Health Care Benefits. Important!

Transcription

1 Health Care Benefits The Major League Baseball Players Welfare Plan (referred to as the Welfare Plan in this section) provides comprehensive health care benefits for you and your eligible dependents. Whether you are covered by the Active, Buy-up, Base, or Buy-down plans, or by the retiree health care benefits plan, your coverage may also include dental and vision benefits. Important! For more information about your health care benefits, refer to Administration. Retiree health care benefits are provided under insurance contracts. (See Retiree Health Care Benefits on page 62 for information.) Your medical and dental coverage is provided through preferred provider organizations ( PPOs ), which gives you choices to see any licensed provider you wish. Each time you need medical or dental care, you have the following options: If you go to a provider that participates in the medical or dental PPO network, your outof-pocket expenses will generally be lower. If you go to a provider who does not participate in the medical or dental PPO network, your out-of-pocket expenses will generally be higher. This difference in expenses exists because when you use network providers, your costs, if any, are based on the contracted rates the providers have agreed to accept from the PPO network for eligible services. You are not responsible for any fees that may exceed those contracted rates. On the other hand, non-network providers are not restricted as to what they can charge for services, and the Welfare Plan will pay only reasonable and customary ( R&C ) charges. You may be required to pay any amounts that exceed R&C when you use non-network providers. 29

2 In This Section See Page Overview Eligibility, Enrollment, and More Who Is Eligible Enrolling in the Welfare Plan Cost of Coverage When Coverage Begins Changing Plan Options When Coverage Ends Continuing Coverage Your Health Care Options Active Plan Buy-up Plan Base Plan Buy-down Plan Medical Coverage Deductible Copayment Reasonable and Customary ( R&C ) Charges Out-of-Pocket Maximum Annual Maximum Coordination with Medicare Medical Case Management Covered Services Second Opinion for Therapeutic Use Exemption Services Not Covered International Coverage Retiree Health Care Benefits Prescription Drugs Retail Pharmacy Purchases Mail Order Home Delivery Service Purchases Prescriptions Covered and Special Rules Prescriptions Not Covered Dental Benefits Overview How the Dental Plan Works Vision Benefits Filing Claims for Health Care Benefits Claims Determinations Coordination of Benefits Credit Reserve Overpayments...80 Subrogation and Reimbursement Preventing Fraud on the Welfare Plan

3 OVERVIEW Whether you see a network provider or a non-network provider, the Welfare Plan covers a broad range of medical services and supplies, including preventive (wellness) care, emergency care, mental health and substance abuse benefits, and prescription drug benefits, as shown in the chart below. The chart provides only a summary; it does not contain all the details that you may need to know. (See Covered Services on page 52 and Services Not Covered on page 60 for more detailed information.) The Welfare Plan believes it is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act ). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that the Welfare Plan is not required to include certain consumer protections of the Affordable Care Act that apply to other plans, such as the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act; for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the Benefit Plan Office. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor, at or This website has a table summarizing which protections do and do not apply to grandfathered health plans. Plan Feature Active Buy-up Base Buy-down Who s covered Automatic for active members and their dependents Automatic for disabled members and their dependents until the member is no longer disabled or begins receiving retirement benefits Automatic for a player on the 40-man roster Automatic for eligible employees of the Players Association Elective for newly inactive members and their dependents who are qualified beneficiaries until the end of the applicable COBRA period Elective for qualified beneficiaries until the end of the applicable COBRA period Elective for newly inactive members and retired members who have at least 4 years of credited service under the Welfare Plan, until age 65,* plus the widows of those members, until age 65,* and the dependents of those members, for as long as they satisfy the definition of dependent (see Your Dependents in Understanding Your Benefits) Elective for qualified beneficiaries until the end of the applicable COBRA period Elective for newly inactive members and retired members who have at least 4 years of credited service under the Welfare Plan, until age 65,* plus the widows of those members, until age 65,* and the dependents of those members, for as long as they satisfy the definition of dependent (see Your Dependents in Understanding Your Benefits) Elective for qualified beneficiaries until the end of the applicable COBRA period Elective for newly inactive members and retired members who have at least 4 years of credited service under the Welfare Plan, until age 65,* plus the widows of those members, until age 65,* and the dependents of those members, for as long as they satisfy the definition of dependent (see Your Dependents in Understanding Your Benefits) 31

4 Plan Feature Active Buy-up Base Buy-down Note: For certain members who are eligible for Medicare, the Welfare Plan assumes you are covered by Medicare Parts A and B and will determine your benefit based on the amount that Medicare would pay regardless of whether you actually have Medicare. See Coordination of Benefits on page 79. Coverage includes Medical * On or after age 65, retiree health care benefits are available. However, a member or spouse who reaches age 65 and who has not enrolled in Medicare Part B because the member or spouse is covered by another employer-sponsored health plan, upon reaching age 65, may remain in the Buy-up, Base, or Buy-down plan until the effective date of the member or spouse s Medicare Part B coverage following an election of such Medicare Part B coverage during the applicable Medicare special enrollment period. (For more information on the retiree health care benefits, see Retiree Health Care Benefits on page 62.) Dental Vision Cost of coverage No charge for active and disabled members and their dependents Deductible (per plan year) Out-of-pocket maximum (per plan year) Annual maximum benefit per person Newly inactive members and their dependents electing continuing coverage during the COBRA period pay a portion of the cost of coverage $200 per person $400 per family Applies to all benefits except certain X-rays and diagnostic laboratory services, preventive care benefits, evaluations for therapeutic use exemption, and prescription drugs $1,200 per person $3,400 per family Charges over the reasonable and customary ( R&C ) charges are not counted toward the out-ofpocket maximum $10 million (limit applies only to nonessential major medical benefits) 4 Medical Optional Dental Optional Vision All pay a portion of the cost of coverage (the Buy-up plan has the highest monthly premium) $200 per person $400 per family Applies to all benefits except certain X-rays and diagnostic laboratory services, preventive care benefits, and prescription drugs $1,200 per person $3,400 per family Charges over the reasonable and customary ( R&C ) charges are not counted toward the out-ofpocket maximum $10 million (limit applies only to nonessential major medical benefits) 4 Medical Optional Dental Optional Vision All pay a portion of the cost of coverage (premiums are lower than for the Buy-up plan) $500 per person $1,500 per family Applies to all benefits except certain preventive care benefits and prescription drugs $2,500 per person $7,500 per family Charges over the reasonable and customary ( R&C ) charges are not counted toward the out-ofpocket maximum $10 million (limit applies only to nonessential major medical benefits) 4 Inpatient Hospital Services that Are Medically Necessary Are Covered at the Following Rates 1 Up to 120 days (including semiprivate hospital room and board) Over 120 days (including semiprivate hospital room and board) 100% 100% 80% 80% 80% 80% 80% 80% Medical Optional Dental Optional Vision All pay a portion of the cost of the coverage (premiums are lower than for the Buy-up and Base plans) $1,300 per person 3 $2,600 per family 3 Applies to all benefits, including prescription drugs, except certain preventive care benefits $6,350 per person 3 $12,700 per family 3 Charges over the reasonable and customary ( R&C ) charges are not counted toward the out-ofpocket maximum $10 million (limit applies only to nonessential major medical benefits) 4 32

5 Plan Feature Active Buy-up Base Buy-down Surgery, including 100% 100% 80% 80% Physician s fees Anesthesia Outpatient Hospital Services that Are Medically Necessary Are Covered at the Following Rates 1 Surgery (physician s fees) 100% 100% 80% 80% Anesthesia 100% 100% 80% 80% Emergency room 100% 100% 80% 80% treatment 2 Radiation, chemotherapy, and dialysis Diagnostic services (X-ray, EKG, EEG, ultrasound, lab) 100% 100% 80% 80% 100% 100% 80% 80% Preventive Care Is Covered at the Following Rates 1 Routine physicals (once every 24 months), including certain tests if performed no more than 10 days before office visit or 10 days after office visit 6 Pap tests (once every calendar year) 100% 100% 100% 100% 100% 100% 100% 100% Well-child care 2 100% 100% 100% 100% Routine 100% 100% 100% 100% mammograms 2 Colonoscopy 100% 100% 100% 100% screening 2 Bone density 100% 100% 100% 100% screening 2 Contraceptive care 100% 100% 100% 100% subject to deductible Immunizations 2 100% 100% 100% 100% Other Services that Are Medically Necessary Are Covered at the Following Rates 1 Doctor visits (office and inpatient) Physical therapy (under doctor s direction) 2 Durable medical equipment (rental or purchase) Orthotic devices (if medically necessary) 80% 80% 80% 80% 80% 80% 80% 80% 80%, up to the purchase price 80%, up to $350 per plan year 80%, up to the purchase price 80%, up to $350 per plan year 80%, up to the purchase price 80%, up to $350 per plan year Psychiatric benefits 2 80% 80% 80% 80% Initial prosthetic 80% 80% 80% 80% devices 2 80%, up to the purchase price 80%, up to $350 per plan year 33

6 Plan Feature Active Buy-up Base Buy-down Autism spectrum disorder treatment 2 80% 80% 80% 80% Substance Abuse Treatment that Is Medically Necessary Is Covered at the Following Rates 1 Inpatient 100%, covered as any other hospitalization if medically necessary 100%, covered as any other hospitalization if medically necessary 80%, covered as any other hospitalization if medically necessary 80%, covered as any other hospitalization if medically necessary Outpatient 100% 100% 80% 80% Special Hospitalization and Other Benefits that Are Medically Necessary Are Covered at the Following Rates 1 Home health care (prescribed before discharge from a covered hospital stay) %, up to 90 visits per calendar year 100%, up to 90 visits per calendar year 80%, up to 90 visits per calendar year Hospice care 100% 100% 80% 80% Ambulance 5 100% 100% 80% 80% International Coverage Coverage for medical services provided outside the United States Available under the Active plan for members and dependents whose primary residence is outside the United States. See International Coverage on page 62 for information. Not available under the Buy-up plan Available under the Base plan for members and dependents whose primary residence is outside the United States. See International Coverage on page 62 for information. 80%, up to 90 visits per calendar year Not available under the Buy-down plan Retail Pharmacy (up to a 30-day supply) Generic $10 copayment $10 copayment $10 copayment $10 copayment, subject to deductible Brand name with no generic equivalent $20 copayment $20 copayment $20 copayment $20 copayment, subject to deductible Brand name with a generic equivalent 7 $30 copayment $30 copayment $30 copayment $30 copayment, subject to deductible Mail order Home Delivery Service Program (up to a 90-day supply) 8 Generic $20 copayment $20 copayment $20 copayment $20 copayment, subject to deductible Brand name with no generic equivalent $40 copayment $40 copayment $40 copayment $40 copayment, subject to deductible Brand name with a generic equivalent 7 $60 copayment $60 copayment $60 copayment $60 copayment, subject to deductible 1 Network services are paid as a percentage of the PPO contracted rate for those services. Non-network services are paid as a percentage of the R&C charges. You pay any charges above R&C Subject to certain limits on coverage. These limits are effective in The IRS may increase these amounts in subsequent years. Beginning April 1, 2014, the annual maximum benefit will not apply to the extent such expenses are considered essential benefits under the Affordable Care Act. Ambulance care is provided to transport the sick or injured to the nearest hospital that is capable of providing the required treatment. The 10-day rule relating to screening tests became effective April 1, Previously, certain tests performed as part of the physical exam or within five days after the physical exam were covered. For patients for whom it would be medically inappropriate to take a generic equivalent of a specific brand-name drug, such brand-name drug will be subject to the $20 copayment provided that the patient submits satisfactory documentation to the Welfare Plan from the patient s physician that supports why it is medically necessary for the patient to take the specific brand-name drug. Upon the receipt and acceptance of such documentation by the Welfare Plan, the Welfare Plan will reimburse the patient for the difference between the $20 and $30 copayments, or $40 and $60 copayments, as applicable. For those covered by the Buy-up, Base, or Buy-down plans, prescriptions for up to a 30-day supply of maintenance therapy drugs may be filled three times at a participating retail pharmacy for the retail pharmacy copayment. Subsequent refills of such prescription drugs for maintenance therapies may be obtained by mail order for the mail order copayments, or at a participating retail pharmacy for a copayment of $10 for generic, $20 for brand-name drugs with no generic equivalent, or $30 for brand-name drugs with a generic equivalent plus 50% of the cost of the prescription drug.

7 ELIGIBILITY, ENROLLMENT, AND MORE This section explains who is eligible to participate in the Welfare Plan, and how and when to enroll. Who Is Eligible Members As a player, you become eligible for health care benefits if you are on a club s: list of players eligible to appear in Major League games for at least one day during a championship season (including days on the disabled list or on a disciplinary suspension); or 40-man roster for at least one day during a championship season. You also become eligible for health care benefits if you are: a manager, a coach, a trainer, or an assistant trainer/physical therapist designated by your club to participate in the Welfare Plan; a disabled member; or an eligible employee of the Players Association. Employees of the Players Association become eligible for health care benefits when they begin full-time employment. Part-time employees of the Players Association may be eligible for coverage, with the approval of the Players Association and Pension Committee. If you are a part-time employee, the Players Association will notify you if you are eligible for health care benefits. Inactive Members, Retired Members, and Widows You may be eligible to continue your health care coverage if you are an inactive member, a retired member, or a widow of an eligible member. You must pay the required premiums for this coverage. If you are an inactive member with less than four years of credited service, you may be eligible to continue health care coverage for up to 24 months after your status as an active member ends. (See Continuing Coverage on page 39 for more information about COBRA coverage.) If you are an inactive or retired member with four or more years of credited service, you may continue health care coverage for yourself and your dependents as long as you pay the required premiums. Your eligibility to continue inactive health coverage ends when you stop paying premiums. Years of credited service for this purpose includes pension credited service as a player and/or cumulative service as an employee of the Players Association. Dependents Your dependents are eligible for health care coverage under the Welfare Plan anytime you are eligible. (See the definition of dependents in Terms.) Surviving Dependents If you die, your surviving spouse and other eligible dependents will continue to be eligible for health care coverage by paying any applicable premiums. (See Continuing Coverage on Widow The term widow includes a widow or widower. 35

8 page 39 and Your Health Care Options on page 46 for more information about the length of time during which your surviving dependents can continue the coverage.) Enrolling in the Welfare Plan If you enroll yourself and your dependents within 60 days after you first become eligible, you and your eligible dependents will be covered for health care benefits as of the first day you are eligible for coverage. If you add a dependent at a later date, you must notify the Benefit Plan Office in writing within 60 days following the date your dependent becomes eligible for coverage (i.e., the date of marriage, birth, or placement for adoption). At such time, the Benefit Plan Office will provide you with an enrollment form. You must return the completed enrollment form and any requested documentation to the Benefit Plan Office. If you do so, coverage for your dependent is effective from the day you added the dependent for example, your wedding day, the baby s birth, or the date of an adoptive placement. If you fail to meet the 60-day enrollment or notice deadline, as applicable, for yourself or your dependents, coverage does not become effective until the first day of the month after the Benefit Plan Office receives the completed enrollment form and any requested documentation, with the exception of a newborn dependent child who is automatically covered for the first 30 days from birth. (See Overview on page 31 or Your Health Care Options on page 46 for more information about the options available to you when you enroll.) ID Cards When you enroll in the Welfare Plan, you will receive medical plan ID cards for each covered family member and two prescription cards per family. Be sure to carry your ID card with you at all times and have it available whenever you make an appointment or receive medical services, so the provider knows you are a Welfare Plan member. If your card is lost or stolen, go to to order new ID cards. You can also call the Benefit Plan Office at Cost of Coverage 36 Active and disabled members and their eligible dependents are not required to pay any portion of the cost for their coverage under the Welfare Plan (other than deductibles, out-ofpocket expenses, and any ineligible expenses). The full cost for coverage is paid by contributions made by the Major League clubs under an agreement with the Players Association. The Players Association pays the full cost of coverage for its eligible employees. Inactive members, retired members, widows and their dependents, and COBRA-qualified beneficiaries must pay a monthly premium to continue their health coverage under one of the options available to them under the Welfare Plan. (See Overview on page 31 or Your Health Care Options on page 46 for details.) The amount of your premium depends on: the plan you select; whether you add dental or vision coverage; whether you choose single or family coverage; and whether you or a dependent is covered under Medicare. Check your enrollment materials or contact the Benefit Plan Office for details about current premium amounts.

