SPRINGS WINDOW FASHIONS LLC GROUP BENEFIT PLAN PHARMACY BENEFIT SUMMARY

Transcription

1 SPRINGS WINDOW FASHIONS LLC GROUP BENEFIT PLAN PHARMACY BENEFIT SUMMARY This is a summary of benefits provided under the Springs Window Fashions, LLC Pharmacy Program (the Program ), as a component of the Springs Window Fashions LLC Group Benefit Plan (ERISA plan number 508) ( Wrapper Plan ). This Program Summary is effective January 1, This Program Summary is part of (and integrated with) the Springs Window Fashions LLC Group Benefit Plan Summary Plan Description, amended and restated effective as of January 1, 2018 ( SPD Supplement ). Both the Wrapper Plan and SPD Supplement are incorporated by reference. Caremark PCS Health, L.L.C. ( CVS Caremark ) manages the. ELIGIBILITY Employee Eligibility: As employee of the Employer ( Employee ), you are eligible to participate in the Program if the following requirements are satisfied: (1) You will be eligible to participate in the Program if you are regularly scheduled to work at least 30 hours per week. You will enter the Program on the first day of the month following one month of employment from initial date of employment. (2) Variable Hour Employee. If you are (i) classified as a Variable Employee (i.e., regularly scheduled to work less than 30 hours per week, or a variable hour or seasonal Employee), and (ii) are determined by the Employer to have averaged at least 30 hours per week during a measurement period, you will be eligible to become a participant in the Plan designated by the Employer for the immediately subsequent stability period. If, as a Variable Employee, you are determined by the Employer to be an eligible Employee for a given stability period, you will remain an eligible Employee for the entirety of such stability period, even if you are transferred during such stability period to a position in which you will work or are expected to work less than 30 hours per week, on average, on a regular basis, as long as you remain an Employee of the Employer without a period of thirteen or more weeks during which you do not provide any hours of service to the Employer. The standard measurement period each year is a twelve month period measured from October 3 through October 2, the standard administrative period each year is a 90 day period measured from October 3 through December 31, and the standard stability period each year is a twelve month period measured from January 1 through December 31; provided however that your initial measurement, administrative and stability periods will be based on your date of hire. As a Variable Employee, you will enter the Plan, with respect to the Medical Plan for which you are eligible, on the first day of the applicable stability period following the date the Employer determines you, as a the Variable Employee, have satisfied the Plan s eligibility requirements. The Employer may, from time to time, adopt policies and procedures to implement and administer the provisions of the Plan relating to Variable Employees in a manner consistent with the Affordable Care Act ( Variable Employee Policy ). If you are an employee of an affiliated employer of the Employer set forth in Appendix B, you may participate in the Program if you satisfy all eligibility requirements under the Program. Appendix B may be amended from time to time by the Employer without any formal amendment to the Program or other formal action of the Plan Administrator or any other person. Page 1

2 If you are a new Employee of the Employer (or its affiliated employers set forth in Appendix B) who was acquired in an acquisition, merger or similar transaction by the Employer (or any affiliated employer) ( Acquisition ), your credited service for eligibility and entry into the Program may be altered as determined by the Employer or as set forth in a purchase agreement documenting such Acquisition. The Employer will communicate to you any change in credited service for eligibility and entry into the Program as soon as practicable after such Acquisition. Except as required by law with respect to benefits subject to Affordable Care Act, if you are a reemployed former participant, you will reenter the Program when you again satisfy the eligibility requirements under the Program. Your coverage under this Program will terminate as provided in the Employer s medical plan. Any Employee who does not meet the above eligibility requirements is not eligible to participate in the Program. Dependent Eligibility: Your dependents will be eligible to participate in and enter the Program as provided in the Employer s medical plan. Your covered dependents coverage under this Program will terminate as provided in the Employer s medical plan. COVERAGE The Program provides high and low prescription drug options through C V S Caremark. Coverage under the high and low prescription drug options are described in Appendix A. You and your covered dependents may continue your prescription drug coverage with your medical coverage under certain circumstances, according to the terms of your Employer s leave of absence policy, the Family and Medical Leave Act of 1993 (FMLA), the Uniformed Services Employment and Reemployment Rights Act (USERRA), and the Consolidated Omnibus Budget Reconciliation Act (COBRA) as described in the SPD Supplement. ASSIGNMENT PROCESS The applicable tier for Generic, Preferred Brand-Name Non-Preferred Brand-Name, and Specialty drugs, as well as excluded products, is determined by CVS Caremark Pharmacy and its Therapeutics Committee that meets periodically to review determinations based on current clinical information. IN-NETWORK PHARMACY The pharmacy program covers FDA-approved (federal legend) medications that require a prescription from your physician (or other prescribing provider). Over-the-Counter Drugs are not covered by the Program unless covered as Preventative Care Services as required by Federal law and prescribed by a physician. CVS Caremark provides three ways for you to purchase prescriptions: 1. At a retail pharmacy that participates in the CVS Caremark national network, or Page 2

