Important Telephone and Contact Information
Injuries and Illnesses
Allowable Charges
PPO Versus Non-PPO Providers
What You Pay
Coinsurance
Copayments
Maximum Out-Of-Pocket Spending Limits
Calendar Year Deductibles
Lifetime Maximum Benefit
Healthcare Spending Accounts
Healthcare Spending Account Administrator
Who Pays For My Benefits?
Am I Eligible For Benefits?
How Do I Enroll?
Who Does The Plan Cover?
When Does My Coverage End?
What Is A Certificate Of Credible Coverage?
Can I Change My Coverage?
What If My Spouse and I Both Work At Cooper?
Benefit Options
An Overview Of The Medical Benefit Options
Catastrophic Option
Premium and Basic PPO Options
Out-Of-Area Option
Medical Benefits Options At A Glance
Medical Benefits: What Your Plan Covers
Doctor and Specialist Services and Supplies
Emergency, Hospital, and Surgical Services
Hospice, Skilled Nursing Facility, and Home Healthcare
Durable Medical Equipment and Orthotic Devices
Inpatient Mental Health and Substance Abuse
Outpatient Mental Health and Substance Abuse
Medical Benefits: Specific Plan Exclusions and Limitations
Care Management and Pre-Certification
Pre-Certification
Contacting Health Design Plus
Case Management
Experimental, Investigational and Unproven Procedures
Medically Necessary Care and Treatment
Determinations By The Plan Administrator
Dental Benefits Options At A Glance
Dental Benefits: What Your Plan Covers
Dental Benefits: Specific Plan Exclusions and Limitations
Vision Benefits: What Your Plan Covers
Covered Vision Care Benefits and Materials
Member Providers and Non-Member Providers
Vision Benefits: Specific Benefit Exclusions and Limitations
Your Prescription Drug Benefits
Prescription Drug Benefits At A Glance
Prescription Drug Benefits: What Your Plan Covers
Covered Prescription Drugs
The Plan's Prescription Drug Benefit Manager
Generic Drugs Versus Brand-Name Drugs
Prescriptions From Non-Participating Pharmacies
Initial Prescriptions, Refills and Maintenance Drugs
Prescription Drug Benefits:
Specific Benefit Exclusions and Limitations
General Plan Exclusions and Limitations:
Medical, Prescription Drug, Dental, and Vision Benefits
Federal Laws Impacting Your Benefits
The Women's Health and Cancer Rights Act
The Newborns' and Mothers' Health Protection Act
Qualified Medical Child Support Orders
COBRA Continuation Coverage
Which Plan Pays First?
How Does Coordination Of Benefits Work?
What Are The Special Rules For Medicare?
Third-Party Liability and Subrogation
Who Can Elect COBRA Coverage?
What Is A Qualifying Event?
Is COBRA Coverage Automatic?
What Coverage Can Be Continued?
How Long Can Coverage Be Continued?
Special COBRA Rules For Medicare Entitlement
What Are The Notice Requirements?>
When Does COBRA Coverage Terminate?
How Do I Add Dependents Under My COBRA Coverage?
What Are The Election and Payment Deadlines?
General Claims and Appeals Procedures
Claims Filing Limit
Medical and Dental Claims
Prescription Drug Claims
Vision Benefit Claims
Medical and Dental Claims Payment
What If My Claim Is Denied?
What Are The Appeals Procedures?
Interpretation Of Plan Provisions
Amendment or Termination Of The Plan
Provider Decisions
Workers' Compensation
Plan Administrator
Employer Identification Number and Plan Number
Plan Year
The Plan Administrator is:
Cooper Tire & Rubber Company (Cooper)
Medical/Prescription Drug Plan, Dental Plan and Vision Plan Administrator
Attn: Vice President, Human Resources Department
701 Lima Avenue
Findlay, OH 45840TELEPHONE: (419) 423-1321
Cooper has contracted with Health Design Plus, Inc. (HDP) to perform third-party claims administration, COBRA administration and Care Management:
Health Design Plus, Inc.
1755 Georgetown Road
Hudson OH 44236Claims and Network Information: 1-877-286-3559
Pre-Certification: 1-877-286-3560
The Preferred Provider Organization ("PPO") Option for Medical Benefits is available to you, depending upon your residential zip code. The currently available PPO's are:
NPPN (800) 557-1656
OhioHealth Group (800) 635-7207
PPOM (800) 831-1166
MedCost (800) 824-7406
Health Link (800) 453-7536
In lieu of a PPO, you may select the Catastrophic Option. If you do not live in a PPO coverage area, you can be enrolled in the Out-Of-Area Option.
Cooper has contracted with Vision Service Plan, Inc. to provide you with a Vision Care Plan:
Vision Service Plan, Inc. (VSP)
3333 Quality Drive
Rancho Cordova, CA 956701-800-877-7195
Cooper has contracted with AdvancePCS to provide you with a Prescription Drug Plan.
Advance PCS Health L.P.
9501 East Shea Boulevard
Scottsdale, AZ 85260-67191-800-966-5772
Cooper's Health & Well-Being Program is a comprehensive program for full-time salaried and nonbargained Cooper employees and their eligible dependents.
This document is your Summary Plan Description (SPD) for Medical/Prescription Drug Plan, Dental Plan and Vision Plan benefits (collectively Plan) only. It does not provide information regarding any other benefits you may have in the Health & Well-Being Program, such as life insurance, dependent care spending account, short-term disability, or long-term disability.
The SPD is a summary of the Plan and describes:
If information contained in the SPD is inconsistent with the Plan document, then the Plan document shall govern.
No person, other than the Plan Administrator, has the authority to interpret any provisions of the Plan, or this SPD.
YOUR PLAN CONTAINS CERTAIN PRE-CERTIFICATION REQUIREMENTS. IF YOU FAIL TO OBTAIN PRE-CERTIFICATION WHEN REQUIRED BY THE PLAN YOU MAY BE SUBJECT TO A $250 BENEFIT PENALTY. SEE Care Management and Pre-Certification FOR ADDITIONAL INFORMATION REGARDING PRE-CERTIFICATION.
These definitions are provided for your general understanding of terms as they apply to the Plan. More detailed information may be found throughout the text of this SPD.
Accident: An unexpected, unusual, unforeseen, or unlooked for event or happening that causes or results in a bodily injury.
Admission(s): Confinement in a public or private facility, licensed and operated as an acute care, or psychiatric Hospital that provides care and treatment by Doctors and nurses on a 24-hour basis for an illness or injury through the medical, surgical and diagnostic facilities on its premises. An admission may also refer to a confinement in a Skilled Nursing Facility, Hospice, licensed residential treatment center, rehabilitation center, or any other type of healthcare facility approved by the Plan.
Allowable Charges: The maximum amount considered for covered services. The Plan pays the percentage of the Allowable Charges shown in the schedule of benefits, or a percentage of the actual bill, whichever is less. To the extent benefits are paid pursuant to the PPO agreement or Contracted Rate, the Allowable Charge is the rate specified in such agreement(s).
Alternate Birthing Facility: A facility licensed as an Alternate Birthing Facility by an agency of the state in which such facility operates. If licensing is not required in the state of operation, the center must meet the American Public Health Association Guidelines for operation of birthing centers.
Ambulatory Medical-Surgical Facility: A freestanding ambulatory surgical center or a facility offering ambulatory medical services, provided such facilities are not part of a Hospital and further provided that such facilities have been licensed to provide medical treatment by the appropriate State Board of Health.
Care Management: Also known as "utilization management" or "utilization review." The system utilized by the Plan or its designee for implementing the necessary, appropriate, and cost-effective allocation of healthcare resources and services provided to or proposed for an eligible employee or eligible dependent. Care Management consists of, but is not limited to: (i) Pre-Certification, (ii) concurrent review, (iii) retrospective review, of certain inpatient and outpatient surgical procedures, hospitalizations, diagnostic testing, prescription drug therapies, and such other services, treatments, and procedures as specified in the Plan's schedules of benefits, as amended from time to time.
Case Management: A program administered by the Plan or its designee, whereby medical professionals work with you, family/caregivers, Doctors, and other healthcare providers to coordinate and develop a timely and cost effective treatment.
COBRA: The federal law by which eligible employees and eligible dependents may continue to receive benefits available under the terms of the Plan after such eligible employees and their eligible dependents no longer satisfy the Plan's eligibility requirements, provided that such employees and dependents who would otherwise lose coverage satisfy the criteria for COBRA eligibility.
Coinsurance: The portion (as a percent of the cost for services), that you must pay each time you use a service. The amount varies, depending on the cost of the service.
Contracted Rate: The rates specified in the Plan's agreements with PPO Providers for specific services.
Coordination of Benefits (COB): A payment policy of the Plan that states how benefits will be paid if you or your eligible dependents are covered under this Plan and another health plan, and/or how benefits will be paid if you and your eligible dependents have dual coverage under this Plan and another health plan.
Copayments or Copays: The dollar amount that you or your eligible dependents must pay directly to a provider out of your own pocket at the time services are rendered when accessing certain benefits available under the Plan, as set forth in the Plan's applicable schedules of benefits.
Corrective Appliances: The general term for appliances or devices that support (Orthotic) or replace (Prosthetic) body parts to alleviate a body defect.