9 When Coverage Begins If you are an active member when you or your dependents become eligible for coverage and enroll in the Welfare Plan, your coverage begins as explained in Enrolling in the Welfare Plan and your coverage continues for the rest of that plan year. Your dependent s coverage will continue as long as your coverage is in effect unless your dependent s eligibility as a dependent changes. (See Terms for more information.) When inactive members, retired members, or widows and their dependents elect one of the optional plans for which they are eligible, coverage generally begins on the following April 1 and continues for the rest of that plan year as long as the required premiums are paid. (See Changing Your Coverage in Understanding Your Benefits for events that may allow you to make changes during the plan year.) When inactive members, retired members, and dependents who are age 65 and over elect retiree health benefits, coverage generally begins as of the covered individual s 65 th birthday and, for subsequent years, on January 1. Changing Plan Options If you are an inactive member, a retired member, or a widow, and you are continuing inactive health care coverage under the Welfare Plan, you can be covered by the Buy-up, Base, or Buy-down plans or (after age 65) the retiree health care benefits. If you are continuing coverage under COBRA, you may be covered by the Active, Buy-up, Base, or Buy-down plans. (See Overview on page 31, Your Health Care Options on page 46, Continuing Coverage on page 39, and Retiree Health Care Benefits on page 62 for more information about the plan options.) Following your first election of a plan option, you may change one time to any other coverage option. Each March, you will have the opportunity to elect a different plan option or to add/delete dental and/or vision benefits. Once you make a change to your coverage (by changing plans or by adding or deleting dental or vision coverage), the new coverage you elect will remain in effect for five years, and you will not be permitted to change plan options again until April 1 following the fifth anniversary of the last change. This includes adding or deleting dental or vision coverage. For example, an inactive member who elected the Base plan as of April 1, 2013 may change to the Buy-up plan on April 1, 2014 and may not change again until April 1, The rules on making changes to your coverage by changing plans or by adding or deleting dental or vision coverage changed on April 1, Please see the Major League Baseball Players Benefit Plan Summary of Material Modifications dated February 2015 for the rules that are effective as of April 1, When you reach age 65, or your spouse reaches age 65, retiree health care benefits become available. You or your spouse will have to switch to such coverage (if you want to remain covered under the Welfare Plan) when you each reach age 65 unless you have not enrolled in Medicare Part B because you or your spouse is covered by another employer-sponsored health plan. If that is the case, upon reaching age 65, you and your spouse may remain in the Buy-up, Base, or Buy-down plan until the effective date of your or spouse s Medicare Part B coverage following an election of such Medicare Part B coverage during the applicable Medicare special enrollment period. (For more information on the retiree health care benefits, see Retiree Health Care Benefits on page 62.) If You Elect Buy-up, Base, or Buy-down Dental Vision Then Any April 1 You Can switch to one of the other plans, but only one time during the next five years Can drop dental, but only one time during the next five years Can drop vision, but only one time during the next five years Limited Options to Rejoin Plans If you choose to stop your coverage under the Welfare Plan or if you fail to pay the required premiums, you cannot rejoin the Welfare Plan at a later date, unless you become an active member of the Welfare Plan. 37

10 Also, if you choose to stop your coverage under the Welfare Plan or if you fail to pay the required premiums, you cannot rejoin the Welfare Plan at a later date, unless you become an active member of the Welfare Plan. You will immediately be enrolled in the Active plan if you have stopped your coverage and you: become an active member again; or begin to receive disability benefits from the Pension Plan. (See Who Is Eligible under Disability Benefits in Pension Benefits for who is eligible to receive disability benefits from the Pension Plan.) When Coverage Ends In general, your health care coverage under the Active plan ends: when you become inactive;* when you die; when you retire; if you are a disabled member receiving disability benefits under the Pension Plan, when you attain age 65 or are no longer disabled, whichever is earlier;** if you are a player, when you are no longer on the 40-man roster;* if you are an employee of the Players Association, when your hours are reduced below the level required for coverage; or if you are covered under the Active plan through COBRA, when you fail to pay required premiums for coverage. Your dependents health care coverage ends when: your coverage ends; your dependent no longer meets the Welfare Plan s age or dependency requirements; or you and your spouse divorce or legally separate (your own children s coverage will continue). Coverage for you and your dependent(s) will also end if the Welfare Plan is terminated. If you have four or more years of credited service under the Welfare Plan, you or your dependents are entitled to continue inactive health care coverage for as long as the Welfare Plan allows such continuation of coverage. Your inactive health care coverage may be terminated for any of the following reasons: the Welfare Plan no longer provides inactive health care coverage; you die; except in the case of the retiree health care benefits, you attain age 65 provided that you are not covered as an active employee under any other employer-sponsored group health plan; or your premium for inactive health coverage is not paid on time. * Your coverage as an active member under the Active plan will continue until midnight of the day preceding the day of the first scheduled game of the next succeeding championship season after your status changes to that of an inactive member. However, you may elect COBRA continuation coverage under the Active, Buy-up, Base, or Buy-down plans for the COBRA period for you and your dependents provided that you submit a timely election form and pay the required premiums. ** Your coverage under the Active plan will continue until midnight of the day preceding the day of the first scheduled game of the next succeeding championship season. 38

11 Benefits Provided After Coverage Ends Extended Maternity If you or your dependent is pregnant when coverage ends, the Welfare Plan will provide extended coverage for expenses related to the pregnancy up to nine months after coverage terminates. If the mother or the newborn child incurs medical expenses as a result of complications arising from the pregnancy, the Welfare Plan will provide extended coverage for such expenses until the April 1 following the calendar year in which the child was born or the pregnancy otherwise terminated. Extended Coverage Due to Disability If you or your dependent is totally disabled (as defined in the Plan) when coverage ends for a reason other than failure to pay required premiums, the Welfare Plan will provide extended coverage for expenses related solely to the illness or injury that caused the total disability. Such coverage will end on the earlier of the date the individual is no longer disabled or on April 1 following the calendar year in which the coverage terminated. In all cases, benefits are extended only for treatment of the condition that is the reason for the extension of coverage. No additional premium is required to continue benefits under the extended benefits. Continuing Coverage Under a federal law called the Consolidated Omnibus Budget Reconciliation Act of 1985, or COBRA, you and/or your dependents may be eligible to continue medical coverage (called COBRA coverage or COBRA continuation coverage ). You may elect to continue coverage at your own expense when the coverage that you have through the Welfare Plan as an active member ends (other than for gross misconduct). This COBRA coverage is available to certain eligible individuals described below ( qualified beneficiaries ) in certain instances called qualifying events where coverage that you receive as an active member under the Welfare Plan would otherwise end. The coverage described below may change as permitted or required by changes in any applicable law. Please note that COBRA requires certain minimum continuation coverage. In certain instances the Welfare Plan provides you with an opportunity to continue coverage for a period of time beyond the minimum requirements in COBRA or at a cost that is less than the maximum allowed under COBRA. (See Your Health Care Options on page 46 for details.) The following information is intended to inform you of your rights and obligations under the continuation coverage provisions of COBRA and the terms of the Welfare Plan, when continuation coverage may become available to you and your family, and what you need to do to protect your rights. You do not have to show that you are insurable to choose COBRA coverage. However, COBRA coverage is provided subject to your eligibility for coverage as described below. The Major League clubs and the Players Association reserve the right to terminate your coverage retroactively if it is determined that you are ineligible under the terms of the Welfare Plan. 39

12 COBRA at a Glance The following table provides an overview of available COBRA coverage. See the sections following the table for more details. Who Is Affected Qualifying Event Who Is Eligible for COBRA Coverage You Your spouse or dependent child Your dependent child 40 Your status changes from active to inactive for reasons other than gross misconduct, or your status changes from active to retired You are a Players Association employee and your employment terminates or your scheduled work hours drop below the level required for benefit eligibility You are Social Security disabled when you become eligible for COBRA or within the first 60 days after the COBRA continuation coverage period begins You die You and your spouse become divorced or legally separated Your spouse and/or dependent child is disabled when he/she becomes eligible for COBRA or within the first 60 days after the COBRA continuation coverage period begins Your dependent child is no longer an eligible dependent (for example, due to age limit) You, your spouse, and dependents (who were already covered under the Welfare Plan) You, your spouse, and dependents (who were already covered under the Welfare Plan) You, your spouse, and dependents (who were already covered under the Welfare Plan) Your spouse and dependents (who were already covered under the Welfare Plan) Your spouse and any children who may lose coverage because of the divorce or legal separation You, your spouse, and dependents The dependent child who loses coverage Duration of COBRA Coverage Up to 24 months* Up to 24 months* Up to 29 months** Up to 36 months* Up to 36 months Up to 29 months** Up to 36 months * If you have four or more years of credited service, you and your spouse and eligible dependents are also eligible for inactive health coverage under the Buy-up, Base, or Buy-down plans, or the retiree health care benefits, beyond and/or in lieu of the COBRA coverage period. (See Your Health Care Options on page 46 for details.) ** You are required to provide proof of eligibility for Social Security disability benefits to be eligible for the additional five months of COBRA coverage. Who Is Eligible for COBRA If you are covered by the Welfare Plan on the day before a qualifying event, you have the right to choose COBRA coverage if you lose that coverage because: your employment terminates (unless you are terminated because of your gross misconduct); or you are an employee of the Players Association whose scheduled work hours are reduced below the level required for coverage. If you are enrolled in the Welfare Plan and do not return to work following a leave of absence qualifying under the Family and Medical Leave Act ( FMLA ), the event that will trigger COBRA coverage is the date that you indicate you will not be returning to work following the leave or the last day of the FMLA leave period, whichever is earlier. If you are the spouse of a member and you are covered by the Welfare Plan on the day before the qualifying event, you are considered a qualified beneficiary. That means that you have the right to choose COBRA coverage for yourself if you lose group health coverage under the Welfare Plan for any of the following reasons: your spouse dies;

13 your spouse s employment terminates (for reasons other than your spouse s gross misconduct) or your spouse s work hours are reduced; you divorce or legally separate from your spouse; or your spouse becomes entitled to Medicare. If you are a dependent child of a member and you are covered under the Welfare Plan on the day before the qualifying event, you are also considered a qualified beneficiary. This means that you have the right to COBRA coverage if your coverage under the Welfare Plan is lost for any of the following reasons: the member dies; the member s employment terminates (for reasons other than the member s gross misconduct) or the member s work hours are reduced; the member divorces or legally separates; the member becomes entitled to Medicare; or you cease to be a dependent child under the Welfare Plan. If you are a covered retiree, you and/or your covered surviving spouse and covered dependents may also have COBRA coverage rights due to a bankruptcy proceeding with respect to a Major League club or the Players Association under Title 11 of the U.S. Code. Your Duties Under the law, the member, a family member, or an authorized representative must inform the Benefit Plan Office of a divorce, legal separation, or child s loss of dependent status under the Welfare Plan. This notice must be provided within 60 days from the date of the divorce, legal separation, or loss of dependent status. Notice must be provided to the Benefit Plan Office on the appropriate form, which may be obtained from the Benefit Plan Office. The notice must include information about the member or qualified beneficiary requesting COBRA coverage and the qualifying event that gave rise to the individual s right to COBRA coverage. In addition, the member or qualified beneficiary must provide the Benefit Plan Office with documentation of the qualifying event. Acceptable documentation includes the documents listed below and any other supporting documentation approved by the Benefit Plan Office. divorce a copy of the divorce decree legal separation a copy of the separation decree or agreement If the member, family member, or authorized representative fails to return the form and/or supporting documentation to the Benefit Plan Office during this 60-day period, any family member who loses coverage will lose the right to elect COBRA coverage. You may also be required to repay the Welfare Plan for any medical benefits it paid on behalf of an ineligible dependent before the Benefit Plan Office received notice. When the Benefit Plan Office receives timely notice that one of these events has happened, the Benefit Plan Office will notify the affected qualified beneficiaries of their right to choose COBRA coverage. 41

14 42 Employer s Duties Qualified beneficiaries will be notified of the right to elect COBRA coverage (without any action required by the member or a family member) if they lose coverage because of any of the following events: the member dies; the member s employment terminates (for reasons other than the member s gross misconduct) or the member s work hours are reduced; or a Major League club or the Players Association experiences a bankruptcy. Electing COBRA To elect or inquire about COBRA coverage, contact the Benefit Plan Office. As permitted by law, the Welfare Plan requires that you elect COBRA coverage within 60 days from the date you would lose your active coverage because of one of the events described earlier, or, if later, 60 days after you receive notice of your right to elect COBRA coverage. A member or family member who does not choose COBRA coverage within the time period described above loses the right to elect COBRA coverage. If the Benefit Plan Office does not receive timely notice of the events described earlier, the member and family members will be required to reimburse the Welfare Plan for any claims paid after the date coverage would normally have ended. If you choose COBRA coverage, your coverage will be the same coverage you had immediately before the event and the same coverage that is being provided to similarly situated beneficiaries. Similarly situated refers to an active member or dependent who has not had a qualifying event. You will have the same opportunity to change coverage as active members have (e.g., if you gain a new dependent). This also means that if the coverage for similarly situated members or their family members is modified, your coverage will be modified in the same way. Your COBRA rights are provided as required by law; however, if the law changes, your rights under COBRA may also change. If the covered member elects COBRA coverage and then has a child (either by birth, adoption, or placement for adoption) during the COBRA coverage period, the new child is a qualified beneficiary. In accordance with the terms of the Welfare Plan and the requirements of federal law, these qualified beneficiaries can be added to COBRA coverage by providing the Benefit Plan Office with a written notice of the new child s birth, adoption, or placement for adoption. This written notice should include information about the member or qualified beneficiary receiving COBRA coverage and the new child who will be receiving COBRA coverage. The Benefit Plan Office may ask you to provide documentation supporting the birth, adoption, or placement for adoption of the new child. If the qualified beneficiary fails to notify the Benefit Plan Office in a timely fashion (in accordance with the terms of the Welfare Plan), the qualified beneficiary will not be offered the option to elect COBRA coverage for the new child. In such event, the new child may be added to the qualified beneficiary s COBRA coverage as a dependent by notifying the Benefit Plan Office, according to the Welfare Plan s rules that apply to active members, but the new child will not be treated as a COBRA beneficiary, which means that the child will not have independent COBRA rights and protections. Separate Elections Each qualified beneficiary has the right to elect COBRA coverage. This means that a spouse or dependent child can elect COBRA coverage even if the covered member chooses not to elect COBRA coverage. A member or spouse may elect COBRA coverage on behalf of other qualified beneficiaries, and a parent or legal guardian may elect COBRA coverage on behalf of a minor child.

