The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Copayments and Coinsurance
Copayments are payments you make on a per service basis for eligible expenses after the
deductible has been satisfied. Copayments are applied to the out-of-pocket maximum. For
example, after the deductible is satisfied, you will pay a $150 copayment along with your
coinsurance for emergency room services if you are enrolled in the Early Retiree Medical option.
Copayments for the Early Retiree Medical and Comprehensive options can be found in the
“What the Options Cover” charts in this SPD. Copayments related to pharmacy coverage for
these options can be found in the “Pharmacy Coverage Summary” section in this SPD.
Coinsurance is a percentage of the cost of the service that you pay for eligible expenses once the
deductible has been satisfied. The cost is the lesser of the allowed amount and the provider's
actual billed charge. How much coinsurance you pay (after your applicable deductible and/or
copayment is met) depends on the service received and if you use an in-network/participating
provider or not. The coinsurance you pay is applied to the out-of-pocket maximum. If you
receive services from a non-participating provider, you will also be responsible for paying any
amount in excess of the allowed amount in addition to coinsurance. In certain locations, this also
applies when out-of-network providers are used. Refer to the “Which Network Providers to Use”
section in this SPD for more information. The excess amount you pay will not be applied to the
out-of-pocket maximum. A change to the cost during a plan year will not result in a recalculation
of any coinsurance paid. Coinsurance for the Early Retiree Medical and Comprehensive options
can be found in the “Health Care Option Summary” section in this SPD. Coinsurance related to
pharmacy coverage for these plans can be found in the “Pharmacy Coverage Summary” section
in this SPD.
Out-of-Pocket Maximum
The out-of-pocket maximum is the per plan year limit you must pay toward eligible expenses
before any additional eligible services you incur are paid by the Program at 100% of the allowed
amount for the remainder of the year (as long as any applicable annual or lifetime maximums
have not been exceeded). The limit you pay includes the total of the applicable deductible,
copayments and coinsurance. The out-of-pocket maximum under the health care options is
explained below. The out-of-pocket maximums stated are for in-network/participating providers
only. Information for out-of-network/non-participating out-of-pocket maximums can be found in
the “Health Care Option Summary” section in this SPD.
Early Retiree Medical Option
The Early Retiree Medical option has a combined medical/pharmacy out-of-pocket maximum
and the out-of-pocket-maximum is non-embedded, which means:
• If you elect the Individual coverage level, you only need to meet the per person out-ofpocket
maximum of $5,000.
• If you elect the Family coverage level, you will need to meet the Family out-of-pocket
maximum of $7,500. The Family out-of-pocket maximum can be met by one covered
member or any combination of covered members. The per person out-of-pocket
maximum does not apply.
Comprehensive Option
The Comprehensive option has separate medical and pharmacy out-of-pocket maximums; they
are not combined and the out-of-pocket maximum is embedded, which means:
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