Cosmetic or Reconstructive Surgery: Any surgical procedure primarily for:
Deductible: The amount of eligible expenses which must be incurred by an eligible employee or eligible dependent during each calendar year before benefits become payable under the Plan.
Dentist: An individual who is licensed to practice dentistry or perform oral surgery in the state where the dental service is performed and who is operating within the scope of his license. For the purpose of this definition, a Doctor will be considered to be a Dentist when he performs an eligible dental service and is operating within the scope of his or her license.
Doctor: A person who is licensed to practice medicine and surgery as a Doctor of Medicine or Osteopathy or a person who is a licensed Dentist, podiatrist, chiropractor, or optometrist who is practicing within the scope of his or her license. For purposes of the Plan, "Doctor" does not include the employee or his or her dependents or any person who is a relative by blood or marriage of the employee or his or her spouse, even if he or she otherwise satisfies the requirements as contained in the Plan's definition of Doctor.
Durable Medical Equipment: Equipment that:
Durable Medical Equipment includes, but is not limited to, oxygen, ventilators, hospital beds, and wheelchairs.
Emergency Admission: An emergency admission is an admission resulting from an unforeseen injury or illness requiring surgical, medical, or behavioral health services treatment of sufficient severity that in the absence of immediate surgical, medical, or behavioral health treatment could result in serious physical impairment of bodily functions or death. An emergency admission is also defined as one where a Doctor admits an individual to an acute care Hospital due to a sudden or unexpected change in the individual's physical or mental condition that is severe enough to require immediate confinement to such institution as an inpatient.
Emergency Treatment: Medically necessary treatment received in connection with an unforeseen injury or illness requiring surgical, medical, or behavioral health attention within 24 hours of onset, and which, without care, would result in serious physical impairment or death. The Plan Administrator has sole discretion in determining what is considered an emergency.
Employer: Cooper Tire & Rubber Company.
ERISA: The Employee Retirement Income Security Act of 1974 is a legislative act defining the fiduciary responsibilities of the people engaged in the administration, supervision and management of health and pension plans. ERISA also gives specific rights to participants of health and pension plans.
Experimental, Investigational, or Unproven Procedures: Experimental, investigational, or unproven procedures are those which are classified that way by agencies or subdivisions of the federal government such as the Food and Drug Administration (FDA) or the Office of Health Technology Assessment of the Health Care Financing Administration (HCFA); or according to HCFA's Medical Coverage Issues Manual or Medicare.
Home Health Care: Continued care or treatment of an eligible employee or eligible dependent in his/her home. To qualify, a plan must be established in writing by a Doctor who certifies that the eligible employee or eligible dependent would require confinement in a Hospital if he did not have the care and treatment stated in the plan. The plan is subject to review and approval by an approved medical review organization.
Hospice: A Medicare certified and licensed facility and/or personnel contracted with the Plan to provide inpatient acute care services and outpatient services to terminally ill eligible persons.
Hospital: An institution that:
A Hospital is not an institution or part of an institution that is primarily a nursing home or primarily a place for rest for the aged.
Illness: Any physical or mental sickness or disease which manifests treatable symptoms and which requires treatment of a Doctor. This definition also includes pregnancy and the treatment for alcohol and substance abuse, as well as psychiatric conditions.
Injury: Trauma to the body requiring treatment by a Doctor, caused by a sudden, unforeseen, unexpected external event, or Accident.
Medically Necessary Care and Treatment: Those procedures, treatments, services, supplies, and facilities where treatment is rendered, which are, whether rendered on an impatient or outpatient basis:
The final determination as to what constitutes Medically Necessary Care and Treatment under the Plan shall be made by the Plan Administrator and/or its designee, unless otherwise specified in the Plan Document or in the policies and procedures adopted by the Plan Administrator from time to time, as they deem appropriate in carrying out the administration of the Plan.
Medicare: Benefits provided under Title XVIII of the United States Social Security Act of 1965, as amended from time to time.
Mental Illness: Mental disease or disorder or functional nervous disorder as recognized or defined by the American Psychiatric Association.
Nurse Midwife: A person who:
Nurse Practitioner: A person who:
Plan Administrator: Cooper Tire & Rubber Company.
Plan: The plan, program, method, and procedure adopted by the Plan Administrator for the payment of medical, prescription drug, vision, and dental benefits permissible under 29 U.S.C. Section 186, and in accordance with such amendments, rules, and regulations, as are adopted by the Plan Administrator.
PPO Provider: Healthcare professionals or facilities that have a contract with the Plan to provide specific services to Plan participants at specific rates.
Preferred Provider Organization (PPO) Benefits: Those health benefits payable under the Plan for services received from PPO Providers that have been contracted with the Plan to provide services at established rates.
Pre-Certification: Also known as "prior-authorization" or "pre-admission review." The requirement that the Plan or its designee be provided with justification, as a condition of coverage and reimbursement by the Plan, for the delivery of particular services, and/or medications to an eligible employee or eligible dependent prior to the actual provision of such services, supplies, and/or medications. The Plan or its designee may, from time to time, amend categories of medical services, supplies, and/or medications that require prior authorization under the Plan.
Prosthetic Appliance (or Device): An artificial appliance or device designed to replace all or part of a body part and used to alleviate a body defect, including, but not limited to, artificial limbs, heart pacemakers, corrective lenses needed after cataract surgery.
Reasonable or Customary Charge: A charge for healthcare services that is consistent with the prevailing rate or charge within a certain geographical area for identical or similar services or supplies. A fee is considered to be Reasonable and Customary if it falls within the parameters of the average or commonly charged fee for the particular service or supply within that specific community.
Room and Board: Charges made by a Hospital for the cost of a semi-private room, general duty nursing care, and other services routinely provided to all inpatients, not including Special Care Units.
Second Opinion: A medical opinion by a Doctor other than an eligible employee's or eligible dependent's treating Doctor. The Plan, or its designee, has the right to require you to obtain a second opinion prior to receiving any benefits that may otherwise be available under the Plan.
Skilled Nursing Facility: An institution or that part of any institution which operates to provide convalescent or nursing care and:
Social Security Disability: Disability under Social Security is based upon your inability to work. The Social Security Administration considers you disabled under Social Security Rules if you cannot do work you did before and the Social Security Administration determines that you cannot adjust to other work due to your medical condition. Your disability must also be expected to last for at least one year or to result in death.
Special Care Unit: A Hospital unit which provides concentrated special equipment and skilled personnel for the care of the critically ill patients requiring immediate, constant and continuous attention. This includes charges for intensive care, coronary care, and acute care units of a Hospital, but does not include a surgical recovery or post-operative room. The unit must meet the required standards of the Joint Commission on Accreditation of Hospitals for Special Care Units.
Subrogation: The Plan's right to withhold benefits and/or recover amounts paid on behalf of an eligible employee or eligible dependent if another party or another party's insurer may be liable for the expenses.
Substance Abuse: Dependence on drugs or alcohol. This includes, but is not limited to, dependence on drugs that are medically prescribed.
Surgical Assistant: A person who is a graduate of a Surgeon Assistant program approved by the Commission on Accreditation of Allied Health Education Programs and is currently certified by the National Commission on Certification of Physician Assistants, who is certified to perform medical services with Doctor supervision by the Board of Medical Examiners of the State in which the treatment was provided. For purposes of the Plan, the term "Surgical Assistant" does not include the eligible employee or his or her eligible dependents or any person who is a spouse, child, parent, brother, or sister of the eligible employee, or his or her spouse, even if he or she otherwise satisfies the above-described requirements.
Surgical Supplies: Supplies and dressings required to cover or protect an open wound resulting from a covered surgical procedure. Surgical Supplies does not include support hose.
Terminal Illness: Any sickness or disease determined to have no effective treatment or cure and resulting in a life expectancy of six (6) months or less.
Total Disability: An eligible employee is considered to be Totally Disabled if he or she is prevented by Accident, Injury, or Illness from engaging in any occupation for which he or she is reasonably qualified by education, training or experience, provided that such Total Disability is established by objective medical evidence of a nature satisfactory to the Plan or its designee, and further provided that the nature of the disability for which benefits are claimed are of such severity as to require the employee to be under the regular and continuous care of a Doctor. The Plan, or its duly authorized designee, shall review and assess the objective medical evidence submitted by the eligible employee. Such objective medical evidence must indicate, to the extent feasible with respect to a given condition, clinical evidence of the cause of the condition, such as laboratory results, x-rays and imaging files, and such other medical tests as are appropriate to permit measurement of the claimed Injury or Illness. Subjective complaints by an eligible employee shall not constitute objective medical evidence within the meaning of the Plan. The Plan, or its designee, shall have the right, in their sole discretion, to determine what records and/or test results constitute objective medical evidence.
Urgent Care: Medical care services or supplies, without which a person's life, health, or ability to regain maximum function would be in serious jeopardy.
Urgent Care Facility: A freestanding facility offering ambulatory medical services, provided such facility is not part of a Hospital and further provided that such facility has been licensed to provide medical treatment by the appropriate State Board of Health.
Well-Baby Care: Care obtained for non-illness related visits to a healthcare professional for dependent children to age 4.
Workers' Compensation: The laws of any state that impose liability on an employer of a person who is injured, becomes ill, or killed as a result of, or in connection with, a work-related activity, or whose Injury, Illness, and/or death, arise out of, or in the course of such employment, or which impose such liability on the employer's Workers' Compensation insurance.