15 Length of COBRA Coverage If elected, COBRA coverage generally begins on the date your coverage as an active member ends or on the date of the qualifying event. For a dependent who no longer satisfies the requirements for dependent coverage, COBRA coverage begins on the date dependent coverage ends. However, coverage will not take effect unless COBRA coverage is elected as described above and the required premium is received. The maximum duration of COBRA coverage depends on the reason you or your covered dependents are eligible for COBRA coverage. If group health coverage ends because your covered employment ends or your work hours are reduced, COBRA coverage may continue for you and your covered spouse and dependents for up to 24 months. COBRA requires that a group health plan provide continuation coverage for at least 18 months (which may, in certain instances, be extended to 36 months). Continuation coverage beyond the minimum COBRA period is not required by law. COBRA coverage for your covered spouse and dependents may continue for up to 36 months if coverage would otherwise end because: you die; you become covered by Medicare under Part A, Part B, or both; you divorce or legally separate; or your dependent child loses eligibility for coverage. Inactive Health Coverage If you have four or more years of credited service, you and your spouse and eligible dependents are also eligible to continue inactive health coverage at the end of your COBRA coverage period or in lieu of COBRA coverage under the Buy-up, Base, and Buy-down plans, or retiree health care benefits. For this purpose, credited service means the total of your years of pension credited service, as measured by the Pension Plan, and/or your cumulative years of service as an employee of the Players Association. This additional coverage is not COBRA coverage, rather it is inactive health coverage made available to eligible members and their eligible dependents in lieu of or in addition to COBRA coverage. Additional Qualifying Events Your spouse and dependents may have additional qualifying events while they are covered under COBRA. If they are otherwise entitled to only 24 months of continuation coverage, these events can extend their continuation period up to 36 months, but in no event will they have more than 36 months of COBRA coverage measured from the date of the loss of coverage that originally allowed them to elect COBRA. This extension may be available to the spouse and any dependent children receiving COBRA coverage if the member or former member dies or gets divorced or legally separated, or if the dependent child stops being eligible under the Welfare Plan as a dependent child, but only if the additional event would have caused the spouse or dependent child to lose coverage under the Welfare Plan had the first qualifying event not occurred. The law requires a qualified beneficiary to notify the Benefit Plan Office if any of these additional qualifying events occur. This notice must be provided within 60 days from the latest of: the date of the second qualifying event; the date coverage would have been lost because of the event; or the date on which the qualified beneficiary is informed of the responsibility to provide the notice. 43

16 Notice of the additional qualifying event must be provided to the Benefit Plan Office on the appropriate form, which may be obtained from the Benefit Plan Office. The notice must include information about the qualified beneficiary requesting additional COBRA coverage and the qualifying event that created the individual s right to additional COBRA coverage. In addition, the qualified beneficiary must provide the Benefit Plan Office with documentation of the qualifying event. Acceptable documentation includes the documents listed below and any other supporting documentation approved by the Benefit Plan Office: death a copy of the death certificate; Medicare entitlement a letter from the Social Security Administration indicating that the member is entitled to Medicare benefits; divorce a copy of the divorce decree; and legal separation a copy of the separation decree or agreement. If a qualified beneficiary (or his or her authorized representative) fails to provide the appropriate notice and supporting documentation, if required, to the Benefit Plan Office during the 60-day notice period, the qualified beneficiary will not be entitled to extended COBRA coverage. Special Rules for Disability The 24 months of COBRA coverage may be extended to 29 months if a member or covered dependent is determined by the Social Security Administration to be disabled at any time during the first 60 days of the 24-month COBRA coverage period. This five-month extension is available to all family members who have elected COBRA coverage due to the termination of employment or reduction in hours. It applies even to family members who are not disabled. To benefit from the extension, the qualified beneficiary must provide the Benefit Plan Office with the disability determination within 60 days after the latest of: the Social Security Administration s determination of disability; the date on which a qualifying event occurs; the date coverage is lost because of the qualifying event; or the date on which the qualified beneficiary is informed of the responsibility to provide the notice. The notice of Social Security disability must be furnished to the Benefit Plan Office before the end of the original 24-month COBRA coverage period. If the Social Security Administration determines that the qualified beneficiary is no longer disabled during a COBRA coverage period, the qualified beneficiary must inform the Benefit Plan Office of the re-determination. The qualified beneficiary must provide notice within 30 days after the latest of: the re-determination; or the date on which the qualified beneficiary is informed of the responsibility to provide the notice and the procedures for providing such notice. This notice must be provided to the Benefit Plan Office on the appropriate form, which may be obtained from the Benefit Plan Office. The five-month COBRA extension for all covered family members will end at the end of the month in which the notice is received. If a qualified beneficiary is receiving COBRA coverage under a disability extension and has another qualifying event during the 29-month continuation period, then the COBRA coverage 44

17 period extends until 36 months after the date coverage was originally lost. The qualified beneficiary must provide the appropriate notice to the Benefit Plan Office, as described above under Your Duties. Early Termination of COBRA Coverage The law provides that your COBRA coverage may be cut short before the expiration of the 24-, 29-, or 36-month period for any of the following reasons: the Welfare Plan no longer provides group health coverage to any of its members; the premium for COBRA coverage is not paid on time (within the applicable grace period); the qualified beneficiary becomes covered after the date COBRA coverage is elected under another group health plan that does not contain any applicable exclusion or limitation for any pre-existing condition of the individual; the qualified beneficiary first becomes entitled to Medicare after the date COBRA coverage is elected; or coverage has been extended for up to 29 months due to disability, and the Social Security Administration has made a final determination that the individual is no longer disabled. COBRA and FMLA Taking an approved leave under the Family and Medical Leave Act ( FMLA ) is not considered a qualifying event that would make you eligible for COBRA coverage. However, a COBRA qualifying event occurs if: you or your dependent is covered by the Welfare Plan on the day before the leave begins (or you or your dependent becomes covered during the FMLA leave); and you do not return to employment at the end of the FMLA leave or you terminate employment during your leave. The date of the qualifying event is the earlier of the following: when you inform your employer that you are not returning to work; or the end of the leave, if you do not return to work. Cost of COBRA Coverage The Pension Committee sets the premiums for continuation coverage. The Welfare Plan charges no more than the Welfare Plan s cost of coverage for similarly situated members who have not had a qualifying event. Please note that the cost of coverage is determined without regard to whether an employer or a member pays for the cost of coverage. The Pension Committee will change the premium amounts periodically usually once a year with the new premiums taking effect on April 1. Premiums may change during a plan year if the Welfare Plan has been charging less than the maximum permissible amount. The initial payment for COBRA coverage is due 45 days from the date of your election. Thereafter, you must pay for coverage on a monthly basis. You have a grace period of 30 days. Contacting the Benefit Plan Office If you have any questions about COBRA coverage or the application of the law, contact the Benefit Plan Office at You may also contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration ( EBSA ). Addresses and phone numbers of regional and district EBSA offices are available through EBSA s website at 45

18 Also, you must notify the Benefit Plan Office in writing immediately if: your marital status has changed; you, your spouse, or a dependent has a changed address; or a dependent loses eligibility for dependent coverage under the terms of the Welfare Plan. Coverage Certificate When your COBRA coverage ends, you automatically receive a certificate of coverage that: confirms that you had whatever medical coverage you continued through COBRA; and states how long you were covered. If you become eligible for other medical coverage that excludes or delays coverage for certain pre-existing conditions, you can use this certificate to receive credit against the new plan s pre-existing condition limit for the time you were covered by the Welfare Plan. In addition to the certificate you receive automatically, you also may request an additional certificate within 24 months after coverage ends. Coverage certificates will no longer be provided after December 31, When You Reach Age 65 When you reach age 65 you should: enroll in Medicare Part A; enroll in Medicare Part B (unless you have active employee coverage through an employer-sponsored plan); and notify the Benefit Plan Office 60 days before your 65 th birthday. This gives the plan administrator time to help you to enroll in the appropriate coverage. YOUR HEALTH CARE OPTIONS The Welfare Plan offers four health care coverage options plus retiree health care benefits (see Retiree Health Care Benefits on page 62 for more information): Active; Buy-up Base; and Buy-down. Active and disabled members automatically participate in the Active plan. Newly inactive members can choose to continue coverage under COBRA in any of the four health care options by paying the required premiums for the first 24 months after becoming inactive. Inactive members and retired members with four or more years of credited service, and their widows can choose to continue inactive health coverage in the Buy-up, Base, or Buy-down plans either when they first lose active coverage or after the 24 months of COBRA coverage ends, by paying the required premiums. Beginning at age 65, inactive members and retired members with four or more years of credited service, and their dependents or widows who are age 65 or older may continue coverage in the retiree health care benefits options by paying the required premiums. (See Retiree Health Care Benefits on page 62.) If you are covered by a group health plan because of your own active employment or your spouse s active employment, you may wait and enroll in Medicare Part B when that active employer-sponsored coverage ends. But, even if you have group plan coverage, you should enroll in Medicare Part A when you reach age 65. Contact the Benefit Plan Office for more information. 46

19 If You Are an Active member or disabled member who is receiving disability benefits from the Pension Plan* Newly inactive member Inactive member, retired member, or widow under age 65, if the member had four or more years of credited service* Inactive member, retired member, eligible dependent, or widow age 65 or older* You Are Covered by Active plan at no charge Active, Buy-up, Base or Buy-down plans by electing COBRA coverage and paying the required premium Buy-up, Base, or Buy-down plans by electing coverage and paying the required premium Retiree health care benefits by electing coverage and paying the required premium * Benefits for certain members and dependents who are over age 65 or who are eligible for Medicare because of disability will be paid by the Welfare Plan as if they have Medicare Parts A and B, even if they have not enrolled in Medicare, unless the member or spouse is covered by another employer-sponsored health plan. (See Coordination of Benefits on page 79 for details.) Accordingly, in order to receive full benefits for health care after you become eligible for Medicare, you should enroll in Medicare Parts A and B. You can postpone enrollment in Medicare Part B if you are covered by a group health plan through your own current employment or your spouse s current employment. Each of the four coverage options is a preferred provider organization ( PPO ) plan that utilizes the contracted PPO network and gives you the flexibility to use doctors or medical facilities of your choice. Through the PPO, you have a choice of using network providers or non-network providers. Before seeking medical care, you should know whether your health care provider participates in the PPO network. Keep in mind that the list of network providers occasionally changes, so you will want to make sure the provider you choose is currently in the PPO network. You can access an online provider directory, without charge, by visiting the PPO network s website listed on your medical ID card. When you choose a network provider, your out-of-pocket costs usually will be lower because these providers have agreed to accept the PPO contract rate, which generally is lower than reasonable and customary ( R&C ) charges. If you see a non-network provider, your out-ofpocket costs usually will be higher because the Welfare Plan only pays a percentage of R&C charges for non-network services. This means that you may pay more for the non-network care you receive and that you will have to pay any charges above R&C. You may also be required to first pay the full cost of your medical care then file a claim to receive reimbursement. The Welfare Plan will accept assignment of benefits from non-network providers; however, you must sign the provider s form authorizing the Welfare Plan to send payment for covered charges directly to those providers. Network providers should not request payment at the time of service over and above your remaining deductible and any copayment. Contact the Benefit Plan Office for more information. Active Plan Active plan coverage includes: medical benefits; dental benefits; and vision benefits. Locating a Network Provider To locate a network provider, go to the PPO network s website as listed on your medical ID card or call When you use network providers, you may pay lower out-of-pocket costs. 47

