Smartchoices Summary Plan Description

PetSmart, Inc. SmartChoices and Flexible Benefits Plans Summary Plan Description Effective January 1, 2020 TABLE OF CONTENTS Contents OVERVIEW ................................................................................................................................................. 1 BENEFITS AT A GLANCE .................................................................................................................... 2 ELIGIBILITY & PARTICIPATION ............................................................................................................ 4 ENROLLMENT RULES .......................................................................................................................... 4 MAKING CHANGES .............................................................................................................................. 8 WHEN COVERAGE ENDS .................................................................................................................. 11 COBRA CONTINUATION COVERAGE ............................................................................................. 13 MEDICAL BENEFITS ............................................................................................................................... 20 HOW THE PLAN WORKS ................................................................................................................... 20 PLAN TERMS ........................................................................................................................................ 27 HEALTH REIMBURSEMENT ACCOUNT ......................................................................................... 29 PERSONAL HEALTH SUPPORT-CARE MANAGEMENT ............................................................... 32 PRIOR AUTHORIZATION ................................................................................................................... 33 BEHAVIORAL HEALTH BENEFITS .................................................................................................. 37 ADDITIONAL COVERAGE AND PRIOR AUTHORIZATION ......................................................... 38 LIMITS & EXCLUSIONS – MEDICAL BENEFITS............................................................................ 65 FLEXIBLE SPENDING ACCOUNTS ...................................................................................................... 79 HEALTH CARE AND LIMITED PURPOSE FSAs.............................................................................. 80 DEPENDENT DAY CARE FSA ........................................................................................................... 82 FILING CLAIMS FOR FSA REIMBURSEMENT ............................................................................... 84 HEALTH SAVINGS ACCOUNT (HSA) .............................................................................................. 86 PRESCRIPTION DRUG PROGRAM ........................................................................................................ 90 PAYING FOR YOUR PRESCRIPTIONS CHART ............................................................................... 92 PRESCRIPTION MANAGEMENT PROGRAMS ................................................................................ 94 DENTAL BENEFITS ................................................................................................................................. 97 HIGHLIGHTS – DENTAL PLANS I & II ............................................................................................. 97 SCHEDULE OF DENTAL BENEFITS ................................................................................................. 98 LIMITS & EXCLUSIONS – DENTAL PLANS I & II ........................................................................ 100 HIGHLIGHTS – DHMO PLAN ........................................................................................................... 102 DHMO PATIENT CHARGE SCHEDULE ......................................................................................... 102 LIMITS & EXCLUSIONS – DHMO PLAN ........................................................................................ 113 VISION BENEFITS ................................................................................................................................. 115 SUMMARY PLAN DESCRIPTION 2020 LIMITATIONS & EXCLUSIONS – VISION BENEFIT PLAN ......................................................... 115 SCHEDULE OF VISION BENEFITS ................................................................................................. 116 LIFE & AD&D INSURANCE ................................................................................................................. 117 LIFE INSURANCE BENEFITS ........................................................................................................... 117 AD&D BENEFITS ............................................................................................................................... 119 AD&D LIMITS & EXCLUSIONS....................................................................................................... 122 BENEFICIARY .................................................................................................................................... 123 DISABILITY ............................................................................................................................................ 125 SHORT TERM DISABILITY (EXCLUDING NJ, CA, RI, AND WA) .............................................. 125 SCHEDULE OF STD BENEFITS ....................................................................................................... 125 SHORT TERM DISABILITY - NJ, CA, RI, HI, WA .......................................................................... 126 LONG TERM DISABILITY ................................................................................................................ 127 SCHEDULE OF LTD BENEFITS ....................................................................................................... 127 LONG TERM DISABILITY CLAIMS IN NJ, CA, HI, RI AND WA ................................................ 127 LTD LIMITS & EXCLUSIONS........................................................................................................... 129 LTD ADDITIONAL REQUIREMENTS & BENEFITS ..................................................................... 130 PLAN ADMINISTRATION .................................................................................................................... 132 FUNDING & ADMINISTRATION ..................................................................................................... 132 PAYMENT RULES .............................................................................................................................. 132 SUBROGATION RULES .................................................................................................................... 135 WHEN A COVERED PERSON QUALIFIES FOR MEDICARE .......................................................... 140 MEDICARE CROSSOVER PROGRAM ............................................................................................ 140 CLAIMS UNDER ERISA'S CLAIMS AND APPEALS PROCEDURES .............................................. 142 CLAIMS PROCEDURE ....................................................................................................................... 144 APPEAL AND CLAIM PROCEDURES -UNITEDHEALTHCARE ................................................. 145 APPEAL AND CLAIM PROCEDURES – CVS CAREMARK .......................................................... 155 APPEAL AND CLAIM PROCEDURES – CIGNA DENTAL ........................................................... 162 APPEAL AND CLAIM PROCEDURES – CIGNA DISABILITY ..................................................... 164 APPEAL AND CLAIM PROCEDURES – LIFE INSURANCE ......................................................... 167 HIPAA PRIVACY RIGHTS ................................................................................................................ 169 PLAN CHANGES ................................................................................................................................ 172 ERISA RIGHTS.................................................................................................................................... 172 LEGAL OR EQUITABLE ACTION ................................................................................................... 174 QUICK REFERENCE CHART................................................................................................................ 175 GLOSSARY OF DEFINED TERMS ....................................................................................................... 177 FORMS AND NOTICES ......................................................................................................................... 198 SUMMARY PLAN DESCRIPTION 2020 HIPAA NOTICE OF PRIVACY PRACTICES .................................................................................... 199 IMPORTANT NOTICE FROM PETSMART ABOUT YOUR PRESCRIPTION DRUG COVERAGE & MEDICARE...................................................................................................................................... 205 INITIAL NOTICE OF COBRA RIGHTS ............................................................................................ 207 SPECIAL RIGHTS FOLLOWING MASTECTOMY ......................................................................... 210 MOTHER’S

Load more