Plan benefits for Injuries or Illnesses are based on Allowable Charges for covered services resulting from Medically Necessary Care and Treatment prescribed or furnished by a Doctor or healthcare professional.
READ THIS SECTION CAREFULLY, AS IT EXPLAINS HOW MUCH THE PLAN WILL PAY AND HOW MUCH YOU MAY BE REQUIRED TO PAY FOR SERVICES AND SUPPLIES.
The Plan provides medical benefits for the treatment of Illnesses or Injuries not related to employment.
The Plan pays benefits based upon Allowable Charges. An Allowable Charge is the amount upon which benefits are based for covered treatments, services, or supplies. The Plan's Allowable Charge may be less than the amount of the bill from the provider.
The Plan Administrator has the sole authority to determine the level of Allowable Charges the Plan will use, and in all cases the Plan Administrator's determination will be final and binding.
For purposes of payment of benefits, the Plan distinguishes between treatment by PPO Providers in your network, and treatment by non-PPO Providers. If you select either PPO Option, to receive the Plan's highest reimbursement levels, all medical treatment must be administered by PPO providers in your network. Treatment received from PPO Providers outside of your PPO network or non-PPO Providers is generally reimbursed at a lower level. Reduced health care costs are the primary advantage to using PPO Doctors and Hospitals in your network. Because services are provided at discounted rates, your out-of-pocket costs - the amounts you have to pay - are lower than they would be otherwise. You only have to pay the difference between Plan benefits and the provider's discounted rate. For treatment by a non-PPO Provider or a PPO Provider outside of your network, you pay the difference between Plan benefits and the provider's billed charge.
You are responsible for paying the Deductible, any required Copayments or Coinsurance, and any portion of charges the Plan does not pay.
Coinsurance is the portion (as a percent of the cost for services) which you pay each time you use a service. The amount will always depend on the cost of the service. The Coinsurance percentage differs based upon the type of benefit option you select (Catastrophic, Basic PPO, Premium PPO, or Out-of-Area) and based upon the type of service or supply rendered, and based upon whether or not the services are provided by a provider within the network or outside of the network you have selected. Please see Medical Benefits Options At A Glance for Coinsurance amounts applicable to your Medical Benefits.
The amount you pay each year in Coinsurance and Deductibles counts toward satisfaction of your annual out-of-pocket limits, except charges related to inpatient and outpatient mental health/substance abuse services.
A Copayment is the amount you must pay at the time treatment is received from a PPO Provider within your network. However, Copayments will not be applied to the medical calendar year deductible or maximum out-of-pocket spending limits. Copayments differ depending on the type of services you obtain. Please see Medical Benefits Options At A Glance for specific medical benefit Copayment requirements. Copayments for medical services only apply if you select either Basic or Premium PPO coverage.
Each of the four benefit options has a different maximum out-of-pocket spending limit. This is the maximum amount that you must pay out of your pocket for benefits. Once you have paid this maximum amount, the Plan will pay 100 percent of the Allowable Charge for the remainder of the calendar year, except for those benefits subject to Copayment amounts. Maximum out-of-pocket limits are as follows:
Catastrophic Option I
Individual: $ 6000 Family: $12000
Basic PPO Option II
Individual: $ 1,000 Family: $ 2,000
Individual: $ 2,500 Family: $ 5,000
Premium PPO Option III
Individual: $ 500 Family: $ 1,000
Individual: $ 1,800 Family: $ 3,600
Out-of-Area Option IV
Individual: $ 1,000 Family: $ 2,000
Before any medical benefits are paid for certain kinds of covered expenses, you pay a portion of the Allowable Charges. The portion you pay is called the Deductible. The Plan counts your Deductible payment on a calendar year basis.
The Deductible amount differs depending on which option you have selected and whether you selected individual or family coverage. Deductibles are as follows:
Catastrophic Option I
Individual: $1,000 Family: $2,000
Basic PPO Option II
Individual: $ 250 Family: $ 500
Individual: $ 500 Family: $1,000
Premium PPO Option III
Individual: $ -0- Family: $ -0-
Individual: $ 300 Family: $ 600
Out-of-Area Option IV
Individual: $ 250 Family: $ 500
All family members can satisfy the family Deductible.
Example: Your family has the Basic PPO Option II family coverage, receives medical services from PPO Providers within your network, and incurs the following Deductibles:
Employee: $200.00 Spouse: $ -0- First Dependent Child: $175.00 Second Dependent Child: $125.00 TOTAL: $500.00
These Deductibles total $500.00 and therefore you have met the family Deductible requirement. In addition, once the family Deductible is satisfied, no further Deductible will apply to any individual in your family.
If you are in either PPO Option your Deductibles co-mingle; that is, if you satisfy $100 of your out-of-network deductible, $100 of your in-network Deductible is also met. Deductibles count toward satisfaction of your out-of-pocket limits, except for charges related to mental health/substance abuse.
The maximum amount of medical benefits the Plan will pay during a person's lifetime for covered expenses is $2,000,000. This amount includes mental health and substance abuse benefits, but does not include benefits for dental and vision services. Once the maximum amount is reached, no further medical benefits can be paid.
The Plan offers you the advantage of establishing a Healthcare Spending Account. This account may offer you tax benefits; as you may use pre-tax dollars to pay for eligible out-of-pocket expenses. A Healthcare Spending Account allows you to pay for eligible out-of-pocket healthcare expenses which are not covered by the Plan, such as Copayments or Deductibles. Money contributed to this account is deducted from your pay before taxes are withheld. You have the option of contributing between $260 and $2990 per year to a Healthcare Spending Account.
Cooper cannot provide you with financial or tax advice, so you may wish to consider consultation with your personal financial advisor or tax advisor regarding the financial benefits of establishing this type of account. By federal law, any remaining balance in your account at the end of each calendar year must be forfeited. You must use this benefit or lose it.
Cooper's Healthcare Spending Account Administrator is:
Health Design Plus, Inc.
1755 Georgetown Road
Hudson OH 44236
The telephone number for Healthcare Spending Account information is:
1-877-286-3559
Cooper's Health & Well-Being Program is a flexible benefit program. This approach to benefits allows you to choose coverage to fit your needs. Each coverage option has a different price tag, or cost, and Cooper provides you with a flex allowance to help offset the cost of coverage.
A flexible benefit program gives you more control over how much you pay for healthcare coverage, based on the coverage choices you make.
Cooper will provide each eligible employee with a flex allowance, each year, toward the cost of coverage you choose.
For your medical benefits, the amount of the flex allowance is based on the type of coverage you select and your number of eligible dependents.
For your dental benefits, the flex allowance is a flat dollar amount regardless of your number of dependents, and may differ based on your employment location.
There is no flex allowance for vision benefits.
Depending on the benefits you select, you may be required to contribute toward the cost of your Plan. If your flex allowance is more than the cost of your benefit choices, you will receive the difference, in taxable income, each pay period.
You are eligible to participate in the Plan if you are a full-time salaried or non-bargained Cooper employee. You are eligible for benefits beginning on the first of the month following the date you first render services for Cooper and are actively at work.
In order to participate in the Plan, you must first enroll. There are two ways to enroll in the Plan:
IF YOU DO NOT ENROLL IN THE PLAN, YOU WILL NOT BE ABLE TO RECEIVE BENEFITS.
The Plan covers you and your eligible dependents. For purposes of this Plan, your eligible dependents are:
- Your unmarried children (having never been married) to age 19;
- Your unmarried children (having never been married) to the earlier of three months following termination of full-time student status or to age 25, who are full-time students in an accredited school. You will be required to submit proof of full-time student status to the Plan to continue coverage.
- Children, including stepchildren, legally adopted children, and children over whom you have legal guardianship, provided that they reside with you in a normal parent/child relationship. Eligibility is subject to appropriate legal documentation.
- A child for whom you are required to provide health insurance under a Qualified Medical Child Support Order.
- A child who is physically or mentally incapable of self-support and is 19 years or older, subject to a Doctor's written certification.
Additions of a spouse or dependent children due to a qualifying event will be effective as of the date of the qualifying event, provided that you notify Cooper within 31 days of the qualifying event. If you do not notify Cooper within 31 days of the qualifying event, you must wait until the next open enrollment period to add these dependents.
Coverage ends for you and your eligible dependents when you are no longer a full-time salared or non-bargained Cooper employee. For example, if you terminate employment, or change from full-time to part-time status, your coverage will end as of that date. After your coverage ends, you are able to obtain COBRA continuation insurance. Please see How Can Coverage Be Extended? for more information on COBRA.
Your coverage will also end in the event that the Cooper Spectrum Medical/Prescription Drug Plan, Dental Plan and Vision Plan is terminated by Cooper.
In the event that you lose eligibility during a Hospital confinement the Plan will continue to pay claims you incur during that confinement, provided that (1) you were eligible on the first day of your stay, and (2) the claims are for services or supplies rendered as a result of the course of treatment associated with that specific Hospital stay. Any changes for services incurred after the date of discharge will not be covered, even if the services are related to the cause of that hospitalization.
