The eligibility and enrollment rules for the U

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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: 26
Retiree Health Care SPD Effective January 1, 2012 • If you elect the Individual coverage level, you only need to meet the per person out-ofpocket maximum of $1,750. • If you elect the Family coverage level (but only have one or two covered dependents), each of you will be responsible for the per person out-of-pocket maximum of $1,750. The Family out-of-pocket maximum does not apply since it’s the same as each per person amount that applies to you and your covered dependent. • If you elect the Family coverage level (with at least three dependents covered), the per person out-of-pocket maximum of $1,750 will apply if one covered member meets this amount on their own and at least two other covered member will be responsible for the remaining per person out of pocket maximum of $1,750. Otherwise the Family out-ofpocket maximum of $5,250 can be met by any combination of at least three or more covered members if none of the covered members can meet the per person out-of-pocket maximum of $1,750 on their own. The charges that do not apply to your deductible (listed previously) also do not apply to your out-of-pocket maximum, except for copayments. 27
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The eligibility and enrollment rules for the U

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