The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Dear Retiree: U.S. Bank is pleased to offer health care coverage for eligible retirees and their eligible dependents. The material in this summary plan description (SPD) summarizes the current terms of the U.S. Bank Retiree Health Care Program. Our philosophy about health care benefits is the same for retirees as it is for our active employees. We create our programs to provide cost-effective, quality benefits. To help moderate premium increases due to rising health care costs, we continue to modify plan features and diligently pursue efforts to control both retiree and company costs as much as possible. We encourage you to be an informed consumer and take time to understand these benefits so that you may make good health care decisions for you and your family. Please read this material carefully. Also, it is important for you to be fully informed about Medicare. Your State Health Insurance Assistance Program can tell you how to get more information, or you may access Medicare information online at www.medicare.gov. You may also wish to access the American Association for Retired Persons (AARP) Web site at www.aarp.org. Beginning January 1, 2006, the Medicare Part D prescription drug benefit became available to retirees that are Medicare eligible. Because prescription drug coverage will continue to be primary (except for prescription drugs covered under Medicare Parts A or B) under U.S. Bank’s Retiree Health Care Program, we strongly recommend THAT YOU DO NOT ENROLL IN MEDICARE PART D. More information is included in the “How Coverage Works If You Are Age 65 Or Older Or Pre-65 And Medicare Eligible” section of this SPD. If you do enroll in Medicare Part D coverage, you will no longer receive prescription drug coverage under the Retiree Health Care Program, and your monthly Retiree Health Care Program premium will not be reduced. Your monthly premium covers both medical and pharmacy benefits, and it will not be changed. If you decide to enroll in Medicare Part D, you will pay additional unnecessary premiums, as you will be paying a premium for both Medicare Part D and the Retiree Health Care Program. Please Note: If you are enrolled in the UHC PPO option, Medicare will cancel your UHC PPO coverage if you enroll in Medicare Part D. Once Medicare cancels your UHC PPO coverage you will no longer be enrolled in the U.S. Bank Retiree Health Care Program. Please also keep in mind that U.S. Bank offers Retirement Counselors to help you make the most of your retirement. Counselors are professionally trained on the benefits offered to retirees of U.S. Bank and provide one-on-one assistance. There is no cost to you for a consultation(s). Just call 1-800-806- 7009 and ask to speak to a Retirement Counselor. Retirement Counselors are available between 8 a.m. and 5 p.m. CT, Monday through Friday. Please keep this SPD handy for future reference. If you have questions about any information in the SPD, please call the appropriate number listed in the “Important Resources” section of this SPD. Sincerely, Ellen M. Peterson Senior Vice President, Human Resources 2
Retiree Health Care SPD Effective January 1, 2012 Table of Contents Eligibility and Enrollment ........................................................................................7 Eligibility and Enrollment Rules ...............................................................................................................................7 Additional Eligibility and Enrollment Information .................................................................................................12 Retiree Health Care Options ..................................................................................16 Your Health Care Options — Retirees Under Age 65 and non-Medicare Eligible .................................................16 Your Health Care Options — Retirees Age 65 or Older or Pre-65 and Medicare Eligible .....................................19 Pre-Existing Conditions Limitations .......................................................................................................................21 How to Show Previous Creditable Coverage...........................................................................................................22 Wellness ..................................................................................................................................................................23 Deductibles, Coinsurance and Maximums............................................................24 Deductibles..............................................................................................................................................................24 Copayments and Coinsurance..................................................................................................................................26 Out-of-Pocket Maximum.........................................................................................................................................26 Health Care Options Summary..............................................................................28 What the Options Cover .........................................................................................30 Early Retiree Medical Option..................................................................................................................................30 Comprehensive Option ............................................................................................................................................38 How Coverage Works if You Are Under Age 65 and Not Medicare Eligible....46 Which Network Providers to Use ............................................................................................................................46 Allowed Amounts....................................................................................................................................................48 Transition of Care....................................................................................................................................................50 Preadmission Notification and Prior Authorization for BCBS of MN-Administered Benefits ...............................51 When You Have Other Coverage – BCBS of MN ..................................................................................................54 Liability of Another Party: When Another Person is Responsible for Your Covered Health Care Expenses.........55 What Happens When You or a Dependent Turn Age 65 or Become Medicare Eligible Before Age 65.................56 Medicare Eligible Retirees and Dependents Turning Age 65 .............................57 What Happens When You Turn Age 65 or Become Medicare Eligible before Age 65 ..........................................57 What Happens When a Dependent Turns Age 65 or becomes Medicare Eligible Before Age 65 ..........................57 Preadmission Notification and Prior Authorization.................................................................................................58 Your Benefit Option Integration With Medicare.....................................................................................................58 Claiming Health Care Benefits with Medicare........................................................................................................59 How Coverage Works If You Are Age 65 or Older or Pre-65 and Medicare eligible .......................................................................................................................60 Your Benefit Option If You are Medicare Eligible .................................................................................................60 Your Prescription Drug Coverage under the Program and Medicare Part D...........................................................61 Pharmacy..................................................................................................................63 Pharmacy Deductibles, Coinsurance and Maximums..............................................................................................63 Pharmacy Coverage Summary ................................................................................................................................66 Formulary Drugs......................................................................................................................................................68 Diabetic Supply Exception ......................................................................................................................................69 Mail Order Maintenance Drug Provision ................................................................................................................69 Specialty Drug Provision.........................................................................................................................................70 Medco’s –Mail Order Service Pharmacy.................................................................................................................71 Education and Safety...............................................................................................................................................75 Retail Pharmacy.......................................................................................................................................................75 Prior Authorization for Pharmacy Coverage ...........................................................................................................76 Step Therapy............................................................................................................................................................77 Additional Pharmacy Benefit Limitations ...............................................................................................................79 Infertility Coverage Maximum ................................................................................................................................79 Vaccines Covered by Medicare Part D....................................................................................................................80 Drugs Not Covered..................................................................................................................................................80 Filing Pharmacy Claims – Medco ...........................................................................................................................80 3
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The eligibility and enrollment rules for the U

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