Retiree Health Plan
Retiree Health PlanMarathon PetroleumRetiree Health PlanAmended and RestatedJanuary 1, 2022
Retiree Health PlanTable of ContentsI.Purpose. 1II.Helpful Terms. 2III.Retiree Health Plan Participation. 6A. Member Eligibility. 61. Retiree Member or LTD Retiree Member. 62. LTD Terminated Member.103. Surviving Spouse Member.104. Spouse Member.115. Domestic Partner Member.116. Child Member.127. Continued Member.13B. Dependent Eligibility.131. Spouse.132. Children.133. Domestic Partner.144. Children of Domestic Partner.145. Dependent Disabled Child.146. Children Covered by Qualified Medical Child Support Order.15C. When Coverage Ends or May be Continued.15IV.Cost of Coverage. 16A. “Non-Employee Group” Member Contributions.16B. Tax Treatment.18V.Enrolling in the Plan. 18A. Annual Enrollment.18B. Member Enrollment.181. Enrollment When First Eligible for Coverage.19a. Retiree Member, LTD Retiree Member and LTD Terminated Member Coverage.19b. Spouse Members, Surviving Spouse Members, and Child Members.192. Late Enrollment.193. Enrollment for Continued Member Coverage.20C. Dependent Enrollment.20VI.Changing Coverage Options While Enrolled. 21VII.Waiver of Coverage. 21VIII.Special Provisions for Under-Age-65 Disabled/ESRD Individuals.22A. Offset Provision. 22IX.Overview of How the Plan Works.22A. Plan Options. 22B. Types of Programs.23C. Comparing the Plan’s Options.24i
Retiree Health PlanX.Medical/Surgical Program. 24A. Plan Deductible.24B. Out-of-Pocket Maximum Limit.25C. Covered Expenses.251. Hospital Inpatient Charges.262. Physician and Surgeon Charges.263. Office Visits — Primary Care.274. Office Visits — Specialist Care.275. Office Visits — LiveHealth Online.286. Urgent Care Facility.287. Emergency Room Charges.288. Ambulance Services. 299. Diagnostic Tests. 2910. Therapeutic Treatment. 2911. Immunizations, Injections, and Allergy Shots. 2912. Treatment for TMJ. 2913. Hearing Aids. 3014. Coverage for Autism Spectrum Disorder and Rett Syndrome. 3015. Infertility Treatment.3116. Mental Health Parity and Substance Abuse Equity.3117. Other Covered Expenses. 3318. Hospitalization Alternatives. 3319. Case Management. 3620. Transplant Management Program. 3621. Clinical Trials.3722. COVID-19 Diagnostic Testing. 38D. Pre-Certification Requirements. 391. Pre-Certification Review Unit and Contact Information. 392. Inpatient Admissions and Outpatient Services Requiring Certification. 393. Time Frame for Making the Certification . 39E. Assistance from 24/7 NurseLine and ConditionCare. 40F. Medical/Surgical Program — Member Coinsurance and Copay Chart.41XI.Physical Examination and Preventive Services (Preventive Services).43A. Eligibility. 43B. Deductible. 431. In-Network Level of Benefits. 432. Out-of-Network Level of Benefits. 43C. Out-of-Pocket Maximum Limit. 43D. Covered Expenses. 431. Well-Baby and Well-Child Care. 442. Adults — Routine Physical Examination, Preventive Screening Tests and PreventiveImmunizations. 443. Claims for Covered Preventive Services. 45E. Preventive Services Program Coinsurance and Coverage Chart. 45ii
Retiree Health PlanXII.Classic and Saver HSA Options. 46A.B.C.D.E.How Do the PPO Options Work?. 46How to Locate a Provider Who Participates in the PPO Network. 46General PPO Coverage. 46Using the PPO Options.47Obtaining Medical Care in the Anthem PPO Network Area.471. Routine or Urgent Care in the Anthem PPO Network Area.472. Emergency Care in the Anthem PPO Network Area.47F. Obtaining Medical Care When Temporarily Out of the Anthem Network Area. 481. Living Outside of the United States. 48G. Exception Benefit Level. 49XIII.Managed Prescription Drug Program. 49A. Coverage. 501. To Receive Coverage. 502. Outpatient Prescription Drugs. 50B. Saving Yourself and the Plan Money When You Buy Prescription Drugs.51C. Prescription Drug Benefit Levels.51D. Using the Retail Pharmacy Component. 55E. Exceptions. 55F. Using Express Scripts Mail Order Pharmacy or Smart90 Walgreens Program for MaintenanceDrugs. 56G. Prescription Drug Out-of-Pocket Maximum. 56H. Clinical Programs Administered by Express Scripts.57I. Special Preventive Coverage.57XIV.Expenses Not Covered Under the Plan.58XV.Coordination of Benefits. 59A. Coordination With Other Group Health Plans.59B. Coordination With Other Plans. 60C. When a Covered Person Qualifies for Medicare. 60XVI.Claims and Appeals. 61A. Filing an Initial Claim for Benefits. 621. Medical/Surgical Claims and Preventive Services Claims. 622. Managed Prescription Drug Program Claims. 62B. Appealing a Denied Claim. 641. First Level of Internal Appeal for Denied Claims (Mandatory). 652. Voluntary Second Level of Internal Appeal for Denied Claims. 663. External Review to an Independent Review Organization.67C. Finality of Decision and Legal Action. 69D. Appointment of Authorized Representative. 69E. Non-Assignability.70F. Outstanding Claim Checks.70iii