20 When you use network providers, the Active plan covers eligible expenses at 80% or 100% of the discounted PPO contract rate. The PPO contract rate is the amount that network providers have agreed to charge for eligible expenses. Network providers will not charge more than the PPO contract rate. When you use a non-network provider, the Active plan covers eligible expenses at 80% or 100% of reasonable and customary charges ( R&C ). (See Reasonable and Customary ( R&C ) Charges on page 50 for more information.) You must pay a plan year deductible before the Active plan begins to pay certain benefits. (See Deductible on page 49, Copayment on page 49, Reasonable and Customary ( R&C ) Charges on page 50, and Out-of-Pocket Maximum on page 50 for a description of expenses that you may incur.) Buy-up Plan Locating a Network Provider To locate a network provider, go to the PPO network s website as listed on your medical ID card or call When you use network providers, you may pay lower out-of-pocket costs. The Buy-up plan provides medical coverage for eligible inactive members, retired members, and widows (in each case who are under age 65), plus eligible dependents. Dental or vision coverage may be added to the Buy-up plan for an additional premium. When you use network providers, the Buy-up plan covers eligible expenses at 80% or 100% of the discounted PPO contract rate. The PPO contract rate is the amount that network providers have agreed to charge for eligible expenses. Network providers will not charge more than the PPO contract rate. When you use a non-network provider, the Buy-up plan covers eligible expenses at 80% or 100% of reasonable and customary charges ( R&C ). (See Reasonable and Customary ( R&C ) Charges on page 50 for more information.) You must pay a plan year deductible before the Buy-up plan begins to pay certain benefits. (See Deductible on page 49, Copayment on page 49, Reasonable and Customary ( R&C ) Charges on page 50, and Out-of-Pocket Maximum on page 50 for a description of expenses that you may incur.) Base Plan Locating a Network Provider To locate a network provider, go to the PPO network s website as listed on your medical ID card or call When you use network providers, you may pay lower out-of-pocket costs. The Base plan provides medical coverage for eligible inactive members, retired members, and widows (in each case who are under age 65), plus eligible dependents. Dental or vision coverage may be added to the Base plan for an additional premium. When you use network providers, the Base plan covers most eligible expenses at 80% of the discounted PPO contract rate (preventive care generally is covered at 100%). The PPO contract rate is the amount that network providers have agreed to charge for eligible expenses. Network providers will not charge more than the PPO contract rate. The Base plan covers most eligible non-network expenses at 80% of reasonable and customary charges ( R&C ) and eligible preventive care benefits at 100% of R&C charges. You must pay a plan year deductible before the Base plan begins to pay most benefits. You must pay a plan year deductible before the Buy-up plan begins to pay certain benefits. (See Deductible on page 49, Copayment on page 49, Reasonable and Customary ( R&C ) Charges on page 50, and Out-of-Pocket Maximum on page 50 for a description of expenses that you may incur.) 48

21 Buy-down Plan The Buy-down plan provides medical coverage for eligible inactive members, retired members, and widows (in each case who are under age 65), plus eligible dependents. Dental or vision coverage may be added to the Buy-down plan for an additional premium. When you use network providers, the Buy-down plan covers most eligible expenses at 80% of the PPO discounted contract rate (preventive care generally is covered at 100%). The PPO contract rate is the amount that network providers have agreed to charge for eligible expenses. Network providers will not charge more than the PPO contract rate. The Buy-down plan covers most eligible non-network expenses at 80% of reasonable and customary charges ( R&C ) and eligible preventive care benefits at 100% of R&C charges. You must pay a plan year deductible before the Buy-up plan begins to pay certain benefits. (See Deductible on page 49, Copayment on page 49, Reasonable and Customary ( R&C ) Charges on page 50, and Out-of-Pocket Maximum on page 50 for a description of expenses that you may incur.) You must pay a plan year deductible before the Buy-down plan begins to pay most benefits. The Buy-down plan is a high-deductible health plan, which means that the deductible is higher, and unlike the other plans, prescription drug benefits are subject to the deductible. Your prescriptions will be applied to your deductible and your out-of-pocket maximum. Because the Buy-down plan is a high-deductible health plan, if you are covered under the Buy-down plan, you may be eligible to participate in a Health Savings Account at a financial institution of your choosing in accordance with applicable IRS guidelines. Health Savings Accounts are not offered as part of the Buy-down plan. Locating a Network Provider To locate a network provider, go to the PPO network s website as listed on your medical ID card or call When you use network providers, you may pay lower out-of-pocket costs. MEDICAL COVERAGE The following section describes how benefits are paid, important things to know about the Welfare Plan, and what is covered and what is not covered. Retiree health care benefits are subject to different rules. See Retiree Health Care Benefits on page 62 for details. Deductible All plans require you to pay a deductible. The deductible is the amount you pay each plan year before the plans begin to pay benefits, and the deductible applies to all benefits except eligible preventive care. All plans pay certain preventive care benefits even if you have not met the deductible. All plans have both an individual deductible and a family deductible. (See Overview on page 31 for the deductible amounts under each plan.) Individual deductible: All plans begin paying for certain covered expenses after you meet your individual deductible. Only allowable expenses count toward your deductible. Family deductible: You meet the family deductible when the collective allowable expenses of two or more of your covered family members reach the family deductible amount. However, for each covered person only expenses up to the individual deductible amount count toward meeting the family deductible. Copayment For the Active, Buy-up, Base, and Buy-down plans, some expenses are covered at 80%. That means that you are responsible for paying the remaining 20% of the cost of the service. The portion you pay is considered your copayment. 49

22 If you use non-network providers, amounts above R&C charges are not paid by the Welfare Plan and are not considered part of your copayments. You are responsible for any amount above R&C charges in addition to any required copayments for eligible services. (See Overview on page 31 for the copayments that apply to services under the Welfare Plan.) Reasonable and Customary ( R&C ) Charges The Welfare Plan pays benefits for non-network services only up to reasonable and customary ( R&C ) charges, which are based on the lower of: the amount the physician or facility usually charges for similar services; or the 90 th percentile of fees charged under similar circumstances by physicians with comparable training and experience in the same geographic area. You are responsible for any charges in excess of R&C charges. When you visit a network provider, eligible expenses you incur are paid according to the negotiated PPO contract rate so it is not necessary for the Welfare Plan to evaluate whether the network provider s charges are reasonable and customary. R&C charges apply only when you see a non-network provider. The Welfare Plan does not cover non-network charges above R&C limits those charges are your responsibility and do not count toward your deductible or out-of-pocket maximum benefit. How Reasonable and Customary ( R&C ) Charges Compare R&C charges are determined for geographic areas. For example, the R&C charge for a surgical procedure in Los Angeles might be $3,400. In Milwaukee, the R&C charge for the same procedure might be $2,500. Continuing with this example, let s assume a non-network surgeon in Los Angeles charges $3,200 for the procedure and the Welfare Plan pays 100% for that service under the Active or Buy-up plans. That means the Welfare Plan pays the full $3,200 since that fee is less than the R&C charge of $3,400. But if a non-network surgeon in Milwaukee charges $2,800, the Welfare Plan would pay only $2,500 under the Active or Buy-up plans since that is 100% of the R&C charge for that geographic area. You would be responsible for paying any amount above the R&C charge. Under the Base or Buy-down plans, the Welfare Plan would pay 80% of the R&C charge. Out-of-Pocket Maximum 50 The out-of-pocket maximum is the most you will have to pay in one plan year for eligible medical expenses, including the required deductibles. Once you reach the out-of-pocket maximum, the Welfare Plan pays 100% of your eligible medical expenses for the rest of the plan year. The out-of-pocket maximum applies only to eligible medical expenses. Expenses that do not apply to the out-of-pocket maximum are charges: above R&C charges for an eligible non-network service; and for services not covered by the Welfare Plan. Under the Active and Buy-up plans, the individual out-of-pocket maximum is $1,200 and the family out-of-pocket maximum is $3,400. Under the Base plan, the individual out-of-pocket maximum is $2,500 and the family out-of-pocket maximum is $7,500. Under the Buy-down plan, the individual out-of-pocket maximum in 2015 is $6,450; and the family out-of-pocket

23 maximum is $12,900 which is subject to change in future years in accordance with federal law governing high-deductible health plans. Only expenses up to the individual out-of-pocket maximum for your plan count toward the family out-of-pocket maximum. Annual Maximum You and each covered dependent have an annual $10 million major medical benefit while covered under any of the health care options offered by the Welfare Plan, but not including retiree health care benefits. Major medical benefit reimbursements are charged against this maximum. Note, however, that beginning April 1, 2014, the annual maximum benefit will not apply to the extent that such expenses are considered essential benefits under the Affordable Care Act. Once you reach the annual maximum, the Welfare Plan pays no other major medical benefits. Coordination with Medicare (See Coordination of Benefits on page 79 for information on how the Welfare Plan coordinates coverage with Medicare.) Medical Case Management Medical Case Management ( MCM ) is a professional management service that helps: you and your family get the most from your medical benefits; and the Welfare Plan provide the most cost-effective coverage. You do not have to use MCM for most conditions, but you are strongly encouraged to do so. In some cases, MCM can advise you of treatments that may not be covered so you can avoid unexpected charges. Treatment for autism spectrum disorder must be based on an individual treatment protocol reviewed and approved by the MCM program. Using MCM MCM costs you nothing. The staff members at MCM work with your attending physician to evaluate your case and identify the most appropriate and sensible treatment plan for you. MCM also offers: significant support to you and your family during times of medical crisis; nationwide referrals to quality health care facilities, services, and providers; the support of a nationally recognized panel of physician experts who offer guidance on the most up-to-date treatment methods; and the personal attention of a skilled coordinator assigned to your case. When to Call You should contact the MCM administrator if you or anyone in your family faces one of the following conditions or situations whether as an inpatient or an outpatient: cerebral vascular accident ( CVA, or stroke); multiple sclerosis ( MS ); amyotrophic lateral sclerosis ( ALS, or Lou Gehrig s disease); acquired immune deficiency syndrome ( AIDS ); end-stage cancer; MCM Required for Autism Spectrum Disorder Treatment Treatment for autism spectrum disorder must be based on an individual treatment protocol reviewed and approved by the MCM program. 51

24 high-risk pregnancy; high-risk infancy; major head trauma; spinal cord injury; amputations; multiple fractures; severe burns; chronic alcoholism or substance abuse; severe psychiatric disorders; or autism spectrum disorder. (Treatment for autism spectrum disorder must be based on an individual treatment protocol reviewed and approved by the MCM program.) You may contact the Benefit Plan Office for more information at , ext Covered Services Occupational Illnesses or Injuries The Welfare Plan does not pay benefits for services or supplies used to treat on-thejob illnesses or injuries. On-the-job illnesses or injuries are covered in other ways, such as: the Basic Agreement; your individual contract; or workers compensation. All four plan options offered by the Welfare Plan cover a range of medical services and supplies, subject to plan deductibles, copayments, exclusions, and limits. However, the Welfare Plan does not cover any occupational illnesses or injuries that is, illnesses or injuries that are caused by the patient s work. For Welfare Plan purposes, services performed in the clubhouse or club facility are considered treatment for on-the-job illnesses or injuries and are not covered by the Welfare Plan. The amounts you pay for deductibles and/or copayments depend on whether you are covered by the Active, Buy-up, Base, or Buy-down plans; where you receive services; and the type of service you receive. To be covered, all services and supplies must be medically necessary. That means the Welfare Plan pays benefits only for services and supplies that are medically necessary. Medically necessary means that the service or supply is: furnished, prescribed, or ordered by a physician to identify or treat an illness or injury; appropriate according to contemporary standards of good medical practice; consistent with the diagnosis and treatment of your condition; the most appropriate level of care necessary to treat your illness or injury that can be provided safely; not provided solely for the convenience of you or the provider; for inpatient care, care that could not be provided safely on an outpatient basis; and provided by a legally operated hospital, licensed physician, licensed or registered physical therapist, or licensed nurse. For all expenses, the fact that the service or supply was furnished, prescribed, or ordered by a physician does not necessarily mean that it was medically necessary. Services are divided into categories and explained in this section as follows: Preventive care charges fees for preventive care; Inpatient charges fees for room, board, services, and supplies during a hospital stay; 52

25 Outpatient charges fees for services, supplies, and facilities used without an admission to a hospital; Special charges fees for home health care, hospice care, ambulance, and other services as listed; Major medical charges fees for professional services, durable medical equipment, prosthetic devices, and other services and supplies as listed; and Prescription drug charges fees for prescription drugs dispensed through a retail pharmacy or mail order program as described in this section. Preventive Care Charges The Welfare Plan covers charges for certain services related to preventive care at 100% with no deductible. Preventive care includes: Routine physical exams once every two years for patients age 17 and older. Coverage for the physical exam includes the following when performed in conjunction with the physical examination for screening purposes on the same day as the office visit or no earlier than 10 days before the office visit and no later than 10 days after the office visit*: laboratory services for kidney, liver, and thyroid function tests; a chest X-ray; an EKG or ECG; a fecal occult blood test for individuals age 50 and older; and items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force with respect to the individual involved. * The 10-day rule relating to screening tests became effective April 1, Previously, certain tests performed as part of the physical exam or within five days after the physical exam were covered. Well-child care through age 16, including examinations, immunizations, and laboratory tests, limited to a maximum of 18 visits according to approximately the following schedule: 1 st visit 15 months 6 years 2 months 18 months 8 years 4 months 2 years 10 years 6 months 3 years 12 years 9 months 4 years 14 years 12 months 5 years 16 years Mammograms based on the following schedule: ages 35 39: two within five years ages 40 and over: one every calendar year Office visits for prescribing, fitting, or inserting contraceptives includes contraceptive medications and devices that require a prescription (unless they are paid for under the prescription benefits provided by the Welfare Plan). In the Active plan, Buy-up plan, and Base plan you do not have to satisfy your deductible before the Welfare Plan pays these benefits. In the Buy-down plan contraceptive care benefits are not paid until you have satisfied your deductible. Pap smears (including related office visit) one every calendar year Bone density screening at the ages and frequencies recommended by the American Academy of Orthopedic Surgeons for patients in the individual s particular risk category based upon symptoms and family history 53

26 Colonoscopies for cancer screening at the ages and frequencies recommended by the American Cancer Society for patients in the individual s particular risk category based upon symptoms and family history Immunizations for routine use for members, spouses, and dependents 17 years of age and older, as listed on the Recommended Adult Immunization Schedule of the Centers for Disease Control and Prevention ( CDC ), as updated annually or temporarily by the CDC. For members and dependents who live outside the United States, the Welfare Plan also covers those immunizations that the CDC would recommend for U.S. residents traveling to the particular country in which the member, spouse, or dependent resides. Inpatient Charges The Welfare Plan covers semi-private hospital room and board as well as services and supplies needed to treat you when hospitalization is medically necessary. The Active and Buy-up plans cover inpatient services provided by a network provider at 100% after you meet your deductible. Services provided by a non-network provider are covered at 100% of R&C charges after you meet your deductible. In each case, the Active and Buy-up plans cover 100% of eligible inpatient charges for up to 120 days of hospital confinement. The Base and Buy-down plans cover inpatient services provided by a network provider at 80% after you meet your deductible. Services provided by a non-network provider are covered at 80% of R&C charges after you meet your deductible. Eligible inpatient services include the following to the extent medically necessary: a room with more than one bed, regardless of the hospital s classification if you choose a private room, Active and Buy-up plans pay up to $20 a day above the semi-private room rate (Base and Buy-down plans do not cover charges above the semi-private room rate) anesthesia supplies and services use of operating, cystoscopic, and recovery rooms, and intensive care blood administration and processing mental health and substance abuse treatment, including services related to detoxification and treatment for chronic alcoholism and drug abuse diagnostic services, including: electrocardiograms ( EKGs ) electroencephalograms ( EEGs ) laboratory and pathology nuclear medicine radiology ultrasound other electronic diagnostic procedures that are recognized by the appropriate medical board drugs and medications used in the hospital dressings and casts general nursing care oxygen and equipment 54