Any time a person loses coverage, the Plan will automatically send a certificate documenting up to 18 months of coverage under the Plan. The certificate is required by the Health Insurance Portability and Accountability Act (HIPAA), and if you or a dependent become covered under another group health plan, the length of coverage under this Plan can be used to reduce any pre-existing condition time limits imposed by the new plan. The Plan automatically sends a certificate when your eligibility terminates, either as a result of a COBRA qualifying event or other causes. A second certificate is automatically sent when a person's COBRA continuation coverage ends. For details on COBRA, see How Can Coverage Be Extended?. A copy of the last certificate issued, updated to show any additional coverage, can also be requested within the 24 months immediately following the date Plan coverage ends.
Among other things, each certificate shows the persons covered by the Plan and the length of coverage applicable to each. For those with less than 18 months of coverage, the waiting period before coverage begins will also be shown.
The benefits you choose are in effect for the entire year, unless you experience a qualified status change. If you want to change coverage when you experience a qualified status change, you must change your benefit choices within 31 days of the event. If you do not change your benefit choices within 31 days of a qualified status change you will not be eligible to make a change until the next annual open enrollment.
Qualified Status Changes include the following:
If you are married to another Cooper employee who is eligible for Plan benefits, you cannot be covered as both an employee and a dependent. For purposes of the Medical Plan, if you and your spouse have no additional dependents, each of you must enroll in employee-only coverage. If you and your spouse have additional dependents, the employee with the earlier calendar year birth date is responsible for covering your entire family (you must select employee + two or more coverage) and your spouse must select "No-Coverage." For additional information, see Coordination Of Benefits.
The Plan offers you options to enroll yourself, your spouse, and your dependents for medical/prescription drug, dental and vision benefits. You can select which benefits you would like your dependents to enroll in. However, any dependents you decide to enroll in the medical/prescription drug, dental and/or vision plan, must have the same benefit options (e.g., Premium PPO Plan, Dental Option I) as you select, or less coverage. At no time may a dependent have greater coverage than you.
You have various choices in selecting the kind of benefits you want. With respect to your medical benefits, your benefit choices depend on your residential zip code.
If you live in a Preferred Provider Organization ("PPO") service area, you have the following medical benefit choices:
If you do not live in a PPO service area, you have the following benefit choices:
Each benefit option-Catastrophic, Basic PPO, Premium PPO, and Out-of-Area-has different calendar year Deductibles, different out-of-pocket benefit maximums, and different plan payment percentages. Please see Medical Benefits Options At A Glance for an overview of these Plan options.
Catastrophic Option: The Catastrophic Option is offered as an alternative option only in areas where PPO Options are available. It offers you the opportunity for coverage of the services of the Plan at a basic level of cost. Under this Plan, you may see any Doctor or provider you wish; however, you are required to pay a higher Deductible and a higher out-of-pocket maximum than exists under the other available options.
Premium and Basic PPO Options: The Premium and Basic PPO Options offer you the same benefits, but differ in how costs are shared. With both PPO Options, you have a choice each time you seek care. You can obtain services from a Doctor, Hospital, or other medical providers who are PPO Providers in your PPO Network or you can use "out-of-network" providers. If you choose to use an out-of-network provider for services, you will pay more out-of-pocket for your care. The Premium PPO Option offers lower Deductibles, out-of-pocket costs, and Copays than the Basic PPO Option.
A PPO option offers a network of providers who have agreed to perform services at set rates. Providers who have agreements with the PPO are known as PPO Providers. All other providers are known as "out-of-network" providers. For benefit purposes, the PPO Options distinguish between in-network and out-of-network providers. To receive the Plans' highest reimbursement levels, all medical treatment must be administered by in-network providers. Treatment received from out-of-network providers is generally reimbursed at a lower level. Additionally, your out-of-pocket costs are always lower when you use a PPO Provider.
Out-of-Area Option: If you do not live in a PPO area, you may select the Out-of-Area Option. The Catastrophic Option is not available. The Out-of-Area Option has a lower Deductible amount than the Catastrophic Option and allows you to see any healthcare provider you wish.
The Plan only pays for services rendered by a covered provider. A covered provider must be practicing within the scope of his or her license in order for the Plan to pay for benefits received. The following providers are covered under the Plan:
| Catastrophic Option I | Basic PPO Option II Where a network is available |
Premium PPO Option III Where a network is available |
Out-of-Area Option IV Where a network is NOT available |
|||
|---|---|---|---|---|---|---|
| In-Network | Out-of Network | In-Network | Out-of Network | |||
| Calendar Year Deductible | $1,000/ $2,000 |
$250/ $500 |
$500/ $1,000 |
$0/ $0 |
$300/ $600 |
$250/ $500 |
| Coinsurance | Covered at 80% after deductible | Covered at 80% after deductible | Covered at 70% after deductible | Covered at 90%. | Covered at 70% after deductible | Covered at 80% after deductible |
| Maximum Out-of-Pocket Limits (includes individual/family deductible) | $6,000/ $12,000 |
$1,000/ $2,000 |
$2,500/ $5,000 |
$500/ $1,000 |
$1,800/ $3,600 |
$1,000/ $2,000 |
| Office Visit Copay* | Covered at 80% after deductible | $15 Copay | Covered at 70% after deductible | $10 Copay | Covered at 70% after deductible | Covered at 80% after deductible |
| Urgent Care Copay* | Covered at 80% after deductible | $35 Copay | Covered at 70% after deductible | $25 Copay | Covered at 70% after deductible | Covered at 80% after deductible |
| Emergency Room Copay* | Covered at 80% after deductible | $50 Copay | Covered at 70% after deductible | $50 Copay | Covered at 70% after deductible | Covered at 80% after deductible |
| Routine Adult Physical Examination* | Covered at 80% after deductible | $15 Copay | Covered at 70% after deductible | $10 Copay | Covered at 70% after deductible | Covered at 80% after deductible |
| Adult Preventive Testing | Covered at 80% after deductible | Covered at 100% | Covered at 70% after deductible | Covered at 100% | Covered at 70% after deductible | Covered at 80% after deductible |
| Inpatient Mental Health | 30 days/year |
30 days/year |
30 days/year |
30 days/year |
||
| Outpatient Mental Health/Substance Abuse* | ||||||
| Visits 1-15 | Covered at 80% after deductible | $15 Copay | Covered at 70% after deductible | 10 Copay | Covered at 70% after deductible | Covered at 80% after deductible |
| Visits 16-30 | Covered at 60% after deductible | $30 Copay | Covered at 50% after deductible | $20 Copay | Covered at 50% after deductible | Covered at 60% after deductible |
| Inpatient Substance Abuse Benefits | 30 days/year, 60 days/life |
30 days/year, 60 days/life |
30 days/year, 60 days/life |
30 days/year, 60 days/life |
||
| Lifetime Maximums | $2 million per person |
$2 million per person |
$2 million per person |
$2 million per person |
||
* Copays do not apply toward the deductible or the maximum out-of-pocket limits.
The Plan covers the following supplies and services, subject to applicable Copayments, Deductibles, and annual and lifetime maximums.
Routine mammograms, limited to one baseline per individual, between ages 35 and 40, and one per calendar year after age 40.
Routine PAP Smears, limited to one per individual per calendar year at age 18.
Routine Prostate Specific Antigen (PSA) test limited to one per calendar year after age 50.
Annual benefit maximum of $1000 per individual
One spinal x-ray per calendar year per individual
Services provided only by a licensed Doctor of Chiropractic
If more than one surgical procedure is performed through the same incision or natural body orifice during the same operation, benefits payable are as follows:
Primary Surgical Procedure: 100 percent Secondary Surgical Procedure: 50 percent Tertiary Surgical Procedure: 25 percent Professional services of an Assistant Surgeon, subject to a maximum of 25 percent of the surgical allowance, as well as services provided by someone other than a Doctor, subject to a maximum of 10 percent of the surgical allowance.
Heart
Bone Marrow
Lung
Kidney
Liver
Pancreas
Heart and Lung
The Plan participates in a Centers of Excellence Program for Transplants. This is a voluntary program. The Centers of Excellence Program includes a designated facility which provides quality transplant services and is nationally recognized for these services. If you choose to participate in the program, the Centers of Excellence Facility that the Plan approves for you may require travel. If so, the Plan will pay the reasonable travel expenses for you and a companion. The Plan will also pay the reasonable medical and hospital expenses of a donor or prospective donor, which are directly related to you or your dependent's organ transplant.
Contact Health Design Plus at 1-877-286-3560 if you are considering use of the Centers of Excellence Program
Inpatient care for up to a 6-month period.
At home care.
Respite Care limited to a 7-day period.
A disability is any period of Illness or Injury, or multiple Illnesses or Injuries arising from the same cause, including any and all complications, which are not separated by complete recovery as certified by the attending Doctor and which preclude return to active employment in the case of the eligible employee, or return to the resumption of the normal activities of a person of the same age and in good health in the case of an eligible dependent.
Your Plan requires Pre-Certification of Durable Medical Equipment and Orthotic Devices that exceed $300. Please see Care Management and Pre-Certification for additional information about precertification requirements.
Charges subject to the deductible and/or Copayment for outpatient mental health and substance abuse benefits do not accumulate toward your out-of-pocket maximums. Therefore if your medical out-of-pocket maximums are met, your mental health/substance abuse services continue to be subject to Copayments and Coinsurance.
The Plan includes different Copayment and/or Coinsurance amounts you must pay for outpatient mental health benefits, depending on the number of visits. See Medical Benefits Options At A Glance for specific outpatient mental health/substance abuse payment information.