3 2. CVS Caremark Mail Service Pharmacy for your maintenance medications (prescription drugs that treat ongoing conditions such as diabetes or high blood pressure), or 3. A CVS Caremark specialty pharmacy Whenever you or your covered dependent has a prescription to be filled, present your medical plan identification card to the pharmacy. When you fill a covered prescription at a participating retail pharmacy you must pay the pharmacy the required cost share for each separate prescription or refill. This Program will pay the pharmacy directly for the remainder of the cost of the prescription or refill. The Program will pay for no more than a 30 or 90-calendar day supply of the drugs on each occasion when you have the prescription filled or refilled at a retail pharmacy. You are encouraged to ask your physician (or other prescribing provider) to prescribe genericequivalent drugs as appropriate whenever possible and to prescribe drugs from the preferred formulary when prescribing Brand-Name Drugs. The prescription order must be issued by a provider legally authorized to issue the prescription order. The prescription order must be filled by a licensed pharmacist in a Participating Pharmacy licensed by the state. The Program will only make payments to a pharmacy which is a member of our pharmacy network. A pharmacy which is a member of our pharmacy network is one which has entered into an agreement to provide prescription drug benefits to eligible persons. OUT-OF-NETWORK RETAIL PHARMACY Your pharmaceutical benefits are managed through a network of Participating Pharmacies. If you choose to fill a prescription at a Non-Participating Pharmacy, the Program will pay 100% of the submitted price less your cost share. The cost share for out-of-network prescriptions is the same that applies to your in-network prescriptions. When you use a Non-Participating Pharmacy, you must pay the pharmacy the full price of the drug and submit the pharmacy receipt to CVS Caremark. You will have 365 days from the date the prescription is filled to file the prescription with CVS Caremark. Contact Customer Care: (844) or Caremark.com Mail pharmacy receipts to: CVS Caremark P.O. Box Phoenix, AZ MAIL ORDER PRESCRIPTION DRUGS The Program also pays for FDA-approved, maintenance medications, which require a prescription. Mail order prescription drugs may be dispensed in up to a 90 consecutive day supply, and are intended for purchasing maintenance medications. Generally these are drugs Page 3

4 that are taken on a regular basis for conditions such as heartburn, asthma, blood pressure, and high cholesterol. The maintenance medication list is updated periodically. You can call CVS Caremark at For TDD assistance, please call to find out if your prescription drug is considered a maintenance medication. When you have a prescription filled through mail order, you must pay the required pharmacy cost share for each separate prescription or refill. By selecting CVS Caremark Mail Service Pharmacy Program benefit, you are taking advantage of added savings and convenience. Tips for Using Mail Order How the Program Helps You: Free standard shipping of your medication. Up to a 90-day supply of medication with each order 24-hour access to a pharmacist. Reduced cost. It s Easy to Get Started Online: Get your online benefits by registering on Caremark.com/startnow and set up your home delivery profile. Phone: Our contact center representatives will set up a profile and contact the physician (or other prescribing provider) for new prescriptions For TDD assistance, please call Mail: Complete the required documentation as provided on Caremark.com and mail in with your 90 day mail order prescriptions. If you have any questions concerning your mail order, contact CVS Caremark s Mail Order Customer Care at Note, we have multiple mail order facilities depending on the area of the country you live in. SPECIALTY DRUGS WITH CVS CAREMARK CVS Caremark has CVS Caremark specialty pharmacies which dispense oral and injectable specialty medications for the treatment of complex chronic diseases such as multiple sclerosis, hemophilia, cancer, and rheumatoid arthritis. Specialty Drugs are prescription drugs which: Are approved to treat limited patient populations, indications or conditions; Page 4

