2018 Retiree Health Care Program Summary Plan Description

Transcription

1 2018 Retiree Health Care Program Summary Plan Description Table of contents Your Program Options and Claims Administrators... 3 Networks... 6 Cost of Retiree Health Care Coverage... 9 Deductibles, Coinsurance and Maximums...11 What s Covered Medical Coverage Requirements, Limitations and Exclusions Medical What s Covered Pharmacy Coverage Requirements, Limitations and Exclusions Pharmacy What s Covered Wellness How Benefits are Paid (Early Retiree Medical option only) Enrolling Situations That Could Affect Your Coverage (Including Becoming Medicare-Eligible) When Coverage Ends Continuing Dependent Coverage Under COBRA Appeals and Disputes Required Legal Information Glossary Whom to Contact Introduction About this document This is the summary plan description (SPD) for the U.S. Bank Retiree Health Care Program ( Program ) and the Wellness Program, components of the U.S. Bank Benefits Program. Please read the information carefully and file it with your benefits materials. U.S. Bank has established the U.S. Bank Comprehensive Welfare Benefits Plan ( Plan ), which provides severance, medical, wellness, dental and retiree health care benefits. The U.S. Bank Comprehensive Welfare Benefits Plan consists of distinct programs, each of which covers a specific category of benefits for a particular group of employees/retirees. For convenience, U.S. Bank has created a separate summary for each program. This SPD applies to retirees enrolled in the Early Retiree Medical, Medica Prime Solution, or UnitedHealthcare Medicare Advantage PPO (UHC MA PPO) options under the Retiree Health Care Program and the Wellness Program. For a list of the separate summaries describing the other categories of benefits available to U.S. Bank employees under the U.S. Bank Comprehensive Welfare Benefits Plan, please see Required Legal Information. HR1201P (11/2017) U.S. Bank 2018 Retiree Health Care Program Summary Plan Description

2 The information in this SPD pertains in full to the following medical options: Early Retiree Medical UHC CPN Early Retiree Medical UHC MCN Early Retiree Medical UHC OOA This document is intended only to provide a summary of the benefits that are available. The final administration of claims is handled by the Claims Administrator. If there is any discrepancy between this document and the official plan/program documents (for benefits where the summary plan description is not part of the plan document), the official plan/program documents govern. UnitedHealthcare Medicare Advantage PPO (UHC MA PPO) or Medica Prime Solution plans If you are enrolled in the UHC MA PPO plan or Medica Prime Solution plan, you will receive materials directly from the UHC MA PPO or Medica Prime Solution plan explaining the benefits provided and any requirements or limitations for receiving benefits. When read with the information in the following sections of this SPD, these materials are the complete summary plan description for the UHC MA PPO or Medica Prime Solution plans. Introduction Your Program Options and Claims Administrators Cost of Retiree Health Care Coverage Who s eligible Enrolling Situations That Could Affect Your Coverage (Including Becoming Medicare-Eligible) Coverage Cancellation When Coverage Ends Continuing Coverage Under COBRA Required Legal Information Whom to Contact The materials you receive from the UHC MA PPO plan or the Medica Prime Solution plan will include important information regarding the doctors you may see, the medical services you may receive, any copayments or other out-of-pocket expenses for which you may be responsible, requirements you must satisfy before receiving services (e.g., preadmission notification and prior authorization) and the services and expenses that are excluded under the benefit plan. Your responsibilities Carefully review this information and keep it for future reference. Enroll or request qualifying changes by the deadlines described in this document. If you miss certain deadlines, processing may be delayed or your request may not be processed at all. After enrolling or making a change, carefully review your confirmation statement and any other documents. Provide documentation as requested to verify eligibility of any dependents you enroll. Verify that the provider you or a covered family member uses is a participating pharmacy or network provider before you receive care to ensure eligible services are covered at the highest benefit level. U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 2

3 Call the U.S. Bank Employee Service Center if you have questions not answered by the information in this document, or contact your claims administrator/insurance company for specific questions about coverage or claims information. Eligibility and enrollment The U.S. Bank Retiree Health Care Program is closed to new enrollments for employees that terminate/retire on or after Jan. 1, You are eligible for the Retiree Health Care Program if you were enrolled on or before this date. Newly eligible dependents can be added to coverage if enrolled within 60 days of becoming an eligible dependent, see Who s Eligible, Enrolling and Situations That Could Affect Your Coverage. Your Program Options and Claims Administrators The health care option available to you depends on your age (as the U.S. Bank retiree), Medicare eligibility and the area in which you live. For any of the options available to you, there are two coverage levels: You Only (the retiree only); or Family (you/retiree; and any eligible dependents). You (the retiree) are younger than 65 and not Medicare eligible (regardless of any dependent s age or Medicare eligibility) Options Claims administrators Depending on your permanent home address, you and Medical: UnitedHealthcare your dependents will be enrolled in: Services, Inc. (UHC) Early Retiree Medical Medica Choice (MCN) Early Retiree Medical Choice Plus (CPN) Early Retiree Medical Out-of-Area (OOA Pharmacy: Express Scripts You (the retiree) and your dependent(s) are 65 or older or younger than 65 and Medicare eligible Options Claims administrators Depending on your permanent home address, you and your dependents will be enrolled in: UnitedHealthcare Medicare Advantage PPO (UHC MA PPO); or Medica Prime Solution Medical: UnitedHealthcare Group Medicare Advantage PPO or Medica Group Prime Solution SM Pharmacy: Express Scripts U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 3

