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Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace Detailed Table of Contents
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Table of Contents
Detailed Table of Contents
Index

Introduction

Who Is Eligible

Retiree Eligibility Requirements

Benefits-Eligible Position

Examples

If You Are Involuntarily Separated

If You Are on an Authorized Leave of Absence

If You Die

Spouse Eligibility Requirements

Domestic Partner Eligibility Requirements

Enrolling for Coverage

General Information

Enrolling Yourself and Your Spouse/Domestic Partner

Eligible Surviving Spouse/Domestic Partner’s Enrollment

If You or Your Spouse/Domestic Partner Is Receiving Treatment When Coverage Begins

Program Premium Cost

Determining an Annual Premium for You and Your Spouse/Domestic Partner

Total Cost of Coverage

If You Are Not Eligible for an Annual Subsidy Cap Amount

How Your Monthly Contributions Change When You or Your Spouse/Domestic Partner Becomes Eligible for Medicare

Making Required Premium Payments

Your Rights and Responsibilities

General Information

Your Rights

Statement of Rights Under the Newborns’ and Mothers’ Health Protection Act

Your Responsibilities

How the Retiree Group Health Program Works

General Information

Deductibles

Coinsurance

Out-of-Pocket Limits

Lifetime Maximum Benefit

Glossary of Key Terms

Retiree Group Health Program Design – Medical Programs

Primary Care Physicians (PCPs)

Specialty Care

Emergency Care

Urgent Care

Retiree Group Health Program Design – Mental Health and Substance Abuse Program

A Summary Chart of the Retiree Group Health Program – CIGNA Open Access Plus

A Summary Chart of the Retiree Group Health Program – CIGNA Indemnity

A Summary Chart of the Retiree Group Health Program – CIGNA Post-65 Medicare

Retiree Group Health Program – Other Services Available

Disease Management Services

CIGNA HealthCare Healthy Rewards

CIGNA HealthCare Health Information Line

CIGNA HealthCare Health Information Library

CIGNA HealthCare Medical Self-Service

Preadmission Certification – CIGNA

How to Precertify Your Hospital Admission

If You Do Not Precertify a Hospital Admission

Emergency Notification

What Is an Expense That May Be a Covered Expense – Medical Program

Professional Services

Reproductive Services

Outpatient Hospital/Facility and Emergency Room Services

Inpatient Hospital Services

Miscellaneous Services

What Expense is Excluded From Being a Covered Expense – Medical Program

What Is an Expense That May Be a Covered Expense – Mental Health and Substance Abuse Program

What Expense is Excluded From Being a Covered Expense – Mental Health and Substance Abuse Program

How the Prescription Drug Program Works

General Information

Glossary of Key Terms

Prescription Drug Program Design

A Summary Chart of Your Prescription Drug Coverage

What Is an Expense That May Be a Covered Expense – Prescription Drug Program

What Expense Is Excluded From Being a Covered Expense – Prescription Drug Program

Prior Authorization

How to Fill Your Prescriptions at a Retail Pharmacy

How to Fill Your Prescriptions through the Mail Service Pharmacy

Your Legal Right to Continuation Coverage

General Information

Notification

Election Procedure

Payment

When Continuation Coverage Ends

Trade Act Implications

Coordinating Benefits With Other Programs

General Information

How Coordination of Benefits Works

Medicare

Medicare Part A (Hospital Insurance) and Part B (Medical Insurance)

Examples

Medicare Part C

Medicare Part D

How to File a Claim

General Information

Retiree Group Health Program Claims

Medicare Electronic Claim Submission (Medicare Crossover)