The Plan does not cover certain benefits, services, and supplies.
In addition to the Plan's General Exclusions and Limitations (see General Plan Exclusions and Limitations: Medical, Prescription Drug, Dental, and Vision Benefits), no medical benefits will be provided for:
the correction of injuries sustained while covered by the Plan and occurs within 24 months after the Accident, or
breast reconstruction following a mastectomy.
The Plan defines "Morbid Obesity" as a Body Mass Index ("BMI") of 35-40 and 100 pounds over ideal weight or a BMI of 31-35 and 100% over ideal weight.
Care Management is a mandatory program requiring Pre-Certification and review of certain treatments and procedures.
The Plan requires all participants and dependents to pre-certify the following healthcare encounters:
It is important for you to inform a Nurse Manager at HDP as soon as you know that you or your dependent will be admitted to a medical facility as an inpatient or outpatient or as soon as you know that you need to have an outpatient surgery or diagnostic test performed. Notification for elective admissions should be made at least seven days prior to admission or as soon as you are aware of your doctor's intent to admit you to the Hospital or schedules you for an outpatient surgery or diagnostic test.
Notify your HDP Nurse Manager by calling 1-877-286-3560.
Please have the following information available when you call:
Your HDP Nurse Manager will discuss your history and symptoms with you, as well as prior treatment and potential needs for continuing care after hospitalization or surgery. If it appears that there will be a need for home care or special equipment after leaving the Hospital, the Nurse Manager will begin the process of planning for these items at that time. Please feel free to discuss with the Nurse Manager what you or your doctor anticipate your needs to be after hospitalization.
After you notify HDP, your Nurse Manager will contact your Doctor for medical information. With the information provided by you and your Doctor, HDP will certify the admission based on Medically Necessary Care and Treatment. Certification does not guarantee payment nor does it verify or approve that services are in-network or out-of-network.
HDP will notify you and the provider of service (Doctor, Hospital, free standing surgical facility, Durable Medical Equipment vendor, Home Health Care agency, etc.) by telephone whether or not the requested medical service has been certified by issuing you a certification number. If the requested service is not certified, you and your provider will be notified by letter.
For a maternity admission, you are required to call your HDP Nurse Manager as soon as you are aware that you or your spouse is pregnant. You must call again at the time of your admission to the Hospital for delivery. Should you be admitted to the Hospital for complications of pregnancy or premature labor prior to delivery, you must call HDP within one working day following admission.
If you experience an emergency situation and are admitted to the hospital, either as an inpatient or on an observation basis, you are required to call HDP within one working day following admission.
The Nurse Manager telephone lines are staffed 8:30 A.M.-5:00 P.M. (E.S.T.) Monday through Friday at 1-877-286-3560. You may call this number 24 hours a day. For your convenience, you will reach the confidential mailbox of your Nurse Manager after office hours and over weekends and holidays. You may leave a message which is confidential, dated and timed. Simply leave a telephone number with area code where your Nurse Manager can reach you or a family member to obtain the required information.
Failure to pre-certify any admission/procedure may result in a monetary penalty of $250. Penalties do not apply toward Deductibles or out-of-pocket maximums.
Certification does not guarantee payment. Certification is valid only when the patient is eligible for services on the date the service is provided. All charges for such services are subject to Plan provisions (Deductibles, Copays, Coinsurance, out-of-pocket maximums, benefit reimbursement levels, covered services, excluded services).Verification of benefits can be obtained by contacting HDP Customer Service at 1-877-286-3559.
Certification does not verify or approve that services are in-network or out-of-network. Utilization of in-network providers is the responsibility of the employee/patient. Verification can be made by contacting the network customer service website and/or by telephoning a network customer service representative. Your customer service representative at HDP can assist you with information as to how to access the PPO website and/or give you the specific PPO customer service telephone number.
If the Nurse Manager, Medical Director, or third party independent medical consultant has any questions about the medical necessity, appropriateness and/or cost effectiveness of a recommended treatment/service/procedure you may be required to obtain an independent medical evaluation/second opinion. The Nurse Manager can assist you by providing names of doctors from whom you may receive this independent medical evaluation/second opinion.
Through all its programs, HDP promotes both the efficiency and effectiveness of care. Therefore, HDP offers you a Patient Advocacy Program by encouraging you to contact the Nurse Manager, not only when required, but at other times when you have questions and concerns about medical care. The Nurse Manager cannot replace your doctor or prescribe treatment, but can assist you to better understand and make better use of the healthcare system.
Cooper has contracted with HDP to conduct case management services for your Plan. Case Management is a utilization management program designed to monitor and coordinate treatment for specific diagnosis, particularly those involving a difficult or complicated medical situation.
If you or your dependent is involved in a difficult or complex medical situation, the Plan may provide you with a case manager to assist you in getting the care you need. Case Managers are professional nurses trained to coordinate healthcare services among providers. They are available to help you and your family obtain equipment or supplies you may need at home.
Case Managers work with you, your Doctors, your Hospitals, and other medical providers to review proposed treatment plans and to assist in coordinating care. Case Managers may, from time to time, make recommendations regarding alternative methods of treatment that may be medically appropriate but more cost-effective for the Plan. The Plan may, in its discretion, approve such alternate treatment even if the treatment would not normally be covered by the Plan.
In all cases, however, all treatment decisions rest with you and your medical providers
The Plan does not pay for procedures which are determined to be Experimental, Investigational, or Unproven, as defined by the Plan in Definitions.
The Plan will only pay for Medically Necessary Care and Treatment, as defined by the Plan in Definitions.
The Plan Administrator has the sole authority to determine what constitutes Medically Necessary Care and Treatment, and Experimental, Investigational, or Unproven procedures. In all cases, the Plan Administrator's determination will be final and binding. However, those determinations are solely for the purpose of establishing what services or courses of treatment are covered by the Plan. All decisions regarding medical treatment are between you and your Doctor and should be based on all appropriate factors, only one of which is the level of benefits available under the Plan.
| Basic Option I | Premium Option II | |
|---|---|---|
| Calendar Year Deductible | Single $50/ Family $150 (does not apply to preventive) |
Single $25/ Family $75 (does not apply to preventive) |
| Coinsurance % | ||
| Preventive | Covered at 80% | 100% |
| Basic | Covered at 50% after deductible |
Covered at 80% after deductible |
| Major | Covered at 50% after deductible |
Covered at 50% after deductible |
| Annual Maximum | $750 per person | $1,500 per person |
| Orthodontics (children to age 19 only) |
||
| Coinsurance | Covered at 50% after deductible |
Covered at 50% after deductible |
| Lifetime maximum | $750 per person | $1,500 per person |
| Election | 2-year enrollment commitment | |
YOUR DENTAL PLAN CONTAINS CERTAIN PREDETERMINATION REQUIREMENTS. IF YOU FAIL TO OBTAIN PREDETERMINATION FOR DENTAL SERVICES OVER $300 YOU MAY BE SUBJECT TO A $250 PENALTY.
Regardless of where you live, you have the following dental plan choices:
If you choose dental coverage, the Plan provides you with two dental benefit options: Option I and Option II. Each option has different Deductibles, Coinsurance and annual dollar limitations. Each Option provides preventive services, basic restorative services, major restorative services, and orthodontic care.
Benefits provided under both options are as follows:
Preventive Care Services
Basic Restorative Services
Major Restorative Services
Orthodontic Services
Orthodontic care for eligible children under age 19, subject to lifetime limits.
"Orthodontic treatment" means appliance, surgical, or functional-myofunctional treatment of dental irregularities which result from abnormal growth and development of teeth, gums, or jaws or as a result of accidental injury which requires repositioning (except for preventive treatment) of teeth to establish normal occlusion.
YOUR DENTAL PLAN CONTAINS CERTAIN PREDETERMINATION REQUIREMENTS. IF YOU FAIL TO OBTAIN PREDETERMINATION FOR DENTAL SERVICES OVER $300 YOU MAY BE SUBJECT TO A $250 PENALTY.