4 You (the retiree) are 65 or older or younger than 65 and Medicare eligible, and your dependent(s) are younger than 65 and not Medicare eligible Options Claims administrators Depending on your permanent home address, you will be enrolled in: UnitedHealthcare Medicare Advantage PPO (UHC MA PPO); or Medica Prime Solution Depending on your permanent home address, your dependent(s) will be enrolled in: Medical: UnitedHealthcare Group Medicare Advantage PPO or Medica Group Prime Solution SM Pharmacy: Express Scripts Medical: UnitedHealthcare Services, Inc. (UHC) Early Retiree Medical Medical Choice (MCN) Early Retiree Medical Choice Plus (CPN) Early Retiree Medical Out-of-Area (OOA): locations without access to a network Pharmacy: Express Scripts When you or your dependent(s) turn age 65 or become Medicare eligible before age 65 you must enroll in Medicare Part A and Part B. If your covered dependent(s) become Medicare eligible and are enrolled in one of the pre-65 health care options, the Program expects your covered dependents will enroll in Medicare Parts A and B as soon as they are eligible to do so. Medicare Parts A and B will be considered the primary insurer, regardless of whether your covered dependent(s) is actually enrolled in Medicare or not and the Program will provide secondary coverage. This means that if your covered dependent(s) do not enroll in Medicare parts A and B when first eligible, you will be responsible for paying the portion Medicare would have paid had your dependent(s) been enrolled in Medicare when first eligible, in addition to any liability you may be responsible for under your coverage in the Program. UnitedHealthcare Medicare Advantage PPO and Medica Prime Solution options The UHC MA PPO or Medica Prime Solution options are available to retirees enrolled in Medicare Parts A and B and their dependents (as long as the retiree is also enrolled in this option). These options deliver all of the benefits of Medicare Parts A and B, plus additional benefits. (You must be enrolled in Medicare Parts A and B to remain enrolled in the Program. If you are not enrolled in Medicare Parts A and B, your coverage in the Program will be cancelled.) Under these options, you will generally receive benefits only for covered services you receive from providers that accept the terms of your UHC MA PPO or Medica Prime Solution plan option. The option you are enrolled in is determined by your permanent home address: Where you live Minnesota all counties North Dakota counties of Adams, Barnes, Benson, Billings, Bowman, Burleigh, Cass, Cavalier, Dickey, Dunn, Eddy, Emmons, Foster, Grand Forks, Grant, Griggs, Hettinger, Kidder, LaMoure, Logan, McHenry, McIntosh, McLean, Mercer, Morton, Nelson, Oliver, Pembina, Pierce, Ramsey, Ransom, Richland, Rolette, Your plan* Medica Group Prime Solution SM, a Medicare Cost plan U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 4

5 Where you live Sargent, Sheridan, Sioux, Slope, Stark, Steele, Stutsman, Towner, Trail, Walsh, Ward, Wells, Williams South Dakota counties of Aurora, Beadle, Bennett, Bon Homme, Brookings, Brown, Brule, Buffalo, Butte, Campbell, Charles Mix, Clark, Clay, Codington, Corson, Custer, Davison, Day, Deuel, Dewey, Douglas, Edmunds, Fall River, Faulk, Grant, Gregory, Haakon, Hamlin, Hand, Hanson, Harding, Hughes, Hutchinson, Jackson, Jerauld, Jones, Kingsbury, Lake, Lawrence, Lincoln, Lyman, Marshall, McCook, McPherson, Meade, Mellette, Miner, Minnehaha, Moody, Pennington, Perkins, Roberts, Sanborn, Shannon, Spink, Stanley, Sully, Todd, Tripp, Turner, Union, Walworth, Yankton, Ziebach Wisconsin counties of Ashland, Barron, Bayfield, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Pierce, Polk, Sawyer, St. Croix or Washburn Any other location Your plan* UnitedHealthcare Group Medicare Advantage PPO Plan * If you have end stage renal disease, you will need to remain enrolled in the Early Retiree Medical option for 30 months before enrolling in the UHC MA PPO or Medica Prime Solution option even if you turn 65 during that time, per Medicare guidelines. The UHC MA PPO and Medica Prime Solution plan options are offered through insurance contracts with the UHC MA PPO plan and Medica Prime Solution plan who have the sole authority, discretion and responsibility to interpret and construe the option and, determine all factual and legal questions under such option, including but not limited to eligibility, the entitlement of benefits and the amounts of benefits to be paid, and determine all questions arising in the administration of the option. The UHC MA PPO plan and Medica Prime Solution plan provide their own materials. If you enroll in the Program, carefully review and refer to these materials. If you have questions about your health care option, coverage or claims information, contact the UHC MA PPO plan or Medica Prime Solution plan. Your pharmacy coverage under the Program and Medicare Part D Medicare Part D prescription drug coverage is available if you enroll in Medicare Part D and pay an additional Part D premium. However, the U.S. Bank Program provides primary prescription drug coverage at no additional cost, except for prescriptions covered under Medicare Parts A and B. In fact, the prescription drug coverage under the Program provides more cost effective coverage than what is offered under standard Medicare Part D. Because prescription coverage is already available under the Program, we strongly recommend that you do not enroll in Medicare Part D. If you enroll in Medicare Part D, you will no longer receive pharmacy coverage under the U.S. Bank option. Your monthly U.S. Bank Program premium (which covers medical and pharmacy) will not be reduced. You will pay additional unnecessary premiums, as you will be paying a premium for both Medicare Part D and the U.S. Bank option. If you are enrolled in the Medicare Prime Solution plan option and you later decide to cancel your Medicare Part D coverage, you will be eligible to reenroll for U.S. Bank pharmacy coverage, as long U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 5