27 special diets surgical services therapy services, including: radiation therapy chemotherapy dialysis treatment physical therapy respiration therapy occupational therapy speech therapy by a licensed speech therapist to treat a speech deficit caused by illness or injury (but not for children under three years of age) medical expenses connected with the legal adoption of a child. The Active and Buy-up plans cover inpatient hospital charges for the birth mother and infant and the physician s charges for delivery, if the member is legally responsible to pay these costs in connection with the legal adoption of a child. The deductible is applied as if the adoptive mother were the birth mother. Inpatient services listed above do not include physician services, including in-hospital medical visits. Notices Relating to Maternity Benefits and Mastectomy Benefits Group health plans and health insurance issuers (such as insurance carriers) generally may not, under federal law, restrict benefits for any hospital stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours after delivery (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for a hospital stay unless it exceeds 48 hours (or 96 hours). If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women s Health and Cancer Rights Act of For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: (i) all stages of reconstruction of the breast on which the mastectomy was performed; (ii) surgery and reconstruction of the other breast to produce a symmetrical appearance; (iii) prostheses; and (iv) treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and copayments applicable to other medical and surgical benefits provided under the Welfare Plan. If you would like more information on the Women s Health and Cancer Rights Act of 1998, please contact the Benefit Plan Office. Limits on Hospital Stays under the Active and Buy-up Plans Charges are paid for up to 120 days per hospital confinement. As an active member, a player on a club s 40-man roster, or an employee of the Players Association, if you return to work for at least one day between two successive hospital stays, the stays are counted as separate confinements. If you are an inactive member, retired member, disabled member, spouse, widow, or eligible dependent, two successive stays must be separated by at least 90 consecutive days to be 55

28 56 considered separate confinements unless the second inpatient stay is for an unrelated diagnosis. If your hospital confinement lasts longer than 120 days, eligible expenses after the 120 th day are paid as major medical charges. (See Major Medical Charges, below.) Limits on Hospital Stays under the Base and Buy-down Plans The Base and Buy-down plans have no specific limits on the number of days covered for hospital confinement. Instead, the Base and Buy-down plans cover the number of days of hospital confinement that are medically necessary as major medical services. Outpatient Charges The Welfare Plan pays benefits for hospital services and the use of hospital facilities related to outpatient care. The Active and Buy-up plans cover outpatient services provided by a network provider at 100% after you pay the deductible. Services provided by a non-network provider are covered at 100% of R&C charges after you pay the deductible. The Base and Buy-down plans cover outpatient services provided by a network provider at 80% after you pay the deductible. Services provided by a non-network provider are covered at 80% of R&C charges after you pay the deductible. Eligible outpatient charges include the following to the extent medically necessary: anesthesia supplies and services medical emergency care within 48 hours of the onset of a life-threatening emergency treatment of an accidental injury within 72 hours of the accident pre-admission testing and studies needed in connection with a scheduled inpatient hospital admission, provided the services: are performed within seven days before the admission, are in lieu of services following admission, and would have been covered when you were admitted mental health treatment substance abuse treatment from an alcoholism or drug abuse treatment program rendered by a facility that is described in the definition of hospital (See Terms.) surgery therapy services and home therapy services, including: chemotherapy dialysis treatment radiation therapy X-rays and other diagnostic services, including: electrocardiograms ( EKGs ) electroencephalograms ( EEGs ) laboratory and pathology nuclear medicine radiology

29 ultrasound other electronic diagnostic procedures that are recognized by the appropriate medical board Special Hospitalization Benefits The Welfare Plan pays benefits for special charges related to medically necessary home health care, hospice care, ambulance services, prosthetic devices, and durable medical equipment. The Active and Buy-up plans cover certain home health care, community home health care, hospice, ambulance services, prosthetic devices, and durable medical equipment provided by a network provider at 100% after you pay the deductible. Services provided by a non-network provider are covered at 100% of R&C charges after you pay the deductible. The Base and Buy-down plans cover certain home health care, community home health care, hospice, ambulance services, prosthetic devices, and durable medical equipment provided by a network provider at 80% after you pay the deductible. Services provided by a non-network provider are covered at 80% of R&C charges after you pay the deductible. Covered charges include the following to the extent medically necessary: Ambulance service to the nearest hospital capable of providing required treatment for injury or illness covered under the Welfare Plan, limited to transportation in a vehicle used only for transporting the sick and injured Home health care or community home health care agency services prescribed by a physician before your discharge from covered confinement. Services are limited to 90 visits per year and include: professional services from an RN, LPN, or LVN; physical therapy; occupational therapy; speech therapy by a licensed speech therapist to treat a speech deficit caused by illness or injury (but not for children under three years of age); medical and surgical supplies; oxygen and its administration; medical social service consultation; and health aide services if you are receiving covered nursing or therapy services Initial prosthetic devices (other than dental) that replace all or part of an internal body organ or all or part of the function of an external body part, such as braces for the neck, leg, arm or back, and artificial legs, arms, or eyes, when such devices are supplied by a hospital, extended care facility, home health agency, rehabilitation agency, or public health agency Inpatient and outpatient hospice care and palliative and supportive services for a terminally ill member and the member s family, including: skilled and unskilled nursing services; administration of pain relief treatments; psychological counseling; physical therapy; and medical equipment and supplies 57

30 Rental or purchase of durable medical equipment supplied by a hospital, extended care facility, home health agency, rehabilitation agency, or public health agency, provided the equipment: can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally is not useful to a person in the absence of illness or injury; is necessary and reasonable to treat the patient s condition or improves the functioning of a malformed body part; and is used in the patient s home. Major Medical Charges The Active and Buy-up plans cover medically necessary major medical services provided by a network provider at 80% after you pay the deductible. Services provided by a non-network provider are covered at 80% of R&C charges after you pay the deductible. The Base and Buy-down plans cover medically necessary major medical services provided by a network provider at 80% after you pay the deductible. Services provided by a non-network provider are covered at 80% of R&C charges after you pay the deductible. The Welfare Plan pays benefits for eligible major medical charges including the following to the extent medically necessary: Professional services from a licensed practicing physician for diagnosing or treating an illness or injury including: home care; hospital care; office visits; and in-hospital medical visits. Professional services of an assistant surgeon. Psychiatric services provided by a physician, psychologist, licensed clinical social worker, licensed marriage and family therapist, or licensed clinical professional counselor to treat mental, psychoneurotic, or personality disorders. X-rays and diagnostic laboratory services used to diagnose a specified illness or injury (covered at 100% under the Active and Buy-up plans). Blood and blood derivatives not donated or otherwise replaced. Covered inpatient hospital charges incurred after 120 days of a confinement. Initial prosthetic devices (other than for dental conditions) not provided by a hospital, extended care facility, home health agency, rehabilitation agency, or public agency, including: those that replace all or part of an internal organ or its function; artificial legs, arms, and eyes; and trusses or braces for the leg, arm, or back. Replacement of prosthetic devices is not covered unless it is due to the normal growth of a child, a change in physical or medical condition, or an accidental injury. 58

31 Initial and replacement orthotic devices, up to $350 per plan year, including: initial office visit; one follow-up visit for dispensing the device; X-rays; biomechanical exam; and molds and casting. Noncustodial outpatient services provided by a professional registered or licensed practical nurse a note is required from the attending physician that confirms medical necessity. Physical therapy services, limited to diagnostic or therapeutic services for physical rehabilitation needed because of an acute illness or injury,* through the use of machinery or hands, provided the services meet all of the following requirements: they are prescribed in writing by a licensed physician or licensed chiropractor; they are rendered by a licensed physician or licensed chiropractor, or by a licensed physical therapist (or in states that do not license physical therapists, a registered physical therapist) or by a licensed athletic trainer certified by the National Athletic Trainers Association and working under the orders of a physician; they achieve progress toward the patient s rehabilitation which the Welfare Plan s medical consultant finds satisfactory; and the patient s condition clearly indicates the necessity for such treatment. * All claims for physical therapy or chiropractic services are subject to the Welfare Plan s medical necessity requirement. While initial claims for physical therapy and chiropractic services may be covered, future claims for physical therapy or chiropractic services even a claim for services similar to the initial services that may be covered by the Welfare Plan may be denied if those services are determined to be not medically necessary. The standard of medical necessity is described above. The Welfare Plan does not cover physical therapy or chiropractic services provided for maintenance of chronic conditions, to prevent or slow the deterioration of bodily systems or functions, or to maintain fitness or health. A claim(s) will be denied if appropriate documentation supporting the medical necessity standard is not provided. Accordingly, it is important for you to provide sufficient documentation of the medical necessity of your services to treat an acute illness or injury, including, when requested, a detailed case summary from the prescribing physician and/or the therapist. Outpatient therapy for autism spectrum disorders based upon an individual treatment protocol approved by the Welfare Plan s Medical Case Management ( MCM ) program. Any change to an individual treatment protocol must be reviewed and approved by the Welfare Plan s MCM program. To the extent that the Welfare Plan has on-going MCM, such therapy will only be covered as long as the patient remains in MCM. The outpatient therapy may include physical therapy, occupational therapy, speech therapy (including children under three years of age), and applied behavior analysis therapy, in each case provided by a Board Certified Behavior Analyst ( BCBA or BCBA-D ) or a Board Certified Assistant Behavior Analyst ( BCaBA ) under the supervision of a BCBA or BCBA-D specializing in that form of treatment. Rental or purchase of durable medical equipment ( DME ) not provided by a hospital, extended care facility, home health agency, rehabilitation agency, or public agency, provided the equipment: can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally is not useful to a person in the absence of illness or injury; 59

32 is necessary and reasonable to treat the patient s condition or to improve the functioning of a malformed body part; and is used in the patient s home. Speech therapy by a licensed speech therapist to treat a speech deficit caused by illness or injury (but not for children under age three, except as authorized for autism spectrum disorders). Second Opinion for Therapeutic Use Exemption A player who is on a club s 40-man roster at any time during a championship season will be paid or reimbursed for an evaluation that is performed for the purpose of providing the second opinion required for a therapeutic use exemption ( TUE ) for an ADD/ADHD medication, on the following conditions: the evaluation is performed by a clinician certified by Major League Baseball; only one second opinion is covered each plan year unless the TUE is valid for less than a year; reimbursement for an evaluation by a clinician who has not previously seen the player will not exceed three sessions or a total cost of $1,800; evaluation by a clinician who has previously seen the player for this purpose will not normally exceed one session; the player will be responsible for a $20 copayment for each session; and the deductible does not apply to this benefit. Services Not Covered The four plans limit coverage in the same way. The Welfare Plan does not pay benefits for services, supplies, or charges that are for: any occupational condition, illness, or injury arising out of and in the course of employment with a current or former employer for which the employer is responsible or that are covered by workers compensation, or which are furnished to a member or dependent under the laws of the United States of America, or any state or political subdivision. Services performed in the clubhouse or other club facility are considered treatment for on-the-job conditions and are not covered by the Welfare Plan. artificial insemination, assisted conception (including, but not limited to, procedures such as in vitro fertilization and gamete or zygote intrafallopian transfer), and reversal of sterilization. care of teeth and dental structures, except that benefits will be provided for repair of an injury to natural teeth to the extent that the expense is not a covered dental expense under the Welfare Plan (see Dental Benefits on page 66 for covered dental expenses). cosmetic surgery or expenses incurred in connection with cosmetic surgery, except as required for the prompt repair of injury or for improvement of the functioning of a malformed body part. custodial care or rest cures. 60

33 diagnosis or treatment (except for orthotic devices; see Major Medical Charges in Covered Services on page 52) of: weak, strained, unstable, or flat feet, or any tarsalgia, metatarsalgia, or bunion (except for operations that involve the exposure of bones, tendons, or ligaments). expenses incurred in connection with any of the following: vitamins, minerals, and food supplements, except for prenatal vitamins covered as a prescription drug; dietary or nutritional counseling of any kind; and/or exercise programs of any kind. corrective lenses, hearing aids, and charges incurred in connection with vision or hearing examinations for the purpose of prescribing corrective lenses or hearing aids. hospital admissions primarily for diagnostic studies. hospital admissions primarily for physical therapy. hospitalization for conditions related to autism spectrum disorders, hyperkinetic syndromes, learning disabilities, behavioral problems, or mental retardation. hospitalization for environmental change. illnesses and injuries resulting from participation in declared or undeclared war. medical, surgical, psychiatric, or pharmaceutical therapies that are experimental in nature, obsolete, or administered for the purpose of medical research, including services or supplies determined by the Pension Committee or its designee to be educational, investigative, experimental, or obsolete based on consideration of competent medical evidence, including the opinion of the Welfare Plan s medical advisors. Therapies will be considered experimental if their use for treatment of the patient s condition is restricted to facilities authorized by an agency of the federal government under approved protocols (also known as clinical trials ). New therapies that are not regulated by federal agencies are also considered experimental until their effectiveness for treatment of the patient s condition has been verified by several independent investigators and has been reported in major medical journals. personal hygiene and convenience items such as, but not limited to, air conditioners, humidifiers, and physical fitness equipment. routine physical examinations and related services or supplies, except as described in Preventive Care Charges on page 53. services and supplies provided by a medical or dental department or clinic maintained by or on behalf of an employer, mutual benefit association, labor union, trust, or similar person or group. except as expressly permitted under the coordination of benefits rules, services or supplies for which payment has been made under Medicare, or would have been made if the member or dependent had enrolled in Medicare and claimed Medicare benefits. services or supplies not specifically listed as covered medical services. services rendered by a person or an organization other than hospitals, physicians, and other health care providers, including services provided by a patient s immediate family. 61

