The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Participating Provider
For the Comprehensive option, a provider that has entered into a service agreement with BCBS.
If you receive services from a participating provider, your expenses are generally covered at a
higher level than if you had chosen a non-participating 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.
Pharmacy Deductible
The annual amount you must pay toward eligible prescription drug purchases or prescribed
supplies received at a pharmacy each year before benefits are paid on your behalf.
Pharmacy Out-of-Pocket Maximum
For the Comprehensive, UnitedHealthcare and Medica options the dollar amount you pay
(deductible plus coinsurance) toward prescription drug purchases or prescribed supplies in a year
before the Program will pay 100% of the allowed amount for any additional eligible drugs or
supplies you incur for the rest of that year, as long as any annual or lifetime maximums have not
been exceeded. See Out-of-Pocket Maximum in the “Pharmacy” section earlier in this SPD for
more information.
Plan Year
January 1 through December 31.
Preferred Provider Organization (PPO) Plan
A Preferred Provider Organization (PPO) is a plan that uses a network of medical care providers
that have agreed to provide various health care services for specified fees. You are generally
required to use a provider who is participating in the PPO network. You do not need to select a
primary care physician and you do not need a referral to other PPO network providers.
Premium
For insured benefits (Kaiser Colorado, Medica and UnitedHealthcare), the amount of money a
policyholder agrees to pay an insurance company for an insurance policy, in return for which the
insurance company provides payment of specified benefits. For self-insured benefits (BCBS of
MN), your contribution to the total cost of medical and pharmacy expenses paid by the plan and
is billed monthly.
Prescription Drugs
Drugs, including insulin, that are required by state or federal law to be dispensed only by
prescription of a health professional who is authorized by law to prescribe the drug. Medco
maintains listings of brand-name and generic drugs, called formulary (preferred) drugs.
Preventative Service
Generally, a routine service that promotes good health, is performed on a regular basis, not as a
result of your medical or family history, or associated with an injury or illness.
Provider
For health care plans, any individual, institution or agency that provides health services to health
care consumers.
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