6 as you remain enrolled in the Medica Prime Solution plan. Your U.S. Bank prescription drug coverage will be reinstated the first of the month following the date your Medicare Part D coverage ends and you contact the U.S. Bank Employee Service Center, unless you contact the service center on the first of the month. In this case, your coverage will become effective on that day. If you are enrolled in the UHC MA PPO plan option and you enroll in Medicare Part D, Medicare will automatically terminate your UHC MA PPO plan coverage and you will no longer be enrolled in the U.S. Bank Retiree Health Care Program. Your dependent s coverage will also be terminated, as dependents are not eligible to be enrolled in the Program if the retiree is not enrolled. If your dependent is enrolled in the UHC MA PPO plan option and he or she enrolls in Medicare Part D, Medicare will automatically terminate your dependent s UHC MA PPO plan coverage and (s)he will no longer be enrolled in the U.S. Bank Retiree Health Care Program. If you are enrolled in UHC MA PPO plan or Medica Prime Solution plan, vaccines that are covered by Medicare Part D are not covered by these medical carriers. However, these vaccines (such as the shingles or tetanus vaccines), will be covered by Express Scripts if the prescription is filled at a participating network retail pharmacy. See Vaccines covered by Medicare Part D to learn more. Early Retiree Medical option claims administrators Medical claims administrator: United HealthCare Services, Inc. (UHC) is the claims administrator for medical services. Pharmacy claims administrator: Express Scripts is the claims administrator for prescription drug coverage. Networks Advantages of using network providers When you receive medical services, you are encouraged to use network providers and participating pharmacies for the following reasons: Higher level of coverage You and your covered dependents (including dependents not living with you or attending school away from home) will receive a higher level of coverage for covered services and prescriptions when using network providers or participating pharmacies. If you or your covered dependents use a non-network provider or non-participating pharmacy, you will receive a lower level of coverage. See What s Covered Medical, and What s Covered Pharmacy. to learn more. Filing claims When you use network providers or participating pharmacies, your claims will be filed for you. When you use non-network providers or non-participating pharmacies, you may need to file your own claims. See How Benefits are Paid for more information on medical and pharmacy claims. Allowed amounts By using network providers, you generally will only pay the allowed amounts negotiated by UHC to ensure the fees charged by providers are not excessive. If you obtain care from a non-network provider, you may have to pay any excess over the allowed amount and it may not count toward your deductible or out-of-pocket maximum. See Allowed amounts for more information. See the Glossary for definitions of network and non-network, participating and non-participating pharmacies. U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 6

7 Determine your network Your network is based on your medical claims administrator and in some cases, where you live or receive services; see the table below: Where you live*: Minnesota, North Dakota, South Dakota or Western Wisconsin (Ashland, Barron, Bayfield, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Pierce, Polk, Sawyer, St. Croix and Washburn counties only) Your network Early Retiree Medical: Medica Choice (MCN) Network for medical services Express Scripts** for prescriptions only Additional provisions apply for bariatric surgery, infertility treatment (including prescription drugs), spine and joint procedures, and transplants. See Centers of Excellence later in this section. All other locations Early Retiree Medical: Choice Plus (CPN) Network for medical services Express Scripts** for prescriptions only Additional provisions apply for bariatric surgery, infertility treatment (including prescription drugs), spine and joint procedures, and transplants. See Centers of Excellence later in this section. * In limited circumstances, there may be a location without adequate network access. In this case, the Out-of-Area (OOA) network will apply for medical services. See Special Out-of-Area network later in this section for additional information. **Most pharmacies and pharmacy chains in the United States are in Express Scripts participating retail pharmacy network. For prescriptions by mail; you need to use Express Scripts home delivery or Accredo, (Express Scripts specialty pharmacy). Find a network provider To find a network provider or participating pharmacy, call UHC or Express Scripts or visit their websites. Every effort is made to ensure the list of providers on the website is up-to-date and accurate. However, networks are subject to change throughout the year. It is your responsibility to verify a provider s network or participation status with your claims administrator before you or your covered dependents receive care. Additional considerations for finding a medical provider Centers of Excellence If you are in the Choice Plus or Medica Choice network, UHC has clinical programs that provide access to designated providers who specialize in certain types of care in order to provide the best possible care. You are required to use UHC s clinical programs prior to receiving services for bariatric surgery, infertility treatment (including prescription drugs) and transplants. Bariatric surgery, infertility treatment (including prescription drugs) and transplants are not covered if you do not use UHC s clinical programs. You are required to enroll in UHC s clinical program prior to receiving services for spinal fusion, disc procedures and joint replacements for your services to be eligible for coverage under the plan. If enrolled, you will receive the network level of benefits if you use a designated facility. Services received at a UHC network facility that is not a designated facility are U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 7

