Intel Retiree Medical Plan (IRMP) Summary Plan …

1 Intel Retiree Medical plan and Sheltered Employee Retirement Medical Account 2016 Summary plan Description The information provided in this booklet is the plan document and Summary plan Description (the SPD ) for the Intel Retiree Medical plan (IRMP) - Medical and vision plans, and the Sheltered Employee Retirement Medical Account (SERMA). Intel reserves the right to modify, change, or discontinue anything provided or defined under the IRMP and the SERMA program, at its sole discretion, by appropriate action of its board of directors or other persons designated by the board. Nothing in this booklet can be modified or changed in any way by the oral representation or statements of any party. ABOUT THIS Summary plan DESCRIPTION This document provides information and describes the general features and benefits offered under the IRMP and SERMA. The IRMP Medical and vision plans are plans available from Intel Corporation ( Intel ) to eligible retirees and their eligible dependents.

2 This document also provides information about SERMA, an administrative and accounting mechanism that helps eligible Intel retirees purchase health insurance. Table of Contents Section 1 Overview .. 1 IRMP & SERMA Overview .. 1 Maximize the Value of Your SERMA .. 1 Section 2 IRMP Eligibility and Enrollment .. 3 IRMP Eligibility .. 3 Surviving Dependent Eligibility .. 3 Your Responsibility .. 3 Enrollment .. 4 Eligible Dependent .. 4 Special Eligibility Circumstances .. 5 Split Enrollment for IRMP- Medical Coverage .. 6 Proof of Continuous Coverage .. 6 Important Information you Need to Know if you Choose Not to Enroll in IRMP Medical plan upon Retirement .. 7 Changing Your Coverage Elections .. 7 Change-in-Status Events .. 8 When you Become Medicare-Eligible .. 8 When IRMP Medical and Vision Benefits Begin .. 8 When IRMP Medical and Vision Benefits End .. 9 Section 3 - IRMP Medical Non-Medicare plan (typically under age 65).

3 11 Split Family Enrollment .. 11 How the IRMP Cigna Coinsurance plan 11 Deductibles .. 11 Coinsurance Payments .. 12 About the Cigna Provider Network .. 12 In-Network Benefit .. 13 Primary Care Physician (PCP) .. 13 Choosing or Changing your Primary Care Physician .. 13 Out-of-Network Benefits .. 13 Out of Pocket Maximum .. 14 MAXIMUM LIFETIME BENEFIT .. 14 Additional Networks .. 15 IRMP Medical - Cigna Coinsurance Benefits Chart .. 15 Formulary Drug List .. 20 How to Request Preferred Drugs on the Formulary Drug List .. 21 Your Express Scripts Card is Important .. 21 How the IRMP Coinsurance Prescription Drug Benefit Works .. 21 Retail Refill Allowance .. 22 Maintenance Medication .. 23 Express Scripts Pharmacy .. 23 Dispensing 24 Quantity Limits .. 24 Prior Authorization Review Program .. 24 Drug Utilization Review Program .. 25 Preferred Drug Step Therapy .. 25 Coverage of Specialty Medications.

4 25 Elective Surgery .. 25 What is an Emergency .. 26 What to do in an Emergency .. 26 Emergency Hospital Admission .. 27 Hospital Preadmission Certification and Continued Stay Review .. 27 Prior Authorization Requirements .. 27 Medical Case Management .. 28 Health Advisor .. 28 24-Hour Information Line .. 28 Second and Third Surgical Opinions .. 29 Travel .. 29 Determining the Primary plan .. 29 Examples of Coordinated Benefits .. 30 How to File Claims if you have Multiple Coverage .. 30 Section 4 - IRMP Medical Medicare-eligible (typically over age 65) .. 32 How IRMP Cigna Indemnity plan Works .. 33 Deductibles .. 33 Coinsurance Payments .. 33 Out-of-Pocket Maximum .. 33 Medical Lifetime Benefit Maximum .. 34 How the plan Works? .. 34 About the Cigna Network .. 35 Additional Networks .. 35 Benefits Chart .. 36 Specialty Services: Medicare-Eligible .. 42 Prescription Drug Benefits .. 42 Formulary Drug List.

5 42 How to Request Preferred Drugs on the Formulary Drug List .. 43 Your Express Scripts Card is Important .. 43 How the IRMP Indemnity with RX Prescription Drug Benefit Works .. 43 Retail Refill 44 Maintenance Medication .. 45 Prescriptions and your Out of Pocket Maximum .. 46 Dispensing 46 Quantity Limits .. 46 Prior Authorization Review Program .. 46 Drug Utilization Review Program .. 47 Preferred Drug Step Therapy .. 47 Coverage of Specialty Medications .. 47 Elective Surgery .. 48 What is an Emergency? .. 48 What to do in an Emergency .. 48 Hospital Preadmission Certification and Continued Stay Review .. 49 Prior Authorization Requirements .. 49 Medical Case Management .. 50 24-Hour Information Line .. 50 Second and Third Surgical Opinions .. 50 Travel .. 50 Coordination of Benefits: Medicare Eligible .. 51 Reduction of Benefits for Medicare .. 51 Coverage Through Another Medical plan Other than Medicare.

