Medicare Supplement Plan
Medicare Supplement Plan
of Marathon Oil Company
Medicare Supplement Plan
Table of Contents
I. Purpose ... 1
II. Definitions ... 1
III. Health Plan Participation ... 2
IV. Cost of Coverage ... 5
V. Enrolling in the Plan ... 7
VI. Waiver of Coverage ... 10
VII. Special Provisions for Under-Age-65 Disabled/ESRD Individuals ... 10
VIII. Overview of How the Plan Works ... 11
IX. Managed Prescription Drug Program ... 12
X. Coordination of Benefits ... 17
XI. Claim Submission Procedures ... 18
XII. If a Claim is Denied (Claim Appeal Procedures) ...20
XIII. Miscellaneous Situations Affecting Plan Benefits ...26
XIV. Legal Right to Continue Coverage Under COBRA ...28
XV. Administrative Information...33
XVI. Special Provisions Relating to Medicaid ...35
XVII. Participation by Associated Companies or Organizations ...35
XVIII. Modification and Discontinuance of Plan ...36
XIX. Further Information ... 37
Appendix A — Member Contributions ...38
Appendix B — Additional Information on Participant Contributions ... 41
Appendix C — Eligibility Grid ...44
Medicare Supplement Plan
I. Purpose
Medical expenses can place sizeable financial burdens on retirees, and their survivors, especially in cases of long-term or other catastrophic illnesses. The Medicare Supplement Plan is designed to provide the post age 65 retiree and his or her post age 65 spouse, disabled individuals under age 65 whose primary group health plan coverage is Medicare, with coverage to help pay for expenses not covered under Federal Medicare.
The Plan provides the retiree and their spouse with coverage to help pay for expenses covered under Part A and Part B of Medicare, plus coverage for prescription drugs under the Managed Prescription Drug Program of the Medicare Supplement Plan.
II. Definitions
When used in this Medicare Supplement Plan, the following terms shall have the meanings ascribed to them below:
Allowed amount — The maximum amount on which payment is based for covered health care services.
Copayments — A fixed dollar amount a Participant pays for covered health care, usually when the Participant receives the service.
Coinsurance — The percentage of covered costs the Plan or the Participant pays after any required deductibles are met.
Deductible — The amount each Participant pays toward most covered charges in a Plan Year before the Plan begins paying benefits. For purposes of determining whether a Participant has satisfied the deductible, any amount accumulated from January 1 – March 31 will reset effective April 1.
ERISA — The Employee Retirement Income Security Act of 1974, as amended.
Formulary — A list of preferred drugs. Express Scripts maintains the formulary list using an independent committee that meets regularly to review the drugs on the formulary based on safety, efficacy, and cost, and to decide whether any new drug should be added.
Hospital — A legally constituted and operated institution which has on-the-premises organized facilities (such as for diagnosis and major surgery) to care for and treat sick and injured persons. There must be a staff of doctors and a Registered Nurse on duty at all times. This term does not include an institution, or part of one, used mainly for rest or nursing care, convalescent care, care of the aged, care of the chronically ill, custodial care, or educational care.
Marathon Oil Company — In this document, this can be referred to as the Company. It means Marathon Oil Company, and, as appropriate, includes members of the Marathon Oil Company controlled group that are participating employers in this Plan.
Medically Necessary — Services or supplies that are provided for the diagnosis or treatment of a medical or mental health and chemical dependency condition; are appropriate for the medical or mental health and chemical dependency condition; are done within the proper setting or manner required for the medical or mental health and chemical dependency condition; and meet generally accepted health care practices.
Medicare Supplement Plan
Network — The facilities, providers and suppliers the Plan has contracted with to provide health care services.
Out-of-Pocket Maximum — The most each Participant would pay including deductible and coinsurance in a Plan Year. Once a program’s out-of-pocket maximum has been met, the Plan pays 100% for covered health care services and supplies under that program for the remainder of the Plan Year. However, for purposes of determining whether a Participant has satisfied the out-of-pocket maximum, any amount accumulated from January 1 – March 31 will reset effective April 1.
Participant — An individual who meets eligibility requirements and participates in the Plan.
Plan — This Medicare Supplement Plan of Marathon Oil Company.
Plan Year — The Plan Year is the calendar year.
The following do not count toward satisfying out-of-pocket maximum limits: • Charges above Reasonable and Customary and Negotiated Fee Schedules;
• Non-covered charges, including charges incurred after Out-of-Pocket Maximums have been reached; and
• For purposes of the Medical/Surgical Program’s out-of-pocket maximum, all deductibles and coinsurances paid under the Managed Prescription Drug Program. For purposes of the Mail-Order component out-of-pocket maximum of the Managed Prescription Drug Program, and all deductibles and coinsurances paid under the Medical/Surgical Program.
Provider — A licensed physician, a hospital, or other health care professional recognized by the Plan.
Reasonable and Customary — The usual charge for a medical service or mental health and chemical dependency service or treatment in a geographic area. Unusual circumstances and complications are taken into consideration. The Medical/Surgical Program uses the 90th reasonable and customary percentile.
Spouse — The man or woman to whom a Participant is legally married under the laws of a domestic or foreign jurisdiction with the legal authority to sanction marriages.
Urgent Care — Urgent care is treatment for a sudden illness or injury that demands immediate medical attention but is not life threatening. Examples or urgent situations include: sprains/strains, high fever, minor burns, vomiting, ear infections and urinary tract infections.
III. Health Plan Participation
A. Participant Eligibility
You are eligible to participate in the Plan as a “Participant” as follows:
1. Retiree Participant Over-Age 65 or LTD Retiree Participant
Medicare Supplement Plan
• They are over-age 65;
• as of their date of retirement were eligible for coverage under either the Health Plan of Marathon Oil Company or the International Medical Plan; and
• have at least ten years of actual service under the Employee Service Plan.
Note: Those who were hired on or after January 1, 2008 are limited to 10 years of total combined post-employment coverage in this Plan or the Health Plan of Marathon Oil Company.
Coverage begins on the first day of retirement.
Former Retiree Participants who are rehired will be able to return to their prior Retiree Participant status and subsidy level (no credit will be given for additional service for subsidy purposes).
For purposes of determining eligibility for Retiree Participant coverage, past service which has been granted to an otherwise eligible employee under the Employee Service Plan as a result of an acquisition, merger or other corporate transaction supported by a signed definitive agreement signed on or after March 1, 2004, will count towards eligibility to be a Retiree Participant provided the signed definitive agreement governing the merger, acquisition or other corporate transaction specifically provides for the recognition of service under the Employee Service Plan for the purpose of determining eligibility for retiree medical benefits.
2. LTD Terminated Participant
A former employee whose primary group health plan coverage is through Medicare and whose employment was terminated upon reaching the maximum 24 months of Sick Leave allowed under the Marathon Oil Company Sick Leave Plan, but who continues after the termination to remain eligible for disability benefits under the Marathon Oil Company Long Term Disability (LTD) Plan is eligible to participate as an LTD Terminated Participant. Coverage as an LTD Terminated Participant begins on the first day following such a termination.
