The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Early Retiree Medical Option, continued Participating Non- Participating Provider/In- Provider/Out- Network of-Network Service¹ Coinsurance² Coinsurance² Special Notes DNA Analysis You pay 25% You pay 45% Genetic testing covered for the following indications only: • To enable those affected by inherited disorders to make informed choices about future reproduction; • To detect breast, colon, or ovarian cancer in persons who have two first-degree relatives with a history of these cancers. Only one firstdegree relative is required for persons with a family history of premenopausal breast or ovarian cancer or colon cancer diagnosed before age 50; or • To verify a diagnosis when specific pre-clinical evidence is present. Durable Medical Equipment (DME) and Medical Supplies Emergency Room Care You pay 25% You pay 45% You pay 25% after $150 ER copay You pay 25% after $150 ER copay All other genetic testing and counseling is not covered. Covered DME and Medical Supplies (including disposable) must be prescribed by a physician and medically necessary for treatment of an illness or injury. Coverage includes DME such as: wheelchairs, ventilators, oxygen and equipment, and side rails; stockings, and casts; insulin pumps, glucometers and related equipment and devices; prosthetics, including breast, artificial limbs and eyes required as the result of a congenital defect, injury or illness; liquid nutrition (including amino acid-based elemental formula) when recommended by a physician; IUDs; SADD lights; implants; scalp hair prosthesis (wigs) for alopecia areata only (see limitations that follow); and custom foot orthoses (see limitations that follow). Limitations: • Wigs are covered for the medical condition of Alopecia Areata only and limited to $350 paid by the plan per plan year. • Custom foot orthoses limited to $500 paid by the plan per plan year. • No coverage for over-the-counter products and items. • DME and Supplies are covered up to the BCBS allowed amounts to rent or buy item. Syringes, test strips, lancets and needles are covered by Medco, not BCBS. See the “Pharmacy” section in this SPD for more information. The copayment will be waived if an inpatient admission occurs for the same condition within 24 hours. Refer to the “Emergency Care” section in this SPD. Enteral Nutrition (tube feeding) You pay 25% You pay 45% Pharmaceuticals given to you while in the Emergency Room will be covered under this benefit by BCBS, not Medco. If you are given a written prescription to be filled at the time you leave the Emergency Room, it will be covered by Medco, not BCBS. See the “Pharmacy” section in this SPD for more information. Covered when sole source of nutrition or inborn error of metabolism. Eyeglasses or You pay 25% You pay 45% Covered only for the medical conditions keratoconus and ulcerative Contact Lenses keratitis and post-cataract surgery (aphakia), accidental injury, or as a therapeutic bandage. Limited to one pair of eyeglasses or contact lenses after surgery paid by the plan. Thereafter, coverage applies only to lens replacement if prescription changes. 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. 32
Retiree Health Care SPD Effective January 1, 2012 Early Retiree Medical Option, continued Service¹ Hearing Aids and Tests for Hearing Aids Home Health Care Home Infusion Therapy Participating Provider/In- Network Coinsurance² Non- Participating Provider/Outof-Network Coinsurance² Special Notes You pay 25% You pay 45% Hearing aids are covered for a dependent child under age 13 who has a hearing loss due to a congenital loss of hearing that cannot be corrected by other covered procedures. Coverage is limited to $1,000 paid by the plan per ear every third plan year and includes the hearing aid, dispensing fee, molds, impressions, batteries and repairs. Replacements are not covered if lost. You pay 25% You pay 45% No coverage for tests for hearing aids. To be covered, skilled care must be prescribed by a physician and provided by a Medicare approved or other pre-approved licensed home health agency. Coverage is limited to $15,000 paid by the plan per plan year. $15,000 limit does not include lab and x-ray charges, drugs or Durable Medical Equipment purchased through home health care provider. See “Durable Medical Equipment (DME) and Medical Supplies” in this chart. Services for custodial care, non-skilled care, services of a nonmedical nature, private duty nursing, rest cures and mental health are not covered. You pay 25% You pay 45% To be covered, care must be ordered by a physician and provided by a Medicare approved or other pre-approved licensed home health agency. Covered services include solutions and pharmaceutical additives, pharmacy compounding and dispensing services, durable medical equipment and supplies, nursing services to train you or your caregiver to monitor your therapy, and collection, analysis and reporting of lab tests. Infusion services do not apply to the Home Health Care maximum. Hospice Care You pay 25% You pay 45% Hospice care for terminally ill patients provided by a Medicare-certified hospice provider or other pre-approved hospice. Coverage for inpatient and outpatient hospital care, routine and continuous home nursing care, home health aide visits, physical therapy, speech therapy, language therapy, occupational therapy, social worker visits, dietary/nutritional counseling, durable medical equipment, routine medical supplies and other supportive services provided to meet the physical, psychological, spiritual, and social needs of the dying patient. Coverage includes patient care instructions, respite care and other supportive services for the family, both before and after the death of the patient. Coverage for respite care is limited to 10 days paid by the plan during the episode of hospice care. To be eligible for hospice care, a physician must document that according to best medical judgment, the patient has six months or less to live, and the patient/family must agree not to pursue curative treatment. Inpatient care in a hospice or hospital is covered under Hospital Inpatient Services. Take-home drugs will process under this benefit level. Medical care services unrelated to the terminal illness may be covered according to other Plan benefits and requirements. Eligible services provided by a skilled nursing facility are covered but are separate from the hospice benefit. (See Skilled Nursing under “Hospital Inpatient Services” in this chart.) 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. 33
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The eligibility and enrollment rules for the U

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