The eligibility and enrollment rules for the U

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;
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