3. Surviving Spouse Participant Over-Age 65
The over-age 65 surviving Spouse of an active employee of the Company, LTD Terminated Participant or Retiree Participant (including an LTD Retiree Participant) on the date of the death shall be eligible to participate as a Surviving Spouse Participant,if the deceased employee or retiree was eligible for coverage in the Health Plan of Marathon Oil Company, the Retiree Health Plan of Marathon Oil Company, or the International Medical Plan on the day of their death.
An over-age 65 surviving Spouse who is covered under the Health Plan of Marathon Oil Company or the Retiree Health Plan of Marathon Oil Company as a dependent spouse of an employee or retiree on the date of death of the employee or retiree will automatically have their coverage under this Plan begin as a Surviving Spouse Participant on the day following the death of the employee or retiree.
Medicare Supplement Plan
An over-age 65 surviving Spouse who is not covered under the Health Plan of Marathon Oil Company or the Retiree Health Plan of Marathon Oil Company as a dependent spouse of an employee or retiree on the date of death of the employee or retiree must complete, sign and submit the proper enrollment form to Marathon Oil Company within 31 days after the date of death for coverage under this Plan to begin as a Surviving Spouse Participant. Provided that the surviving Spouse properly enrolls, coverage under this Plan will be effective on the day following the death of the employee or retiree.
4. Spouse Participant Over-Age 65
The over-age 65 Spouse of an under-age 65 active employee or under-age 65 retiree (including an employee whose employment terminates as a result of disability) shall be eligible to participate in this Plan if the employee or retiree participates in the Health Plan of Marathon Oil Company.
5. ESRD Participant or LTD Participant Under-Age 65
An employee or retiree of the Company or the Spouse or other dependent of such an employee or retiree who is under age 65 and whose primary group health plan coverage is through Medicare due to disability or ESRD is eligible to elect coverage under this Plan. ESRD Participants who are not over age 65 will cease to be eligible for participation in this Plan on March 31, 2015. Such participants will be eligible to elect coverage under the Health Plan of Marathon Oil Company effective April 1, 2015.
B. Dependent Eligibility
Your eligible dependents may be covered under the Plan; provided, however that no individual may be covered as both a dependent and another type of Participant. Eligible dependents include:
1. Spouse
The over-age 65 Spouse of a Participant is an eligible dependent under the Plan.
2. Domestic Partner
The over-age 65 qualified domestic partner of an active employee or retiree of the Company is an eligible dependent under the Plan. Domestic partners must meet the requirements established in the Marathon Oil Company Affidavit of Domestic Partner Relationship form prior to benefit enrollment.
C. Who Is Not Eligible
An individual is not eligible for coverage under this Plan if such individual is: 1. a dependent child;
2. eligible for medical coverage under another group health plan maintained in the United States, toward which Marathon Oil Company or a member of its controlled group
Medicare Supplement Plan
3. eligible for medical coverage under another group health plan sponsored by a non-participating member of the controlled group which includes Marathon Oil Company.
D. When Coverage Ends or May Be Continued
The following are instances of when coverage under the Plan is terminated or may be continued. In most instances, if coverage may be continued, contributions are required to be paid.
1. The Participant fails to pay the required Participant contributions on a timely basis; • Coverage terminates on the last date for which contributions were paid.
2. The retirement eligible ESRD Participant on a Sick Leave is terminated under the neutral discharge practice rules after the first day of the month and has elected to retire the first day of the following month;
• Coverage may be continued provided the required monthly contributions are paid. 3. If a retiree waives coverage under this Plan in order to participate in an “appropriate
alternative plan,” such as the Veteran’s health care plan, a Medicare Advantage Plan (Part C of Medicare) or TRICARE, coverage under this Plan for the eligible dependents may be continued. See Appendix C.
4. If a Retiree Participant and Spouse die simultaneously coverage terminates as of death; If a Participant becomes divorced;
• Coverage for the Spouse terminates at the effective date of the divorce and may be continued provided the required monthly contributions are paid.
5. If a Surviving Spouse Participant remarries;
• Coverage for the Surviving Spouse Participant and eligible dependents terminates at the end of the month in which the marriage occurs.
6. If a dependent becomes an employee of the Company;
• Coverage terminates when the dependent becomes eligible for medical coverage under another group health plan maintained in the United States, toward which Marathon Oil Company or a member of its controlled group contributes. However, if the dependent is a Spouse, coverage as an employee or as a dependent is optional.
7. The participant was hired after January 1, 2008 and has reached ten years of combined participation in the Pre-65 and/or the Medicare Supplement Plan. Coverage terminates the last day of the month prior to your tenth year of retirement.
IV. Cost of Coverage
The Plan is funded by the contributions of plan Participants and the general assets of Marathon Oil Company. The Plan is designed so that the Company would pay approximately 80% of the cost of the Plan and Participants would pay approximately pay 20% of the Plan cost through contributions if all Participants were entitled to receive the full Company subsidy of their contribution amounts, but in certain circumstances, Participants may pay a higher percentage, and in certain circumstances the Company may pay a higher percentage. The total cost of the Plan is ultimately determined by
Medicare Supplement Plan
Participants will be advised of changes in monthly contributions prior to the start of each calendar year. Participants pay for coverage through payroll deductions, or, if not receiving pay, by monthly payments in advance.
A. Participant Contributions
The total cost for the Plan is determined annually based on past claims experience for Participants. The Company subsidy for the group is then calculated such that the Company would be paying approximately 80% of the cost if all Participants were eligible for the full Company subsidy. Thus the Participant cost for those individuals who are eligible for 100% of the Company subsidy is approximately 20% of the total cost of the Plan.
However, the amount of Company subsidy for a Participant may be less than 100%, and is currently determined using the “4% accrual method.” Under the 4% accrual method, an employee age 30 or older earns 1% of the eventual Company subsidy for each calendar quarter in which they are either actively employed or on one of the approved leave statuses on the last day of the quarter. Generally this means that an employee earns 4% of the eventual Company subsidy per year. If an employee works continuously from age 30, they will be entitled to 100% of the eventual Company subsidy by age 55. The amount of subsidy earned for each individual is frozen at their retirement, and will then be used to determine all future Plan Participant
contributions for the Retiree Participant and any covered dependent.
See Appendix A for actual rates based on the possible accrued percentage of Company subsidy.
Participant contributions for Spouse Participants and Surviving Spouse Participants of retirees are determined using the percent of Company subsidy earned by their respective Retiree Participant and frozen at the time of the Retiree Participant’s retirement.
Participant contributions for Surviving Spouse Participants of Employees who died while actively employed with the Company (prior to retirement) are determined using 100% of the Company subsidy.