34 except as required by law, services, supplies, or treatment for which expenses are reimbursable by any local or other governmental agency. except as required by law, services, supplies or treatment in a Veteran s Administration Hospital or other hospital operated by the United States government. services, supplies, or treatment furnished under conditions in which the member or dependent has no legal obligation to pay, or that would have been furnished without cost in the absence of insurance. telephone consultations, charges for failure to keep a scheduled visit, additional fees for after-hours treatment when after-hours treatment is not deemed medically necessary, or charges for completion of a claim form. weight loss programs and other treatment of obesity, except for treatment of morbid obesity consistent with current standards of medical necessity. membership fees for health clubs or fitness centers. services, supplies, or treatment provided at a time when the patient was not enrolled in the Welfare Plan for health benefits or after such enrollment was terminated for failure to pay any required premiums. If your allowable covered services were provided outside of the United States, generally you must pay the provider and submit your itemized bills with proof of payment to the Benefit Plan Office for reimbursement. INTERNATIONAL COVERAGE When you enroll in the Active plan or Base plan, you will have the option to elect international coverage based on your international residency. International coverage is not provided under the Buy-up or Buy-down plans. You must complete and return the international coverage enrollment form in the time and manner determined by the Welfare Plan. You may contact the Benefit Plan Office for more information. Aetna and La Universal administer the international coverage in the Dominican Republic. Aetna administers the international coverage in other countries. The international coverage benefits are those benefits described in the international coverage charts, which will be provided to you if you enroll in international coverage. The international coverage charts are also available free of charge upon request, by contacting the Benefit Plan Office. Widow The term widow includes a widow or widower. RETIREE HEALTH CARE BENEFITS Inactive members or retired members with four or more years of credited service, and their widows or eligible dependents who are age 65 or older; enrolled in Medicare Part A and Part B; and not covered by another employer-sponsored health plan as an active employee may elect retiree health care benefits by completing and returning the enrollment forms in the time and manner required by the Welfare Plan and by paying the required premiums. Two types of retiree health care coverage are available: Medicare supplement Medicare Advantage 62

35 Both types of coverage provide prescription drug coverage. Under certain options, you also may elect dental and vision coverage for additional premiums. The Medicare supplement and Medicare Advantage programs are fully-insured products insured and administered by Aetna. Aetna determines the retiree health care benefits payable under the programs. Benefits are not paid by the Welfare Plan; rather they are paid by Aetna. The Benefit Plan Office will assist with your annual enrollment and the collection of premiums; however, all claim and appeal determinations are made by Aetna. The retiree health care benefits are those benefits described in the certificates of coverage (also called evidence of coverage) issued by Aetna. The certificate of coverage will be provided to you if you enroll in retiree health care benefits. The certificate of coverage is also available free of charge upon request, by contacting Aetna. The benefit year for retiree health care is the calendar year. PRESCRIPTION DRUGS When you enroll in one of the health plan options under the Welfare Plan, you will automatically receive prescription drug coverage. (Prescription drug benefits under the retiree health care benefits are provided by Aetna. See Retiree Health Care Benefits on page 62 for information.) You have a choice when you buy prescription drugs. You can: purchase the medication you need from any retail pharmacy; or purchase your medications through the mail order Home Delivery Service. Whether you use a retail pharmacy or the mail order Home Delivery Service, the Welfare Plan covers a range of generic and brand-name drugs. Express Scripts ( ESI ) currently administers the prescription drug benefits. Retail Pharmacy Purchases You can purchase up to a 30-day supply of medication, or a one-cycle supply of an oral contraceptive, from any participating retail pharmacy. Your copayment will be $10 for generic drugs; $20 for brand-name drugs that do not have a generic equivalent; or $30 for brand-name drugs that have a generic equivalent. In all cases, you will pay only the pharmacy s usual and customary price, if it is less than the copayment. For the Buy-down plan, these copayments are subject to the Buy-down plan s deductible, as described in Buydown Plan on page 49. If it would be medically inappropriate for you to take a generic equivalent of a specific brandname drug, the brand-name drug with a generic equivalent that you must take will be subject to the $20 copayment, provided that you submit satisfactory documentation to the Welfare Plan from your physician that supports why it is medically necessary for you to take the specific brand-name drug. Upon the receipt and acceptance of the documentation by the Welfare Plan, the Welfare Plan will reimburse you for the difference between the $20 and $30 copayments. When you have your prescription filled at a participating (network) retail pharmacy, be sure to present your prescription drug ID card. You simply pay the required copayment when the prescription is filled, and the Welfare Plan covers the rest of the cost of the prescription. Locating a Network Pharmacy To locate a network pharmacy, go to or call Express Scripts directly at

36 If you do not show your prescription ID card when you have your prescription filled or if you use a non-network retail pharmacy, you will have to pay the full cost of the prescription and file a claim for reimbursement within one year after incurring the costs. You will be reimbursed at the wholesale rate minus your copayment. Claims submitted after the one-year period will not be paid by the Welfare Plan. (See Filing Claims for Health Care Benefits on page 72 for more information about filing claims for reimbursement.) Mail Order Home Delivery Service Purchases You can order up to a 90-day supply of maintenance medication through the mail order Home Delivery Service. When you order medication through the mail order Home Delivery Service, you will receive up to a 90-day supply of medication for the price of a 60-day supply. Your copayment will be $20 for generic drugs; $40 for brand-name drugs that do not have a generic equivalent; or $60 for brand-name drugs that have a generic equivalent. For the Buydown plan, these copayments are subject to the Buy-down plan s deductible, as described in Buy-down Plan on page 49. If it would be medically inappropriate for you to take a generic equivalent of a specific brandname drug, the brand-name drug with a generic equivalent that you must take will be subject to the $40 copayment, provided that you submit satisfactory documentation to the Welfare Plan from your physician that supports why it is medically necessary for you to take the specific brand-name drug. Upon the receipt and acceptance of the documentation by the Welfare Plan, the Welfare Plan will reimburse you for the difference between the $40 and $60 copayments. For those covered by the Buy-up, Base, or Buy-down plans, prescriptions for up to a 30-day supply of maintenance therapy drugs may be filled only three times at a participating retail pharmacy for the retail pharmacy copayments. You may get subsequent refills of your prescription drug for maintenance therapy through mail order Home Delivery Service for the copayments that apply to mail order Home Delivery Service. If you get a subsequent refill at a participating retail pharmacy, you will be required to pay the retail copayment of $10 for generic, $20 for brand-name drugs that have no generic equivalent, or $30 for brand-name drugs that have a generic equivalent, plus 50% of the cost of the prescription drug. To order a prescription through the mail order Home Delivery Service, obtain an order form from Express Script s ( ESI s ) website, or call ESI at Then, complete and return the order form to ESI, together with the prescription from your doctor. Your doctor also can fax your prescription or it to ESI. You can arrange to have your copayment charged to your credit card, or ESI will bill you for your copayment. You will receive your medication within 10 days from the date ESI receives your order. If you need your medication sooner, ask your doctor to write two prescriptions: one for up to a 30-day supply to be filled immediately at a retail pharmacy (and paid at the regular retail copayment that applies); and one that you can send to the mail order Home Delivery Service for an additional 90-day supply at the applicable copayment level. 64

37 Prescriptions Covered and Special Rules Prescription drugs covered are drugs that by either state or federal law may be dispensed only by prescription, plus prenatal vitamins, Oseltamivir (Tamiflu) prescribed by a physician, and for patients with diabetes, insulin, hypodermic needles, and test strips. Prescriptions for CNS stimulants, Strattera, and amphetamines, except for those prescriptions for the specified drugs that are Dispense as Written prescriptions, will be subject to a step therapy program. For details, contact the Benefit Plan Office. Except for hypnotic drugs dispensed to active players under the therapeutic use exemption, hypnotic drugs will be subject to limitations on quantity and frequency of dispensing. For details, contact the Benefit Plan Office. From January 1, 2014 through March 31, 2015, ESI would not fill prescriptions for certain prescription drugs. Those prescription drugs were still covered under the Welfare Plan. Please see the November 11, 2013, letter to members, a copy of which can be obtained from the Benefit Plan Office. The letter lists the excluded prescription drugs that were in effect from January 1, 2014, through March 31, 2015, and describes how to get reimbursed if you paid full-price for them. As of April 1, 2015, ESI is filling prescriptions for the prescriptions drugs that ESI previously excluded. Prescriptions Not Covered The Welfare Plan does not pay for prescriptions associated with Services Not Covered on page 60. Additionally, the following are excluded from the definition of prescription drugs, even if a physician prescribes them: cosmetic drugs cosmetics health and beauty aids appliances devices bandages heat lamps braces, splints, and artificial appliances dietary supplements (other than prenatal vitamins) all other drugs that can be purchased without a prescription beginning January 1, 2015, all compound medications comprised of at least one ingredient listed on ESI s targeted compound ingredient list unless the compound medication is determined upon appeal to be medically necessary. 65

38 Locating a Network Provider To locate a network dental provider, go to When you use network providers, you may pay lower out-of-pocket costs. DENTAL BENEFITS If you have coverage through the Active plan, you automatically receive dental coverage without an additional premium. If you have coverage through the Buy-up, Base, or Buy-down plans, you may receive dental coverage by electing the additional coverage and paying the required premium. Dental coverage may also be available under the retiree health care benefits, but it will be provided through the retiree health care plan, and not as described in this section. (See Retiree Health Care Benefits on page 62 for information.) Dental benefits are currently provided through a PPO administered by Aetna Cofinity. Each time you need dental care, you have the option of seeing any licensed dentist you wish. You may go to any provider that participates in the Aetna Cofinity PPO network, and your out-of-pocket expenses will be lower; or You may go to any non-network dentist, and your out-of-pocket expenses will be higher. Like your medical options, the Welfare Plan pays a percentage of the PPO contract rates for services when you visit network dentists. Non-network services are paid as a percentage of reasonable and customary ( R&C ) charges for those services, and you pay your percentage plus any amounts above R&C. Your out-of-pocket costs usually will be lower when you use network dentists. Overview The chart below provides an overview of your dental benefits. Who s covered Members and dependents enrolled in the Active plan for medical benefits. COBRA beneficiaries enrolled in the Active plan and who pay the required COBRA premiums. Inactive and retired members who specifically elect dental benefits and pay the required premiums. Cost of coverage None for active and disabled members and their dependents. Plan year deductible None. If COBRA beneficiaries pay premiums for Active plan coverage, those premiums include dental coverage. Inactive and retired members who specifically elect dental coverage pay an additional required premium for dental benefits. Plan year maximum $5,000 each for covered members and dependents.* Orthodontia lifetime maximum $4,000 each for covered members and dependents.* Services covered at 100%** Two routine oral examinations each plan year, including diagnosis, X-rays, and prophylaxis. 66

39 Services covered at 80%** Extractions, fillings, inlays, onlays, crowns, root canal therapy, and periodontal treatment. Oral surgery. Dentures and fixed bridgework (the initial installation, addition to, repair, or alteration). Anesthesia, if medically necessary. Replacement of a broken crown if it had been in place for at least eight years. Replacement of worn or broken dentures that cannot be made serviceable and that had been supplied to the patient at least eight years earlier. Services covered at 75%** Orthodontic treatment and appliances, up to a lifetime limit of $4,000* * The annual and/or lifetime limit will not apply under the Active plan to the extent that such charges are considered essential health benefits under the Affordable Care Act. ** Services received from a network provider are paid as a percentage of the PPO contract rate for those services. Services received from a non-network provider are paid as a percentage of the R&C charges. You are responsible for any amount above R&C charges. How the Dental Plan Works There is no plan year deductible for dental services the Welfare Plan pays benefits for covered services immediately. Benefits are limited to $5,000 per plan year for each covered member and dependent, but the annual limit will not apply under the Active plan to the extent that such charges are considered essential health benefits under the Affordable Care Act. For some services, the Welfare Plan pays 100% of the PPO contract rate for those services and 100% of the R&C charges. For orthodontic appliances and treatment, the Welfare Plan pays 75% of the PPO contract rate or 75% of R&C charges. For all other covered services, the Welfare Plan pays 80% of the PPO contract rate or 80% of the R&C charges. You are responsible for paying the remaining 25% or 20% your coinsurance. 67

40 Treatment Plans A treatment plan is a report your dentist writes in connection with an examination that describes: the results of the examination; and the major dental treatment that your dentist recommends. 68 In addition, when you use non-network providers, the Welfare Plan pays a percentage of the R&C charges for those services. You are responsible for your coinsurance amount and any amount above R&C charges. Treatment Plans Your dentist should submit a treatment plan to the Benefit Plan Office whenever your dentist recommends that you have major dental treatment, including orthodontic services and services related to fixed bridgework. Additionally, the Welfare Plan may ask for a treatment plan at other times. If a treatment plan is necessary, your dentist should submit it within 20 days after the examination. That way you can find out what the Welfare Plan will cover and how much it will pay before receiving services and make informed decisions about your treatment options. Covered Services Services Covered at 100% When services are provided by a network dentist, the Welfare Plan pays 100% of the PPO contract rate (with no deductible) for two routine oral examinations per covered person each plan year. Covered expenses include diagnosis, X-rays, and prophylaxis related to the examinations. Services provided by a non-network provider are covered at 100% of R&C charges with no deductible. Services Covered at 80% The Welfare Plan pays 80% of the PPO contract rate for the following services, when provided by a network provider. When services are provided by a non-network provider, the Welfare Plan pays 80% of R&C charges: extractions, fillings, inlays, onlays, crowns, root canal therapy, and periodontal treatment; installation of, addition to, or repair of full or partial dentures or fixed bridgework; oral surgery; anesthesia, if the Welfare Plan s dental consultant determines that it is medically necessary; replacement of a broken crown if the crown had been in place for at least eight years; and replacement of worn or broken dentures that cannot be made serviceable and that were supplied to the patient at least eight years earlier. Services Covered at 75% Orthodontic Appliances and Treatment The Welfare Plan also pays 75% of the PPO contract rate or 75% of the R&C charges for orthodontic appliances and treatment, up to a lifetime limit of $4,000 per individual, but the lifetime limit will not apply under the Active plan to the extent that such charges are considered essential health benefits under the Affordable Care Act. Benefits Provided After Coverage Ends If you begin receiving certain dental work and your coverage ends before the work is completed, the Welfare Plan will pay benefits for work completed within 90 days after your coverage stops. Provided the work or events below happen while you are covered, the Welfare Plan will continue to pay benefits when you: have a tooth or teeth first prepared for any covered fixed bridgework, crowns, inlays, onlays, or gold restoration;

41 have an impression made for a full or partial removable denture; have a tooth opened for root canal work; begin a course of orthodontic treatment and have a fixed orthodontic appliance installed; or suffer an accidental injury to your natural teeth. In all cases, benefits are extended only for treatment of the condition that is the reason for the extension of coverage. Benefits are extended for a maximum of 90 days. Services Not Covered The Welfare Plan does not pay benefits for dental services or supplies that are: due to any occupational condition, ailment, or injury arising out of or in the course of employment with a current or former employer and for which the employer is responsible or that are covered by workers compensation. furnished under the laws of the U.S., or any state or political subdivisions, or reimbursable by any government, except as required by law. except as required by law, provided in a Veteran s Administration hospital or other hospitals operated by the U.S. government. provided in a dental or medical department maintained by an employer, or that would have been furnished without cost in the absence of insurance or for which the member is not legally obligated to pay. for treatment where the patient has previously incurred the same or similar treatment by the same or a different dentist or physician, with respect to the same tooth or teeth or the same dental area. for services, supplies, or treatment incurred on account of: the patient s participation in declared or undeclared war; dentistry for cosmetic reasons, including the alteration or extraction and replacement of sound teeth for the purpose of changing appearance; athletic mouth guards; duplicate prosthetic appliances; tooth implants and attachments; or oral hygiene, dietary plaque control, and other educational programs. for services, supplies, or treatment that were not recommended as necessary by a dentist or physician. for which benefits are payable under any other part of the Welfare Plan. for services, supplies, or treatment provided at a time when the patient was not enrolled in the Active plan or in optional dental coverage or after such optional enrollment was terminated for failure to pay any required premiums. 69