Retiree Health PlanXVII.Miscellaneous Situations Affecting Your Plan Benefits. 70A. Expenses for Which a Third Party May Be Responsible.701. Third Parties.702. Subrogation/Right of Reimbursement.713. Lien of the Plan.714. Additional Terms.72B. Limitations on Benefits You May Expect to Receive.73C. Rescission and Cancellation of Coverage.73D. Missing Person.74E. American Jobs Creation Act of 2004.74F. Genetic Information Nondiscrimination Act of 2008 (GINA).74XVIII.Your Legal Right to Continue Coverage Under COBRA. 74A. Group Covered.75B. Qualifying Events and Maximum Length of Continuation Periods.751. Covered Spouse Loses Coverage.752. Eligible Child Loses Coverage.753. Bankruptcy.75C. Maximum Length of Continuation Periods.76D. Termination of Continued Coverage.76E. Notification Procedure.76F. Type of Coverage.77G. Cost.78H. Surviving Spouse and Surviving Dependents.79I. Alternatives to COBRA Continuation Coverage.79XIX.Administrative Information. 79A.B.C.D.E.F.G.H.Type of Plan.79Plan Sponsor and Administrator. 80Plan Funding. 80Plan Identification Number and Plan Name. 80Plan Year. 80Type of Administration.81Agent for Service of Legal Process.81Use and Disclosure of Protected Health Information. 82XX.Special Provisions Relating to Medicaid.83XXI.Participation by Associated Companies or Organizations.84XXII.Modification and Discontinuance of Plan.84XXIII.Further Information.84XXIV.Your Rights Under Federal Law.85iv
Retiree Health PlanAppendix A — Eligible Retiree Subsets (or Dependents) of Current and Former ParticipatingCompanies and Organizations. 87Appendix B — Grandfathered Eligible Legacy Andeavor Employees/Retirees Specific to theAndeavor Acquisition of Western Refining.88Appendix C — Non-Employee Group Member Contributions.89Appendix D — Classic and Saver HSA Option Comparison.96Appendix E — Pre-Certification List.98Appendix F — 2022 SaveOnSP Specialty Drug List. 104Appendix G — Kaiser Permanente Northern California HMO Option. 108Appendix H — Kaiser Permanente Southern California HMO Option. 109Appendix I — Extended Timeframes Due to National Emergency. 110v
Retiree Health PlanMarathon Petroleum Company LP (Company) sponsors and maintains the Marathon Petroleum RetireeHealth Plan (the “Plan” or “Retiree Health Plan”). This document amends and restates the Plan effective asof January 1, 2022. This document serves both as the plan document and the Summary Plan Description(SPD) for the Plan. To the extent not preempted by the Employee Retirement Income Security Act of 1974(ERISA), the provisions of this instrument shall be construed and governed by the laws of the State of Ohio.I.PurposeMedical expenses can place sizeable financial burdens on individuals, especially in cases oflong-term or other catastrophic illnesses. The Company therefore offers this group Retiree HealthPlan to provide financial assistance for most medical expenses. Unless otherwise stated herein,coverage under the Plan ends when a Member becomes eligible for Medicare due to age. PlanMembers may elect coverage under one of the following options: The Saver HSA Option is a self-funded high deductible health plan option with a lowermonthly cost to participants. It works like a Preferred Provider Organization (PPO) with theability to contribute to a Health Savings Account (HSA). The Saver HSA Option is availableto all Members. The Classic Option is a self-funded lower deductible PPO option that provides higher levelsof reimbursement for a higher monthly cost to participants and is available to all Members.Coverage under the Medical/Surgical Program (which includes mental health and substanceabuse), Managed Prescription Drug (Prescription) Program, and the Routine Physical andPreventive Services (Preventive Services) Program are provided to Members enrolled in eachof the above Options. The Kaiser Permanente Traditional HMO Plan — Northern California Region is a fully-insuredoption available to Members who reside within the Kaiser northern California service area. The Kaiser Permanente Traditional HMO Plan — Southern California Region is a fully-insuredoption available to Members who reside within the Kaiser southern California service area.The above-mentioned fully-insured HMO options through Kaiser Permanente (“Kaiser”) mayprovide benefits that differ from those available under the Saver HSA and Classic options. Referto Appendices F and G for Evidence of Coverage documents which provide a comprehensivedescription of the terms of eligibility and description of benefits coverage under each of theseHMO options. It should be noted that not all sections of this document are applicable to Kaiserenrollees; the Kaiser provisions shall supersede where applicable.1