Retiree Participants other than LTD Retiree Participants or LTD Terminated Participants who worked more than 50% of their total service as regular part-time employees will receive 50% of the Company subsidy that the Retiree Participants would otherwise have been entitled to. However, a Participant who moved from service as a regular full-time employee to service as a regular part-time employee after becoming eligible to retire shall receive the full Company subsidy and shall continue to accrue additional Company subsidy as if such Participant remained employed as a regular full-time employee.
Rehired regular employees receive credit for any previously earned Company subsidy percentage. Regular employees who were rehired prior to January 1, 2008 also accrue additional Company subsidy percentages for their period of subsequent employment. Regular employees who were rehired on or after January 1, 2008 do not accrue any additional
Medicare Supplement Plan
Important Note: Prior to January 2, 2004 a different method, the “Age and Service Point System,” was used to determine the amount of Company subsidy for retirees who participate in the Health Plan of Marathon Oil Company. Those individuals who were employed at the time the Age and Service Point System was in effect earned the percent of subsidy using this method. Appendix B explains how this method worked, and also certain “grandfather” provisions that are used when an individual has earned percentages under both methods.
V. Enrolling in the Plan
A. Benefits Open Enrollment
There is a Benefits Open Enrollment each year during the fall. During Benefits Open Enrollment, eligible individuals may enroll in the Plan. No evidence of good health is required. Plan
coverage elected during Benefits Open Enrollment will be effective the following January 1. In connection with the change in this Plan to provide a defined contribution benefit beginning in April 2015, eligible individuals (as described above) will have an additional Benefits Open Enrollment opportunity to elect coverage under the Plan effective April 1, 2015 under the new defined contribution option.
B. Participant Enrollment
Eligible individuals may elect coverage under the Plan at the times indicated below. Individuals who waive coverage may not cover their Spouse or dependents under this Plan, although coverage for an under-age 65 Spouse may be available under another plan in accordance with the terms of such plan.
1. Enrollment When First Eligible for Coverage a. Retiree Participant Coverage
i. Prospective Retiree Participants, LTD Retiree Participants, and LTD Terminated Participants who are enrolled in the Health Plan of Marathon Oil Company on the day immediately prior to their first date of eligibility under this Plan as a Retiree Participant, LTD Retiree Participant, or LTD Terminated Participant will be automatically enrolled in this Plan. They are not required to complete an enrollment form in order to be enrolled in this Plan.
ii. Prospective Retiree Participants, LTD Retiree Participants, and LTD Terminated Participants who are not enrolled in the Health Plan of Marathon Oil Company on the day immediately prior to their first date of eligibility under this Plan as a Retiree Participant, LTD Retiree Participant, or LTD Terminated Participant must complete, sign, and submit the proper enrollment form in order to be covered as Participants under this Plan. If the enrollment form is received by the Company on or before the first date of eligibility or within 31 days after the first date of eligibility, participation is effective on the eligibility date.
Medicare Supplement Plan
iii. An election to be covered under this Plan by an eligible individual with ESRD or an under-age 65 LTD Participant previously covered under the Health Plan of Marathon Oil Company shall be effective on the first date of coverage by Medicare, where Medicare is the primary payer of benefits, provided that such election is received by the Company within 31 days after the first date of coverage by Medicare where Medicare is the primary payer of benefits.
b. Spouse Participants, Surviving Spouse Participants, and Domestic Partners
i. Prospective Spouse Participants, Surviving Spouse Participants, and Domestic Partners who are enrolled in the Health Plan of Marathon Oil Company as a dependent of a Participant on the day immediately prior to their first date of eligibility under this Plan as a Participant will be automatically enrolled in this Plan as a
dependent. Such Participants will not be required to complete, sign and submit an enrollment form to the Company in order to be enrolled in this Plan.
ii. Prospective Spouse Participants, Surviving Spouse Participants, and Domestic Partners who are not enrolled in the Health Plan of Marathon Oil Company as a covered dependent of a Participant on the day prior to their first date of eligibility under this Plan must complete, sign, and submit the proper enrollment form to the Company in order to be covered as Participants under this Plan. If the enrollment form is received by the Company on or before the first date of eligibility or within 31 days after the first date of eligibility, participation is effective on the eligibility date. If the enrollment form is not received within 31 days after the date of any qualified life event, participants may be enrolled during the Benefits Open Enrollment Period.
2. Late Enrollment
An eligible individual may late enroll in the Plan due to any of the following six events: a. marriage or divorce;
b. death of a Spouse;
c. acquiring an eligible dependent due to birth, adoption, or placement for adoption; d. an eligible dependent’s loss of eligibility for coverage under another group health benefit
plan or other health insurance coverage obtained either through another employer or through self-employment;
e. the exhaustion of COBRA continuation of coverage by either an eligible retiree or eligible dependent, under another employer plan; or
f. moving back to and establishing a permanent residence in the United States or Puerto Rico from a foreign country.
If the enrollment form is received on or before the date of any of the above events or within 31 days following the event, participation is effective on the date of the event.
Medicare Supplement Plan
For purposes of this section, the phrase “loss of eligibility for coverage” includes any loss of health coverage which results from a legal separation, divorce, death, termination of employment, reduction in the number of hours of employment, and the termination of employer contributions towards that coverage. Loss of eligibility for coverage does not include a loss of coverage due to any individual’s failure to make timely premium payments (or other required contributions) for any reason or due to termination of coverage for cause. In addition, under the Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009, effective April 1, 2009, an eligible individual may enroll in the Plan within 60 days of either (1) termination of Medicaid or CHIP coverage due to loss of eligibility or (2) becoming eligible for a state premium assistance program under Medicaid or CHIP coverage.
C. Dependent Enrollment
Except as provided in Article III or Article V, an eligible dependent may only be enrolled in the Plan if the Participant to which the dependent is related is also enrolled in the Plan.
1. If the enrollment form for an eligible dependent or dependents is received by the Company before or within 31 days of the date of an event described below, participation is effective on the date of the event:
a. the first date of eligibility of the Participant; b. the first date of eligibility of the dependent;
c. the loss of eligibility for coverage by an eligible dependent of a Participant under another group health benefit plan or other health insurance coverage obtained either through another employer or through self-employment; or
d. exhaustion of COBRA continuation of coverage under another employer’s group health benefit plan by a prospective member and/or by an eligible dependent of either a prospective member or a Participant; provided, however that dependents of Spouse Participants, or Surviving Spouse Participants are not eligible to be enrolled due to this event (d).
If the enrollment form is not received within 31 days after the date of any of the above events, eligible dependents may be enrolled during the Benefits Open Enrollment Period. For purposes of this section, the phrase “loss of eligibility for coverage” does not include a loss of coverage due to any individual’s failure to make timely premium payments (or other required contributions) for any reason or due to termination of coverage for cause.
Under the Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009, effective April 1, 2009, dependents may be enrolled in the Plan within 60 days of either (1) termination of Medicaid or CHIP coverage due to loss of eligibility or (2) becoming eligible for a state premium assistance program under Medicaid or CHIP coverage.