5 Are normally injected, infused or require close monitoring by a physician or clinically trained individual; or Have limited availability, special dispensing and delivery requirements, and/or require additional patient support, Any or all of which make the drug difficult to obtain through traditional pharmacies. As indicated on Appendix A, you must order your Specialty Drugs directly from a CVS Specialty Pharmacy. Some limitations may apply. For more information contact CVS Caremark at or please call For TDD assistance, please call If you send a prescription for specialty drugs to CVS Caremark Mail Service Pharmacy, CVS Caremark will first contact the prescribing provider to confirm the specialty drug and, if applicable, CVS Caremark will forward the prescription to a CVS Specialty Pharmacy. DRUG QUANTITY MANAGEMENT To help make the use of prescription drugs safer and more affordable, our Program uses a Drug Quantity Management program. That is, for certain medications, you can receive an amount to last you a certain number of days. This gives you the right amount to take the daily dose considered safe and effective, according to the recommendations of the U.S. Food and Drug Administration (FDA). Based on the FDA s guidelines and other medical information, our Program developed this Drug Quantity Management program together with CVS Caremark. The limits are based on a 30-day supply, but our benefit may provide a different supply. For instance, you may be able to get a 90-day supply of your medication. Your physician (or other prescribing provider) could also request a prior authorization. If this request is approved, a prior authorization would let you receive more than the recommended quantity. Following are examples of drugs that may have quantity limits without post-limit prior authorization: Long & Short Acting Beta2-Agonists (respiratory/asthma inhalers) Intranasal Steroids/Antihistamines Anticholinergic, Combination, And Mast Cell Stabilizer Oral Inhalation (misc. asthma / COPD agents) Corticosteroid Oral Inhalation (steroid inhalers) Antiemetics (Anti-nausea) AntiMigraine Influenza Lidocaine Topical, Lidocaine-Prilocaine, Lidocaine-Tetracaine Sedative/ Hypnotics (insomnia drugs) ED Alprostadils, PDE-5 Inhibitors Limit & ED-BPH Cialis 5mg Post Limit PA To verify if a prescription drug is subject to drug quality management or if you receive a message on your prescription that says Qty lmt exceeded PA reqrd call Specialty phone # , call Page 5

6 PRIOR AUTHORIZATION CVS Caremark has developed a list of medications with a high potential for inappropriate use. To ensure patient safety, these drugs will require prior authorization by CVS Caremark before your prescription is filled. Specifically, the following drugs will require prior authorization: Narcolepsy drugs such as Nuvigil and Xyrem. GI motility drugs such as Lotronex and Viberzi Compounded medications exceeding $300 Heart failure drugs such as Entresto Sublingual Immunotherapy (SLIT) Agents such as Grastek, Oralair, and Ragwitek Retinoids (topical) such as Tretinoins Testosterone Products (for a 12-month period) for transgender care such as testosterone (topical/buccal/nasal), Delatestryl, Testopel or Depo-Testosterone If your physician (or other prescribing provider) prescribes a drug requiring prior authorization, the pharmacist will check to see if there is a prior authorization on file. If no prior authorization is on file, the pharmacist can ask your physician (or other prescribing provider) to contact Caremark Prior Authorization Department for a review, available 24 hours a day; provided, however, that there is a one-time override for urgent requests after hours for medications for the following therapy conditions: Neutropenia (white blood cell disorder) Anemia Infertility Oncology Contact Information: To determine if prior authorization is required or receive prior authorization for nonspecialty prescriptions, call CVS Caremark at or fax them at or visit the Claims Administrator s website on Caremark.com. To determine if prior authorization is required or receive prior authorization for specialty prescriptions, call Caremark at or fax them at or visit the Claims Administrator s website on Caremark.com. A list of medications requiring prior authorization can be found on Caremark.com. DRUGS THAT ARE NOT COVERED UNDER THE PROGRAM The following items are not covered under the Program: Devices of any type, such as therapeutic devices, artificial appliances, hypodermic needles, syringes or similar devices, except for those devices required by law Drugs that do not require a prescription or are available over-the-counter (except as required to be covered as Preventive Care Services as required by Federal Law and prescribed by a physician and medically necessary) Charges for the following diabetic medicines and supplies: alcohol swabs, urine glucose testing strips, acetone testing strips, ketone testing strips, oral glucose, continuous blood glucose monitors, insulin pumps, and insulin pump supplies. Page 6

