Microsoft word - bayer spd_revisions active changes accepted.docx
Prescription Drug Coverage
For Members of:
Blue Health &Savings Plan (Anthem BCBS Network)
80% PPO Plan (Aetna Network) If you are enrolled in a medical plan listed above, your prescription benefits will be provided through a CVS Caremark Drug Card Plan. Most prescription medications are covered under the Bayer prescription plan except the following:
Over-the-counter products Durable medical equipment Respiratory Therapy (such as Aerochamber) Non-self administered injectable medications Allergy Shots or Serums Anti-obesity agents Diaphragms, Spermacides Insulin Pump Needles Lancet Devices Infertility Medications Fluoride Products (except for Oral Fluoride products relative to HCR) Medications normally prescribed for cosmetic uses (such as Renova, Propecia, and Rogaine,
Vitamins and Minerals (Prescription Vitamin D only is covered in certain circumstances)
Medications not approved for prescribed use by the FDA Diet Medications
Prescription Drug Coverage – Aetna_Anthem 2013 The following products or their equivalent require a prior authorization from CVS Caremark
6 per 30 days (retail) or 18 per 90 days (mail)
75 mg capsules: 14 capsules every 180 days 45 mg capsules: 14 capsules every 180 days 30 mg capsules: 28 capsules every 180 days 60 mg/5 mL suspension: 180mL every 180 days
Based on drug prescribed (see below) 1 Month Limit 3 Month Limit
Maxalt oral & MLT tabs (5 mg, 10 mg)
Zomig oral & ZMT tabs (2.5 mg & 5 mg) 12 tabs
Prescription Drug Coverage – Aetna_Anthem 2013
Coverage of Preventative Services The following are covered at 100% relative to Health Care Reform -Aspirin -Iron Supplements -Oral Fluorides -Folic Acid -Smoking (tobacco) cessation Women’s Preventative Services The following are covered at 100% relative to Health Care Reform -Oral Contraceptives -Emergency Contraceptives -Injectable Contraceptives -Implantable Devices and Vaginal Rings -Transdermal Contraceptives -Barrier Methods to Contraception Plan Provisions as of January 1, 2013 Blue Health & Savings Plan (Anthem BCBS Network)
(applies to eligible medical and Prescription drug expense)
Prescription Drug Coverage – Aetna_Anthem 2013 Plan Provisions as of January 1, 2013 80% PPO Plan (Aetna Network)
Annual Maximum out of pocket Combined Retail/Mail
Prescription Limits. Prescriptions by retail and/or by mail order are limited to a 90 day supply at one time. Refills are not allowed until 70% of the previous fill has been used (must be more than 63 days after a 90 day supply has been filled). What is “Prior Authorization”? Prior authorization is the process of obtaining approval to receive select medications as a covered benefit. Why do certain medications require prior authorization? Medications are selected for prior authorization only if there is a potential for inappropriate use. Inappropriate use can lead to a situation where the prescribed medication is not approved for a specific medical condition. An example of this is the prior authorization for Retin-A and Differin. These medications are both used and approved to treat acne and other skin conditions, but recently are at times being used for cosmetic reason such as photo-aged skin or wrinkles. Prior authorization for these medications after the age of 29 ensures that they are being used appropriately. How is prior authorization obtained? The prior authorization process may be initiated by either your pharmacist or your physician. Through your pharmacist When your pharmacist enters your prescription into the computer system, he or she will receive an on-line computer message stating that prior authorization of the medication is requested. The message also includes a toll-free telephone number, with which your pharmacist may contact a call center representative at CVS Caremark, to initiate the prior authorization Prescription Drug Coverage – Aetna_Anthem 2013
process. In order to apply the medical criteria to the prior authorization request, the call center representative will request information from your pharmacist. If the pharmacist does not have all the necessary information, the call center representative will contact your physician. After applying the information gathered from your pharmacist and/or physician, the call center representative will notify your pharmacist with the decision of coverage. If the request for prior authorization is approved, the medication will be covered and filled as usual. If the request is not approved, the medication will not be covered; however, the physician may be able to prescribe an alternative medication, which is covered, or you can choose to pay for the medication outside of the plan. Through your physician If you know that your prescription will require prior authorization, you can ask your physician to contact the CVS Caremark Prior Authorization Department. The CVS Caremark call center representative will apply the medical criteria to the information gathered from your physician. If the request for prior authorization is approved, the authorization will be entered into the pharmacy system, and you may take your prescription to your network pharmacy and have the prescription covered and filled as usual. If the request is not approved, the physician will be notified, and he may be able to prescribe an alternative medication, which is covered or you can choose to pay for the medication outside of the plan.
