The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
Early Retiree Medical Option, continued
Service¹
Cosmetic,
Reconstructive or
Plastic Surgery
Dental-Related
Services
Dental services covered
under the U.S. Bank
Retiree Health Care
Program are limited to:
1. Treatment of
fractured jaw
2. Accident-related
dental services from a
physician or dentist for
the treatment of an
injury to sound and
healthy natural teeth
3. Inpatient or
outpatient hospitaliz -
ation and anesthesia
charges for medically
necessary dental
services provided to a
covered person who is
a child under age five
(5), is severely
disabled, or has a
medical condition that
requires hospital -
ization or general
anesthesia for dental
treatment, as determ -
ined by the medical
Claims Administrator.
Participating
Provider/In-
Network
Coinsurance²
Non-
Participating
Provider/Outof-Network
Coinsurance² Special Notes
You pay 25% You pay 45% Coverage only for reconstructive surgery that is incidental to or
follows surgery resulting from injury, sickness, or other diseases of the
involved body part; reconstructive surgery performed on a dependent
child because of congenital disease or anomaly that has resulted in a
functional defect as determined by the attending physician; or
treatment of cleft lip and palate for a dependent child under age 19. See
“Cleft Lip and Palate” in this chart.
You pay 25%
You pay 25%
You pay 25%
You pay 45%
You pay 45%
You pay 45%
Panniculectomy covered when both chronic, recurrent infection is
documented and interference with hygiene and activities of daily living
are documented.
No coverage for psychological or emotional reasons. No coverage for
repair of scars and blemishes on skin surfaces or cosmetic,
reconstructive or plastic surgery for any other purpose. Refer to “The
Women’s Health and Cancer Rights Act of 1998” section in this SPD
for mastectomy with reconstructive surgery.
No coverage for actual dental treatments that may be performed as part
of services (1), (2), or (3) shown to the left. Such dental treatments
include dental implants and prostheses, osteotomies and other
procedures associated with fitting of dentures or dental implants, root
canals, removal of impacted teeth or tooth root. Also see “TMJ
Services” in this chart.
Accidents or injuries sustained prior to the effective date of coverage
are eligible as coverage is based on actual date of treatment and not the
date the accident or injury occurred. Chewing injuries to teeth not
covered. Dental caries (cavities) not covered.
See “Hospital Inpatient Services” in this chart. Covered only when
related to a medical condition and necessary to protect and safeguard
the life of the patient.
¹ Refer to the “Preadmission Notification and Prior Authorization for BCBS-Administered Benefits” section in this SPD to see if
any action is recommended or required on your part before receiving the service.
² The percentage in this column is based on the BCBS allowed amount. All coinsurance amounts (unless otherwise noted) are
paid after the deductible has been satisfied. Refer to the “Health Care Option Summary” section in this SPD for the deductible
information related to your health care option.
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