7 Charges or fees for drug administration or injection (except for any preventative care vaccines mandated by the Affordable Care Act such as certain flu vaccines) Vitamins that by law do not require a prescription (except for any prescribed vitamins mandated by the Affordable Care Act such as certain prenatal, pediatric and multiple vitamins) Appetite suppressants, unless medically necessary Nutritional supplements for treatment of phenylketonuria, branched-chain ketonuria, galactosemia and homecystinuria when administered under the direction of a Physician, unless medically necessary Modified solid food products to treat certain inherited diseases of amino acid or organic acid metabolism, unless medically necessary Compounded medications that are (i) bulk ingredients (i.e., bulk chemicals, bulk powders, bulk compounding ingredients, hormone replacement bulk ingredients), (ii) other ingredients (high cost bases, compound kits, etc.) and (iii) some IV, antibiotic and anti-infection bulk ingredients) Medications for cosmetic purposes only, except that medications shall be covered for medically diagnosed congenital defects and birth abnormalities and for any other conditions for which a medication is medically necessary. Replacement of lost, stolen or damaged prescription medications, unless approved by a CVS Caremark Account Manager for Review. Contact CVS Caremark for more information. Refills not dispensed in accordance with the prescription (i.e., unless you have completed 75% of your previous fill, your prescription will generally be rejected through the pharmacy. There are no refill restrictions at this time for maintenance medications for the number of 30 day fills you can have). Generally a Participating Pharmacy will not refill beyond one year from the original prescription date Medications not approved by the FDA or which the FDA has determined to be contraindicated for the specific treatment for which the drug has been prescribed, unless otherwise required by law or unless medically necessary CVS Caremark will also not cover medications that are considered experimental or investigational unless medically necessary. This is not an all-inclusive list of excluded drugs and the list of excluded drugs may change periodically. For more information about excluded medications, please contact C V S Caremark at or please call For TDD assistance, please call COVERED DRUGS UNDER THE PROGRAM The following prescription drugs are covered under the Program: Generally, those allowable prescription drugs listed in (a) the Caremark Performance Drug List - Standard Control (limitations may apply) or (b) the High Deductible Health Plan (HDHP) - Health Savings Account (HSA) Preventive Therapy Drug List which are located at Caremart.com, include, but are not limited to: Insulin and self-administered injectables, including amylin analogs (Symiln), incretin mimetics (Byetta, Victoza), needles, syringes and insulin pen devices Diabetic supplies and equipment, including lancets, lancet devices, glucose blood testing strips, glucagon emergency injection kits, and blood glucose monitors Page 7

8 Enteral formulas for home use that are medically necessary and proven effective for the specific disease when prescribed by a written order by a physician or other health care provider licensed to prescribe under applicable law Infertility drugs up to certain limits as set forth in Appendix A Contraceptive drugs or devices from a pharmacy or administered at a provider s office that are approved by the FDA or generic equivalents approved as substitutes by the FDA, under prescription of an authorized health care provider Bone mineral density drugs and devices covered under the standards and criteria of the federal Medicare Program and the National Institute of Health Refills for up to one year from the date of the original prescription, if authorized by the physician (or other prescribing provider) and indicated on the prescription The cost for medication in excess of Program limits will be paid under CVS Caremark s Usual and Customary (U&C) Charge Acne products are covered up to age limit of 35, if medically necessary There is a 28 day supply limit that applies to all Hepatitis C therapy drugs This is not an all-inclusive list of covered drugs and the list of covered drugs may change periodically. For more information about covered medications, please contact CVS Caremark at or please call For TDD assistance, please call GENERAL PROGRAM INFORMATION 1. Name of Program: The Springs Window Fashions, LLC Pharmacy Program is part of the plan entitled the Springs Window Fashions LLC Group Benefit Plan. 2. Plan Sponsor and Plan Administrator: 3. Employer Identification Number: Springs Window Fashions, LLC 7549 Graber Road Middleton, WI (608) Type of Program: Welfare benefit plan providing prescription drug benefits for participating employees and their dependents. 5. Original Effective Date: January 1, Plan Year: January 1 through December Plan Number: The Springs Window Fashions, LLC Pharmacy Program is part of wrapper plan number 508, entitled the Springs Window Fashions LLC Group Benefit Plan. Page 8

9 8. Agent for Service of Legal Process: Springs Window Fashions, LLC John Comerford, Senior VP Corporate Administration, or successor in office 7549 Graber Road Middleton, WI Claims Administrator: CVS Caremark Prescription Claims - CVS Caremark P.O. Box Phoenix, AZ Appeals: Fax (866) Urgent Verbal Appeals (866) Program Benefits Provided by: The Program is self-funded by the Plan Sponsor, with benefits paid through general assets of the Plan Sponsor. Page 9

