The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Comprehensive Option All benefit payments are based on the BCBS allowed amounts. Although this option does not have a BCBS network, if you use participating BCBS providers, you generally will not be responsible for payment of charges in excess of the BCBS allowed amount. Please note that eligible services are covered at 80% of the allowed amount regardless if the provider is participating or non-participating for retirees that are enrolled in Medicare Part A and Medicare Part B. If a service is not listed, it is likely not a covered service. Please call BCBS of MN if you have questions about coverage for a specific procedure. Telephone numbers are listed in the “Important Resources” section of this SPD. Service 1 Participating Provider After Deductible Coinsurance 2 Non- Participating Provider After Deductible Coinsurance 2 Special Notes Acupuncture You pay 20% You pay 40% Coverage is limited to pain management only and services must be provided as part of a comprehensive pain management program after all other treatment options have failed. Coverage also provided for prevention and treatment of nausea associated with surgery, chemotherapy or pregnancy. Allergy Testing and Treatment You pay 20% You pay 40% No coverage for therapeutic acupuncture, weight loss management, smoking cessation or other non-listed purposes. Coverage provided for testing, serum, and allergy shots. Ambulance You pay 20% You pay 40% Coverage is limited to air or ground transportation from the place of departure to the nearest facility equipped to treat the illness, and to prearranged medically necessary air or ground ambulance transportation requested by an attending physician or nurse. If BCBS of MN determines air ambulance was not medically necessary but ground ambulance would have been medically necessary, the Program pays up to the BCBS of MN allowed amount for ground ambulance. Benefit You pay 20% You pay 40% If the benefit substitution of treatment is a prescription drug, see the Substitution section “Pharmacy” in this SPD. Chemical Dependency/ Substance Abuse Chiropractic Services Cleft Lip and Palate Cosmetic, Reconstructive or Plastic Surgery Benefit substitution is a course of treatment approved and authorized by a BCBS case manager as an alternative to the services and supplies that would otherwise have been covered by the Program. The benefit substitution must be at a cost equal to or lower than that of the care being provided and maintain the same quality of care. Failure to follow an approved treatment plan may result in nonpayment of services. Call the customer service number on your ID card for further information. See the “Mental Health and Substance Abuse Coverage” section in this SPD for more details. You pay 20% You pay 40% Limited to 25 visits paid by the option per plan year. You pay 20% You pay 40% Coverage only provided for a dependent child under age 19. Dental implants and orthodontia services provided as part of the treatment would be eligible. You pay 20% You pay 40% 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. Continued on next page 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. 38
Retiree Health Care SPD Effective January 1, 2012 Comprehensive Option, continued Service 1 Cosmetic, Reconstructive or Plastic Surgery, continued 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 hospitalization 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 hospitalization or general anesthesia for dental treatment, as determined by the medical Claims Administrator. Participating Provider After Deductible Coinsurance 2 Non- Participating Provider After Deductible Coinsurance 2 Special Notes You pay 20% You pay 40% Panniculectomy covered when both chronic, recurrent infection is documented and interference with hygiene and activities of daily living are documented. You pay 20% You pay 20% You pay 20% You Pay 40% You Pay 40% You Pay 40% 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 in (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 the section “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. 39
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