42 VISION BENEFITS If you have coverage through the Active plan, you automatically receive vision coverage. If you have coverage through the Buy-up, Base, or Buy-down plan, you may receive vision coverage by electing the additional coverage and paying the required premium. Vision coverage may also be available under the retiree health care benefits, but it will be provided by the retiree health care plan, and not as described in this section. (See Retiree Health Care Benefits on page 62 for information.) Overview The chart below provides an overview of maximum vision benefits payable for covered services. Who s covered Members and dependents enrolled in the Active plan for medical benefits. COBRA beneficiaries enrolled in the Active plan and who pay the required COBRA premiums. Inactive and retired members who specifically elect vision benefits and pay the required premiums. Cost of coverage None for active and disabled members and their dependents. Plan year deductible None Covered services (limited to once every 12 consecutive months, except in the case of prescription change or breakage)* If COBRA beneficiaries pay premiums for Active plan coverage, and those premiums include vision coverage. Inactive and retired members who specifically elect vision coverage pay an additional required premium for vision benefits. Examinations: Up to $150 per person when services are provided by a doctor, an optometrist, or an optician. Frames: Up to $150 (but not in any 12-consecutive-month period in which the patient is reimbursed for contact lenses, unless due to a prescription change). and Lenses: or Single: up to $100 Bifocal: up to $160 Trifocal: up to $200 Lenticular: up to $240 Aphakic (two lenses): up to $500 Contact lenses: up to $200 * The annual dollar limits under the Active plan will not apply to any pediatric vision benefit that is considered an essential health benefit under the Affordable Care Act. How the Plan Works There is no plan year deductible the Welfare Plan pays benefits for covered services immediately. In most cases, each type of service or supply is limited to once every 12 consecutive months, except in the case of prescription change or breakage. Benefits are also limited to a maximum dollar amount. However, the annual limit will not apply to certain pediatric vision benefits under the Active plan to the extent that such benefits are considered essential health benefits under the Affordable Care Act. 70

43 Covered Services Examinations The Welfare Plan pays up to $150 per person once in a 12-consecutive-month period for an eye examination provided by a doctor, an optometrist, an ophthalmologist, or an optician. Frames The Welfare Plan pays up to $150 per person once in a 12-consecutive-month period for eyeglass frames. Benefits for frames and lenses are in lieu of contact lenses. Lenses The Welfare Plan pays up to the following amount once in a 12-consecutive-month period for eyeglass lenses: single lenses: $100 bifocal lenses: $160 trifocal lenses: $200 lenticular lenses (two lenses): $240 aphakic lenses (two lenses): $500 Benefits for lenses and frames are in lieu of contact lenses. If you have a prescription change or if your glasses break, the Welfare Plan pays benefits more often than once in a 12-month period, but only up to the dollar amount listed here. A new period of 12 consecutive months will begin with the purchase of the replacement frames or lenses. Contact Lenses The Welfare Plan pays up to $200 per person once in a 12-consecutive-month period for contact lenses. For disposable contact lenses, the patient is limited to reimbursement for the purchase of a single supply of contact lenses in each 12-consecutive-month period. Benefits for contact lenses are in lieu of frames and lenses. If you have a prescription change, the Welfare Plan pays benefits for contact lenses more often than once in a 12-month period, but only up to $200. A new period of 12 consecutive months will begin with the purchase of the new contact lenses. Services Not Covered For each covered vision service, the Welfare Plan generally pays benefits only once during a 12-consecutive-month period, whether or not you have reached the maximum dollar benefit. In addition, the Welfare Plan does not pay benefits for vision services, supplies, or charges: that you would not legally have to pay if you had no insurance; for an occupational condition, ailment, or injury arising out of and in the course of employment for which a current or former employer is responsible or that are covered by workers compensation; that are furnished under the laws of the United States, or any state or political subdivisions thereof, except as required by law; payable under any other part of the Welfare Plan; for sunglasses; 71

44 for the repair of frames; or for services, supplies, or treatment provided at a time when the patient was not enrolled in the Active plan or in vision coverage, or after such enrollment was terminated for failure to pay any required premiums. One Year Filing Deadline All claims must be filed within one year of the date you or your dependent received the services or other treatment. Claims filed after one year will be denied as untimely. FILING CLAIMS FOR HEALTH CARE BENEFITS Network providers in the United States are expected to file claim forms for you. All claims should be returned to the appropriate address as it appears on the back of your medical ID card. If a non-network provider will not file a claim for you, or if a provider is located outside the United States and you do not have international coverage, you must submit the following to receive reimbursement from the Welfare Plan: itemized bill with diagnosis; date(s) of service(s); type(s) of service and charge per service, including prescription drugs; and proof that you paid for the services. If you purchase prescription drugs from a non-network pharmacy, you must submit a claim for reimbursement to Express Scripts ( ESI ) at the address on the claim form. Call ESI at to obtain a claim form. However, if between January 1, 2014 and March 31, 2015, you purchased any of the excluded prescription drugs, you must submit a claim for reimbursement to the Benefit Plan Office and not to ESI. (See Prescriptions Covered and Special Rules on page 65 to learn how to obtain additional information.) Claims, including appeals of claims, for retiree health care benefits will be reviewed and administered by Aetna. You should review the certificate (or evidence) of coverage that Aetna provided to you for additional information, including information on how to file claims. You may also call Aetna at for Aetna Advantage and for Traditional Choice Supplemental for more information. All claims must be filed within one year of the date you or your dependent received the services or other treatment. Claims filed after one year will be denied as untimely. If you are not satisfied with the outcome of your claim, you can ask to have the claim reviewed. (See Claims Appeal Process on page 76 for details.) Claims Determinations 72 For the Welfare Plan, the Benefit Plan Office has final responsibility and authority for responding to claims for all health care benefits except prescription drugs and retiree health care benefits. The prescription drug benefit administrator (identified on your prescription card) is responsible for processing claims (other than the excluded prescription drugs, which are processed by the Benefit Plan Office) and first-level appeals for prescription drug benefits. Aetna is responsible for processing all claims and appeals for retiree health care benefits. Each of these the Benefit Plan Office, the prescription drug benefit administrator, and Aetna is considered the claim administrator for the benefits it processes. Each claim administrator has a specific amount of time, by law, to evaluate and respond to benefit claims. These time limits apply to plans subject to ERISA. The period of time the claim administrator has to evaluate and respond to a claim begins on the date the claim is first filed. There also are specific timelines and information requirements that you must comply with when filing a claim or an appeal, or the claim may be denied and the rights you otherwise would have may be forfeited. You must exhaust the Welfare Plan s internal appeal

45 procedures before you can bring a lawsuit under Section 502(a) of ERISA regarding a claim for benefits under the Welfare Plan. You may designate another individual to act as your authorized representative with respect to a claim or an appeal by providing a written notice of such authorization to the applicable claim administrator. The written notice must be signed and must provide reasonable detail regarding the identity of the authorized representative. If you want to designate an authorized representative with respect to retiree health care benefit claims or appeals, you must complete the form required by Aetna, which you can get by contacting Aetna. In the case of an urgent care claim, a health care professional with knowledge of your medical condition may act as your authorized representative, without regard to the Welfare Plan s procedures for identifying authorized representatives. Initial Benefit Determination The initial benefit determination is the first time the claim administrator considers your benefits claim and makes a decision on your claim. Notices of benefit determinations may be provided in writing or in electronic form. The Welfare Plan recognizes four categories of claims, as explained below. Urgent Care Claims: Claims that have to be decided more quickly because using the normal time frames for decision making could seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function, or, in the judgment of a physician, would subject the patient to severe pain that could not be adequately managed without the care or treatment that is the subject of the claim. For urgent care health claims, the claim administrator will notify you of the determination, whether adverse or not, as soon as possible considering the medical exigencies, but not later than 72 hours after receipt of the claim. If you fail to provide sufficient information for the claim administrator to determine whether, or to what extent, benefits are covered or payable under the Welfare Plan, the claim administrator will notify you as soon as possible of the specific information necessary to complete the claim, but not later than 24 hours after the claim administrator receives the claim. You will be given a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. The claim administrator will notify you of its benefit determination as soon as possible, but no later than 48 hours after the Welfare Plan s receipt of the specified information or the end of the period you were given to provide the specified additional information, whichever happens first. The claim administrator may provide notices of urgent benefit determinations orally; oral notice will be followed by written or electronic notice within three days. Pre-service Claims: Claims for a benefit that must be approved in advance of receiving medical care (for example, requests to pre-certify a hospital stay or for pre-approval under a utilization review program). 73

46 For pre-service health claims, the claim administrator will notify you of the determination, whether adverse or not, within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after receipt of the claim. This period may be extended by 15 days, provided the claim administrator determines that an extension is necessary due to matters beyond the claim administrator s control and notifies you within the initial 15-day period of the circumstances requiring the extension and the date by which the claim administrator expects to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information. You will be given at least 45 days from receipt of the notice within which to provide the specified information. Post-service Claims: Claims involving the payment or reimbursement of costs for medical care that has already been provided. For post-service health claims, the claim administrator will notify you of an adverse determination within a reasonable period of time, but no later than 30 days after receipt of the claim. This period may be extended by 15 days provided the claim administrator determines that an extension is necessary due to matters beyond the claim administrator s control and notifies you, within the initial 30-day period, of the circumstances requiring the extension and the date by which the claim administrator expects to render a decision. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information. You will be given at least 45 days from receipt of the notice within which to provide the specified information. Concurrent Care Claims: Claims where the Welfare Plan has previously approved an ongoing course of treatment over a period of time or a specific number of treatments, and either the claim administrator later reduces or terminates coverage for those treatments before the end of that period or you request an extension of the treatment beyond the approved period of time or number of treatments. Concurrent care claims may fall under any of the other three categories, and different notice and appeal time frames apply: If an ongoing course of treatment will be reduced or terminated, you will be notified sufficiently in advance so that you have the opportunity to appeal and obtain a decision on appeal before the benefit is reduced or terminated. If you request an extension of ongoing treatment in an urgent circumstance, you will be notified as soon as possible given the medical exigencies, but no later than 24 hours after the claim administrator receives your claim (provided the request to extend treatment is submitted to the Welfare Plan at least 24 hours before the expiration of the prescribed time period or number of treatments). If you request an extension of ongoing treatment in a non-urgent circumstance, the request will be considered a new claim and decided according to post-service or preservice time frames, whichever applies. Improperly Filed Pre-service Claims If a pre-service claim is not filed in accordance with the Welfare Plan s claim procedures, you will be notified as soon as possible, but no later than five days after the claim is received by the Welfare Plan. If the claim is an urgent care case, you will be notified within 24 hours. Notice of an improperly filed pre-service claim may be provided orally, or in writing, if you request. The notice will identify the proper procedures to be followed in filing the claim. 74

47 In order to receive notice of an improperly filed pre-service claim, you or your authorized representative must have provided a communication regarding the claim to the Benefit Plan Office. The communication must include: the identity of the claimant; a specific medical condition or symptom; and a request for approval for a specific treatment, service, or product. Note: Claim determinations for medical benefits are made by the Benefit Plan Office, not the PPO network. Please advise any provider who is filing a request for a medical claim determination on your behalf to submit the pre-service claim to the Benefit Plan Office. Adverse Benefit Determination An adverse benefit determination is a denial, reduction, or termination of a benefit, or failure to provide or pay for (in whole or in part) a benefit. This can also include a decision to deny benefits based on the individual s ineligibility to participate in the Welfare Plan. An adverse benefit determination also might mean denying a claim on the grounds that the treatment is experimental or investigational or not medically necessary. This also includes concurrent care determinations (other than a reduction in coverage due to plan amendment or termination). The claim administrator has discretionary authority to determine benefit payment under the Welfare Plan. In reviewing your claim, the claim administrator will apply the plan or insurance contract terms and use discretion in interpreting plan or insurance contract terms. Benefits will be paid only if you have met the eligibility and participation requirements and the claim administrator determines you are entitled to the benefits. In the event of an adverse benefit determination, the notice will include: the specific reasons for the adverse determination; the specific plan provisions on which the determination is based; a request for any additional information needed to reconsider the claim and the reason this information is needed; a description of the Welfare Plan s review procedures and the time limits applicable to such procedures; a statement of your right to bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on review; if any internal rules, guidelines, protocols, or similar criteria were used as a basis for the adverse determination, either the specific rule, guideline, protocols or other similar criteria, or a statement that a copy of such information will be made available free of charge upon request; for adverse determinations based on medical necessity, experimental treatment, or other similar exclusions or limits, an explanation of the scientific or clinical judgment used in the decision, or a statement that an explanation will be provided free of charge upon request; and for adverse determinations involving urgent care, a description of the expedited review process for such claims (this notice can be provided orally within the time frame for the expedited process, as long as written notice is provided no later than three days after the oral notice). 75