The Plan does not cover certain benefits, services, and supplies. In addition to the Plan's General Exclusions and Limitations (see General Plan Exclusions and Limitations: Medical, Prescription Drug, Dental, and Vision Benefits), no Dental Benefits will be provided for:
Services relating to existing denture or bridgework that cannot be repaired, duplicated, or made serviceable, and at least 5 years have elapsed since it was installed; or
Services where existing denture is an immediate temporary denture which cannot be made permanent, and replacement by a permanent denture is required and takes place within twelve (12) months from the date of initial installation of the immediate temporary denture.
| PLAN BENEFITS | MEMBER PROVIDER BENEFITS | NON-MEMBER PROVIDER BENEFITS |
| VISION CARE SERVICES | ||
| Vision Examination (once every 24 months) |
Covered in Full/$5.00 Copayment | Up to $55.00 |
| VISION CARE MATERIALS: Lenses (once every 24 months) |
||
| Single Vision | Covered in Full/$10 Copayment at the time materials are ordered | Up to $60.00 paid by the Plan*/$10 Copayment at the time materials are ordered |
| Bifocal | Covered in Full/$10 Copayment at the time materials are ordered | Up to $70.00 paid by the Plan*/$10 Copayment at the time materials are ordered |
| Trifocal | Covered in Full/$10 Copayment at the time materials are ordered | Up to $80.00 paid by the Plan*/$10 Copayment at the time materials are ordered |
| Lenticular | Covered in Full/$10 Copayment at the time materials are ordered | Up to $110.00 paid by the Plan*/$10 Copayment at the time materials are ordered |
| VISION CARE MATERIALS: Frames (once every 24 months) |
||
| Covered up to Plan Allowance | Up to $65.00 paid by the Plan* | |
| VISION CARE MATERIALS: Contact Lenses (once every 24 months) |
||
| Visually Necessary: Professional Fees and Materials |
Covered in Full* | Up to $180.00* |
| Elective: Professional Fee and Materials |
Covered up to $90.00** Includes examination. |
Up to $100.00. Includes examination. |
| LOW VISION: Professional Services, as necessary, for severe visual problems not corrected with regular lenses, including: |
||
| Supplemental Testing (includes evaluation, diagnosis, and prescription of vision aids where indicated) |
Covered up to 75% of cost | Up to $125.00 |
| Supplemental Aids | Covered up to 75% of cost | Covered up to 75% of cost |
| Maximum allowable for all Low Vision benefits of $1000.00 every two (2) years. | ||
*Subject to Copayment if any
** Additional discount applies to Member Provider's usual and customary professional fees for contact lens evaluation and
fitting.
The Plan covers vision care services and vision care materials (including lenses, frames, and contact lenses) for you and your covered dependents. The Plan has contracted with Vision Service Plan (VSP) to provide you and your dependents with vision care benefits. VSP also provides administrative and claims services relating to your Vision plan.
VISION SERVICE PLAN
3333 Quality Drive
Rancho Cordova, CA 956701-800- 877-7195
Each time you obtain vision services or supplies, you must make a Copayment. The amount of the Copayment is the same regardless of your medical option choice. See Vision Benefits At A Glance for an overview of the Vision Copayments required.
The Plan covers the following vision benefits and materials:
Supplemental Testing (evaluation, diagnosis and prescription of vision aids where indicated); and
Supplemental Aids, subject to a plan maximum payment.
VSP has a network of licensed optometrists, ophthalmologists and dispensing opticians. If you obtain vision care and materials from a Member Provider, you will pay less out of pocket than if you obtain vision care and materials from a Non-Member Provider.
Member Provider: Covered Benefits
| Vision Examination (once every 24 months) | Covered in Full/$5 Copayment | |
| VISION CARE MATERIALS (once every 24 months) | ||
| Single Vision Lenses: | Covered in Full/$10 Copayment at time of order | |
| Bifocal Lenses: | Covered in Full/$10 Copayment at time of order | |
| Trifocal Lenses: | Covered in Full/$10 Copayment at time of order | |
| Lenticular Lenses: | Covered in Full/$10 Copayment at time of order | |
| Frames: | Covered up to Plan Allowance | |
| Contact Lenses (once every 24 months) | ||
| Visually Necessary: | Covered in Full/$10 Copayment at time or order. | |
| Elective: | Covered up to $90; Includes examination; No Copayment | |
| LOW VISION CARE (Maximum Allowable for all Benefits is $1,000 every two (2) years): |
||
| Supplemental Testing: | Covered in full | |
| Supplemental Aids: | Covered up to 75 percent of cost. | |
Non-Member Provider: Covered Benefits
| Vision Examination (once every 24 months): | Up to $55.00 paid by the Plan/$5 Copayment. | |
| VISION CARE MATERIALS (once every 24 months) | ||
| Single Vision Lenses: | Up to $60.00 paid by the Plan/$10 Copayment at time of order. | |
| Bifocal Lenses: | Up to $70.00 paid by the Plan/$10 Copayment at time of order. | |
| Trifocal Lenses: | Up to $80.00 paid by the Plan/$10 Copayment at time of order. | |
| Lenticular Lenses: | Up to $100.00 paid by the Plan/$10 Copayment at time of order. | |
| Frames: | Up to $65.00 paid by the Plan/$10 Copayment at time of order. | |
| Contact Lenses (once every 24 months) | ||
| Visually Necessary: | Up to $180.00 paid by the Plan. | |
| Elective: | Up to $100.00 paid by the Plan; Includes examination. | |
| LOW VISION CARE (Maximum Allowable for all Benefits is $1,000 every two (2) years): |
||
| Supplemental Testing: | Up to $125.00 paid by the Plan. | |
| Supplemental Aids: | Covered up to 75 percent of cost. | |
Claims Procedure for Non-Member Provider Services
If you obtain vision services and/or materials from a Non-Member Provider, you must pay the full cost of the full amount due the provider and seek reimbursement from VSP based on the benefits available under the Plan. In order to obtain reimbursement you must contact VSP to obtain an authorization number to add to the receipt.
VISION SERVICE PLAN
3333 Quality Drive
Rancho Cordova, CA 956701-800-877-7195
The Plan does not cover certain benefits, services, and supplies. In addition to the Plan's General Exclusions and Limitations (see General Plan Exclusions and Limitations: Medical, Prescription Drug, Dental, and Vision Benefits), no Vision Benefits will be provided for:
| Catastrophic Option I |
Basic PPO Option II |
Premium PPO Option III |
Out-of-Area Option IV |
||
|---|---|---|---|---|---|
| Participating Pharmacy (initial prescription up to 30-day supply) |
Brand Copayment | Greater of 20 percent of drug cost or $20.00 | Greater of 20 percent of drug cost or $15.00 | Greater of 20 percent of drug cost or $15.00 |
Greater of 20 percent of drug cost or $15.00 |
| Generic Copayment | Greater of 20 percent of drug cost or $10.00 | Greater of 10 percent of drug cost or $8.00 | Greater of 10 percent of drug cost or $8.00 |
Greater of 10 percent of drug cost or $8.00 | |
| Maintenance Medication MAIL ORDER ONLY (Refills and 31-day supply, up to 90-day supply) |
Brand Total Cost | $50.00 | $30.00 | $30.00 | $30.00 |
| Generic Total Cost | S25.00 | $15.00 | $15.00 | $15.00 | |
| Non-Participating Pharmacy | Brand Copayment | Greater of 30 percent of drug cost or $20.00 | Greater of 20 percent of drug cost or $15.00 | Greater of 20 percent of drug cost or $15.00 |
Greater of 20 percent of drug cost or $15.00 |
| Generic Copayment | Greater of 20 percent of drug cost or $10.00 | Greater of 10 percent of drug cost or $8.00 | Greater of 10 percent of drug cost or $8.00 |
Greater of 10 percent of drug cost or $8.00 | |
The Plan covers prescription medications for you and your covered dependents. Each time you obtain a prescription, you must make a Copayment. The amount of the Copayment depends on the type of medical benefit Option you have selected, either Catastrophic Option I, Basic PPO Option II, Premium PPO Option III, or Out-Of-Area Option IV. See Prescription Drug Benefits At A Glance for an overview of the Prescription drug Copayments required under each medical benefit Option.
The Plan only covers prescription drugs which are dispensed by any person or organization licensed to dispense drugs upon the order of a Doctor.
The Plan covers the following prescription drugs:
A Prescription Legend Drug is any medical substance which has been approved by the Food and Drug Administration and which, under federal or state law, can be dispensed only by a prescription from a licensed Doctor. Prescription Legend Drugs must bear the label: "Caution: federal law prohibits dispensing without a prescription."
The Plan has contracted with AdvancePCS to manage its prescription drug program. Please contact Advance PCS directly with any questions about your prescription drug benefit.
ADVANCE PCS: 1-800-966-5772
The Plan has different Copayment requirements, under each medical benefit Option, for Brand-Name drugs and Generic drugs.
A Brand-Name drug is a prescription drug for which the manufacturer has a patent. The name of the drug is usually the name assigned by the manufacturer.
A Generic drug is a prescription drug which is a chemical equivalent copy of a Brand-Name drug. Generic drugs are formulated upon a manufacturer's Brand-Name drug patent expiration. Generic drugs are usually less expensive than branded drugs and are usually sold by their chemical formula or "generic" name. For example, Valium is a Brand-Name drug, whereas Diazepam is its chemically equivalent generic.
Advance PCS has a network of pharmacies which are the Plan's PPO Providers. If you obtain your prescription from a PPO Provider, you only pay the applicable Copayment. If you obtain your prescription from a pharmacy that is not a PPO Provider, you are required to pay the dispensing fee for the drug, (which is the fee that the individual pharmacy most frequently charges customers for dispensing drugs), plus:
| Catastrophic Option I: | |
| Brand: | The greater of $20.00 or 30 percent of the cost of the covered prescription. |
| Generic: | The greater of $10.00 or 20 percent of the cost of the covered prescription. |
| Basic PPO Option II, Premium PPO Option III, and Out-Of -Area Option IV: | |
| Brand: | The greater of $15.00 or 20 percent of the cost of the covered prescription. |
| Generic: | The greater of $8.00 or 10 percent of the cost of the covered prescription. |
The Copayments listed above are applicable to the initial requirement for each prescription of thirty (30) days or less. When a refill or refills of the first prescription are required and the combined total requirement exceeds a thirty (30) day drug supply, the drug is considered a Maintenance drug.
