| Navigation Options | |
 |
|
| Table of Contents | |
|
|
|
Detailed Table of Contents |
|
|
| Index | |
|
|
Introduction
Who Is Eligible
 |
|
 |
|
|
|
|
|
Enrolling for Coverage
|
|
|
Program Premium Cost
| Determining an Annual Premium for You and Your Spouse/Domestic Partner |
|
|
|
|
Your Rights and Responsibilities
|
|
How the Retiree Group Health Program Works
|
|
|
|
|
|
|
|
|
|
|
| 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 |
|
|
|
|
|
|
|
|
|
|
| What Is an Expense That May Be a Covered Expense – Medical Program |
|
|
|
|
|
| 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
|
|
|
|
| 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 |
|
|
| How to Fill Your Prescriptions through the Mail Service Pharmacy |
Your Legal Right to Continuation Coverage
|
|
|
|
|
|
Coordinating Benefits With Other Programs
|
|
|
How to File a Claim
|
|
ERISA Claims and Appeals Procedures
|
|
Situations Affecting Your Benefits
|
|
| Right to Reimbursement, Assignment of Rights, and Duty to Notify |
Administrative and Contact Information
|
Special Rules for Certain Participants
|
|
|
|
|
|
|
| Wallace, Litho, Nielsen Retiree Group (retired on or after January 1, 2004) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Skilled Nursing Facility/Inpatient Rehabilitation Facility Services |
| Spinal Treatment, Chiropractic, and Osteopathic Manipulative Therapy |
|
|
|
|
|
|
|
|
| Experimental or Investigational Services or Unproven Services |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Your ERISA Rights
|
|
|
|
|
|
Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace
How to File a Claim
Filling Prescriptions at Non-Participating Retail Pharmacies
CVS Caremark is the claims administrator and network manager for the Prescription Drug Program.
You or your spouse/domestic partner is responsible for paying the full cost at the time you or your spouse/domestic partner has your prescription filled. You or your spouse/domestic partner must complete a Prescription Drug Claim Form, which is available by calling the claims administrator at the phone number listed on your prescription ID card.
Complete the form (you or your spouse/domestic partner may want to keep a copy for your records) and send it, with the original receipts attached, to the claims administrator at the address on the form. It is important that you or your spouse/domestic partner fill out the claim form completely, including:
 | The name of the drug received (when filing a claim for prescriptions outside the United States); |
| The name of the pharmacy dispensing the drug, and the seven-digit NCPDP (National Council for Prescription Drug Programs) number of the pharmacy; |
| The date you or your spouse/domestic partner purchased the drug; |
| The prescription number, name, NDC# (National Drug Code number) supply (number of days), and quantity of the drug; and |
|
You or your spouse/domestic partner must also include an itemized receipt that shows the amount you or your spouse/domestic partner paid for each prescription. When your claim is processed and approved, you or your spouse/domestic partner may receive a partial reimbursement of the retail cost depending on the Medical Program you choose.