Medicare Supplement Plan
VI. Waiver of Coverage
Except as otherwise provided in this Article VI, a Participant may waive coverage under this Plan for the Participant and/or dependents in conjunction with a Qualified Life Event or Benefits Open Enrollment. The waiver is effective the day the proper form is received by the Company. Subject only to the exception described in Section (B) below, if Participant coverage is waived, all dependent coverage must also be waived.
A prospective Participant and dependents who have previously waived coverage may rejoin the Plan as provided in Article V.
A. If a Participant is making contributions to the Plan through a cafeteria plan, coverage may not be waived except:
1. when the waiver is due to a “change in family or employment status” and the applicable cafeteria plan would permit the Participant to change the contribution amount; or
2. during Benefits Open Enrollment.
B. In certain instances, a Retiree Participant, LTD Retiree Participant, or LTD Terminated Participant may waive coverage under the Medicare Supplement Plan for themselves and cover their eligible dependents. An example is:
1. Participant elects to enroll in an “approved alternative plan” such as the Veteran’s health care plan, a Medicare Advantage Plan (Part C of Medicare) or TRICARE. The chart attached as Appendix C illustrates what options are available.
VII. Special Provisions for Under-Age-65 Disabled/ESRD Individuals
If an eligible individual or Spouse are under age 65, covered by Medicare due to disability or ESRD and have Medicare as the primary payer of benefits, they may choose to change their coverage from the Health Plan of Marathon Oil Company to this Plan; provided, however, that this option shall no longer apply after March 31, 2015. Such Participants who elect coverage under this Plan may continue to cover their eligible under-age-65 dependents under the Health Plan of Marathon Oil Company or the Retiree Health Plan of Marathon Oil Company.
A. Offset Provision
This offset provision applies to Participants who are disabled or have ESRD and “eligible for Medicare Benefits” and have (or would have if Medicare were elected) Medicare as the primary payer of benefits (with this Plan as the secondary payer of benefits). Under the offset provision, benefits under this Plan will be reduced (offset) by the benefits payable under Medicare Parts A and B (or that would have been payable had Medicare been elected). “Eligible for Medicare Benefits” means the individual is or could be covered under Medicare Part A, or Part A and B, because of 1) the entitlement to Social Security benefits for themselves or for one of their parents (in the case of a child) or 2) ESRD.
Medicare Supplement Plan
VIII. Overview of How the Plan Works
A. Expenses Not Covered
Items not covered by Medicare, such as custodial care, are not covered by this Plan. Participants are not eligible for preventative services. Expenses must be reasonable and necessary for treatment of an illness or injury. In addition, this Plan will not pay benefits that would have been payable from Medicare Parts A and B. This Plan requires that you enroll in Medicare Parts A and B, and the Plan will offset any payments that would have been payable from Medicare even if you fail to enroll in Medicare Parts A and B.
B. Benefit Coverage Under the Plan 1. General Types of Programs
Benefits under the Plan are provided by the following two programs:
a. Medical/Surgical Program — Covers services and supplies relating to a medical diagnosis. Benefits are provided under the Medical/Surgical Program of the Plan, which supplements Parts A and B of Medicare.
i. Medical/Surgical Program
• The Medical/Surgical Program of the Plan provides benefits for services and supplies covered under Part A and Part B of Medicare. Services and supplies not covered by Part A and B of Medicare are not covered by the Medical/Surgical Program of the Plan. The Plan does not provide benefits for services and
supplies covered under a Medicare Advantage Plan (Part C) of Medicare or under a Medicare Prescription Drug Plan (Part D) of Medicare.
• The Medical/Surgical Program is a Medicare “carve out” plan. As such, before final payment is made under the Plan, the amount paid by Medicare for the claim is “carved out” or subtracted from the Plan benefit amount. The Plan will pay the remaining amount, if any.
• All benefits under the Medical/Surgical Program of the Plan are reimbursed from charges approved by Medicare as “reasonable and necessary” covered services and charges incurred in connection with an illness or injury. Medicare does not cover care that is “custodial.” The Medical/Surgical Program pays for only those expenses incurred for services, supplies or treatment which are ”reasonable and customary” (as determined by Medicare) in connection with an illness or injury and which are included for coverage.
b. Managed Prescription Drug Program — the Managed Prescription Drug Program covers prescription drugs as described in Article IX.
Medicare Supplement Plan
2. Medical/Surgical Program Coverage a. Coinsurance Defined
Under the Plan, coinsurance is the portion of the covered cost that the Participant pays. The Plan calculates 80% of the approved cost, then pays the difference, if any, between the calculated amount and the payment Medicare has already made. The Participant is responsible for any of the approved cost not covered after both Medicare and the Plan have made payment.
b. Medical/Surgical Out-of-Pocket maximum
The Medical/Surgical out-of-pocket maximum applies to all covered charges under the Medical/Surgical Program. Once the Participant has incurred the individual Medical/ Surgical out-of-pocket maximum in the form of coinsurance, the remainder of the covered expenses under the Medical/Surgical portion of the Plan will be paid at 100% for the rest of that calendar year for that individual only.
The Medical/Surgical out-of-pocket maximum is adjusted annually based on the medical cost trend factor experienced by the Plan.
Individuals who were previously covered under Health Plan of Marathon Oil Company and who subsequently enroll in this Plan in the same calendar year will have their Medical/Surgical amounts that were applied to their out-of-pocket maximum under the Health Plan of Marathon Oil Company recognized for purposes of calculating the Medical/Surgical out-of-pocket maximum of this Plan for the calendar year in which they enrolled in this Plan. Individuals who were covered under the Health Plan of Marathon Oil Company will only have their in-network Medical/Surgical out-of-pocket amount applied toward the Medical/Surgical out-of-pocket maximum for this Plan.
The following charges do not count towards satisfying the Medical/Surgical out-of-pocket maximum limits:
• Charges above “reasonable and customary” amounts, and
• All coinsurances paid by the Participant under the Prescription Program.
IX. Managed Prescription Drug Program
The Managed Prescription Drug Program is a Medicare approved Part D program administered by Express Scripts Medicare. The Part D prescription drug coverage provided under the Managed Prescription Drug Program is in addition to coverage under Medicare Part A and/or Medicare Part B and is “Creditable Coverage,” which means it is at least as good as the standard Medicare prescription drug coverage. This coverage applies to all Participants covered under the Plan. The Managed Prescription Drug Program has a Retail Pharmacy component and a Mail-Order component. All coverage under the Managed Prescription Drug Program is subject to the determination that the drugs must be Medically Necessary and other limitations, as set forth in this Article IX.
Medicare Supplement Plan
Participants are required to inform Express Scripts Medicare of any other prescription drug
coverage that they are currently enrolled in. A Participant can be in only one Medicare prescription drug plan at a time. A Participant’s enrollment in this Plan may end any enrollment in another Medicare prescription drug plan, a Medicare Advantage Plan with prescription drug coverage, or an individual Medicare Advantage Plan.
