General Provisions
Care can be obtained in-network or out-of-network without a referral. To receive the highest level of benefits, please verify physician network participation.
Out-of-network and Out-of-area benefits are subject to reasonable and customary charges. You pay the out-of- network deductible and coinsurance, plus any charges in excess of reasonable and customary amounts. Amounts
over reasonable and customary do not apply to the plan's out of pocket maximum.
Deductible (eligible medical and prescription drug expenses apply to the deductible)
$1,500 for employee-only coverage; $3,000 if you cover at least one other person
$3,000 for employee-only coverage; $6,000 if you cover at least one other person
Coinsurance 80% 60%
Annual Out-of-Pocket Maximum
$3,400 for employee-only coverage; $6,800 if you cover at least one other person
$6,800 for employee-only coverage; $13,600 if you cover at least one other person
Lifetime Maximum Benefit $2,000,000
Precertification
Precertification of Care is required within 48 hours of an emergency hospitalization, before admission to any facility, and for certain outpatient services. A $300 penalty will apply for not pre-certifying as required and room and board
will not be reimbursed for admission exceeding the approved length of stay.
Inpatient Hospital Services/Office Visits Inpatient Hospital Services
Including Physician Charges 80% coverage after deductible 60% coverage after deductible Maternity Care
Including Delivery 80% coverage after deductible 60% coverage after deductible
Office Visit for Illness or Injury 80% coverage after deductible 60% coverage after deductible Office Visit/Preventive Care
(Preventive Care, Well-Baby Care, Well-child(ren) Care, Well-woman Care, Physical exams, Vision exams)
100% coverage with no deductible
100% coverage with no deductible up to $1,000 annual maximum per person (well-child max is $1,500 for the first 12 months and $1,000 thereafter); (vision exams are limited to 1 annual exam per year); thereafter, subject to the deductible
and coverage at 60%
Ambulatory Services Emergency Room/
Urgent Care Center
80% coverage after deductible for approved emergencies; 60% coverage after deductible for
non-approved emergencies
80% coverage after deductible for approved emergencies; 60%
coverage after deductible for non-approved emergencies
High Deductible Health Plan
In-Network Provider Out of Network Provider
Medical Coverage Outpatient Surgery in Licensed
Ambulatory Surgical Centers 80% coverage after deductible 60% coverage after deductible Physician Office
Surgical Procedures 80% coverage after deductible 60% coverage after deductible Diagnostic Testing (not billed
as preventive care)
80% coverage after deductible; including PAP smears, mammograms, PSAs, digital rectal exams
(DRE) and cholesterol screenings/lipid panels
60% coverage after deductible; including, PAP smears, mammograms, PSAs, digital rectal exams (DRE) and
cholesterol screenings/lipid panels Chemotherapy/
Radiation Therapy 80% coverage after deductible 60% coverage after deductible
Mental Health/ Substance Abuse Inpatient/Intermediate
Care/Partial
Hospital/Residential Treatment
80% coverage after deductible (pre-certification required for inpatient care and certain outpatient
procedures)
60% coverage after deductible (pre-certification required for inpatient care and certain outpatient procedures) Outpatient Office Visit for
Individual or Group Counseling or Therapy
80% coverage after deductible (pre-certification required for inpatient care and certain outpatient
procedures)
60% coverage after deductible (pre-certification required for inpatient care and certain outpatient procedures) Other Services
Skilled Nursing Facility 80% coverage after deductible (120 days per year combined maximum
60% coverage after deductible (120 days per year combined maximum)
Hospice 80% coverage after deductible
(up to 2 successive six month treatments combined)
60% coverage after deductible (up to 2 successive six month treatments combined)
Home Health Care & Private
Duty Nursing 80% coverage after deductible 60% coverage after deductible up to 15 visits per year Ambulance 80% coverage after deductible for approved emergencies; 60% coverage after deductible for non- approved
emergencies
Therapies – Physical / Speech / Occupational
80% coverage after deductible; annual maximum 60 combined visits for Physical Therapy and Occupational Therapy, and 20 visits for Speech
Therapy (medically necessary).