8 only eligible for the non-network level of benefits, and non-network facilities are not covered. If you don t enroll, your services will not be covered. You are encouraged but not required to use UHC s clinical programs for cancer, congenital heart disease and neonatal services. Exceptions and additional provisions apply; see Bariatric Resource Services, Cancer Resource Services, Congenital Heart Disease Resource Services, Neonatal Resource Services, Optum Fertility Solutions, Spine and Joint Solution and Transplant Resource Services for more information. UnitedHealth Premium Program This program identifies UHC network physicians that meet standards for quality and cost efficiency. UHC uses evidence-based medicine and national industry guidelines to evaluate quality. The cost efficiency standards rely on local market benchmarks for the efficient use of resources in providing care. For details on the program including how to locate a UnitedHealth Premium Physician, call UHC or visit their website. You are not required to use providers in this program to receive network benefits. If a network provider is not available If you re unable to locate a network provider within a 30 mile radius of your home zip code call UHC. When necessary, UHC will approve a network gap exception, allowing you to receive the network level of benefits for services received from a non-network provider. Approval for the gap exception must be granted by UHC before you receive care. This does not apply for those in the Out-of-Area network, as use of a network provider is optional. Special Out-of-Area network UHC has clinical programs that provide access to designated providers who specialize in certain types of care in order to provide the best possible care. You and your covered dependents are required to use UHC s clinical programs prior to receiving services for bariatric surgery, infertility treatment (including prescription drugs), spinal fusion, disc procedures, joint replacements and transplants. Bariatric surgery, infertility treatment (including prescription drugs), spinal fusion, disc procedures, joint replacements and transplants are not covered if you don t use UHC s clinical programs. You are encouraged but not required to use UHC s clinical programs for cancer, congenital heart disease and neonatal services. Exceptions and additional provisions apply; see Bariatric Resource Services, Cancer Resource Services, Congenital Heart Disease Resource Services, Neonatal Resource Services, Optum Fertility Solutions, Spine and Joint Solution and Transplant Resource Services for more information. For all other eligible medical services, the network level of benefits will apply when using a non-network provider. Claim payments are based on the billed charge rather than the allowed amount for non-network providers; see How benefits are paid for more information. Identification cards After you enroll, ID cards will be mailed to your home address. You will receive an ID card from your medical claims administrator (UHC), and another ID card from your pharmacy claims administrator (Express Scripts). You must present the appropriate ID card when receiving care, so your claim will be handled properly and promptly. If you do not, you may need to pay for services yourself and file a claim for reimbursement. You may request additional or replacement ID cards by contacting the applicable claims administrator. U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 8

9 Transition of care If you are planning to enroll in a U.S. Bank medical plan and you or a covered family member is currently being treated by a provider who is not in the UHC network applicable to your location, and treatment is expected to continue after you enroll, you or your covered family member may qualify for transition of care (TOC). TOC allows you to be treated by your current non-network provider for a specified period of time (determined by the individual situation) and receive the network level of benefits. TOC is only available for the treatment of acute conditions and not for the convenience of the member being treated. Examples of acute conditions are end-stage renal disease and dialysis, nonsurgical cancer therapies (including chemotherapy and radiation), transplants (solid organ and bone marrow), and conditions where transition of care is required by federal law. If you or a covered family member is pregnant and expects to be in the second or third trimester as of the effective date of coverage, you/she will automatically be eligible for TOC through the first postpartum visit. However, you or your family member must still complete a form to request TOC. Mental health and substance-related and addictive disorders treatment are reviewed on a case-by-case basis. To request TOC, you and your physician will need to complete the form found on UHC s website. You may also need to submit supporting medical information related to your request. Upon receipt of the information, UHC will review your request and notify you of approval or denial. If approved, the notification will indicate the duration of the TOC. During this time, you are responsible for notifying UHC prior to receiving certain services or being admitted to the hospital (see Coverage Requirements, Limitations and Exclusions Medical ) and you may need to file your own claims (see How benefits are paid ). For additional information on TOC, call UHC. Cost of Retiree Health Care Coverage The cost of retiree health care coverage for participants in the Program is based on claims experience and medical expense projections. The cost is generally adjusted on an annual basis and changes on Jan. 1. The cost could, however, in U.S. Bank s discretion, be changed more frequently. Retiree health care credits Employees that met age and service requirements were able to accumulate retiree health care credits from Jan. 1, 2002, through Dec. 31, Effective Jan. 1, 2014, employees can no longer accumulate retiree health care credits. Eligible employees who retired before Jan. 1, 2014, may use their retiree health care credits as described below. Employees who did not retire before Jan. 1, 2014, forfeited any accumulated retiree health care credits. Nature of credits and reservation of rights to change credits As long as U.S. Bank keeps the credits structure in place in its Retiree Health Care Program, it will, for bookkeeping purposes, keep a record of any credits you accumulated. Your accumulated credits will be used to offset your cost of Retiree Health Care Program coverage for you and any covered dependents. Accumulated credits are not like accounts in a 401(k) or pension plan; no trust holds these credits, and there is no bank account in which the credits are deposited. U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 9