By joining this Medicare prescription drug plan, each Participant agrees that Express Scripts Medicare can release information to Medicare and other plans as is necessary for treatment, payment, and health care operations. Each Participant also agrees that Express Scripts Medicare can release their information, including prescription drug event data, to Medicare, who may release it for research and other purposes in accordance with applicable Federal statutes and regulations.
A. Coverage
Express Scripts Medicare has different stages of coverage as described below, which determine the amount a Participant pays for a drug:
• Initial Coverage Stage — When a Participant meets the yearly retail-only deductible of $100, the Participant must pay the cost-sharing amounts described in Article IX, Section B until total yearly drug costs for the individual Participant reach $2,970. For purposes of determining whether a Participant has satisfied the deductible, any amount accumulated from January 1 – March 31 will reset effective April 1.
• Coverage Gap Stage — After yearly drug costs for an individual Participant reach $2,970, the Participant will generally pay the same amount as in the Initial Coverage Stage until the Participant’s yearly out-of-pocket drug costs reach $4,750.
• Catastrophic Coverage Stage — After an individual Participant’s yearly out-of-pocket drug costs reach $4,750, the Participant enters the Catastrophic Coverage Stage and will generally pay the cost-sharing amounts described in Article IX, Section D.
1. To Receive Coverage
To receive coverage under the Plan, outpatient prescription drugs (as defined in Section 2.a. below) must be purchased through the Retail Pharmacy Component (through a participating Express Scripts retail pharmacy) or through the Mail-Order Component (from the Express Scripts’s mail-order pharmacy) of the Managed Prescription Drug Program. Network pharmacies (including both retail and mail-order network pharmacies) offer discounted drug prices, drug utilization review to protect individuals from potentially dangerous drug interactions, and no claim forms to submit.
Except for certain exception situations explained in Article XI, Section 2, there is no coverage for outpatient prescription drugs that are not purchased through a retail or mail-order network pharmacy.
2. Outpatient Prescription Drugs
a. Outpatient prescription drugs are prescription drugs which are:
i. Prescribed to be administered when the Participant is not confined to a hospital as an inpatient (includes certain specialty medications — injectable medications administered either by the Participant or a health care professional); and
Medicare Supplement Plan
ii. Not billed by a home health agency, hospice agency, or sub-acute care facility (extended care facility); and
iii. Federal legend drugs (prescription drugs), state restricted drugs, compounded medications, and oral contraceptives; or
iv. Insulin with a prescription only and covered diabetic supply items with a prescription only. Covered diabetic supply items are syringes (including needles), test strips, lancets, and glucometers. (An insulin pump, as well as tubing and needles for the pump, are covered under the durable medical equipment provisions of the Medical/ Surgical Program and are not covered as a diabetic supply item under the Managed Prescription Drug Program.)
b. Not covered under the Managed Prescription Drug Program but subject to the provisions of the Medical/Surgical Program are:
i. Supply items (other than diabetic supply items), therapeutic devices, and durable medical equipment; and
ii. Prescription drugs and covered diabetic supplies billed by a home health agency, hospice agency, or sub-acute care facility (extended care facility).
B. Prescription Drug Benefit Levels — Initial Coverage Stage
1. When a Participant uses the Retail Pharmacy Component, the Participant will first pay the Retail Deductible Amount found in Appendix D. There is no deductible under the Mail-Order Component. For purposes of determining whether a Participant has satisfied the deductible, any amount accumulated from January 1 – March 31 will reset effective April 1.
Subject to Section B.2. below, when using the Retail Pharmacy Component the amount the Participant pays after satisfying the Retail Deductible Amount will be the higher of the minimum co-payment or the coinsurance percentage as follows (but never more than the total cost of the drug):
Retail (31 Day Supply) Participant Pays the Greater of
Type of Medication Minimum Co-Payment or Participant Percentage
Generics $5 20%
Brand Name Drugs on the
Formulary $25 20%
Brand Name Drugs Not on
the Formulary $35 50%
Retail (90 Day Supply) Participant Pays the Greater of
Type of Medication Minimum Co-Payment or Participant Percentage
Generics $15 20%
Brand Name Drugs on the
Medicare Supplement Plan
When using the Mail Order Component the amount the Participant pays will be the higher of the minimum co-payment or the coinsurance percentage as follows (but never more than the total cost of the drug):
Mail Order (90 Day Supply) Participant Pays the Greater of
Type of Medication Minimum Co-Payment or Participant Percentage
Generics $10 20%
Brand Name Drugs on the
Formulary $50 20%
Brand Name Drugs Not on
the Formulary $100 50%
In addition, any generic or brand name drug on the formulary that is ordered through the Mail Order Component is subject to a $200 maximum per prescription.
Participants can call Express Scripts Customer Service at 1-877-852-7493 to see if a drug is on the formulary or to request a copy of the formulary. Information about the formulary is also available online at www.Express-Scripts.com. Express Scripts Medicare may periodically add or remove drugs from the formulary, make changes to coverage limitations on certain drugs, or change how much Participants must pay for a drug. If any formulary change limits a Participant’s ability to fill a prescription, the Participant will generally be notified before the change is made.
If a Participant requests an exception for a drug that is not covered under the Managed Prescription Drug Program and Express Scripts Medicare approves the exception, the Participant will pay the cost-share for Brand Name Drugs not on the formulary. Express Scripts Medicare may require prior authorization for certain drugs or may require a Participant to first try one drug to treat a condition before the Plan will cover another drug for that condition.
C. Prescription Drug Benefit Levels — Coverage Gap Stage
After an individual Participant’s yearly drug costs reach $2,970, the Participant will generally pay the same cost-sharing amount as in the Initial Coverage stage until the individual Participant’s yearly out-of-pocket drug costs reach $4,750.
If an individual Participant meets the mail order out-of-pocket maximum as described in Section G below, the Participant will pay $0 for covered prescription drugs from the Mail Order Component for the remainder of the Plan Year.
D. Prescription Drug Benefit Levels — Catastrophic Coverage Stage
After an individual Participant’s out-of-pocket drug costs reach $4,750, the Participant will pay the greater of 5% coinsurance or:
• a $2.65 copayment for covered generic drugs (including brand name drugs treated as generics) with a maximum at mail not to exceed $200; or
Medicare Supplement Plan
• a $6.60 copayment for all other covered drugs with a maximum at mail not to exceed $200 except for brand name drugs not on the formulary.
If an individual Participant has not yet met the mail order out-of-pocket maximum as described in Section G below, but the Participant’s yearly out-of-pocket drug costs-including manufacturer discounts-exceed $4,750, the Participant will pay the same cost-sharing amounts as listed above in this Section D.
