximums on certain services. For lifetime maximums related to prescription drugs, see the “Pharmacy” section in this SPD. Medical Supply Supplies prescribed by a physician as medically necessary for treatment of an illness or injury. Examples include casts, splints, trusses, braces or crutches, blood or blood plasma and prosthetics. Medical supplies are not reusable and usually last less than one year. Medically Necessary A health care service, treatment or supply furnished by a particular provider is considered medically necessary if, in the judgment of the Claims Administrator (or any person or third party to whom it delegates authority), it is appropriate for and consistent with the diagnosis, care or treatment of the illness or injury and: • it is in accordance with generally accepted medical standards and good medical practice (e.g., recognized by the American Medical Association) and requires the technical skills of a medical, mental health or dental professional; • it is indicated by the health status of the patient and is as likely to produce a significant positive outcome, and no more likely to produce a negative outcome, as any alternative service or supply; • omitting it would adversely affect the patient's condition or the quality of medical care rendered; • it is the most appropriate level of service or treatment (for example, hospital inpatient care that could not be provided appropriately on an outpatient basis); • it is not furnished solely because the person is an inpatient, when the disease or injury could safely and adequately be diagnosed or treated on an outpatient basis; • it is not solely for the convenience of the patient or the physician, hospital or other provider; and • it is no more costly than any alternative service or supply that meets the above criteria. Relevant information that will be taken into account when determining if a health care service, treatment or supply is appropriate includes: • information provided about the patient's health status; • guidelines established by the BCBS Medical Policy Committee; 147
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