10 If you did not retire by Dec. 31, 2013, or you were not eligible to enroll in retiree health care on/or before Dec. 31, 2013, your credits and deemed interest were forfeited under all circumstances. Credits cannot be paid out to you or used for any other purpose than payment toward U.S. Bank retiree health care coverage under the Program. Additionally, U.S. Bank is not obligated to continue either the Program or the retiree health care credits toward the cost of the coverage. U.S. Bank could terminate your coverage altogether or could amend the Program to eliminate or change (including reducing) the credits including any credits you have already accumulated. This is because retiree health care coverage is not a vested benefit and U.S. Bank has retained its full authority and discretion to amend or terminate the Program. Interest on retiree health care credits Credits are deemed to receive interest payments of 5.5 percent annually. If you have accumulated retiree health care credits, your remaining credit balance (after deductions from the account toward the cost of coverage) as of each Dec. 31 will be deemed to gain interest at the established interest rate. U.S. Bank has reserved the right to increase or decrease the interest rate. Paying for coverage with credits If your employment ended on or before Dec. 31, 2013, and you enrolled in the U.S. Bank Retiree Health Care Program, approximately two-thirds of the annual medical coverage cost will be offset by your accumulated credits, and you will pay the remaining approximately one-third out-of-pocket. Approximately two-thirds of the medical cost will continue to be deducted from your account until the credits are insufficient to cover two-thirds of the cost. The credit balance will be reviewed Jan. 1 of each year and if the credits will not cover two-thirds of the cost of your premium for the entire year, then the balance will be divided by twelve to determine the amount used to offset your premium payment. If your rate changes during the plan year, the dollar amount used to offset your premium payment will be recalculated. After your health care credit balance is depleted, you can continue to participate in the Program by paying 100 percent of the cost out-of-pocket. If you elect coverage for dependents (spouse/domestic partner/children or grandchildren), the annual medical cost includes their coverage. Approximately two-thirds of the total elected coverage will be offset against the accumulated credits to the extent available. If you die with accumulated credits Any remaining credits can be transferred to an eligible spouse or domestic partner if you die while participating in the Program. Your spouse/domestic partner can use the credits for two-thirds of the annual cost of retiree health care coverage. This is the only use for the credits; he or she will not receive any cash payment or be able to use the credits for any other purpose. After the credits are depleted by the spouse/domestic partner, he or she can continue to participate in the Program by paying 100 percent of the cost. Your spouse/domestic partner is the only dependent eligible for transferred credits; no non-spousal dependents receive transferred credits. However, if there are additional eligible dependents (such as a dependent child) receiving coverage at the time of your death, your spouse would continue to receive family coverage and the health care credits would continue to pay two-thirds of the cost until U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 10

11 the credits are insufficient to cover two-thirds of the cost. Special payment rules apply in the year when the credits become insufficient to cover two-thirds of the cost. After your health care credit balance is depleted, your spouse/domestic partner and your covered dependents can continue to participate in the Program by paying 100 percent of the cost. Deductibles, Coinsurance and Maximums This section applies to the Early Retiree Medical option only. If you are enrolled in the UHC MA PPO or Medica Prime Solution option, see the separate materials for your plan option. The following tables provide a summary of key information about the Early Retiree Medical option. See the information that follows the tables for important information about how the deductibles, coinsurance and maximums work. Also see the Glossary for definitions. Early Retiree Medical option Deductible per plan year; combined pharmacy/medical; nonembedded Network Provider You pay: $2,000/person (applies only to You Only coverage level) Non-Network Provider* You pay: $3,100/person (applies only to You Only coverage level) Coinsurance medical only, see What s Covered Pharmacy for prescription drug coverage Out-of-pocket maximum per plan year; combined pharmacy/medical; nonembedded $3,000/family $4,100/family You pay 25% You pay 45% You pay: $5,000/person (applies only to You Only coverage level) You pay: $11,200/person (applies only to You Only coverage level) $7,500/family $16,800/family Option maximums Annual or lifetime maximums apply to certain services; see What s Covered Medical and What s Covered - Pharmacy Network provider and non-network provider deductibles, out-of-pocket maximums, annual maximums and lifetime maximums accumulate jointly; e.g., if you use a non-network provider, the amount applied to your non-network provider deductible also counts toward your network provider deductible, and vice versa. *For retirees in the Out-of-Area network, see Special Out-of-Area network for additional information. Deductibles and out-of-pocket maximums A deductible is the amount you must pay each plan year toward eligible medical and prescription drug expenses before you and the Program begin to share covered expenses. Amounts you pay toward your deductible as well as copayments and coinsurance are applied toward your outof-pocket maximum. The out-of-pocket maximum is the most you will pay toward eligible expenses for medical and prescription drug expenses each plan year. Once you reach the out-of-pocket maximum, the U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 11