60% coverage after deductible; annual maximum 60 combined visits for Physical Therapy and Occupational Therapy, and 20
visits for Speech Therapy (medically necessary).
Alternative Care - Chiropractic and Acupuncture Services
80% coverage after deductible 60% coverage after deductible
$2,500 annual maximum; Chiropractic and Acupuncture services are combined Domestic Partner / Adult Child
Coverage Either a domestic partner or adult dependent child may be covered
Vision Discount Program
If you are an Aetna Medical or Dental Plan participant, the Aetna Vision Discount program may be used for routine exams, hardware (e.g., lenses and frames) and laser surgery at the time of purchase or service. Please contact Aetna to receive a list of participating providers. To receive the discount, present your medical or dental ID card to
the participating provider.
Exclusions
Not every medical service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentist. The plan covers only those services and supplies that are medically necessary and included in the benefits summary and/or the Retiree Medical Plan Supplemental Summary Plan Description. The Retiree Medical Plan Supplemental Summary Plan Description contains the list of applicable exclusions, conditions and limitations.
Coordination of Benefits
Maintenance of Benefits Method – your coverage under the Retiree Medical Plan uses the Maintenance of Benefits Method (“MOB”) of coordination with Medicare. Please see the Retiree Supplemental Summary Plan Description for more information.
Medicare
Important Note About Medicare Enrollment
Medicare is a federal program available to individuals at age 65 or after two years of receiving Social Security disability benefits. Medicare is the primary plan/coverage for you and your covered dependents that are eligible for Medicare due to age or disability. When eligible for Medicare, you and/or your covered dependent must enroll in Medicare Parts A and B and notify the Kraft Foods Benefits Center by calling 1-800-321-7960. Medicare enrollment does impact your premiums and claim payments. If you are eligible for Medicare and do not enroll in Medicare Parts A and B or if you see a physician who does not accept Medicare or has “opted out” of Medicare, your Plan benefits will still be calculated as if you were covered by Medicare.
PLEASE NOTE: You or any of your covered dependents will not be eligible to participate in the Kraft Foods sponsored Retiree Medical Plan if you or your dependents elect the optional prescription drug coverage under the Medicare Modernization Act of 2003 (Medicare Part D). In general, the prescription benefit provided in the Kraft Foods Retiree Medical Plan is at least as good as or better than the standard Medicare D sponsored benefits.
High Deductible Health Plan
In-Network Provider Out of Network Provider
Medical Coverage Health Savings Account
A health savings account is a separate trusteed account maintained at a bank that you own and maintain at all times. There are many potential tax advantages to an HSA:
You can elect to contribute before-tax dollars up to annual limits.
As contributions limits may change year to year, you should verify with the Internal Revenue Service (IRS) what the current annual limit is.
If you will be 55 or older during the year, you may be able to make “catch up” contributions in addition to the otherwise applicable contribution limit for that year. This information can be obtained by contacting the Internal Revenue Service (IRS).
Your account can be invested in the investment options available to you under the health savings account and earnings are tax free.
Distributions are tax free if they are used for “qualified medical expenses” There is a 20% penalty—in addition to other applicable taxes-- for distributions you take before age 65 that are not for qualified medical expenses. (The 20% penalty does not apply if you are enrolled in Medicare or are deemed to be disabled.) At age 65, you can use your account for non-qualified medical expenses without the imposition of the 20% penalty tax. If you die before you have depleted your account, there is no tax on the transfer to your surviving spouse.
“Qualified medical expenses” include any expense incurred for medical care as defined under section 213(d) of the Internal Revenue Code. (See IRS Publication 502 available at www.irs.gov for more information.) You can use your account to pay COBRA premiums and your post-age 65 Medicareand retiree medical coverage as long as the coverage is not a Medigap or Medicare Supplement plan. You cannot, however, use it to pay for over the counter medicines unless prescribed by a physician.
Unlike a health spending account, there is no “use it or lose it” forfeiture rule. You own your account and it is completely portable—meaning that you can transfer it to another health savings account vendor.