10 CLAIMS PROCEDURES When you have a Claim to submit for payment, you must: (1) Obtain a claim form from CVS Caremark. (2) Complete the Employee portion of the form and submit the claim form to: CVS Caremark Prescription Claims - CVS Caremark P.O. Box Phoenix, AZ Appeals: Fax (866) Urgent Verbal Appeals (866) You will have 365 days from the date Out-of-Network prescription is filled to submit that paper claim prescription with CVS Caremark. A claim is defined as any request for a Program benefit made by a claimant (or by an authorized representative of a claimant) that complies with the Program procedures for making a benefit claim. The times listed are maximum times only. A period of time begins at the time the claim is filed. Days means calendar days, not business days. For purposes of determining the amount of, and entitlement to, benefits under this Program, Claims Administrator is CVS Caremark (unless such power is delegated to another party as described in the Plan Administrator, with the full power to make factual determinations and to interpret and apply the terms of the Program as they relate to your benefits. There are different types of claims (group health concurrent and group health post-service), and each one has a specific timetable for either approval, payment, request for further information, or denial of the claim. (a) Pre-Service Claim Determinations. When a covered person requests a medical necessity determination prior to receiving care, the Claims Administrator will notify the covered person of the determination within 15 days after receiving the request. However, if more time is needed due to matters beyond the Claims Administrator s control, the Claims Administrator will notify the individual within 30 days after receiving the request. This notice will include the date a determination can be expected. If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and the covered person must provide the specified information to the Claims Administrator within 45 days after receiving the notice. The determination period will be suspended on the date the Claims Administrator sends such a notice of missing information, and the determination period will resume on the date the covered person responds to the notice. If the determination periods above involve urgent care services, or in the opinion of a physician with knowledge of the covered person s health condition, would cause severe pain which cannot be managed without the requested services, the Claims Administrator will make the pre-service determination on an expedited basis. The Claims Administrator will notify the covered person of an expedited determination within 72 hours after receiving the request. However, if necessary information is missing from the request, the Claims Administrator will notify the individual within 24 hours after receiving the request to specify what information is needed. The covered person Page 10

11 must provide the specified information to the Claims Administrator within a reasonable amount of time (at least 48 hours), taking into account the circumstances. The Claims Administrator will notify the individual of the expedited benefit determination within 48 hours after the individual responds to the notice. Expedited determinations may be provided orally, followed within 3 days by written or electronic notification. If the covered person fails to follow the Claims Administrator s procedures for requesting a preservice medical necessity determination, the Claims Administrator will notify the individual of the failure and describe the proper procedures for filing within 5 days (or 24 hours, if expedited determination is required, as described above) after receiving the request. This notice may be provided orally, unless the covered person requests written notification. (b) Concurrent Claim Determinations. When an ongoing course of treatment, to be provided over a period of time or number of treatments, has been approved for a covered person and there is a reduction or termination of such course of treatment (other than by the amendment or termination of the Program) such reduction or termination constitutes an adverse benefit determination. The Claims Administrator shall notify the claimant of such reduction or termination at a time sufficiently in advance of the reduction or termination to allow the claimant to appeal and obtain a determination on review before the benefit is reduced or terminated. When an ongoing course of treatment to be provided over a period of time or number of treatments has been approved for a covered person and the person requests to extend the course of treatment, such a request is a claim involving urgent care. The covered person must request a concurrent medical necessity determination at least 24 hours prior to the expiration of the approved period of time or number of treatments. When the covered person requests such a determination, the Claims Administrator will notify the covered person of the determination as soon as possible, taking into account the medical exigencies, but not later than 24 hours after receiving the request. (c) Post-Service Claim Determinations. When a covered person requests a claim determination after services have been rendered, the Claims Administrator will notify the covered person of the determination within 30 days after receiving the request. However, if more time is needed to make a determination due to matters beyond the Claims Administrator s control, the Claims Administrator will notify the individual within 45 days after receiving the request. This notice will include the date a determination can be expected. If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and the covered person must provide the specified information to the Claims Administrator within 45 days after receiving the notice. The determination period will be suspended on the date the Claims Administrator sends such a notice of missing information, and the determination period will resume on the date the individual responds to the notice. (d) Notice of Adverse Determination. (i) Every notice of an adverse benefit determination will be provided in writing or electronically in a culturally and linguistically appropriate manner calculated to be understood by the claimant, and will include all of the following that pertain to the determination: (1) information sufficient to identify the claim involved, including the date of service, the health care provider, the claim amount (if applicable), the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning; (2) the specific reason or reasons for the adverse determination; (3) reference to the specific Program provisions on which the determination is based; (4) a description of any additional material or information necessary to Page 11