Filling Prescriptions at Non-Participating Retail Pharmacies

ERISA Claims and Appeals Procedures

General Information

Procedure for Filing a Claim

Defective Claims

Initial Claim Review

Initial Benefit Determination

Claim Involving Urgent Care

Concurrent Care Decision

Pre-Service Claim

Post-Service Claim

Manner and Content of Notification of Denied Claim

Review of Initial Benefit Denial

Procedure for Filing an Appeal of a Denial

Review Procedures for Denials

Timing of Notification of Benefit Determination on Review

Manner and Content of Notification of Benefit Determination on Review

Legal Action

Situations Affecting Your Benefits

General Information

Right of Recovery

Right to Reimbursement, Assignment of Rights, and Duty to Notify

Right to Reimbursement

Assignment of Rights

Duty to Notify

If the Plan Is Modified or Ended

Administrative and Contact Information

General Information

Type of Plan

Plan Sponsor

Employer Identification Number of Plan Sponsor

Plan Name and Number

Plan Year End

Agent for Service of Legal Process

Benefits Committee and Plan Administrator

Eligibility Administration

Claims Administrator and Network Manager

Claims Administrator for Eligibility Claims

COBRA Administrator for Continuation Coverage

Allocation and Delegation of Fiduciary Responsibilities by the Benefits Committee

Trust and Insurance

Self-Funded Benefits

Insured Benefits

Participating Employers

Special Rules for Certain Participants

Who Is Eligible – Closed Eligibility Group

Moore Pre-1979 Retiree Group

Moore 1979 – 1986 Retiree Group

Moore 1986 – 1994 Retiree Group

Moore Post-4/1/1994 Retiree Group

Wallace Subsidized Retiree Group

Wallace, Litho, Nielsen Unsubsidized Retiree Group

Wallace, Litho, Nielsen Retiree Group (retired on or after January 1, 2004)

Program Premium Cost

Cap on Company Subsidies

Retiree Waive Credit Program

Retiree Health Care Account (RHCA)

If You Retired From Moore Prior to July 1, 1997

If You Retired From Moore on or After July 1, 1997

Using Your RHCA to Reimburse the Cost of Coverage

Filing for Reimbursement Under the RHCA Plan

Deadline to Submit Claims

Special Disqualification Rule Regarding Competition

Retiree Group Health Program Summary

How the UHC Retiree Group Health Program Option Works

General Information

Lifetime Maximum Benefit

Glossary of Key Terms – UnitedHealthcare

General Information – UnitedHealthcare

Plan Design Information – UnitedHealthcare

Deductibles

Coinsurance

Emergency Care

Urgent Care

Mental Health and Substance Abuse Services

A Summary Chart of the $200 Retiree Deductible Plan Option

A Summary Chart of the $275 Retiree Deductible Plan Option

Special Services Available – UHC

NurseLine

MyUHC.com

Prior Notification Requirements

Preadmission Certification – UHC

How to Precertify Your Hospital Admission

If You Do Not Precertify a Hospital Admission

Emergency Notification

What Is Covered – UHC

Ambulance Services – Emergency Only

Bariatric Surgery

Dental Services – Accident Only

Durable Medical Equipment

Emergency Health Services

Home Health Care

Hospice Care

Hospital – Inpatient Stay

Injections

Maternity Services

Mental Health and Substance Abuse Services

Outpatient Surgery, Diagnostic, and Therapeutic Services

Physician’s Office Services

Professional Fees for Surgical and Medical Services

Prosthetic Devices

Reconstructive Procedures

Rehabilitation Services – Outpatient Therapy

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Spinal Treatment, Chiropractic, and Osteopathic Manipulative Therapy

Temporomandibular Joint Dysfunction (TMJ)

