SMM, Pages 15-16:
The chart on pages 15-16 of the December 15, 2005 SMM, the text denoting • Retail prescription drugs for Standard Medical Options, and
• In-store purchase of over-the-counter drugs for Standard Medical Options is revised as follows: Type Of Expense Can You Use FSA Card? Can You Use Automatic Rollover? Must You File FSA Claim Manually?
Medical Expenses—Point-of-Service Option
Copayments Yes Yes No
Deductibles (UHC network providers) Yes Yes No
Coinsurance Amounts (UHC network providers) Yes Yes No
Retail Prescription Drugs (network pharmacies) Yes Yes No
Mail Order Prescription Drugs (Medco by Mail) Yes Yes No
Eligible Over-the-Counter (OTC) Drugs Purchased Retail or Online—Point-of-Service Option
Walgreens—in store purchases only Yes No No
Drugstore.com—online only Yes No No
Medical Expenses—Standard Medical Options
Coinsurance (UHC network providers) Yes Yes No
Deductibles (UHC network providers) Yes Yes No
Retail Prescription Drugs (network pharmacies) No Yes No
Mail Order Prescription Drugs (Medco by Mail) Yes Yes No
Eligible Over-the-Counter (OTC) Drugs Purchased Retail or Online—Standard Medical Options
In-store purchases No No Yes
Drugstore.com—online only Yes No No
HMOs
Copayments Yes No No
Coinsurance and Deductibles (UHC network provider) Yes Yes No
Dental Expenses, Including Orthodontia
Coinsurance and Deductibles (network provider) Yes Yes No
Vision Expenses
Copayments Yes Yes No
Coinsurance and Deductibles (network provider) Yes Yes No
Any Other FSA-Eligible Expense Not Filed With Your Health Coverages
No No Yes
Dependent Day Care
SUMMARY OF MATERIAL MODIFICATIONS FOR HEALTH AND WELFARE BENEFIT PLANS SPONSORED BY AMERICAN AIRLINES, INC.
December 15, 2005
This document serves as notice to American Airlines, Inc. active and Leave-of-Absence employees of changes to the American Airlines, Inc.-sponsored health and welfare benefit plans listed below. This Summary of Material Modifications describes the changes that affect your benefit plans, an updates your summary plan descriptions. This Summary of Material Modifications, together with the Employee Benefit Guide, make up the official plan documents and summary plan descriptions. Please read this notice carefully, and place this notice with your summary plan description(s) (the Summary Plan Descriptions are contained in the Employee Benefit Guide for Flight Attendants (“EBG”). These changes are effective January 1, 2006, unless otherwise stated elsewhere in this document.
• Group Life and Health Benefits Plan for Employees of Participating AMR Corporation Subsidiaries (Plan 501, EIN #13-1502798; referred to herein as the “Plan”)
• Supplemental Medical Plan for Employees of Participating AMR Corporation Subsidiaries (Plan 503, EIN #13-1502798; referred to herein as the “SuppMed Plan”)
• American Airlines, Inc. Long Term Disability Plan (Plan 509, EIN #13-1502798; referred to herein as the “LTD Plan”)
• Long Term Care Insurance Plan for Employees of Participating AMR Corporation Subsidiaries (Plan 510, EIN #13-1502798; referred to herein as “LTCIP”)
I. Change the Retail Prescription Drug Administrator in the Plan’s Point-of-Service Option from
UnitedHealthcare to Medco
In the “Contact Information” section (page 2), the chart entry for retail prescriptions information is revised as follows: Prescriptions-Retail—
Point-of-Service Option
Medco
Member Services—Phone Inquiries
(800) 988-4125
Web site: www.medco.com
Filing Retail Prescription Claims—Standard and Point-of- Service Medical Options
Medco
PO BOX 2160
Lee’s Summit, MO 64063-2160
N/A
In the “Medical Benefit Options” section “Prescription drug benefits” (page 44), the last sentence in the second paragraph is revised, and a sentence added, as follows:
. . . Prior to January 1, 2006, if you visit an out-of-network pharmacy, you must submit your receipts to UnitedHealthcare to be reimbursed at the out-of-network benefit rate. Effective January 1, 2006, if you visit an out-of-network pharmacy, you must submit your receipts to Medco to be reimbursed at the out-of- network benefit rate.
In the Point-of-Service Option section, “Retail Drug Program” (page 80), the last sentence is revised, as follows:
Effective January 1, 2006, to request a list of participating pharmacies, contact Medco at 800-988-4125.
In the “Filling Prescriptions” section (page 81), the second bullet under “Out-of-Network Pharmacies” is revised as follows:
File a claim with Medco for reimbursement of Eligible Expenses. Complete an out-of-network prescription claim form and attach the receipt for your prescription, as explained in “Filing Claims” for the Point-of- Service Option (see page 82).
In the “Retail Prescription Clinical Programs” section (page 81), the last sentence of the paragraph is revised as follows:
Additional information about these programs may be obtained from the prescription drug administrator (see Medco in the Contact Information).
In the “Filing Claims” section, the second bullet under “If you use an out-of-network pharmacy” (page 81) is revised as follows:
Complete and file a Medco claim form available on Jetnet or from Medco for consideration of reimbursement, in the same way that you file a claim for out-of-network expenses. Remember to attach a receipt for the prescription medication.
In the “Mail Service Prescription Clinical Programs” section (page 82), the last sentence of the paragraph is revised as follows:
Additional information about these programs may be obtained from the prescription drug administrator (see Medco in the Contact Information).
In the “Filing Claims” section (page 83), the sentence in the fifth paragraph is revised, as follows:
If you have questions about your coverage or your claim, contact UnitedHealthcare or Medco.