How can I get prescriptions filled when I am traveling outside the United States or at a non-participating pharmacy? If you are traveling outside the US or at a non-participating pharmacy and need to get a prescription filled, you will need to pay the full price of the prescription and complete and submit a claim form for reimbursement. A claim form can be requested by calling customer service at 1-866-273-8404. If you obtain a prescription within the US at a non-participating pharmacy, you will be reimbursed based upon what the coverage would have been had you used a pharmacy within the network. If You Are Age 65 or Over
If you are age 65 or over and actively employed, your company medical benefits will continue to provide primary coverage for you, your spouse and any eligible dependent. You may choose Medicare for secondary coverage or postpone Medicare. Your spouse has the same choices for Medicare that you do and can make a separate election from yours. Prescription Drug Coverage – Aetna_Anthem 2013
Co-Ordination of Benefits
To avoid duplication of payment, your company medical coverage is coordinated with other group medical plans. Other Plans
You or your dependents may be covered by other group medical plans. If the other plan (or plans) is employer-sponsored or government-sponsored, benefits from that plan and this company’s medical coverage are coordinated to avoid duplication of payment. Which Plan is Primary The “primary” plan is the one that is required to pay benefits first, without regard to any other coverage. Benefits from the “secondary” plan(s) are determined by taking into account what already has been paid by the primary plan. In general, the plan covering the person as an employee, member or subscriber (that is other than a dependent) will be the primary plan. For a dependent child, if both parents have group health care plans that cover family members, the parent whose birthday comes first during the calendar year will have the primary plan. For instance, if the father’s birthday is May 15 and the mother’s birthday is July 20, the father’s plan would be primary with respect to the children. On the other hand, if the father’s birthday is August 21 and the mother’s birthday is July 20, the mother’s plan would be primary. If both parents have the same birthday, the plan covering the parent the longest period of time would be primary. There are additional guidelines concerning dependents. In the case of a divorce or separation, if a court decree places financial responsibility for a dependent’s medical care on one parent, that parent’s plan always pays first. Otherwise, the plan of the parent with custody of a dependent child usually pays benefits for the child first. If the person with custody remarries, the step-parent’s plan pays second, and the plan of the parent without custody pays third. If none of these situations fit, the plan covering the person the longer time pays first, except when both plans provide that the plan covering a person as an employee always pays before a plan covering that person as a laid-off employee or retiree. In this case, the plan covering the active employee pays first. If the Plan is Secondary
Here’s what happens if this Plan is secondary. First, the primary plan pays benefits. Then this Plan determines what it normally would pay for the expense and subtracts what has already been paid or is eligible to be paid by the primary plan. If the Prescription Drug Coverage – Aetna_Anthem 2013
primary plan pays less in benefits than you would have received under this Plan, this Plan will pay the remainder of what it normally would pay. Otherwise, this Plan will not pay any benefits. This Plan does not duplicate benefits paid by another group plan. For this reason, it may not be to your advantage to cover yourself or your dependents under more than one medical plan. In addition, you may not be covered both as an employee and as a dependent under one or more company plans, HMOs or PPOs. Generally, your eligibility to participate in the Plan will end on the last day of the month in which you leave the company. See the “Life Events” section for additional information. Situations Affecting Plan Benefits In addition to what has been stated elsewhere, the following could affect benefits from company medical options (your prescription drug coverage is part of your medical plan) as summarized here: There may be slight differences in the coverage provided by the company and its
affiliates. If you transfer from one affiliate or another, your coverage may change.
If you don’t properly apply for benefits or provide the necessary claim
information, benefits may be delayed or denied.
If you fail to keep your current address on file and the company cannot locate
you, your benefit payment may be delayed or denied.
The Plan will comply with any additional rules imposed by states that have
received an ERISA exemption, such as Hawaii.
The Plan shall have the right to reduce benefits otherwise payable by the Plan, and to recover one hundred percent of all benefits previously paid, to the extent of any and all of the following: All payments to you or your dependent resulting from a judgement against or
settlement with a person considered to be responsible for the condition giving rise to the medical expense, including payments by that person’s insurer, regardless of whether the payment is characterized as payments for medical expenses or for other damages;
All payments made to, or for the benefit of, you or your dependent by any insurer
to reimburse medical or related expenses which have been paid by the Plan;
Prescription Drug Coverage – Aetna_Anthem 2013
All payments to you or your dependent under any government plan or program,
including, but not limited to, workers’ compensation, Medicaid or Medicare, for medical conditions for which benefits have been or otherwise would be paid under the Plan.
By accepting benefits under the Plan, you and your covered beneficiaries consent to such reimbursement and grant to the Plan whatever liens and rights of intervention as are available under applicable law to secure this obligation. Subrogation The plan is subrogated, to the extent of all benefits paid or payable under this Plan, to any claim or right of recovery which you or a covered dependent may have against any third party which is legally responsible for the condition giving rise to the medical expense paid or to be paid by the Plan. Information The company reserves the right to end, suspend or amend any part of this benefit plan or your contributions to it, at any time, in whole or in part. For eligibility rules, life event changes, and administrative information, please refer to the Bayer Benefits Summary Plan Description. Prescription Drug Coverage – Aetna_Anthem 2013
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