BNSF Exempt Retiree Medical Program Options

BNSF offers nationwide medical programs and in certain areas, HMO's are available as an alternative. Retiree medical benefits are only available for those retirees that are grandfathered into those benefits. To be eligible for retiree medical, exempt employees must have been a BN or SF exempt employee prior to the BNSF merger (September 22, 1995) and remain exempt until their retirement. Exempt employees hired or promoted to exempt status after September 22, 1995 do not have access to retiree medical coverage through BNSF. If an eligible retiree does not enroll when he/she retires, he/she will only be able to enroll later if he/she has a HIPAA Special Enrollment Event as described in the SPD.

Grandfathered Pre-Medicare Santa Fe Retirees have access to the Aetna High Deductible Health Plan (HDHP), the Aetna Network Build Your Own (BYO), and the Blue Cross Blue Shield PPO/BYO options. Retirees in this group may also have access to HMO's in Northern California (Kaiser), Southern California (Kaiser and PacifiCare), Colorado (Kaiser), and Washington State Group Health Options HMO, (a Kaiser affiliate). While these HMO's are generally available, they are not available in all locations in these states. The HMO defines their service area Santa Fe with the State and can only offer services within that service area.

Grandfathered Post-Medicare Santa Fe retirees have access to the CIGNA Indemnity option or HMO's that offer coverage for Post-Medicare retirees (formerly known as Medicare + Choice).

Grandfathered Pre-Medicare Burlington Northern Retirees have access to the Aetna HDHP, the Aetna Network BYO, and the Blue Cross Blue Shield PPO/BYO plans. Use the link below to the BN Retiree Medical Summary Plan Description (SPD) for details about this coverage. BN retiree medical coverage is available only until the retiree is Medicare eligible.

Link to Summary Plan Description (SPD)

Aetna Select EPO and Build Your Own (BYO) Options

In the Aetna Select EPO or Aetna BYO options. It works just like an HMO and uses Aetna’s HMO network. This option is only available in locations across the BNSF system where Aetna has a network available. This will be predominantly in more urban locations.

In this program, you are required to select a Primary Care Physician (PCP) for each member of your family who will direct your care. If you need to see a specialist, your PCP must provide a referral to a specialist in the network.

Under the Aetna Select EPO and BYO Options you pay a copayment for office visits and for certain other items. You also have a coinsurance:

• For the EPO Plan after deductible, at 90% plan paid/10% you for in-network coverage only.
• Under the BYO Option, depending on what level of coverage was elected during enrollment, at 70% or 80% in-network coverage.
• There is no payment for services that are Out-Of-Network.

Additional details regarding the Aetna Select Network EPO/BYO options are available in the Summary Plan Description. Click on the link below to go to the SPD for the Aetna Network EPO/BYO option.

Link to Summary Plan Descriptions (SPD)

Pharmacy Benefits

Pharmacy benefits are provided through Caremark. See the page on Pharmacy Services for details. Click on the link below to go to that page.

Link to Pharmacy Page

Blue Cross Blue Shield PPO/BYO Options

Blue Cross Blue Shield offers nationwide PPO/BYO options. With a PPO plan, the Insurance Company maintains a network of providers and facilities that have agreed to provide services at contracted rates.

You have the option of utilizing the network or seeking care outside the network. If you are treated by a network provider, you receive benefits at a higher level and there is no deductible. If you go Out-of-Network for care, there is a ($750 single/$1500 family; $1250 single/$2500 family; or $2000 single/$4000 family) deductible, and the plan pays at 70% or 80% rather than the 85% for In-Network care. Out-of-Network care is also subject to reasonable and customary charges. In a PPO plan, you do not need to designate a Primary Care Physician. In a PPO plan, it is the participant's responsibility to verify that each healthcare provider (physician, lab, hospital, etc.) is In-Network if you want to receive the higher level of benefit. Even if your network doctor refers you to an Out-of-Network facility or specialist, you will pay more, since it is your responsibility to ensure that providers are in the network.

Reasonable and Customary Charges (R & C)

In addition to a deductible and lower co-insurance, Out-of-Network services are subject to Reasonable and Customary (R & C) guideline limits. R & C amounts are based on the normal range of charges made by providers in the same geographical area and are reviewed and updated each year. You will be responsible for any fees by an Out-of-Network that exceed the R & C limit.

Out-of-Pocket Maximum

The PPO options include a provision that limits the amount you must pay "out of your pocket" in a calendar year. The Out-of-Pocket maximum for In- and Out-of-Network benefits depends on the deductible you elected:

• $750 single, $1,500 family;
• $1,250 single, $2,500 family; or,
• $2,000 single, $4,000 family.

These Out-Of-Pocket maximums are per individual with a family maximum of $5,500 and $10,000.

Pre-certification

If you are hospitalized, it is your responsibility to pre-certify your care with the health plan. There is a $500 penalty if you do not pre-certify inpatient care. If the admission is approved and you stay longer than certified, the additional days will be denied and you will be responsible for those charges.

Pharmacy Benefits

Pharmacy benefits are provided through Caremark. See the page on Pharmacy Services for details. Click on the link below to go to that page.

Link to Pharmacy Page

Additional details regarding the Blue Cross Blue Shield PPO/BYO options are available in the Summary Plan Description. Click on the links below to go to the SPD.