12 perfect the claim and an explanation of why such material or information is necessary; (5) a description of the Program s internal review procedures and time limits applicable to such procedures, available external review procedures, as well as the claimant s right to bring a civil action under Section 502 of ERISA following a final appeal; (6) if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request; (7) if the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Program to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request; (8) in the case of a claim involving urgent care, a description of the expedited review process applicable to such claim; and (9) the availability of and contact information for an applicable office of health insurance consumer assistance or ombudsman established under Section 2793 of the Public Health Service Act. If ten percent or more of the population residing in the county (in which a claims notice is sent) is literate only in the same non-english language, as determined in guidance published by the Secretary, the Employer must: (i) provide assistance with filing claims and appeals in that non- English language, (ii) upon request, provide a notice in that non-english language to the claimant; and (iii) include a non-english statement in the English version of the notice on how to access the non-english language services provided by the Program. (e) Appeal of Denied Claim. (i) First Level of Appeal. If a covered person s claim is denied in whole or in part, then the claimant may appeal that decision directly to the Claims Administrator. A request for reconsideration should be made as soon as practicable following receipt of the denial and in no event later than 180 days after receiving the denial. If a covered person s circumstance warrants an expedited appeals procedure, then the covered person should contact the Claims Administrator immediately. The claimant will be asked to explain, in writing, why he or she believes the claim should have been processed differently and to provide any additional material or information necessary to support the claim. Following review, the Claims Administrator will issue a decision on review. The Claims Administrator s review will be processed in accordance with the following time frames: (a) 72 hours in the case of an urgent care claim; (b) 15 days in the case of a preservice claim; (c) before a treatment ends or is reduced in the case of a concurrent care claim involving a reduced or terminated course of treatment; (d) 24 hours in the case of a concurrent care claim that is a request for extension involving urgent care; or (e) 30 days in the case of a post-service claim. (ii) Second Level of Appeal. If, after exhausting the first level appeal with the Claims Administrator, a claimant is still not satisfied with the result, he or she (or the claimant s designee) may appeal, the claim directly to the Claims Administrator. The request for second level of appeal review must be in writing and be submitted by the deadline set forth in the first level appeal denial letter. The second-level reviewer may not afford deference to the decision at the first level of review, and the reviewer must not be the same person who made the first level review decision on the claim or a subordinate of that person. As part of the appeal process, a Page 12

13 claimant has the right to submit additional proof of entitlement to benefits and to examine any pertinent documents relating to the claim. In the normal case, the Employer will make a determination on the basis of the supporting file documents and written statement as submitted. However, the Employer may require or permit submission of additional written information. After considering all the evidence before it, the Employer will issue a final decision on appeal. The Employer s decision on appeal will be conclusive and binding on the claimant and all other parties. Claims appeals will be processed in accordance with the same timeframes as set forth in subsection (e)(i) above. After exhaustion of the claims procedures provided under this Program, nothing shall prevent any person from pursuing any other legal or equitable remedy otherwise available. (f) Notice of Benefit Determination on Appeal. (i) Every notice of a determination on appeal will be provided in writing or electronically and, if an adverse determination, will include: (1) information sufficient to identify the claim involved, including the date of service, the health care provider, the claim amount (if applicable), the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning; (2) the specific reason or reasons for the adverse determination; (3) reference to the specific Program provisions on which the determination is based; (4) a statement that the individual is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other Relevant Information as defined below; (5) a statement describing any voluntary appeal procedures offered by the Program; (6) if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of the rule, guideline, protocol, or other similar criterion will be provided free of charge to the claimant upon request; (7) if the adverse benefit determination is based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Program to the claimant's medical circumstances, or a statement that such explanation will be provided free of charge upon request; and (8) a statement that claimant may have other voluntary alternative dispute resolution options such as mediation and that one way to find out what may be available is to contact the local U.S. Department of Labor office and state insurance regulatory agency. (iii) Relevant Information is any document, record, or other information which (a) was relied upon in making the benefit determination; (b) was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; (c) demonstrates compliance with the administrative processes and safeguards required by federal law in making the benefit determination; or (d) constitutes a statement of policy or guidance with respect to the Program concerning the denied treatment option or benefit for the claimant s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination. (g) Review Procedures on Appeal. In the conduct of any review, the following will apply: Page 13

