The eligibility and enrollment rules for the U

Retiree Health Care SPD Effective January 1, 2012
The following charges do not apply to your pharmacy deductible:
• Your monthly retiree health care premiums.
• Any costs not covered by your option.
• Any amounts that exceed the Program's allowed amounts when a non-participating Retail
Pharmacy is used. This also applies if you use a participating Retail Pharmacy, but do not
show your Medco ID card or for compound prescriptions not submitted directly to Medco by
the pharmacy.
• Any cost difference between a brand-name drug and a generic equivalent when a brand-name
drug is prescribed and a generic drug is available.
• Amounts paid toward the medical deductible.
• Coinsurance paid for medical services.
• Coinsurance and copayments for prescriptions purchased through the Medco Pharmacy or
Accredo.
• Specialty drugs not filled by Accredo when required.
• Any maintenance medications not filled by the Medco Pharmacy after the first two fills when
required.
• Charges that are not eligible to be applied to the combined medical deductible are also not
eligible to be applied to the pharmacy deductible. See the “Deductibles, Coinsurance and
Maximums” section in this SPD for the list.
Out-of-Pocket Maximum (Pharmacy)
The out-of-pocket maximum is the per plan year limit you must pay toward eligible expenses
before any additional eligible services you incur are paid by the health care option at 100% of the
allowed amount for the remainder of the year (as long as any applicable annual or lifetime
maximums have not been exceeded). The limit you pay includes the total of the applicable
deductible, copayments and coinsurance. There are two different types of out-of-pocket
maximums. They are: pharmacy and medical out-of-pocket maximum. For a definition of each
of these out-of-pocket maximums, refer to the “Glossary of Terms” section in this SPD. The
charges that do not apply to your deductible (listed previously) also do not apply to your out-ofpocket
maximum.
The family out-of-pocket maximum applies to participants with two or more covered
dependents. If you have selected Family coverage but have only one covered dependent, you and
the dependent will each need to meet the per person out-of-pocket maximum.
Copayments and Coinsurance
Copayments are payments you make on a per service basis for eligible services (after deductible
for retail pharmacy). The cost is the lesser of the allowed amount and the provider’s actual billed
charge. How much coinsurance you pay (after your applicable deductible and/or copayment is
met) depends on the service received and if you use a participating provider. The coinsurance
you pay is applied to the out-of-pocket maximum. If you receive services from a nonparticipating
provider, you will also be responsible for paying any amount in excess of the
allowed amount in addition to coinsurance. The excess amount you pay will not be applied to the
out-of-pocket maximum. A change to the cost during a plan year will not result in a recalculation
of any coinsurance paid. Coinsurance can be found in the “Pharmacy Coverage Summary”
section in this SPD. Copayments for prescriptions purchased through the Medco Pharmacy
(Medco’s mail order service) or Accredo (a division of the Medco Pharmacy for specialty drugs)
are not applied to any deductibles.
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