12 Program pays 100 percent of the allowed amount for eligible expenses for the remainder of the year (as long as any applicable annual or lifetime maximums for certain services have not been exceeded). The Early Retiree Medical option has a combined medical/pharmacy deductible and a combined medical/pharmacy out-of-pocket-maximum; they are non-embedded. They can be met by one covered family member or by a combination of covered family members. This means: If you cover just yourself, you only need to meet the per person amount. If you cover your family, you need to meet the family amount. The family amount can be met by one covered member or any combination of covered members. The per-person amounts do not apply. Example 1: Sally is covered under the Early Retiree Medical option at the You Only coverage level. She must have eligible medical and/or pharmacy expenses of $2,000 before she and the Program begin to share covered expenses. Example 2: Joe is covered under the Early Retiree Medical option at the Family level. He and his spouse must have combined eligible medical and/or pharmacy expenses of $3,000 before he and the Program begin to share covered expenses. The $2,000 individual deductible does not apply because Joe has a dependent enrolled in coverage. Expenses that do not apply to your deductible and out-of pocket maximum: Your monthly health care premiums. Any costs not covered by your option. Any amounts that exceed the Program's allowed amounts when non-network providers are used for medical services. Any penalty for failing to provide required notification (applies to those with the UHC Medica Choice Network only). Any penalty for failing to obtain prior authorization (applies to those with the UHC Choice Plus or Out-of-Area network). Any amounts that exceed the Program's allowed amounts when a non-participating retail pharmacy is used for pharmacy services, when you do not present your pharmacy ID card or for covered compound prescriptions not submitted directly to Express Scripts by the pharmacy. Any cost difference between a brand-name drug and a generic equivalent when a brandname drug is prescribed and a generic drug is available. Specialty drugs not filled by Accredo, (Express Scripts specialty pharmacy) when required. Any maintenance medications not filled by Express Scripts home delivery or Smart90 (84-90 day supply at a CVS pharmacy) after the first two fills when required. Any discount amounts associated with a copay assistance program for specialty medications. Any amounts covered 100 percent by the Program, including past-due amounts for home delivery medications that are charged to the plan. The charges that do not apply to your deductible also do not apply to your out-of-pocket maximum. These charges are also not eligible for any reimbursement once the out-of-pocket maximum has been met. U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 12

13 Copayments Copayments (copays) are payments you make on a per service basis for eligible expenses after the deductible has been satisfied. Copayments are applied to the out-of-pocket maximum. Coinsurance Coinsurance is the percentage of the cost of a service (the lesser of the allowed amount and the provider's actual billed charge) you pay for eligible expenses once you have satisfied your deductible. The coinsurance you pay is applied to the out-of-pocket maximum. Your coinsurance depends on your plan, the service received and if you use a network provider or not. If you receive services from a non-network provider, you pay the applicable coinsurance plus any amount in excess of the allowed amount. See Networks for more information. A change to the cost during a plan year will not result in a recalculation of any coinsurance paid. What s Covered Medical The information in this section applies to the Early Retiree Medical option only. This section does not apply to the UHC MA PPO or Medica Prime solution options; refer to your plan materials. Early Retiree Medical option The charts in this section show the coinsurance you pay after your deductible has been satisfied for various services under the Early Retiree Medical option. Coinsurance is based on the allowed amount; you also pay any difference between the provider s billed charge and the allowed amount when using non-network providers; see Networks. If a service is not listed, it is likely not a covered service. Refer to Coverage Requirements, Limitations and Exclusions Medical to see if any action is recommended or required on your part before receiving the service. Please call UHC if you have questions about coverage for a specific procedure. Service Network Provider Non-Network Provider Special Notes Acupuncture You pay 25% You pay 45% Coverage is limited to pain management only and services must be provided as part of a comprehensive pain management program after all other treatment options have failed. Coverage also provided for prevention and treatment of nausea associated with surgery, chemotherapy or pregnancy. Allergy testing and treatment No coverage for therapeutic acupuncture, weight loss management, smoking cessation or other non-listed purposes. You pay 25% You pay 45% Coverage provided for testing, serum and allergy shots. Ambulance You pay 25% You pay 25% Coverage is limited to air or ground transportation from the place of departure to the nearest facility equipped to treat the illness or injury, and to prearranged medically necessary air or ground ambulance U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 13

14 Service Network Provider Non-Network Provider Special Notes transportation requested by an attending physician or nurse. If UHC determines air ambulance was not medically necessary, but ground ambulance would have been medically necessary, the Program pays up to the allowed amount for ground ambulance. Chiropractic services You pay 25% You pay 45% Limited to 25 visits processed by the Program per plan year. Cleft lip and palate You pay 25% You pay 45% Coverage only provided for a dependent child under age 19. Dental implants and orthodontia services provided as part of the treatment are eligible. Clinical trials You pay 25% You pay 45% See Clinical trials for important coverage Cosmetic, reconstructive or plastic surgery information. You pay 25% You pay 45% Coverage only for reconstructive surgery that is incidental to or follows surgery resulting from injury, sickness, or other diseases of the involved body part; reconstructive surgery performed on a dependent child because of congenital disease or anomaly that has resulted in a functional defect as determined by the attending physician; or treatment of cleft lip and palate for a dependent child under age 19. See Cleft lip and palate in this chart. Panniculectomy covered when both chronic, recurrent infection is documented and interference with hygiene and activities of daily living are documented. Dental-related services covered under the U.S. Bank Program are limited to: No coverage for psychological or emotional reasons. No coverage for repair of scars and blemishes on skin surfaces or cosmetic, reconstructive or plastic surgery for any other purpose. See The Women s Health and Cancer Rights Act of 1998 for mastectomy with reconstructive surgery. No coverage for actual dental treatments that may be performed as part of services (1), (2), or (3) shown to the left. Such dental treatments include dental implants and prostheses, osteotomies and other procedures associated with fitting of dentures or dental implants, root canals, removal of U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 14

