The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 RETIREE HEALTH CARE OPTIONS The health care option available to you depends on your age (as the U.S. Bank retiree), Medicare eligibility and the area in which you live. • If you are under age 65 (and not Medicare eligible), you can enroll yourself and your eligible dependents (regardless of their ages) in the pre-65 health care option available in your location. • If you and your eligible dependents are age 65 or older or pre-65 and Medicare eligible, you and your eligible dependents must enroll in the UnitedHealthcare or Medica Plan option available in your area. • If you are age 65 or older but your covered dependents are under age 65 and not Medicare eligible, you must enroll in the UnitedHealthcare or Medica option available in your area and your covered dependents can enroll in the pre-65 health care option available in your area. Your Health Care Options — Retirees Under Age 65 and non-Medicare Eligible The option available to you at your initial enrollment is listed on your enrollment form and depends on where you live. Choices for retirees under age 65 are: Option Claims Administrator(s) No Coverage Early Retiree Medical (in locations with access to the BCBS BCBS of MN BlueCard PPO network) Comprehensive (in locations without access to the BCBS BCBS of MN BlueCard PPO network) Blue Cross and Blue Shield of Minnesota and other Blue Cross Blue Shield plans are independent licensees of the Blue Cross Blue Shield Association. Following is a brief summary of the pre-65 non-Medicare eligible health care options. Early Retiree Medical Option This option is available to pre-65 non-Medicare eligible retirees and their dependents and is available in areas that have access to the BCBS BlueCard PPO network. This option is administered by Blue Cross and Blue Shield of Minnesota. Specific details about the deductible and out-of-pocket maximum related to each option can be found in the “Health Care Option Summary” section in this SPD. Under this option: • You may choose any provider each time you need care – either in or out of the BCBS BlueCard PPO network. However, your benefit level depends on the provider you select. If you use an in-network provider, your expenses are generally covered at a higher level. Refer to the “Which Network Providers to Use” section in this SPD for more information on the provider networks. Benefits are not available for preventive care if you use an outof-network provider. • If either your physician or your clinic leaves the network, you must select another physician or clinic affiliated with your network in order to receive in-network benefits. 16
Retiree Health Care SPD Effective January 1, 2012 • Pharmacy services are included and administered by Medco Health Solutions (Medco). You will need to use your Medco ID card when using these services. Detailed information on pharmacy coverage can be found in the “Pharmacy Coverage Summary” section in this SPD. Comprehensive Option This option is generally available to pre-65 non-Medicare eligible retirees and their dependents that do not have adequate access to the BCBS BlueCard PPO network (although there may be BCBS participating providers in the area). This option is administered by Blue Cross and Blue Shield of Minnesota. Under this option: • You may choose any provider each time you need care – either in or out of the BlueCard Traditional network. However, your benefit level depends on the provider you select. If you use a BlueCard Traditional provider, your expenses are generally covered at a higher level. Refer to the “Which Network Providers to Use” section in this SPD for more information on the provider network. • If either your physician or your clinic leaves the BlueCard Traditional network, you must select another physician or clinic in the BlueCard Traditional network in order to receive “participating provider” benefits. • Pharmacy services are included and administered by Medco Health Solutions (Medco). You need to use your Medco ID card when using these services. Detailed information on pharmacy coverage can be found in the “Pharmacy Coverage Summary” section in this SPD. Kaiser Colorado Option This option is no longer available to retirees effective January 1, 2009. If you were already enrolled in the Kaiser option prior to January 1, 2009, you may remain in this option. If you are enrolled in the Kaiser option, generally you will receive benefits only for covered services you receive from a provider within Kaiser. If you receive non-emergency services from a provider outside Kaiser, you will likely receive no benefits. The Kaiser option is offered through insurance contracts with Kaiser Permanente. Kaiser has the sole authority, discretion and responsibility to interpret and construe the option and, determine all factual and legal questions under such option, including but not limited to eligibility, the entitlement of benefits and the amounts of benefits to be paid, and determine all questions arising in the administration of the option. Kaiser Colorado provides its own materials. Be sure to refer to those materials, as Kaiser may have different provisions and requirements than those described in this SPD. Kaiser Mergers/Terminations/Provider Changes. If you are enrolled in Kaiser and Kaiser merges with another company and is no longer offered by U.S. Bank, or if Kaiser terminates operations during the year, you will be enrolled in either the Early Retiree Medical or the Comprehensive option (depending on whether you have access to the BCBS BlueCard PPO network or not in your area). If either your physician or your clinic leaves Kaiser, you must select another physician or clinic affiliated with Kaiser – you will not be able to change health care options under this circumstance. 17
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The eligibility and enrollment rules for the U

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