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
 Nutritional Supplements

Prescription Drug Coverage – Aetna_Anthem 2013
The following products or their equivalent require a prior authorization from
CVS Caremark

 Amphetamines (Dexedrine /Adderall /Adderall XR / Desoxyn / LiQuadd /  Acne Medication (Atralin / Avita / Retin-A / Retin-A Micro / Differin / Tretinoin  Tazorac  Botox / Myobloc / Dysport / Xeomin  Antifungal Treatments (Lamisil / Sporanox)  Oral Fentanyl (Actiq / Fentora / Onsolis)
The following medications and products are subject to quantity limits

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.
Reimbursement

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

Source: http://mybenefitessentials.bayerweb.com/static/documents/forms/Caremark_SPD_20052_Final_1_21_11.pdf