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Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - RR Donnelley   
Coordinating Benefits With Other Programs
How Coordination of Benefits Works
When you or your spouse has a claim for an expense that is covered by two or more programs, one pays benefits first. This program is known as the primary program. The other programs, called secondary programs, then determine how much of the covered expense, if any, is to be paid from those programs.
When the Program is primary, it pays the amount allowable under the Program.
When the Program is secondary, it pays the amount necessary so that the total amount you or your spouse receives from the Program and the primary program combined is no greater than the amount you or your spouse would have received under the Program alone.
For example, assume that your spouse has other group coverage that is primary and pays first. After his or her employer’s program processes the claim, the Program then determines how much it will pay. The benefit is calculated in the usual way (applying any deductible, coinsurance percentage, penalties, and other limits); then this amount is subtracted from the benefits paid by the primary program.
If the primary program pays more than what the Program would pay, you or your spouse does not receive a benefit from the Program. If the primary program pays less than what the Program would pay, you or your spouse receives the difference.
A program without a COB provision is always considered primary. If all programs have COB provisions, a program that covers a patient as an active employee or a primary beneficiary is primary over a program that covers the patient as a spouse.
The claims administrator may ask you, on an annual basis, to provide or confirm information about other programs under which you and your spouse are covered.
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