Maintenance drugs are only available through the Plan's Mail Order Pharmacy Program
Your cost of Maintenance drugs depends on the Medical Option you have selected, as follows:
| Catastrophic Option I: | |
| Brand: | $50 as full payment for the prescription. |
| Generic: | $25 as full payment for the prescription. |
| Basic PPO Option II, Premium PPO Option III, and Out-Of -Area Option IV: | |
| Brand: | $30 as full payment for the prescription. |
| Generic: | $15 as full payment for the prescription. |
The Brand or Generic Copayment for Maintenance drugs is applicable to each mail order prescription with a maximum ninety (90) day supply.
The Plan does not cover certain benefits, services, and supplies. In addition to the Plan's General Exclusions and Limitations (see General Plan Exclusions and Limitations: Medical, Prescription Drug, Dental, and Vision Benefits), no Prescription Drug Benefits will be provided for:
These exclusions apply to all of your benefits and are in addition to the individual benefits exclusions which related specifically to your medical benefits (Medical Benefits: Specific Plan Exclusions and Limitations) dental benefits (Dental Benefits: Specific Plan Exclusions and Limitations) vision benefits (Vision Benefits: Specific Benefit Exclusions and Limitations) and prescription drug benefits (Prescription Drug Benefits: Specific Benefit Exclusions and Limitations).
Your Plan does not include, and no benefit will be paid under the Plan, for charges incurred or resulting from the following:
for which no charge is made,
for which a person is not required to pay, or
which are furnished by or payable under any plan or law of a federal or state government entity, or provided by a county, parish, or municipal hospital when there is no legal requirement to pay for such treatment, services, or supplies.
The Women's Health and Cancer Rights Act (WHCRA), passed by Congress in 1998, requires all group health plans and health insurance issuers that already offer benefits for a mastectomy, to also provide coverage for the ensuing breast reconstructive surgery. Plans also have to cover surgery on the nonaffected breast to ensure a symmetrical appearance. The legislation also mandates coverage for prostheses and for all other services used to treat physical complications during all stages of a mastectomy, including lymphedemas.
In addition, the legislation prohibits group health plans and health insurance issuers from denying renewal or initial enrollment to an individual in order to avoid providing the mandated benefits. Finally, health plans may not use financial incentives (monetary or otherwise) in order to discourage attending health providers from performing the medical services described in the legislation.
Your Plan is required to provide you with an annual notice about these coverage standards to Plan participants upon enrollment and annually thereafter.
Specifically, the WHCRA requires that your Plan provide the following benefits coverage:
In accordance with the WHCRA, your Plan provides you with the above coverages.
In accordance with The Newborns' and Mother's Health Protection Act, your Plan does not restrict benefits for any hospitalization stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal birth, or less than 96 hours following a caesarean birth, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods, unless agreed to by the mother and her Doctor.
In accordance with federal law, your Plan has written policies and procedures for the receipt and processing of Qualified Medical Child Support Orders. You may obtain a copy of these policies and procedures by making a written request to the Plan Administrator.
If you or your dependents lose coverage under the Plan, you have the right, in certain situations, to temporarily continue coverage, at your expense, beyond the date it would otherwise end. This right is guaranteed under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA).
See How Can Coverage Be Extended? for a full explanation of your COBRA rights and responsibilities.
There is no duplication of benefits under the Plan.
If an employee's spouse is employed full-time and if the spouse's employer makes available a group medical, hospital, surgical, or prescription drug benefit program for its full-time employees, then, if that employer contributes any portion toward the cost of that plan, the working spouse must be enrolled as an employee. If the working spouse's birth date falls earliest in the year, he or she must be enrolled in that employer's plan to provide dependent coverage for all eligible children.
If you or your dependents are covered under this Plan and another group health plan, the two plans will coordinate benefit payments. Coordination of Benefits (COB) means that two or more plans pay for a portion of your covered expenses. However, the combined payments from all plans may not exceed 100% of expenses incurred.
Your Plan coordinates benefits with the following types of plans:
Any other group insurance plan coverage;
Any coverage under governmental programs or provided by any statute, except Medicaid; and
Any automobile insurance policies (including "at-fault" and "no-fault" coverage) containing personal injury protections.
The Plan will not coordinate benefits with Health Maintenance Organization ("HMO") Plans or reimburse an HMO for services provided.
The first step in coordinating benefits is to determine which plan pays first (the primary plan) and which plan pays second (the secondary plan). If this Plan is primary, it will pay its full benefits. However, if this Plan is secondary, the benefits it will pay will be reduced by the benefits provided under the other plan.
Here are examples of how coordination of benefits works when you see a PPO Provider within your network:
| Example 1 | Example 2 | |
|---|---|---|
| Total Allowable Charge: | $200.00 | $200.00 |
| Applied to Cooper Plan deductible: | $100.00* | $100.00* |
| Cooper Plan benefit: | $ 80.00** | $ 80.00** |
| Paid by other carrier: | $ 50.00 | $ 80.00 |
| Cooper Plan will pay: | $ 30.00 | $ 0.00 |
| *Satisfied remaining deductible | ||
| **80% of remaining $100.00 | ||
The general order of payment rules are as follows:
Plans covering the parent whose financial responsibility for the child's healthcare expenses is established by a court order or qualified medical child support order pay first;
If there is no court order establishing financial responsibility, the plan covering the parent with legal custody pays first;
If the parent with legal custody has remarried and the child is covered as a dependent under the plan of the stepparent, the order of payment is as follows:
- The plan of the parent with custody;
- The plan of the stepparent with custody
- The plan of the parent without custody.
If a person is entitled to Medicare while covered by the Plan, Medicare is always secondary to the Plan, except as follows:
Sometimes you or your dependents suffer Injuries and Illnesses and incur medical expenses as a result of an accident or act for which someone else is at fault. Typical examples include injuries sustained:
In an automobile accident caused by someone else; or/
On someone else's property.
In such cases, his or her car insurance or property insurance may be responsible for paying all or part of the resulting medical bills. However, because a determination regarding fault may take time to make, you have the option of submitting the medical bills to the Plan for payment. If you do this, you will be asked to transfer your legal rights and remedies for collection of those medical bills to the Plan as described below. The process of transferring these rights is known as Subrogation.
If you or a covered dependent suffer an Injury or Illness as a result of an accident or act for which someone else is at fault, the Plan requires a signed Subrogation Agreement before it pays any benefits over $500. The Subrogation Agreement transfers any rights of recovery you or a covered dependent may have to the Plan. This allows the Plan to be repaid to the extent you or your covered dependents are paid or have legal rights to receive money from:
The person responsible for the injury;
The insurance company of the person responsible for the injury, orC
Your own liability insurance company, in the case of uninsured or under-insured motorist.
Although the Plan expects full reimbursement for all benefits paid, there may be times when a full recovery is not possible. For example, sometimes the money you or a covered dependent is entitled to may be less than the amount of benefits the Plan provides. When this happens, the Plan expects to be reimbursed to the extent possible. You and your dependents agree to cooperate with the Plan as reasonably requested. In the event that you settle your claim with his or her insurance company, or your insurance company (in the case of an uninsured or under-insured motorist,) the Plan will not make any payments for the medical bills related to that Injury or Illness.
If you or your dependents lose coverage under the Plan, you have the right, in certain situations, to temporarily continue coverage, at your expense, beyond the date it would otherwise end.
This right is guaranteed under the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA).
COBRA benefit administration for your Plan is performed by:
Health Design Plus, Inc.
1755 Georgetown Road
Hudson, Ohio 44236Phone: (330) 656-1072
Fax: (330) 656-9387
or
1-877-286-3559
COBRA continuation coverage can be chosen by an employee or dependent if his or her coverage is lost due to a "qualifying event."
A qualifying event is any of the following events if it would result in a loss of coverage:
- Termination of your employment (except for gross misconduct);
- A change in your employment status from full-time to part-time;
- The last day of a leave of absence governed by and conforming to the requirements of the Family and Medical Leave Act of 1993, as amended, if you don't return to work at the end of that leave;
- A divorce or legal separation from your spouse;
- A child no longer meeting the Plan's definition of dependent; or
- Your entitlement to Medicare.
No. COBRA continuation coverage is not automatic. It must be elected, and the required premiums must be paid when due. A premium will be charged under COBRA as allowed by federal law.
By electing COBRA coverage, you have the same options and can continue the same healthcare coverage available to other Plan participants, including the health care spending account.
In addition to Hospital and medical/prescription drug benefits, healthcare coverage includes dental and vision care benefits, if applicable.
The maximum period for which COBRA coverage can be continued depends upon the type of qualifying event and when it occurs.
If you terminate employment or if your employment status changes from full-time to part-time, the maximum period for which coverage can be continued is 18 months from the date of the qualifying event.
However, if you or a covered dependent are determined to be disabled according to the terms of the Social Security Act of 1965 (as amended) on the date coverage would otherwise end or anytime during the first 60 days of continuation coverage, the maximum period for which coverage for you and your covered dependents can be continued is 29 months from the date of the qualifying event, provided the Plan receives the required notice of disability during the initial 18-month period.
Disability under Social Security is based upon your inability to work. The Social Security Administration considers you disabled under Social Security Rules if you cannot do work you did before and the Social Security Administration determines that you cannot adjust to other work due to your medical condition. Your disability must also be expected to last for at least one year or to result in death.
For all other qualifying events, coverage cannot be continued for more than 36 months from the date of that qualifying event.