6 52 Determining the Primary plan .. 53 Examples of Coordinated Benefits .. 53 Special Rules Regarding End Stage Renal Disease (ESRD) .. 54 How to File Claims if you are enrolled in Multiple Coverage .. 54 Important Information Regarding Medicare Part D .. 54 Coverage History Notice .. 55 Section 5 - IRMP Medical - Covered Medical Services .. 56 Acupuncture .. 56 Allergy Services .. 56 Ambulance .. 56 Breast Reconstruction, Breast Prostheses, and Complications of Masectomy .. 56 Chiropractic Services .. 57 Dental 57 Diagnostic and Therapeutic Radiology Services .. 57 Durable Medical Equipment .. 58 Emergency Services .. 59 External Prosthetic Appliances .. 59 Family Planning Services .. 59 Hearing Care .. 60 Home Birth .. 60 Home Health Care .. 60 Hospice Care .. 61 Hospital Services .. 61 Hospital Ancillary Services .. 61 Infertility Services .. 62 Internal Prosthetic Appliances .. 62 Maternity Care.

7 62 Mental Health and Chemical Dependency Treatment .. 63 Naturopath Services .. 63 Newborn Care .. 63 Non-Durable Medical Supplies .. 63 Nutritional Counseling .. 63 Oral Surgery .. 64 Orthotics .. 64 Outpatient Services .. 64 Physician 64 Podiatry .. 64 Prescription Drugs Benefits .. 64 Private Duty Nursing .. 66 Reconstructive Surgery .. 66 Rehabilitative Therapy .. 66 Skilled Nursing Facility .. 67 Tobacco Cessation Services .. 67 Temporomandibular Joint (TMJ) Syndrome .. 67 Transsexual Surgery .. 68 Transplant Services .. 68 Travel and Living Expenses .. 68 Travel Immunizations .. 69 Vision Therapy .. 69 Weight Reduction Services (This benefit only applies to the IRMP Cigna Coinsurance plan ) . 69 Well-Adult Care .. 69 Section 6 - IRMP Vision plan .. 70 Routine Vision Care Benefits .. 70 Treatment of Minor Medical Conditions of the Eye (Primary Eyecare Program) .. 70 VSP Basic Vision .. 71 VSP PLUS Vision plan .

8 72 Section 7 IRMP Medical - Exclusions and Limitations .. 74 Section 8 Sheltered Employee Retirement Medical Account (SERMA) .. 81 Overview .. 81 SERMA Eligibility .. 81 When SERMA Ends .. 82 Intel SERMA Contributions and Interest .. 82 How Service is Determined for SERMA .. 83 For Service Time Prior to Jan. 1, 2004 .. 83 For Service Time On or After Jan. 1, 2004 .. 83 SERMA Balance Inquiry .. 84 Summary of SERMA Options .. 84 If you Elect IRMP Enrollment .. 85 Changing Your SERMA Percentage For IRMP .. 85 If You Elect Reimbursement for Health Insurance Premiums Outside of IRMP .. 86 How to Manage Your SERMA .. 87 Section 9 Catastrophic RX HRA .. 89 Section 10 Administrative .. 90 Enrollment Conditions .. 90 Women s Health & Cancer Rights Act Breast Reconstruction Medical Benefits .. 90 Newborns & Mothers Health Protection Act .. 90 plan Information .. 91 How the plan is Administered .. 91 Your plan Administrator.

9 91 How the IRMP and SERMA are Funded .. 92 Important Benefit Facts .. 92 The Intel Health Benefits Center .. 92 Program Phone Numbers and Websites .. 93 Employment Retirement Income Security Act (ERISA).. 93 ERISA Rights .. 93 Receive Information About Your plan And Benefits .. 93 Continuous Group Health plan Coverage .. 94 Prudent Actions by plan Fiduciaries .. 94 Enforce Your Rights .. 94 Assistance with Your Questions .. 95 Section 11 Claims .. 96 Filing an IRMP Medical , Vision or Catastrophic RX HRA Claim .. 96 Types of Claims and the Claim Determination Process .. 97 Concurrent Care Claims .. 98 Communications that are Not Claims for Benefits, or are Failed Claims .. 99 Appointing an Authorized 99 Notice of Claim Determination .. 100 What Is an Adverse Determination? .. 100 Unclaimed Funds .. 101 When a Third Party is Responsible for your Medical Expenses (Reimbursement and Subrogation).

10 101 Refund of Overpayments .. 102 Section 12 - Appeals Process .. 103 Procedures for all Appeals .. 105 Appointing an Authorized 106 Notification of Appeal Determination .. 107 Appealing a Denied Claim - Voluntary Appeal .. 107 Request for an Intel Quality Assurance Review .. 108 Contact Information Table Where to File Your Appeal .. 109 Section 13 Medical Privacy .. 110 Medical Privacy .. 110 Section 14 COBRA .. 112 Overview .. 112 COBRA Qualifying Event for IRMP or SERMA Participants .. 112 Qualified 113 Length of COBRA Coverage .. 113 Electing and Paying for COBRA Coverage .. 113 Termination of COBRA Coverage .. 114 Section 15 Glossary .. 115 Section 1 - Overview 1 Section 1 Overview The Intel Retiree Medical plan (IRMP) gives you access to Medical coverage options and vision coverage options upon retiring from Intel . A Retiree health reimbursement account (the Sheltered Employee Medical Retirement Account) is also established for eligible Intel retirees.