Retiree Health PlanII.Helpful TermsHere are some terms, as defined for purposes of the Retiree Health Plan, you may find helpful asyou read through this document.Age 65 — Throughout this document, the terms “age 65,” “post-65” and “over-age-65” mean“eligible for Medicare due to age.” The terms “pre-65,” “under-age-65” and “less than age 65”mean “not eligible for Medicare due to age.” An individual becomes Medicare eligible due to ageon the first day of the month in which they turn age 65 or, if the individual turns age 65 on the firstday of the month, then Medicare eligibility occurs on the first day of the month preceding theindividual’s birth month. The terms are used to assist with readability and comprehension ofprovisions.Coinsurance — The percentage of covered costs the Plan or the Member pays after anyrequired deductibles are met. Examples include the 20% coinsurance the Member pays formost in-network services under the Saver HSA and Classic Options.Copay — A fixed dollar amount (for example, 20) the Member pays for a covered health careservice, usually at the time you receive the service. The amount can vary by the type of coveredhealth care service, such as an office visit or purchase of prescription drug. With an emergencyroom copay, coinsurance will also be applied.Deductible — The amount each covered individual pays toward most covered charges in a PlanYear before the Plan begins paying benefits. Deductible amounts are based on the Option youselect. The Medical/Surgical Program and the Managed Prescription Drug (Prescription) Programeach have separate deductibles under the Classic Option. Under the Saver HSA Option, theMedical/Surgical Program and the Prescription Program deductible is combined.Charges under the Preventive Services Program are not subject to a deductible except forPreventive Services charges incurred out-of-network under the Classic or Saver HSA Options.Such out-of-network preventive services charges are subject to the applicable Optionout-of-network medical/surgical deductible.The deductible for the Classic Option works like this: Once the Classic Option’s deductibleunder the Medical/Surgical Program has been met by an individual covered by the Plan, thePlan starts paying benefits under the Medical/Surgical Program for that individual. When anycombination of two or more covered family Members meet the family deductible under theMedical/Surgical Program, the Plan will start paying benefits under the Medical/Surgical Programfor all covered family Members. (This is called an “embedded” deductible.)Once the Classic Option’s deductible under the Prescription Program has been met by anindividual covered by the Plan, the Plan starts paying benefits under the Prescription Programfor that individual. When
Retiree Health Plan Marathon Petroleum Company LP (Company) sponsors and maintains the Marathon Petroleum Retiree Health Plan (the "Plan" or "Retiree Health Plan"). This document amends and restates the Plan effective as of January 1, 2022. This document serves both as the plan document and the Summary Plan Description (SPD) for the Plan.
When Jenny turns 65, she retires with IU Retiree Status. Both elect IU Retiree coverage: ‒ Jenny—IU Anthem Blue Retiree Plan (for 65 ) ‒ Dan—IU Anthem U65 PPO HDHP (for under 65) When Dan turns 65, he can switch to the IU Blue Retiree plan—the same plan as Jenny. Scenario #1 . Jenny & Dan. Dan - Age 63 (Spouse) Jenny .
Retiree Medical Plan (also referred to as the "Retiree Medical Plan" or "Plan"), which is a Component Plan of the Huntington Ingalls Industries, Inc. Retiree Welfare Benefits Plan (the "Welfare Benefits Plan"). If you have questions that are not answered in this SPD, contact
If you are selecting 'Retiree & Children,' 'Retiree & Spouse' or 'Retiree & Family' coverage, you must complete the dependent information in Section 4. Group Legal Plan: You must complete the dependent information in Section 4. Please send the white copy of the form to: FBMC Benefits Management, Inc. Retiree Direct Bill PO Box 10789
Wells Fargo & Company Retiree Plan. Please take the time to read this supplementary information to the Wells Fargo & Company Retiree Plan (Retiree Plan) describing how testing and evaluation for COVID-19 is covered effective January 1, 2021, and keep a copy of it with your
Retiree contributions will decrease for Retiree Only and increase for all other tiers in the Kaiser Northern California Health Plan option. Retiree contributions for Retiree Family coverage will increase and all other tiers will decrease in the Kaiser Southern California option. For more plan information, please call Kaiser at 1-800-278-3296.
documents") briefly describe your Benefits as well as rights and responsibilities, under the CenturyLink Retiree and Inactive Health Plan (the "Health Plan") and make up the official Summary Plan Description for this benefit under the Employee Retirement Income Security Act of 1974, as amended, and the regulations thereunder ("ERISA").
Retiree Health Plan Advisory Board Public Comment Guideline 1 Public Comment Purpose The public comment period allows individuals to inform and advise the Retiree Health Plan Advisory Board about policy-related issues, problems or concerns. It is not a hearing and cannot be used to address health benefit claim appeals. The
on top of it, including the ASP.NET MVC, Entity Framework, and Enterprise Library. Since it has been around for a long time, most legacy and existing .NET applications are developed for the .NET Framework, and it also has the richest set of libraries, assemblies, and an ecosystem of packages. One of the key challenges for .NET Framework applications is that backward- compatibility can be .