There are special COBRA continuation rules that apply to Medicare entitlement:
COBRA terminates on the date you become entitled to Medicare.
If your COBRA continuation coverage ends because you become entitled to Medicare, COBRA continuation coverage for your dependents can be continued for up to 36 months.
You or a dependent must inform the Plan within 60 days of the following qualifying events:
You must also inform the Plan within 60 days of the date a person is determined to be disabled according to the terms of the Social Security Act of 1965 (as amended).
A person's COBRA continuation coverage will automatically end with the occurrence of any of the following:
If you want to continue Dependent Coverage or add a new dependent after you elect COBRA continuation coverage, you may do so in the same way as active employees do under the Plan, by contacting:
Health Design Plus, Inc.
1755 Georgetown Road
Hudson, Ohio 44236ATTN: COBRA ADMINISTRATOR
Continuation of coverage is not automatic. It must be elected, and the required payments must be paid when due.
Within 45 days after notification of a qualifying event, the Plan's Third Party Administrator, HDP, will send a description of the Plan's COBRA continuation of coverage rights, and an election form, to you and your covered dependents at the last known address the Plan has on file.
If you or a covered dependent want COBRA coverage, the completed COBRA election form must be mailed to Health Design Plus within 60 days from:
The date coverage would otherwise end under the Plan; or
The date you are notified of your right to COBRA continuation coverage, whichever occurs later.
If HDP receives a person's election form within the 60-day election period, HDP will send that person a premium notice stating the amount owed for COBRA coverage. The first payment must equal the premiums due from the date coverage would otherwise end until the end of the month in which payment is being made.
Payments for COBRA continuation coverage must be made by check or money order, payable to Cooper Tire & Rubber Company, and must be mailed to:
Health Design Plus, Inc.
1755 Georgetown Road
Hudson, Ohio 44236ATTN: COBRA ADMINISTRATOR
Health Design Plus must receive the first payment within 45 days after the date it receives the election form. From then on, payments are due on the first day of each month for which coverage is to be continued.
If you have questions about your rights under COBRA, or the process for obtaining COBRA Continuation Coverage, please call HDP at:
1-877-286-3559
Medical, prescription drug, dental and vision claims received after 12 months from the date of service will be denied.
All claims for medical benefits must be sent to the address on the back of your medical ID card. All claims for dental benefits must be sent to:
Health Design Plus, Inc.
CS 5085
Findlay, OH 45839-5085Telephone Number for Claims and Customer Service: 1-877-286-3559
All claims for prescription drug benefits must be sent to the Plan's prescription drug benefit manager, AdvancePCS, at the following address:
Advance PCS Health L.P.
9501 East Shea Boulevard
Scottsdale, AZ 85260-6719Telephone Number for Claims and Customer Service: 1-800-966-5772
All claims for vision benefits should be sent to the Plan's vision plan provider, VSP, at the following address:
Vision Service Plan, Inc. (VSP)
3333 Quality Drive
Rancho Cordova, CA 95670Telephone Number for Claims and Customer Service: 1-800-877-7195
Claims will be processed and paid within 10 business days from the date all information necessary to process the claim is received. If special circumstances require a 90-day extension, you will be notified in writing before the end of the initial 10-business day period.
If benefits have been assigned to a provider of services, that person or institution will receive the benefit payment. If there is an assignment of benefits established by a Qualified Medical Child Support Order, or an assignment required by Medicaid or any state law, the person or institution so assigned will receive the benefit payment.
If all or part of your claim is denied, you will receive written notice of the denial, containing the following information:
If you disagree with the claim denial and want to appeal you must make written application to the Plan Administrator as follows:
Plan Administrator Cooper Tire & Rubber Company (Cooper)
Medical/Prescription Drug Plan, Dental Plan and Vision Plan
701 Lima Avenue
Findlay, OH 45840ATTN: Vice President, Human Resources
You have the right to review pertinent documents and to submit written comments along with documentation supporting why you feel the claim should be paid.
Your appeal must include the following information:
The appeal must be submitted by the claimant or an authorized representative of the claimant, unless they are incapacitated or a minor.
You will receive a final decision within 60 days after the date your application for review is received, unless special circumstances require a 60-day extension. If an extension is necessary, you will be notified in writing before the end of the initial 60-day period.
The decision will be in writing and will include:
You cannot bring a suit against the Plan based upon a denial of benefits until the appeal procedure as described above has been followed completely.
THE PLAN GIVES THE PLAN ADMINISTRATOR FULL DISCRETION AND SOLE AUTHORITY TO MAKE THE FINAL DECISION IN ALL AREAS OF PLAN INTERPRETATION AND ADMINISTRATION, INCLUDING ELIGIBILITY FOR BENEFITS, THE LEVEL OF BENEFIT PROVIDED, AND THE MEANING OF ALL PLAN LANGUAGE, INCLUDING THIS SPD. IN THE EVENT OF A CONFLICT BETWEEN THE SPD AND THE PLAN, THE PLAN SHALL GOVERN. THE DECISION OF THE PLAN ADMINISTRATOR IS FINAL AND BINDING ON ALL THOSE DEALING WITH THE PLAN AND IF CHALLENGED IN COURT, THE PLAN INTENDS FOR THE ADMINISTRATOR'S DECISION TO BE UPHELD UNLESS IT IS DEEMED TO BE ARBITRARY AND CAPRICIOUS.
The Plan Administrator of the Cooper Spectrum Medical/Prescription Drug Plan, Dental Plan, and Vision Plan has sole and exclusive authority to:
The exclusive discretion to increase, decrease, or otherwise change Plan provisions for the efficient administration of the Plan or to further the purposes of the Plan;
The right to obtain additional information needed to coordinate benefit payments with other plans; and
The right to obtain second medical or dental opinions or to have an autopsy performed when not forbidden by law.
The Plan Administrator's decisions are binding on all persons dealing with or claiming benefits under the Plan, unless deemed to be arbitrary or capricious by a court of competent jurisdiction.
Cooper intends to continue the Plan within the limits of the funds available to do so. However, Cooper reserves the right, in its sole discretion, to amend or terminate the Plan, in whole or in part, without prior notification.
In the event that the Plan is terminated, benefits incurred before the termination date will be paid based on available assets.
The decision to use the services of particular medical and/or dental providers is voluntary and the Plan makes no recommendations as to what provider you should use, even when benefits may only be available for services furnished by providers designated by the Plan. You should select a provider or treatment based on all appropriate factors, only one of which is coverage under the Plan.
Providers are not agents or employees of the Plan, and the Plan does not make any representations regarding the quality of services provided.
The Plan does not replace or affect any requirements for coverage under any state Workers' Compensation or Occupational Disease Law. If you suffer a job-related injury or illness, you must notify your employer immediately.
The Plan Administrator and agent for legal process is:
Cooper Tire & Rubber Company (Cooper)
Medical/Prescription Drug Plan, Dental Plan and Vision Plan Administrator
701 Lima Avenue
Findlay, OH 45840ATTN: Vice President, Human Resources
The Employer Identification Number assigned by the Internal Revenue Service to Cooper Tire & Rubber Company is 34-4297750. The Plan Number is 538.
The Plan year is the 12-month period established by the Plan Administrator for purposes of administering the Plan and maintaining its financial records. The Plan year for this Plan is January 1 through December 31 of each year.
As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act (ERISA) passed by Congress in 1974. ERISA gives you the right to:
Examine, without charge, all Plan documents, including detailed annual reports, Plan descriptions, insurance contracts, and copies of all documents filed by the Plan with the Department of Labor. These documents are located at the following address:
Cooper Tire & Rubber Company (Cooper)
Medical/Prescription Drug Plan, Dental Plan and Vision Plan
Human Resources Department
701 Lima Avenue
Findlay, OH 45840You may obtain copies of all Plan documents and other Plan information upon written request to the Plan Administrator; the Administrator may charge $.25 per page for the copies.
Receive a summary of the Plan's annual report.
In addition to creating rights for Plan Participants, ERISA imposes duties upon the Plan's Fiduciaries (the people who operate the Plan). Fiduciaries are required to perform their jobs prudently and in the interest of you and other Plan Participants and Beneficiaries. No one may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or from exercising your rights under ERISA. If your claim for benefits is denied in whole or in part, you are entitled to receive a written explanation from the Plan Administrator explaining the reason for the denial. You have the right to request that the Plan review and reconsider your denied claim.
Under ERISA there are steps you can take to enforce the above rights. If you request materials from the Plan and do not receive them within 30 days, you may file a suit in federal court. The court may require the Plan Administrator to provide the materials and pay you up to $100 per day until you receive the materials, unless the materials are not sent due to reasons beyond the control of the Administrator.c
If your claim for benefits is denied or ignored in whole or in part, you have the right to file suit in state or federal court. If the Plan Fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file a suit in federal court. The court will decide who should pay court costs and legal fees. If you win your suit, the court may order the person you have sued to pay these court costs and fees. If you lose or if the court finds your claim to be trivial, you may be ordered to pay the costs and fees.
If you have any questions about this statement or your rights under ERISA, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory, or the Department of Labor's National Office in Washington, D.C.:
Division of Technical Assistance and Inquiries
Pension and Welfare Benefits Administration
U.S. Department of Labor
200 Constitution Avenue, N. W.
Washington, D.C. 20210