Note: In order to be eligible to contribute to a health savings account for tax law purposes, you have to satisfy several standards including:
You must have no other health coverage that is not qualified as a high deductible health plan. Further, your spouse must not maintain a health care spending account or health reimbursement account under which your medical expenses may be reimbursed (There are exceptions for limited purpose FSAs or HRAs which only provide reimbursement for dental or vision care.)
You must not be eligible for Medicare or enrolled in Tricare.
You may not be claimed as a dependent on someone else’s tax return.
You must maintain your coverage under a high deductible health plan—for 12 months for you to avoid having to pay an excise tax of 6% on over- contributions.
You are responsible for keeping sufficient records to demonstrate compliance with HSA tax requirements and for filing required tax forms.
Important Note: You are solely responsible for determining whether a health savings account and its available investments and fees are right for you.
You are fully responsible for preparing and submitting an IRS Form 8889 if you are claiming a tax deduction for a contribution to your health savings account, or are reporting a distribution or excise tax relating to your health savings account.
General Provisions Prescription Drug benefits provided through Aetna.
A separate I.D. card must be utilized for these services.
Aetna Customer Service: 1-888-598-1577 Please Note:
For maintenance or preventive drugs after first three fills, no benefit will be provided unless ordered via mail order or obtained at a CVS pharmacy.
There is no coordination of benefits for prescription drug benefits. You may choose what benefit plan to use, but you will not be reimbursed any out-of-pocket expenses for prescription drug claims incurred other than under the Medical Plan
If you do not use an Aetna retail network pharmacy to obtain a Value Generic drug, no benefit is payable under the plan for that prescription.
You always pay the lower of the actual cost or the participant cost under the plan.
Lifetime Maximum for infertility drugs: $15,000 (amounts previously paid under a Kraft Foods or Nabisco medical plan apply to the lifetime maximum).
Deductible No separate calendar year deductible for prescription drug coverage; All eligible medical and prescription drug expenses apply toward the in-network, calendar year deductible.
Preventive Drugs and Value
Generics No Deductible
High Deductible Health Plan Prescription Drug Coverage
CO-PAYS AND CO-INSURANCE
TIER 1: GENERICS
Retail: $7.50 co-pay, after deductible
Mail: $15.00 co-pay, after deductible TIER 2: PREFERRED BRAND DRUGS
Retail: 30% co-insurance ($20 min/$50 max), after deductible
Mail: 25% co-insurance ($40 min/$100 max), after deductible TIER 3: NON-PREFERRED BRAND DRUGS
Retail: 45% co-insurance ($35 min/$65 max), after deductible
Mail: 40% co-insurance ($70 min/$130 max), after deductible
Choosing Brand over Generic: If a generic is available, and you choose to get the brand instead, you will pay more. You’ll pay the difference in cost between the brand and generic, plus the applicable copay for your plan.
Use Aetna Mail Service or CVS Pharmacy to Fill Your Long- Term Medications:
You may receive one initial prescription fill, plus two refills of a maintenance (or long-term) medication at a participating pharmacy. After the third fill, a 90-day prescription is required for future maintenance medications and
must be filled through Aetna Mail Service or at a CVS pharmacy to receive benefits. After the third 30 day refill of a maintenance medication, if the prescription is not filled through Aetna Mail Service or a CVS pharmacy with a
90-day prescription, you will pay the full cost of the prescription.
Specialty Drugs If you have been prescribed a specialty drug, contact Aetna Specialty Pharmacy at 1-866-782-2779.
Maximum Out-of-Pocket
There is no separate prescription drug out-of-pocket maximum. Eligible prescription drug and medical expenses apply to the Medical Plan’s calendar year out-of-pocket maximum. Once you have satisfied the applicable deductible
for the calendar year, you continue to pay your out-of-pocket costs for covered drugs until you reach the in-network out-of-pocket maximum for the calendar year. After that point, you have no additional out-of-pocket costs for covered
drugs.
This is intended as a brief summary of benefits for comparison purposes. The Contracts and Master Plan Document govern in all cases. Not all covered services, exclusions and limitations are shown here.