48 Claims Appeal Process For All Benefits Except Retiree Medical Benefits and First-Level Appeals for Prescription Drug Benefits Covered by Express Scripts ( ESI ) If you receive notice of an adverse benefit determination and you disagree with the decision, you are entitled to apply for a full and fair review of the claim and the adverse benefit determination. You (or an authorized representative) will have 180 days after receiving the denial notice to file an appeal. The request must be made in writing and include the reasons you believe the claim was improperly denied and all additional facts and documents you consider relevant to your appeal. You should file the request with the Benefit Plan Office. For appeals of adverse benefit decisions involving urgent care claims, the Welfare Plan will accept either oral or written requests for appeals for an expedited review. All necessary information may be transmitted between the Welfare Plan and you or your health care providers by telephone, fax, or other available expeditious methods. The review will be conducted by the Pension Committee. If the denial was based in whole or in part on a medical judgment, the Pension Committee will consult with a health care professional who has appropriate training and experience in the field of medicine involved in your claim. The health care professional will not be the same person as (and will not be a subordinate of) the person who was consulted on the initial decision. (A medical judgment includes whether a treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate.) No deference will be afforded to the initial adverse benefit determination. You will have the opportunity to submit written comments, documents, records, and other information relating to the claim. You will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim. Whether a document, record, or other information is relevant to the claim will be determined in accordance with the applicable Department of Labor ( DOL ) regulations. The review will take into account all comments, documents, records, and other information submitted relating to the claim without regard to whether such information was submitted or considered in the initial benefit determination. You are also entitled to access to, and a copy of, any internal rule, guideline, protocol, or other similar criteria used as a basis for a decision on your denied claim upon request and free of charge. Similarly, if your claim is denied based on a determination involving a medical judgment, you are entitled to an explanation of the scientific or clinical reasons for that determination free of charge upon request. The Pension Committee will notify you of the determination on review within the following time frames: for appeals of urgent health claims, as soon as possible considering the medical urgency, but no later than 72 hours from the receipt of your request for appeal of a denied claim; for appeals of pre-service claims, within a reasonable period of time given the medical situation, but no later than 30 days from the receipt of your request for appeal of a denied claim; and for appeals of post-service claims, your appeal will be presented at the next scheduled quarterly Pension Committee meeting unless your appeal is received less than 30 days before the meeting. In that event, your appeal will be presented at the second meeting after the Benefit Plan Office receives your appeal. If special circumstances require more time for consideration, you will receive written notice. The Pension Committee s decision of your appeal will be provided to you within 5 (five) days after the meeting. 76

49 For Retiree Health Care Benefits If your claim for retiree health care benefits, including prescription drug benefits, is denied, you may, within 60 days of the date of the written notice of such denial, request in writing a review by Aetna. The appeals procedures for retiree health care benefits are described in the certificate of coverage (also called evidence of coverage) issued by Aetna. For First-Level Appeals of Claim Denials of Prescription Drug Covered by Express Scripts ( ESI ) If you receive notice of an adverse benefit determination and you disagree with the decision, you are entitled to apply for a full and fair review of the claim and the adverse benefit determination. You (or an authorized representative) will have 180 days after receiving the denial notice to file an appeal. The request must be made in writing and include the reasons you believe the claim was improperly denied and all additional facts and documents you consider relevant to your appeal. You should file the request with the prescription drug claim administrator at: Express Scripts PO Box St. Louis, MO ATTN: Benefit Coverage Review Department Fax Number: For appeals of adverse benefit decisions involving urgent care claims, the prescription drug claim administrator will accept either oral or written requests for appeals for an expedited review. All necessary information may be transmitted between the prescription drug claim administrator and you or your health care providers by telephone, fax, or other available expeditious methods. The review will be conducted by the prescription drug claim administrator. If the denial was based in whole or in part on a medical judgment, the prescription drug claim administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in your claim. The health care professional will not be the same person as (and will not be a subordinate of) the person who was consulted on the initial decision. (A medical judgment includes whether a treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate.) No deference will be afforded to the initial adverse benefit determination. You will have the opportunity to submit written comments, documents, records, and other information relating to the claim. You will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim. Whether a document, record, or other information is relevant to the claim will be determined in accordance with the applicable Department of Labor ( DOL ) regulations. The review will take into account all comments, documents, records, and other information submitted relating to the claim without regard to whether such information was submitted or considered in the initial benefit determination. You are also entitled to access to, and a copy of, any internal rule, guideline, protocol, or other similar criteria used as a basis for a decision on your denied claim upon request and free of charge. Similarly, if your claim is denied based on a determination involving a medical judgment, you are entitled to an explanation of the scientific or clinical reasons for that determination free of charge upon request. The prescription drug claim administrator will notify you of the determination on review within the following time frames: for appeals of urgent health claims, as soon as possible considering the medical urgency, but no later than 72 hours from the receipt of your request for appeal of a denied claim; 77

50 for appeals of pre-service claims, within a reasonable period of time given the medical situation, but no later than 30 days from the receipt of your request for appeal of a denied claim; and for appeals of post-service claims, within a reasonable period of time, but no later than 30 days from the receipt of your request for appeal of a denied claim. The prescription drug claim administrator will provide you with written notification of the determination on appeal. In the case of an adverse benefit determination, such notice will include: the specific reason for the adverse determination on appeal; reference to the specific plan provisions on which the determination is based; a statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the benefits claim; a description of your right to bring a civil action under ERISA following an adverse determination on appeal; if any internal rules, guidelines, protocols, or similar criteria were used as a basis for the adverse determination, either the specific rule, guideline, protocol, or other similar criteria or a statement that a copy of such information will be made available free of charge upon request; and for adverse determinations based on medical necessity, experimental treatment, or other similar exclusions or limits, an explanation of the scientific or clinical judgment used in the decision, or a statement that an explanation will be provided free of charge upon request. If you receive notice of an appeal determination from the prescription drug claim administrator, and you disagree with the decision, you may request, in writing, further review by the Pension Committee. You (or an authorized representative) will have 180 days after receiving the appeal denial notice to file an appeal with the Pension Committee. The Pension Committee will follow the review procedures described in Claims Appeal Process beginning on page 76. Notices Following Appeal Benefits other than retiree health benefits will be paid only if the Pension Committee determines that you are entitled to them. If you believe that your benefit was improperly denied, the administrative appeal process described in this Claims Determinations section must be completed before you begin any legal action regarding your claim. The Pension Committee will provide you with written notification of the determination on appeal. In the case of an adverse benefit determination, such notice will include: the specific reason for the adverse determination on appeal; reference to the specific plan provisions on which the determination is based; a statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the benefits claim; a description of your right to bring a civil action under ERISA following an adverse determination on appeal; 78

51 if any internal rules, guidelines, protocols, or similar criteria were used as a basis for the adverse determination, either the specific rule, guideline, protocol, or other similar criteria or a statement that a copy of such information will be made available free of charge upon request; and for adverse determinations based on medical necessity, experimental treatment, or other similar exclusions or limits, an explanation of the scientific or clinical judgment used in the decision, or a statement that an explanation will be provided free of charge upon request. Coordination of Benefits If you or your family has medical coverage under another group plan, governmental program, or casualty insurance policy that pays medical benefits, or could enroll in Medicare, you need to think about how the Welfare Plan s coordination of benefits ( COB ) policy affects your benefits. COB prevents duplicate payments for the same services. Under COB, the plan that pays first is the primary plan. The secondary plan pays after the primary plan. The total payments from both plans will not be more than 100% of the total covered charges. When the Welfare Plan is primary, it will pay benefits for covered services without regard to the other plan s coverage. When the Welfare Plan is secondary, the Welfare Plan will pay the difference between the allowable charges and the amount that the other plan pays, but never more than the Welfare Plan would have paid as the primary plan. Determining the Order of the Plans The primary and secondary plans are determined according to the following guidelines: A benefit plan that acknowledges it is primary or that does not have a COB feature is always primary. A benefit plan that covers a patient through current employment (either as an employee or as the dependent of an employee) is the primary plan and pays before any plan that covers the patient through COBRA or extended coverage for former or retired employees and their dependents. Medicare is primary for inactive or retired members and their dependents. Medicare is secondary for members who are covered through current employment and for their dependents. For all patients who are covered by Medicare due to end-stage renal disease, Medicare is secondary for the first 30 months of Medicare coverage; it is primary thereafter. For an inactive member, a retired member, or an inactive or a retired member s spouse or widow who has reached age 65, is covered under another employer s group health plan because of active employment, and has not enrolled in Medicare Parts A and/or B, the Welfare Plan determines the amount that it covers based upon the benefits that Medicare would have paid if the patient had enrolled in Medicare Part A only and had submitted appropriate claims for Medicare payment. For any other inactive member, retired member, or inactive or retired member s spouse or widow who is eligible for Medicare but has not enrolled in Medicare, the Welfare Plan determines the amount that it covers based upon the benefits that Medicare would have paid if the patient had enrolled in Medicare Parts A and B and had submitted appropriate claims for Medicare payment. For purposes of this coordination of benefit rule, retired member does not include a retired member in active service. 79

52 If a child is covered under both parents plans (when the parents are not divorced or separated), the plan covering the parent whose birthday occurs earlier in the calendar year pays before the plan covering the other parent. This is called the birthday rule. Please note that the year of birth is not relevant, only the day. If both birthdays are the same or if the other plan does not follow the birthday rule, the plan that has covered the family longest is primary. If none of these rules apply, the plan covering the patient for a longer period of time pays before any other plan. In Cases of Divorce or Separation The following rules apply for dependent children of divorced or separated parents. If a court decree provides that one parent has financial responsibility for the child s health care, that parent s plan is primary. If there is no such court decree: the plan of the parent with custody is primary; the plan of the spouse of the parent with custody (the stepparent) is secondary; and the plan of the parent without custody pays last. If none of the above conditions apply, whichever plan has covered the patient the longest is primary. Credit Reserve When the coordination of benefits rules results in a lesser payment being made under the Welfare Plan than would have been made if the Welfare Plan were primary, the Welfare Plan will hold the difference between those two amounts in credit reserve for the individual member or dependent. Credit reserve is applied separately to medical coverage and dental coverage. Amounts in the credit reserve will be applied to reimburse the same individual member or dependent for amounts that he or she would otherwise be required to pay during the same plan year for the deductible or for copayments (other than prescription drug copayments). It cannot be used to pay any amounts that a non-network provider charges in excess of reasonable and customary charges. Credit reserve cannot be carried over from one plan year to the next. Overpayments If the Welfare Plan pays you a benefit that it later determines is an ineligible expense or exceeds the Plan maximums, you must reimburse the Welfare Plan for that payment. The Pension Committee (or its designee) has full authority, in its discretion, to recover the amount of the overpayment plus interest and costs. That authority includes, but is not limited to, the right to reduce benefits payable in the future to the person who received the overpayment; the right to reduce benefits payable in the future to a spouse, surviving spouse, dependent, or other beneficiary who is or becomes entitled to receive benefits under the Welfare Plan by virtue of a relationship with, or designation by, the person who received the overpayment; and the right to take legal action to recover the overpayment plus interest and costs. 80

53 The Pension Committee (or its designee) will decide how you should reimburse the Welfare Plan for any overpayments. Possible methods for reimbursement may include: payment in a lump sum; payment monthly of a prearranged amount; or deduction from future benefits that may be payable to you or your covered dependents. Subrogation and Reimbursement In certain situations, the Welfare Plan may pay benefits to you or a dependent for an illness or injury that was caused by someone who may be financially responsible to you or your dependent for the cost of medical care. Automobile accidents are the most common example of these situations. You or your dependent may also be entitled to recover compensation for that illness or injury from an insurance company (for example, from the other driver or his insurance company, or from your own automobile insurer). In any of these circumstances, the Welfare Plan has a subrogation and reimbursement rule that is designed to prevent duplicate payments and to protect plan assets from being used to pay for medical care that a party at fault (or some other person) should be required to pay. If you or one of your dependents needs medical care as the result of an illness or injury and some other person or insurer may be responsible for your loss, you must sign an agreement to repay the Welfare Plan s benefits out of any compensation you might receive in connection with that illness or injury. That agreement must be signed before the Welfare Plan will pay for medical care relating to the illness or injury. If you later receive compensation for the illness or injury, you will be required to repay the amount of the benefits the Welfare Plan paid to you or your dependent (or that the Welfare Plan paid to a provider on your behalf) in connection with that illness or injury. This is called reimbursement. The Welfare Plan s right to reimbursement applies to any compensation that you or your dependent may receive from any source, if it is related to the illness, injury, or other expense or loss for which the Welfare Plan paid benefits. It requires repayment of the full amount that the Welfare Plan paid in benefits, up to 100% of the amount that you and/or your dependent received as full or partial compensation, even if you and your dependent are not made whole for your losses. The Welfare Plan s right to reimbursement has first priority and will not be reduced for any reason, including for attorney s fees, the fund doctrine, the common fund doctrine, comparative or contributory negligence, collateral source rule, attorney s fund doctrine, regulatory diligence, or any other defenses or doctrines that may affect the Welfare Plan s right to subrogation or reimbursement, unless the following conditions apply: The Welfare Plan understands that you may incur attorney s fees in obtaining recovery from the responsible party or an insurer, so the plan administrator has discretion to reduce the amount that you must repay by a reasonable amount of attorney s fees if your attorney agrees in advance to the Welfare Plan s subrogation and reimbursement rights by signing an Attorney Consent form. The plan administrator also may reduce the amount that must be paid back to the Welfare Plan in other appropriate circumstances, in its discretion. 81

54 By participating in the Welfare Plan and accepting payment of plan benefits, you agree that a constructive trust, lien, or equitable lien by agreement attaches to any amount of compensation you receive related to an illness, injury, or other expense or loss for which the Welfare Plan provided benefits. If you do not repay the Welfare Plan out of the compensation you receive, the Welfare Plan has the right to sue you, your dependent, or anyone else who has received any funds that should have been paid to the Welfare Plan. If the Welfare Plan sues you to enforce its subrogation and reimbursement rights, you may be required to pay the Welfare Plan s reasonable attorney s fees and costs of that action. If you do not repay the Welfare Plan, the Welfare Plan may also recover the amounts owed to it by deducting that amount from any future benefit payments to you or any dependent until the full amount has been repaid. The Welfare Plan also has the right to assert a claim on your (or your dependent s) behalf instead of, or in addition to, your own claim against the responsible party, in order to recover the full amount of the benefits that the Welfare Plan pays in connection with an illness or injury. This is called subrogation. You and your dependents have the obligation to help the Welfare Plan in asserting its subrogation rights. Preventing Fraud on the Welfare Plan The assets of the Welfare Plan are for the benefit of all participants in the Welfare Plan. In order to control the costs of the Welfare Plan, and to keep the premiums that are charged to qualified beneficiaries, inactive and retired members, and widows affordable, it is everyone s responsibility to help prevent fraud that would cause the Welfare Plan to pay more than it should in benefits. If you or any dependent knowingly provides false or incomplete information to the Welfare Plan in order to obtain benefits for a person who is not eligible, to obtain benefits not payable by the Welfare Plan, or to obtain benefits in excess of what the Welfare Plan is obligated to pay, the Pension Committee may take any action that it considers appropriate for the protection of the Welfare Plan, including recovering any benefits that should not have been paid or canceling the benefit coverage of any person who knowingly provided false or incomplete information. You must advise the Welfare Plan of any discounts or price adjustments that a health care provider gives you. A provider who waives or refunds your copayments is entering into a discount arrangement with you. If the Welfare Plan is not advised of that discount arrangement, the Welfare Plan would pay benefits based on the provider s non-discounted fees and would thus pay more than it should. 82

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