15 Service 1. Treatment of fractured jaw 2. Accidentrelated dental services from a physician or dentist for the treatment of an injury to sound and healthy natural teeth Network Provider You pay 25% You pay 25% Non-Network Provider You pay 45% You pay 45% Special Notes impacted teeth or tooth root. Also see TMJ services in this chart. Accidents or injuries sustained prior to the effective date of coverage are eligible as coverage is based on actual date of treatment and not the date the accident or injury occurred. Chewing injuries to teeth not covered. Dental caries (cavities) not covered. 3. Inpatient or outpatient hospitalization and anesthesia charges You pay 25% You pay 45% See Hospital inpatient services in this chart. Covered only when related to a medical condition and medically necessary to protect and safeguard the life of the patient who is a covered child under age five, is severely disabled, or has a medical condition that requires hospitalization or general anesthesia for dental treatment, as determined by UHC. DNA analysis You pay 25% You pay 45% Genetic testing covered for the following indications only: To enable those affected by inherited disorders to make informed choices about future reproduction; To detect breast, colon, or ovarian cancer in persons who have two firstdegree relatives with a history of these cancers. Only one first-degree relative is required for persons with a family history of pre-menopausal breast or ovarian cancer or colon cancer diagnosed before age 50; or To verify a diagnosis when specific preclinical evidence is present. Durable medical equipment (DME) and medical supplies No other genetic testing or counseling is covered. You pay 25% You pay 45% Must be prescribed by a physician and medically necessary for treatment of an illness or injury, including disposable medical supplies. Coverage includes wheelchairs, ventilators, U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 15

16 Service Network Provider Non-Network Provider Special Notes oxygen and equipment, and side rails; stockings, and casts; insulin pumps, glucometers and related equipment and devices; cochlear implants and boneanchored hearing aids; prosthetics, including breast, artificial limbs and eyes required as the result of a congenital defect, injury or illness; liquid nutrition (including amino acidbased elemental formula) when recommended by a physician; SADD lights; implants; scalp hair prosthesis (wigs) for the medical condition of Alopecia Areata only; and custom foot orthoses. No coverage for over-the-counter products and items. Covered up to the UHC allowed amounts to rent or buy the item. Emergency room (ER) care You pay 25% after $150 ER copay You pay 25% after $150 ER copay Syringes, test strips, lancets and needles are covered by Express Scripts, not UHC. See Diabetic supplies and Additional services Livongo for more information. Copay will be waived if an inpatient admission occurs for the same condition within 24 hours. See Emergency care for more information. Enteral nutrition (tube feeding) Eyeglasses or contact lenses Pharmaceuticals given while in the ER will be covered by UHC, not Express Scripts. Written prescriptions to be filled when you leave the ER will be covered by Express Scripts, not UHC. See What s Covered - Pharmacy for more information. You pay 25% You pay 45% Covered when sole source of nutrition or inborn error of metabolism. You pay 25% You pay 45% Covered only for the medical conditions keratoconus and ulcerative keratitis and postcataract surgery (aphakia), accidental injury, or as a therapeutic bandage. Limited to one pair of eyeglasses or contact lenses after surgery paid by the Program. Thereafter, coverage applies only to lens replacement if prescription changes. Hearing aids You pay 25% You pay 45% Hearing aids covered for dependent children U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 16

17 Service and tests for hearing aids Home health care Network Provider Non-Network Provider Special Notes under age 19 who have a hearing loss due to a congenital loss of hearing that cannot be corrected by other covered procedures. Coverage is limited to one hearing aid paid by the Program every third plan year and includes the hearing aid, dispensing fee, molds, impressions, batteries and repairs. No coverage for replacement of lost hearing aids or tests for hearing aids. You pay 25% You pay 45% To be covered, skilled care must be prescribed by a physician and provided by a Medicare-approved or other pre-approved licensed home health agency. Home infusion therapy See Durable medical equipment (DME) and medical supplies in this chart. Services for custodial care, non-skilled care, services of a non-medical nature, private duty nursing, rest cures and mental health are not covered. You pay 25% You pay 45% To be covered, care must be ordered by a physician and provided by a Medicareapproved or other pre-approved licensed home health agency. Covered services include solutions and pharmaceutical additives, pharmacy compounding and dispensing services, durable medical equipment and supplies, nursing services to train you or your caregiver to monitor your therapy, and collection, analysis and reporting of lab tests. Hospice care You pay 25% You pay 45% Hospice care for terminally ill patients provided by a Medicare-certified hospice provider or other pre-approved hospice. Coverage for inpatient and outpatient hospital care, routine and continuous home nursing care, home health aide visits, physical therapy, speech therapy, language therapy, occupational therapy, social worker visits, dietary/nutritional counseling, durable medical equipment, routine medical supplies and other supportive services provided to meet the physical, psychological, spiritual, and social needs of the dying patient. U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 17