14 (i) No deference will be afforded to the initial adverse determination; (ii) The review will be conducted by an appropriate named fiduciary who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual; (iii) In deciding an appeal that is based in whole or in part on a medical judgment, the fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment; (iv) Any medical or vocational experts whose advice was obtained on behalf of the Program in connection with an adverse determination will be identified, without regard to whether the advice was relied upon in making the determination; (v) Any health care professional consulted in making a medical judgment shall be an individual who was neither consulted with in connection with the adverse determination that is the subject of the appeal, nor the subordinate of any such individual; and (vi) In the case of a claim involving urgent care, an expedited review process will be available pursuant to which (a) a request for an expedited appeal may be submitted orally or in writing by the claimant, and (b) all necessary information, including the Program s determination on review, shall be submitted between the Program and the claimant by telephone, facsimile or other available similarly expeditious method. (vii) The claimant will be provided with any new or additional evidence considered, relied upon, or generated by the Program in connection with the claim, as well as any new or additional rationale for denial. The claimant will have a reasonable opportunity to respond to such new evidence or rationale. (h) Deemed Exhaustion of Internal Claims and Appeals Processes. If the Program fails to strictly adhere to the internal claims and appeals requirements of 29 CFR (b)(2), the claimant may initiate an external review or may bring an action under Section 502(a) of ERISA. A deemed exhaustion, however, does not occur if violations of the claims review process are de minimis violations that do not cause, and are not likely to cause prejudice or harm to the claimant so long as the violations were for good cause or due to matters beyond the control of the Program and occurred in the context of an ongoing good faith exchange of information between the claimant and the Claims Administrator. The claimant may request a written explanation of the violation from the Plan Administrator, which must be provided within 10 days, including the basis for asserting that the violation should not cause the internal claims and appeals process to be deemed exhausted. In case there is a deemed exhaustion, the claimant may also be entitled to remedies under Section 502 of ERISA by filing a case in court. Unless otherwise specified herein, the claimant is required to exhaust the internal claim and appeal process before filing a request for external review or filing a lawsuit. (i) External Claims Procedure. After receiving notice of an adverse benefit determination or a final internal adverse benefit determination (or been deemed to have exhausted the internal appeal process), a claimant may file with the Program a request for an external review to the Claims Administrator, except that a denial, reduction, termination, or a failure to provide payment for a benefit based on a determination that a claimant or beneficiary fails to meet the requirements for eligibility under the Program is not eligible for the external review process. A Page 14

15 claimant may request from the Claims Administrator additional information describing the Program s external review procedure. (j) Legal Remedies. Any action under ERISA Section 502(a) may be filed only after the Program s review procedures described above have been exhausted and only if the action is filed within 90 days after the final decision is provided. ERISA RIGHTS As a participant in this Program, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Program participants shall be entitled to: RECEIVE INFORMATION ABOUT YOUR PROGRAM AND BENEFITS Examine, without charge, at the Plan Administrator s office and at other specified locations, such as worksites and union halls, all documents governing the Program, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Program with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Program, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies. Receive a summary of the Program s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. CONTINUE GROUP HEALTH PROGRAM COVERAGE You may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Program as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this SPD Supplement and the documents governing the Program on the rules governing your COBRA continuation coverage rights. PRUDENT ACTIONS BY PROGRAM FIDUCIARIES In addition to creating rights for Program participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Program, called fiduciaries of the Program, have a duty to do so prudently and in the interest of you and other Program participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Page 15

16 ENFORCE YOUR RIGHTS If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Program documents or the latest annual report from the Program and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Program s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that Program fiduciaries misuse the Program s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. ASSISTANCE WITH YOUR QUESTIONS If you have any questions about your Program, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. GLOSSARY OF TERMS Affordable Care Act means the Patient Protection and Affordable Care Act, as amended. Brand-Name Drug(s) or Brand means single-source brand or multi-source brand drugs determined in accordance with the drug classification requirements of this Program. A list of such Brand Drugs are provided on Caremark.com. Claims Administrator means CVS Caremark. The Claims Administrator provides service to the Plan Administrator. The Claims Administrator is not the Plan Administrator or the Plan Sponsor. Compound drug means a drug prepared by a pharmacist using a combination of drugs in which as least one agent is a legend drug. The final product is typically not commercially available in the strength and/or dosage form prescribed by the physician (or other prescribing provider). Page 16