E. Prescription Drug Benefit Levels — Long-Term Care Pharmacy
Residents of a long-term care facility using an in-network Long Term Care pharmacy will pay the cost-sharing amount for a one-month supply at retail for the Initial, Coverage Gap, and Catastrophic Coverage Stages.
F. Using the Retail Pharmacy Component
The names of participating pharmacies in the Retail Pharmacy Component are available by calling Express Scripts Customer Service at 1-877-852-7493, or online at
www.Express-Scripts.com.
G. Mail Order Out-of-Pocket Maximum
To protect Participants who have illnesses requiring significant prescription drugs, the Plan has an individual mail order out-of-pocket maximum of $3,500.
When the coinsurance an individual Participant has paid using the Mail Order Component total $3,500 in a calendar year, covered charges for that individual Participant under the Mail Order Component are paid at 100% for the rest of the calendar year.
There is no out-of-pocket maximum for the Retail Pharmacy Component.
H. Clinical Programs Administered by Express Scripts
The Plan has authorized Express Scripts to implement a number of clinical programs that assure that the drugs are clinically appropriate and consistent with the Plan’s intent. These programs are subject to change as Express Scripts continues to develop and enhance existing programs. As the pharmaceutical industry changes rapidly, the Plan will actively pursue
administrative opportunities to assure patient safety and optimize health plan effectiveness for Plan Participants. At any time a current list of clinical programs administered by Express Scripts can be requested and will be provided to the Participant on a timely basis. The major clinical program areas are as follows:
• Drug Utilization Review — Concurrent and retrospective drug utilization review to assure safety and appropriate use.
Medicare Supplement Plan
• Coverage Management Programs — These programs help ensure the appropriateness of coverage for specific drugs and specific amounts of drugs. The following programs are included under Coverage Management – Traditional Prior Authorization, SMART Prior Authorization, Dose Duration, Quantity Duration, Dispensing Quantity, and Dose Optimization.
These clinical programs will work with the prescribing physician, dispensing pharmacist and Participant to assure that any conflicts that may arise are resolved in a prompt and safe manner.
I. Special Preventative Coverage
A physician may prescribe a preventative vaccine that is available in oral form. A physician may also write a prescription for a Participant to purchase an injectable vaccine at the pharmacy, prior to administration in the physician’s office. In such cases, the Managed Prescription Drug Program will cover the vaccine at 100% not subject to a deductible if purchased using the Retail Pharmacy Component or the Mail-Order Component. Services to administer the vaccine would still be covered by the Medical/Surgical Program.
J. Premiums for Prescription Drug Coverage
The premium paid for the Plan includes coverage for the Managed Prescription Drug Program. A Participant may be charged a late enrollment penalty if they did not enroll in a Medicare prescription drug plan when first eligible for Medicare Part A and/or Part B, and they did not have other prescription drug coverage that met Medicare’s minimum standards, or if they had a break in coverage of at least 63 days. If a Participant owes a late enrollment penalty, the Participant will be notified by Express Scripts Medicare.
K. Service Area
The service area for the Managed Prescription Drug Program is all 50 states, the District of Columbia, and Puerto Rico. A Participant must live in one of these areas to participate in the Managed Prescription Drug Program.
X. Coordination of Benefits
A. Coordination With Other Group Health Plans
To the extent applicable, this Plan coordinates benefits with other health plans under which Participants are covered (such as a Spouse covered under their employer’s plan). In these instances, the plans work together through what is called “coordination of benefits” or “non-duplication of benefits” provisions.
With the exception of benefits under the Managed Prescription Drug Program, when the Plan is secondary to another group plan, benefits paid are determined using the “Benefits Less Benefit” method of coordination of benefits. This method calculates the amount payable under standard Plan provisions, and then reduces that amount by the amount of payment due for the same charges from any other group plan that is primary to the Plan.
Medicare Supplement Plan
The Plan follows standard rules accepted by the insurance industry to determine which plan is primary when an individual is covered by more than one group plan. Some — but not all — of the rules are as follows:
• The plan that covers a Participant as active is primary to a plan that covers the Participant as inactive (for example, retired).
• The plan that covers an individual as a Participant pays primary to a plan that covers the same individual as a dependent of a Participant.
• The plan that has covered an individual the longest pays primary if the individual is covered in the same category by two plans (for example, an individual is actively employed by two different companies).
• If a child is covered as a dependent under two different group plans, coverage is primary under the plan of the parent whose birthday (month and day) occurs earlier in the calendar year. For example, if the father was born on August 16 and the mother on June 11, the mother’s plan is primary and would pay benefits first.
• In the case of divorce or separation, the plan of the parent with custody of the dependent child usually pays benefits for the child first. If the person with custody remarries, the stepparent’s plan pays second, and the plan of the parent without custody pays third. However, if a court decree places financial responsibility for the dependent child’s medical care on one parent, that parent’s plan always pays benefits first.
B. Coordination With Other Plans
To the extent applicable, coordination with Medicare and other government-sponsored plans follows regulations as issued by the appropriate government agencies.
The following types of plans normally coordinate with the Plan:
• Governmental benefit programs provided or required by law, other than Medicare and Medicaid.
• No-fault automobile insurance plans.
• Plans provided by an employer, union, trust, or other similar provider.
• Other group health care plans by which Participants or dependents are covered, including student coverage provided through a school above the high school level.
XI. Claim Submission Procedures
All claims under the Plan must be submitted in accordance with the procedures described below. There is no time limit for filing a claim under the Medical/Surgical Program. A claim for benefits under the Managed Prescription Drug Program must be submitted within six months after the end of the calendar year in which the claim was incurred.
Medicare Supplement Plan
A. Medical/Surgical Program
Health Design Plus is the claim payer under the Medical/Surgical Program and offers Medicare Crossover claims processing, which means that transfer of information will occur automatically from Medicare. There is generally no need for you or your provider to file a claim with Health Design Plus. However, if for some reason a claim needs to be filed manually, the address is: Health Design Plus, P.O. Box 2580, Hudson, OH 44236-2580.
B. Managed Prescription Drug Program
Express Scripts Medicare is the claim payer under the Managed Prescription Drug Program. Claims are adjudicated at the time a prescription is purchased and filled under either the Retail Pharmacy Component or the Mail Order Component of the Managed Prescription Drug Program. There is no coverage for outpatient prescription drugs not purchased at a participating retail pharmacy or through the Express Scripts Mail-Order Pharmacy.
In certain situations, there are exceptions to these provisions as described below. Each of the following situations require the submission of a claim form when outpatient prescription drugs (including covered diabetic supplies) are purchased as indicated. The four exception situations are as follows:
1. Outpatient prescription drugs purchased outside the United States by Participants who reside in the United States, but who are temporarily out of the country due to business or leisure and where a medical need arises.
2. If a Participant purchases outpatient prescription drugs at a participating retail pharmacy but the claim is not filed electronically by the pharmacist for reasons listed below, coverage will be as described in Article IX. Some examples of instances where this may happen include: a. For a new Participant (within the first 30 days of coverage) not included in the Express
Scripts system; and
b. If a Participant did not have their Express Scripts ID card, or for any other reason the claim was not filed electronically.