18 Service Network Provider Non-Network Provider Special Notes Coverage includes patient care instructions, respite care and other supportive services for the family, both before and after the death of the patient. Hospital inpatient service Coverage for respite care is limited to 10 days processed by the Program during the episode of hospice care. To be eligible for hospice care, a physician must document that according to best medical judgment, the patient has six months or less to live, and the patient/family must agree not to pursue curative treatment. Inpatient care in a hospice or hospital is covered under hospital inpatient services. Take-home drugs will process under this benefit level. Medical care services unrelated to the terminal illness may be covered according to other Program benefits and requirements. Eligible services provided by a skilled nursing facility are covered, but are separate from the hospice benefit. (See Skilled Nursing under Hospital inpatient services in this chart.) For mental health, substance-related and addictive disorders coverage, see that section. See Centers of Excellence for hospital services that may have additional requirements. 1. Hospital services You pay 25% You pay 45% Coverage is provided for up to 365 hospital days per plan year, including a semiprivate room, meals, general nursing care, intensive and other special care units, ancillary services and supplies such as operating, recovery, and treatment rooms, supplies, inhospital and take-home drugs. Private room is covered only when medically necessary or at the allowable charges for an average semiprivate room. Patient convenience items and private duty nursing are not covered. 2. Acute rehabilitation (not nursing home) You pay 25% You pay 45% Acute rehabilitation covered when services are expected to make measurable or sustainable improvement within a reasonable amount of time. U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 18

19 Service Network Provider Non-Network Provider Special Notes 3. Skilled nursing facility (not nursing home) Hospital outpatient services 1. Hospital services You pay 25% You pay 45% Skilled nursing must be ordered by a physician and be medically necessary. Limited to 100 days processed by the Program per plan year. Semiprivate room, meals, general nursing care, ancillary services and supplies, and in-facility drugs are covered. Private room is covered only when medically necessary or at the allowable charges for an average semiprivate room. Patient convenience items, custodial care and private duty nursing are not covered. Coverage for scheduled surgery, radiation, chemotherapy, kidney dialysis, respiratory therapy, diabetes outpatient selfmanagement training and education which You pay 25% You pay 45% includes medical nutrition therapy, and all other eligible outpatient hospital care. 2. Ambulatory surgery centers Infertility Treatment You pay 25% You pay 25% You pay 45% Not covered by the Program For mental health, substance-related and addictive disorders coverage, see that section. See Centers of Excellence for hospital services that may have additional requirements. See Optum Fertility Solutions for important coverage information and requirements. Lab, X-ray, CT scans, MRI and nuclear imaging See Maternity in this chart for prenatal lab and X-ray services. Services are paid based on the billing codes used by your provider on the claim submitted to UHC for payment. If a non- network provider performs the procedure and then sends it out to be read, the charges for the reading only will be paid at the network benefit level. 1. Illnessrelated You pay 25% You pay 45% When submitted with an illness diagnosis code. 2. Preventive care The Program pays 100% (no deductible) Not covered by the Program See Preventive care. U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 19

20 Service Mastectomy and reconstructive surgery Maternity Network Provider Non-Network Provider Special Notes You pay 25% You pay 45% See The Women s Health and Cancer Rights Act of See the Maternity Support Program for additional resources available to you. Pregnancy coverage ends when your coverage under your Program otherwise ends for any reason. New dependents must be added within 60 days of birth to be covered, see Who s Eligible and Enrolling. 1. Hospital services (inpatient or outpatient) and postpartum office visits You pay 25% You pay 45% Inpatient benefits will not be restricted to less than 48 hours from the time of vaginal delivery or 96 hours from the time of Cesarean section delivery. See Inpatient maternity care for details. One home health visit upon discharge is allowed; see Home health care in this chart. 2. Prenatal office visits The Program pays 100% (no deductible) You pay 45% Prenatal lab and x-ray services are paid based on where the services are performed. If in a facility, they pay under the hospital services benefit. If in an office, they pay under the prenatal office visits benefit. No coverage for adoption or adoption-related expenses, surrogate pregnancy or related expenses, childbirth classes or delivery at home. Mental health You pay 25% You pay 45% See Mental health, substance-related and addictive disorders coverage for details. Nutritional counseling You pay 25% You pay 45% Covered when provided by a registered dietician to develop a dietary treatment plan to treat and/or manage medical conditions that require a special diet (e.g., anorexia, diabetes, gout, etc.). Coverage is limited to a lifetime maximum of three individual sessions for each medical condition. (This limit does not apply to services billed as preventive care. When nutritional counseling services are billed as a preventive care service, these services will be paid as described in the Preventive care section.) U.S. Bank 2018 Retiree Health Care Program Summary Plan Description 20