Transplant Services

Urgent Care Services

What Is Not Covered – UHC

Alternative Treatments

Comfort or Convenience Services

Dental Services

Drugs

Experimental or Investigational Services or Unproven Services

Foot Care

Infertility Services

Medical Supplies and Appliances

Mental Health and Substance Abuse Services

Nutrition

Physical Appearance

Providers

Reproduction

Services Provided Under Another Plan

Transplants

Vision and Hearing

All Other Exclusions

How to File a Claim Under the UnitedHealthcare Plans

General Information

UHC Retiree Group Health Program Claims

Your ERISA Rights

General Information

Receive Information About Your Program and Benefits

Continue Group Health Plan Coverage

Prudent Actions by Plan Fiduciaries

Enforce Your Rights

Assistance With Your Questions

Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace

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Introduction

The medical, mental health and substance abuse, and prescription drug benefits available to an eligible former employee of Moore Wallace North America, Inc. (“Moore Wallace”) and its subsidiaries (“retiree”) and his or her covered spouse/domestic partner by the R.R. Donnelley & Sons Company Retiree Welfare Benefits Plan (“Plan”) are provided through two programs, the:

“Retiree Group Health Program”; and

“Prescription Drug Program.”

When the term “Program” is used in this Summary Plan Description (“SPD”), it refers collectively to the Retiree Group Health Program and the Prescription Drug Program. The “Retiree Group Health Program” consists of two additional programs, the Medical Program and the Mental Health and Substance Abuse Program, and when the term is used in this Summary Plan Description (SPD), it refers collectively to the Medical Program and the Mental Health and Substance Abuse Program.

This SPD explains retiree coverage for you and your spouse/domestic partner as of January 1, 2006 (unless used otherwise in the context, “you” or “your” when used in this SPD is intended to refer to the retiree, unless deceased, in which case it refers to the eligible spouse/domestic partner of the retiree). It details who is eligible for coverage, when coverage begins and ends, and which expenses are and are not covered under the Program. It also describes how to file a claim and your rights under the Program. Please read this information to familiarize yourself with the Program.

The Plan has contracted with a number of third parties to render services necessary for the operation and administration of the Program as the claims administrator and network manager. Some of these services involve authority and discretion over the Program. CIGNA HealthCare (CIGNA) is the claims administrator and network manager for the Medical Program. CIGNA Behavioral Health, Inc. is the claims administrator and network manager for the Mental Health and Substance Abuse Program. CVS Caremark | Caremark (CVS Caremark) is the claims administrator and network manager for the Prescription Drug Program. (See the “Administrative and Contact Information” section for additional information.)

In general, if you or your spouse/domestic partner is eligible for Medicare Parts A and B, the Program provides secondary coverage that is coordinated with Medicare benefits. However, if you or your spouse/domestic partner is enrolled in Medicare Part C – Medicare Advantage – you or your spouse/domestic partner will be covered only by the Prescription Drug Program. The Retiree Group Health Program will pay no benefits to you or your spouse/domestic partner. If you or your spouse/domestic partner is enrolled in Medicare Part D – Prescription Drugs – the Prescription Drug Program will pay no benefits to you or your spouse/domestic partner. (See the “Coordinating Benefits With Other Programs” section for additional information.)

This SPD and any supplemental information are intended to be a complete, accurate, and up-to-date description of your coverage under the Program. However, since treatments, protocols, and practice patterns continually change, this document cannot adequately define every potentially covered service or exclusion. In all cases, the applicable claims administrator will have the authority and discretion to make the determination of covered services. If there is any discrepancy between this SPD and the Plan, the Plan always governs.

In addition, nothing in this SPD should be interpreted as a guarantee of continued coverage. This summary merely describes the coverages and benefits currently offered to eligible retired employees and their spouses/domestic partners as of January 1, 2006. Moore Wallace reserves the right to change or terminate the Plan or Program, in whole or in part, at any time.

The Plan also provides similar retiree coverage for retirees of R.R. Donnelley & Sons Company (“RR Donnelley”) and its subsidiaries (other than Moore Wallace and its subsidiaries). This retiree coverage is described in a different SPD for those RR Donnelley retirees.

This content contains a summary in English of your rights and benefits under the Program. If you have difficulty understanding any part of this content, call the RR Donnelley Benefits Center at 1-877-RRD-4BEN (1-877-773-4236). Benefits Center Representatives are available from 8 a.m. to 5 p.m. CT, Monday through Friday, except holidays.

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