17 Copayment (Copay) means the specified charge (flat dollar or percentage) that you are required to pay for a Prescription Drug Product; provided that a participant s copayment for a covered drug at a retail pharmacy shall be the lesser of the applicable copayment or the pharmacy submitted usual and customary charge. Covered drug means any drug which is expressly covered under this Program. Covered expense means services incurred by you or your covered dependents due to bodily injury or illness for which benefits may be available under the Program. Covered expenses are subject to all provisions of the Program, including the limitations and exclusions. Covered person means you or any of your covered dependents. CVS Caremark Mail Service Pharmacy means a pharmacy owned and/or operated by Caremark (or by an affiliate of Caremark) that provides mail service pharmacy products and services pursuant to the terms and conditions of this Program. Deductible means the amount of eligible expenses you must pay from your own pocket before the Program will pay for eligible benefits; the Deductible may apply on a monthly, quarterly, yearly or lifetime basis. Dispense as Written means a physician directive not to substitute a product. Participants may be required to pay an additional fee for dispense as written prescriptions as set forth in Appendix A. Employee means you, as an employee of the Plan Sponsor or any affiliated employer set forth in Appendix B. Employer means the Plan Sponsor of the Program, or its successor. ERISA means the Employee Retirement Income Security Act of 1974, as amended, and the regulations promulgated thereunder. FDA means the Food and Drug Administration. Generic Drugs or Generic means all products or drugs that are manufactured, distributed and available from several pharmaceutical manufacturers and as identified by the chemical name in accordance with the drug classification requirements pursuant to the Program. A list of such Generic Drugs is provided on Caremark.com. Non-participating pharmacy means a pharmacy which has not entered into an agreement with the Claims Administrator to participate as part of the Caremark pharmacy network. Maintenance medication means drug products, typically used for chronic conditions, approved by the Plan Sponsor for dispensing in quantities or day supplies (e.g. 90 days) other than the standards covered under the Program. Over-the-Counter (OTC) drug means a drug product that does not require a Prescription Order under federal or state law. Page 17

18 Participant means any Employee who has satisfied the eligibility requirements under the Program, is employed on the relevant entry date, and who has not for any reason become ineligible to participate. Participating Pharmacy means a retail pharmacy that participates in the national retail network established by Caremark. Plan Year means the 12-month period beginning January 1 and ending on December 31. The Plan Year shall be the coverage period for the Benefits provided for under this Program. In the event a participant commences participation during a Plan Year, then the initial coverage period shall be that portion of the Plan Year commencing on such participant s date of entry and ending on the last day of such Plan Year. Prescription means a direct order for the preparation and use of drug, medicine or medication. The drug, medicine or medication must be obtainable only by prescription. The order must be given verbally or in writing by a physician (or other prescribing provider) to a pharmacist for the benefit of and use by a covered person. The prescription must include: 1. The name and address of the covered person for whom the prescription is intended; 2. The type and quantity of the drug, medicine or medication prescribed, and the directions for its use; 3. The date the prescription was prescribed; and 4. The name, address and DEA number of the prescribing physician (or other prescribing provider). Prescription Drug Product means a medication, product or device approved by the FDA and dispensed under federal or state law only pursuant to a Prescription Order or Refill. For the purpose of coverage under this Program, this definition may also include insulin and certain diabetic supplies and over-the-counter medication, products or devices if dispensed pursuant to a Prescription Order or Refill. Prescription Order or Refill means the directive to dispense a Prescription Drug Product issued by a duly licensed health care provider whose scope of practice permits issuing such a directive. Prior authorization (PA) means the process of obtaining certification of coverage for certain Prescription Drug Products, prior to their dispensing. Specialty Drug means drugs that meet a minimum of three (3) or more of the following characteristics: (a) produced through DNA technology or biological processes: (b) target chronic or complex disease; (c) route of administration could he inhaled, infused, oral, or injected; (d) unique handling, distribution and/or administration requirements; (e) are only available via limited distribution model to Specialty Pharmacy provider(s), per manufacturer requirements: and (I) require a customized medication management program that includes medication use review, patient training, coordination of care and adherence management for successful use such that more frequent monitoring and training may be required. A list of Specially Drugs can be provided by Caremark upon request by a participant or covered person. Page 18