Link to Summary Plan Descriptions (SPD)

Aetna High Deductible Health Plans (HDHP) with Health Savings Account (HSA)

Pre-Medicare retirees may select from the Aetna High Deductible Health Plans with Health Savings Account (HSA) Options with in- and out-of-network benefits. You have two choices of deductibles;

• $1,250 single/$2,500 family; or
• $2,500 single/$5,000 family (both in- or out-of-network)

You pay 100% of expenses until you reach the deductible. All your eligible expenses, including expenses paid from your HSA count toward satisfying the deductible.

With the HDHP options, you will have a coinsurance of 80%/20% in-network; 60%/40% out-of-network. HDHPs do not have copays. You pay the full cost of office visits and prescriptions until you satisfy the deductible. You have the flexibility to go to any doctors you choose, but you get the advantage of network discounts and greater coinsurance when you use care providers in the Aetna PPO network. There is a coinsurance maximum of $2,000 single/$4,000 family (in-network) for both options. These amounts double for out-of-network. Your out-of-pocket maximums are:

• $3,250 single/$6,500 family (in-network) for the Aetna 1250/2500 HDHP
• $4,500 single/$9,000 family (in-network) for the Aetna 2500/5000 HDHP

The BNSF will contribute $500 single/$1,000 family for the Aetna 1250/2500 HDHP, and $1,000single/$2,000 family for the Aetna 2500/5000 HDHP. You may contribute additional tax deductible contributions depending on which Plan you choose.

Link to Summary Plan Descriptions (SPD)

CIGNA Indemnity Program

Former Santa Fe retirees covered by Medicare are eligible for the CIGNA Indemnity program. This program coordinates with Medicare. Under this option, Medicare is the primary insurer and the CIGNA Indemnity option is secondary. Under this option, you may obtain care from any provider you choose. Usually, you pay for each medical service up front and then file a claim for reimbursement from CIGNA for covered benefits. Before the Indemnity option begins to pay benefits, you must meet the annual deductible. In addition, you must pay a percentage of each covered expense, referred to as coinsurance. The option has a $1,000,000 lifetime benefit limit for each covered person. This limit is cumulative from your active and Pre-Medicare BNSF Medical Program coverage. For example, if you received $100,000 in benefits while covered under the Medical Program as an active employee, and $25,000 while covered under the Pre-Medicare Retiree Program, you have a remaining lifetime limit of $875,000 under the Post-Medicare Retiree Indemnity Program. Each January 1, if you have used at least $1,000 of the lifetime limit in the prior year, $1,000 will be restored to the limit. The Post-Medicare Retiree Indemnity Program Summary of Benefits appears below. Certain limits also apply to specific benefits.

The Indemnity program has a $250 per person deductible, $500 per family. For most services you pay 20% of the cost of the service after paying your deductible. There is a $1,500 out-of-pocket limit per person and $3,000 per family. For additional information about the program coverage, see the program summary below or use the link below for the Summary Plan Description (SPD).

Link to Summary Plan Descriptions (SPD)

Post-Medicare Indemnity Program Summary of Benefits

*There is a 60-day limit per condition for outpatient rehabilitation. Chiropractic therapy has additional limits. There is a 60-day limit per condition or $1,000 per year, whichever comes first. Chiropractic therapy will be reviewed for medical necessity on the 35th visit.

Reasonable and Customary Charges (R & C)

In addition to a deductible and lower co-insurance, Out-of-Network services are subject to Reasonable and Customary (R & C) guideline limits. R & C amounts are based on the normal range of charges made by providers in the same geographical area and are reviewed and updated each year. You will be responsible for any fees by an Out-of-Network that exceed the R & C limit.

Mental Health and Substance Abuse Benefits

The Post-Medicare Retiree Indemnity Program does not provide mental health or substance abuse benefits for covered persons who are covered by Medicare. Therefore, once you are on Medicare, you become ineligible for the mental health/substance abuse care administered by CIGNA Behavioral Health& and once your eligible dependents are on Medicare, they become ineligible for the mental health/substance abuse care administered by CIGNA Behavioral Health.

Mental health/substance abuse benefits are available for your eligible dependents if they are in the Pre-Medicare programs. For detailed benefit information for Pre-Medicare dependents, refer to "Substance Abuse and Mental Health" section within the Pre-Medicare Retiree Program SPD.

Link to Summary Plan Descriptions (SPD)

Pharmacy Benefits

Pharmacy benefits under this option are provided through Caremark. See the page on Pharmacy Services for details. Click on the link below to go to that page.

You also have the option to elect the Cigna Indemnity Plan without prescription coverage.

Link to Summary Plan Descriptions (SPD)

Link to Pharmacy Page

HMO's

Former Santa Fe retirees may have access to HMO's in several states. The two HMO providers are Kaiser (California, Colorado and Washington state) and PacifiCare (Southern California).

If you select an HMO, there are no Out-Of-Network benefits and pharmacy, and Mental Health and Substance Abuse benefits are provided by the HMO. You must work through the HMO for a referral to a specialist or for the authorization of any procedures or hospitalizations.

Some of these HMO's also offer benefits to retirees over the age of 65. In areas where these Medicare HMO's are available, they are offered as an alternative to the CIGNA Indemnity program.

For more specific information about coverages, contact the HMO directly via the customer service number on your ID card.

The information contained on this page is a summary of the information contained in the more detailed Plan documents. Any inconsistency between the information in this Web site and the actual plan documents is accidental, and the official plan documents govern. BNSF reserves the right to change or terminate those plans at any time without notice. Click on this link in the text below to go to the Summary Plan Description