3. If a Participant resides in the United States and does not have access to (beyond ten miles) a participating retail pharmacy, coverage will be as indicated in Article IX.
Claim forms for use with the above situations, and mail-order forms can be obtained by calling Express Scripts Customer Service at 1-877-852-7493 or online at www.Express-Scripts.com. Submit claim forms to:
Express Scripts P.O. Box 14718 Lexington, KY 40512
Medicare Supplement Plan
C. Outstanding Claim Checks
The Plan has the authority to cancel and stop payment on any claim checks issued by a claim payer under the Plan if the check has been outstanding and not cashed for one year or more. Such action shall not, however, prohibit the Plan from making the claim payment if approached by a Participant or designated representative for payment after the claim check has been cancelled.
XII. If a Claim is Denied (Claim Appeal Procedures)
If a claim is denied, a Participant may ask the claims administrator to review the decision. The process outlined in this section relates to a claim for a particular benefit under the Plan. For eligibility claims, such as a claim to participate in the Plan or to change an election to participate in the Plan during the plan year, appeals should be submitted to the Plan Administrator.
The Claim Appeal Procedure of the Plan differs depending on the claim payer as follows: • Claim Appeal Procedure 1 applies to the following Claim Payers:
– Health Design Plus (Medical/Surgical Program) • Claim Appeal Procedure 2 applies to:
– Express Scripts (Managed Prescription Drug Program)
A. Claim Appeal Procedure 1
(Applies to Claim Payer: Health Design Plus)
If a claim for benefits has been denied in full or in part, or if the Participant does not agree with how the claim was paid, they or their duly authorized representative are entitled to appeal the decision and the appeal must be made by following the appeal procedures outlined below. If the claims payer determines that first level of appeal is denied, the participant may ask the Plan Administrator to review the claim payer’s decision. These two levels of appeal are referred to as “internal appeals.” If the Participant disagrees with the Plan Administrator’s decision, and the basis for the Plan Administrator’s denial involved medical judgment or relates to a rescission of benefits, the Participant may request that a third party independent review organization review the Plan Administrator’s decision. This is defined as an “external appeal.” The decision by the third party independent review organization is final and binding on both the Participant and the Plan.
A Participant must exhaust both levels of internal appeals prior to bringing an external appeal, if eligible for external appeal, or before bringing a lawsuit in court, unless the Plan does not follow the requirements for internal claims and appeals required by law. In this case, a Participant may seek immediate external review or court action, unless the action by the Plan was de minimis, non-prejudicial, attributable to good cause beyond the control of the Plan, in the context of an ongoing exchange of information, and not reflective of a pattern or practice of non-compliance.
Medicare Supplement Plan
Appeals must contain all of the required information in order to be regarded as an appeal under the Plan. If required information is missing the request may not be regarded by the Plan as an appeal and it may be returned to the Participant, or their designated representative, with no determination made. The Participant, or their duly authorized representative, should contact the claim payer denying the claim prior to filing the appeal in order to clarify any questions they may have on the reason for the denial by the claim payer. All appeals to the Plan Administrator must contain the following information:
• A statement that a formal appeal under the Plan is being made and the type of appeal (Urgent Pre-Service Claim Appeal, Non-Urgent Pre-Service Claim Appeal or Post-Service Claim Appeal).
• The name of the individual for whom the claim was denied.
• The Social Security number of the covered Participant, and, if the individual for whom the claim was denied is not the covered Participant, the name of the covered Participant. • Name of Plan.
• Identify the claim denied for which the appeal is being made. Include the date of service, name of the provider and/or facility.
• Any and all information necessary for a complete and thorough review of the claim appeal. Provide the complete name and phone number of any medical professionals to contact for additional information supporting the approval of the appeal.
• Address and telephone number of the individual, or duly authorized representative, making the appeal.
• Authorization for release of personal health information if appropriate and necessary.
For those claim appeal procedures that require the appeal be sent in writing to the claims payer, the address for sending appeals to the various claim payers under the Plan are as follows:
Medicare Supplement Plan: Appeals Coordinator Health Design Plus 1755 Georgetown Road Hudson, OH 44236
Telephone: (877) 747-7818 (toll free)
For those claim appeal procedures that require that the appeal be sent in writing to the Plan Administrator, the address for the Plan Administrator of the Medicare Supplement Plan of Marathon Oil Company is as follows. A form for you to use to submit the appeal can be found at www.MRObenefits.com in the Forms section. The form can also be obtained by requesting a copy from the Marathon Health and Welfare Department at 1-855-652-3067.
Medicare Supplement Plan of Marathon Oil Company Appeals
The Plan Administrator of the Medicare Supplement Plan of Marathon Oil Company 5555 San Felipe Street, Room 2687
Houston, TX 77056
Medicare Supplement Plan
How an appeal is made and the time frames for requesting an appeal vary depending on the type of health service claim denied. The following explains the three types of appeals for the three types of claims and the procedures for making an appeal for each of the three types of appeals: Urgent Pre-Service Claim Appeal, Non-Urgent Pre-Service Claim Appeal, and Post-Service Claim Appeal.
1. Pre-Service Claim Appeal
If a request for healthcare was denied before the health care is rendered (such as a result of a prior authorization, precertification, or preapproval) by a claim payer under the Plan, the claim is a pre-service claim and the Participant may appeal following the pre-service claim appeal procedures. In addition, the pre-service claim appeal procedures depend on if it is an urgent or a non-urgent claim.
An urgent claim appeal is a medical service claim that requires immediate action if a delay in treatment could significantly increase the risk to health or the ability to regain maximum function, or cause severe pain, or jeopardize the life or health of patient or a patient’s unborn child.
a. Urgent Pre-Service Claim Appeal
A Participant, or their designated representative, may appeal a denial decision of an urgent pre-service claim by phone or in writing to the claim payer listed in the denial notice. The appeal must be received by the within 180 days of the initial denial, however, the Participant authorized representative may file an appeal to both the claim payer (first level of internal appeals) and the Plan Administrator (second level of internal appeals) at the same time.
A determination by the Plan Administrator, or others delegated authority to hear appeals by the Plan Administrator, will be made within 72 hours of the claim payer receiving the appeal request. The appeal determination will be sent to the individual making the appeal at the telephone number and address provided in the appeal.
