The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
HEALTH CARE OPTIONS SUMMARY
Early Retiree Medical Option
In-Network*
Combined Pharmacy/Medical
Deductible (non-embedded)** per
plan year
(Level 1) †
You pay $2,000/person (only applies if the
Individual coverage level elected)
Out-of-Network*
You pay $3,100/person (only applies if the
Individual coverage level elected)
You pay $3,000/Family
You pay $4,100/Family
Medical Coinsurance** You pay 25% You pay 45%
Combined Pharmacy/Medical You pay $5,000/person (only applies if the You pay $11,200/person (only applies if the
Out-of-Pocket Maximum (nonembedded)**
per plan year
Individual coverage level elected) Individual coverage level elected)
You pay $7,500/Family
You pay $16,800/Family
Program Lifetime Maximum*** No maximum paid by the Program No maximum paid by the Program
See the section “Glossary of Terms” in this SPD for all definitions and the “Deductibles,
Coinsurance and Maximums” section in this SPD for more information.
* In-network and out-of-network deductibles, out-of-pocket maximums, annual maximums and lifetime maximums
accumulate jointly; e.g., if you use an out-of-network provider, the amount applied to your out-of-network
deductible also counts toward your in-network deductible, and vice versa.
** Deductible and Maximum out of pocket is per plan year.
*** Refer to the “What the Options Cover” section in this SPD for specific annual and/or lifetime maximums for
certain medical services. See the “Pharmacy” section in this SPD for specific annual and/or lifetime maximums for
certain prescription drugs.
† See the “Which Network Providers to Use” section in this SPD for more information.
Refer to the “Pharmacy” section in this SPD for information related to pharmacy coverage
included under this Program.
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