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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

Enrolling for Coverage

General Information

Enrolling Yourself and Your Spouse

Eligible Surviving Spouse’s Enrollment

If You or Your Spouse Is Receiving Treatment When Coverage Begins

Program Premium Cost

Determining an Annual Premium for You and Your Spouse

Total Cost of Coverage

Annual Subsidy Cap Amount

Continuous Service

Examples

If You Are Involuntarily Separated

If You Are on an Authorized Leave of Absence

If You Die

If You Are Not Eligible for an Annual Subsidy Cap Amount

How Your Monthly Contributions Change When You or Your Spouse 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

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 - RR Donnelley

Who Is Eligible

Benefits-Eligible Position

Examples

1. If you terminate employment with RR Donnelley or any of its subsidiaries at age 57, with nine and one-half years of service in a benefits-eligible position, you are not eligible for the Program. If you are rehired by RR Donnelley or any of its subsidiaries in a benefits-eligible position and earn one year of service, when you terminate employment you will be eligible for the Program.
2. If you have been employed eight years in a benefits-eligible position and you transfer at age 53 to a full-time position at RR Donnelley or any of its subsidiaries that is not a benefits-eligible position, you will be eligible for the Program if you continue to be employed in that position until you have 10 or more years of service and attain age 55.
3. If you complete 15 years of service in a benefits-eligible position at age 50, and you then cease to be a benefits-eligible employee, you will not be eligible for the Program when you terminate employment with RR Donnelley or any of its subsidiaries unless you become employed in a benefits-eligible position before you terminate employment with RR Donnelley or any of its subsidiaries. However, if you cease to be benefits-eligible at age 56 with 15 years of service, you will be eligible for the Program when you terminate employment with RR Donnelley or any of its subsidiaries.

For information, see the “Participating Employers” and the “Special Rules for Certain Participants” sections of this SPD.