If the claim is denied at the first and second level of internal appeals and that denial is based on medical judgment, an appeal may be made to an external third party independent review organization (“external appeal”). External appeals must be
requested within four (4) months of a final adverse benefit determination. The request for an external appeal should be sent to the Plan Administrator. The Plan will review the request for external appeal within five (5) business days of receipt for determination that the request is eligible for external review. If the claim is determined eligible for external review, it will be referred to an independent review organization. The independent review organization will notify the Participant of eligibility for review and inform the Participant of the right to submit any additional information within ten (10) business days. The independent review organization will review the claim “de novo,” meaning it will not take into account any prior decisions at the internal appeals level. The Participant will be provided with the independent review organization’s decision within 45 days. If the internal decision denying benefits is reversed, the Plan will immediately provide or pay
Medicare Supplement Plan
Note: A pre-service claim that is “urgent” when it is initially filed and the determination is made by the respective claim payer, will cease to be an “urgent” pre-service claim and will become a non-urgent post-service appeal if between the date of the claim denial and the date the appeal is made, the health care services are actually rendered and the only decision to be made is who will pay for the services.
b. Non-Urgent Pre-Service Claim Appeal
If the Participant or their designated representative disagrees with the handling and disposition of the claim, they are entitled to submit a written appeal to the claim payer at the address found at the beginning of this Section, “Claim Appeal Procedure.” (It is suggested that the Participant send a copy of the written appeal to the claims payer to the Plan Administrator at the address also stated at the beginning of this section.) That written appeal will be reviewed in accordance with the claim payer’s internal appeal procedures. The written appeal must be received by the claim payer within 180 days of the initial denial. The claim payer must respond to a written appeal within 15 days for a Non-Urgent Pre-Service claim.
If after receiving the response to a written appeal from the claim payer the Participant continues to disagree with the handling and disposition of the claim, the Participant is entitled to submit a written appeal to the Plan Administrator as detailed below.
The Participant, or their designated representative, may appeal a denial decision of a non-urgent pre-service claim in writing. (Such appeal must be in writing. Non-urgent pre-service claim appeals cannot be submitted by telephone or facsimile.) The appeal to the Plan Administrator must be received by the Plan Administrator within 60 days of the date of the denial of the first appeal by the claim payer.
The Participant, or their designated representative, is to send the appeal to the Plan Administrator at the Marathon Oil Appeals Administration address stated at the beginning of this section “Claim Appeal Procedure.” A determination by the Plan Administrator, or others delegated authority to hear appeals by the Plan Administrator, will be made within 15 days of the Plan Administrator’s receiving the appeal request. The appeal determination will be sent to the individual making the appeal at the address provided in the appeal.
Medicare Supplement Plan
If the claim is denied at the first and second level of internal appeals and that denial is based on medical judgment, an appeal may be made to an external third party independent review organization (“external appeal”). External appeals must be
requested within four (4) months of a final adverse benefit determination. The request for an external appeal should be sent to the Plan Administrator. The Plan will review the request for external appeal within five (5) business days of receipt for determination that the request is eligible for external review. If the claim is determined eligible for external review, it will be referred to an independent review organization. The independent review organization will notify the Participant of eligibility for review and inform the Participant of the right to submit any additional information within ten (10) business days. The independent review organization will review the claim “de novo,” meaning it will not take into account any prior decisions at the internal appeals level. The Participant will be provided with the independent review organization’s decision within 45 days. If the internal decision denying benefits is reversed, the Plan will immediately provide or pay benefits payable.
2. Post-Service Claim Appeal
If the Participant disagrees with the handling and disposition of the claim, they are entitled to submit a written appeal to the claim payer at the address found at the beginning of this section “Claim Appeal Procedure.” (It is suggested that the Participant send a copy of the written appeal to the claim payer to the Plan Administrator at the address also stated at the beginning of this section.) That written appeal will be reviewed in accordance with the claim payer’s internal appeal procedures. The written appeal must be received by the claim payer within 180 days of the initial denial. The claim payer must respond to a written appeal within 30 days for a Post-Service Claim Appeal.
If, after receiving the response to a written appeal from the claim payer, the Participant continues to disagree with the handling and disposition of the claim, the Participant is entitled to submit a written appeal to the Plan Administrator as detailed below.
A Participant, or their designated representative, may appeal a denial decision of a post-service claim in writing by sending the appeal to the Plan Administrator at the Marathon Oil Appeals Administration address stated at the beginning of this section “Claim Appeal Procedure.” (Such appeal must be in writing and cannot be submitted by telephone or facsimile.) The appeal must be received by the Plan Administrator within 60 days of the date of the denial of the first appeal by the claim payer.
A determination by the Plan Administrator, or others delegated authority to hear appeals by the Plan Administrator, will be made within 30 days of the Plan Administrator receiving the appeal request. The appeal determination will be sent to the individual making the appeal at the address provided in the appeal.
If the claim is denied at the first and second level of internal appeals and that denial is based on medical judgment, an appeal may be made to an external third party independent review organization (“external appeal”). External appeals must be requested within four (4) months of a final adverse benefit determination. The request for an external appeal should be sent
Medicare Supplement Plan
If the claim is determined eligible for external review, it will be referred to an independent review organization. The independent review organization will notify the Participant of
eligibility for review and inform the Participant of the right to submit any additional information within ten (10) business days. The independent review organization will review the claim “de novo,” meaning it will not take into account any prior decisions at the internal appeals level. The Participant will be provided with the independent review organization’s decision within 45 days. If the internal decision denying benefits is reversed, the Plan will immediately provide or pay benefits payable.
B. Claim Appeal Procedure 2
(Applies to the Claim Payer Express Scripts)
Because the drug benefit is provided under Medicare Part D, the Medicare appeal rules apply. The Medicare appeal rules can be found at:
www.http://cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/index.html. If a claim for benefits has been denied in full or in part, or if the Participant does not agree with how the claim was paid, they or their duly authorized representative are entitled to appeal the decision. The appeal must be made by following the appeal procedures outlined below. Level One Appeals should be filed within 60 calendar days from the date of the coverage determination notice. The appeal may be expedited upon request. Appeal request must be handled by an Express Scripts representative not involved in the Initial Coverage Determination decision.
Level Two Appeals should be filed within the timeframe communicated to members in the denial of the Level One Appeal Notice. Level Two Appeals are handled by a government-contracted Independent Review Entity. The appeal may be expedited upon request.
If a Level Two Appeal has been denied, and the dollar level of the drug meets a minimum level, a Third, Fourth, and Fifth Level Appeal can be requested. Steps on how to file for the next level appeal will be in all response notices from the respect appeal level entity.
Express Scripts Medicare has the authority to render decisions on all Level One appeals submitted under the Plan. Level Two appeals will be determined by a government-contracted Independent Review Entity. Level Three Appeals will be heard by an Administrative Law Judge. Level Four Appeals will be heard by a Medicare Appeals Council. Level Five Appeals will be heard by a Judicial Review.
Appeals made must contain all of the required information in order to be regarded as an appeal under the Plan. If required information is missing the request will not be regarded by the Plan as an appeal and it will be returned to the Participant, or their designated representative, with no determination made. The Participant, or their duly authorized representative, should contact Express Scripts prior to filing the appeal in order to clarify any questions they may have on the reason for the denial by the claim payer. All appeals under the Plan must contain the following information:
