Summary Plan Description Accenture Prescription Drug Plan

Transcription

1 Summary Plan Description Accenture Prescription Drug Plan Effective January 1, 2018 Group Number: ACCRXS1

2 TABLE OF CONTENTS SECTION 1 - WELCOME... 1 SECTION 2 PLAN HIGHLIGHTS... 3 SECTION 3 - ADDITIONAL COVERAGE DETAILS... 8 Identification Card (ID Card) Network Pharmacy... 8 Benefit Levels... 8 Retail Mail Order Benefits for Preventive Care Medications Benefits for Standard Preventive Care Medications Assigning Prescription Drugs to the Formulary Notification Requirements Prescription Drug Benefit Claims Limitation on Selection of Pharmacies Supply Limits If a Brand-name Drug Becomes Available as a Generic Special Programs Rebates and Other Discounts Coupons, Incentives and Other Communications SECTION 4 - EXCLUSIONS: WHAT THE PRESCRIPTION DRUG PLAN WILL NOT COVER SECTION 5 - CLAIMS PROCEDURES Prescription Drug Benefit Claims How to File Your Claim Claim Denials and Appeals Federal External Review Program Limitation of Action SECTION 6 - OTHER IMPORTANT INFORMATION Your Relationship with Express-Scripts and Accenture LLP Relationship with Providers Your Relationship with Providers... 28

3 Interpretation of Benefits Information and Records Workers' Compensation Not Affected Future of the Plan Plan Document SECTION 7 GLOSSARY ATTACHMENT I - HEALTH CARE REFORM NOTICES Patient Protection and Affordable Care Act ( PPACA ) Notice of Nondiscrimination

4 SECTION 1 - WELCOME This Booklet describes Employer-sponsored Prescription Drug Benefit as of January 1, It includes summaries of: services that are covered, called Covered Health Services; services that are not covered, called Exclusions; how Benefits are paid; and your rights and responsibilities under the Plan. This Summary Plan Description (SPD) is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA). It supersedes any previous printed or electronic SPD for this Plan. Accenture LLP intends to continue this Plan, but reserves the right, in its sole discretion, to modify, change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice. This SPD is not to be construed as a contract of or for employment. If there should be an inconsistency between the contents of this summary and the contents of the Plan, your rights shall be determined under the Plan and not under this summary. Express Scripts serves as the Claims Administrator for the Accenture Medical Plan prescription drug benefits. The prescription drug coverage under the Plan includes both Retail pharmacy prescription benefits and Home Delivery prescription benefits. Please read this SPD thoroughly to learn how the Accenture LLP Prescription Drug Plan works for participants who are enrolled in a High Deductible Health Plan through Aetna, Blue Cross Blue Shield or Cigna ( High Deductible Health Plan ), the Aetna EPO Plan, or a PPO Plan through Aetna, Blue Cross Blue Shield or Cigna ( PPO Plan ). If you have further questions, call the number on the back of your ID card. How To Use This SPD Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference. Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section. Capitalized words in the SPD have special meanings and are defined in Section 7, Glossary. If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 7, Glossary. Accenture LLP is also referred to as Company. 1 SECTION 1 - WELCOME

5 If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control. For Enrollment, Eligibility, When Coverage Ends, Coordination of Benefits and ERISA information, please see the Accenture US Participating Medical Plan SPD and/or the Accenture US Benefit Plans General Information Summary on the Plan Information page of the Live Well at Accenture website, 2 SECTION 1 - WELCOME

6 SECTION 2 PLAN HIGHLIGHTS The table below provides an overview of the Prescription Drug Plan. It includes a Copay or Coinsurance amount that applies when you have a prescription filled at a Network or non- Network Pharmacy. The Out-of-Pocket Maximum applies to all Covered Health Services under the Medical and In-Network Pharmacy Plans. Covered Services 1 Retail up to a 31-day supply 1 Prescription Drug Cost Payable by You Network Generic 25% but not less than $10 and not more than $20 Prescription Drug Cost Payable by You Non-Network 40% Preferred Brand 25% but not less than $40 and not more than $60 Non-Preferred Brand 25% but not less than $60 and not more than $80 Mail Order up to a 90-day supply 1, 2 Generic 25% but not less than $25 and not more than $50 Preferred Brand 25% but not less than $100 and not more than $150 Non-Preferred Brand 25% but not less than $150 and not more than $200 Annual Deductible (combined Medical and Pharmacy) If you are enrolled in a High Deductible Health Plan: Individual Family (cumulative Annual Deductible) you must meet the full family deductible for pharmacy and medical $1,500 $3,000 40% 40% Not Available Not Available Not Available 3 SECTION 2 PLAN HIGHLIGHTS

7 Covered Services 1 before coinsurance begins Annual Out-of-Pocket Maximum (combined Medical and Pharmacy) If you are enrolled in a High Deductible Health Plan: Individual Family Prescription Drug Cost Payable by You Network $4,500 $9,000 Prescription Drug Cost Payable by You Non-Network 4 SECTION 2 PLAN HIGHLIGHTS

8 Covered Services 1 Prescription Drug Cost Payable by You Network Prescription Drug Cost Payable by You Non-Network Annual Out-of-Pocket Maximum (combined Medical and Pharmacy) If you are enrolled in the Aetna EPO Plan or a PPO Plan: Individual If your annual salary is under $100,000 $3,350 If your annual salary is $100,000 to $250,000 $3,900 If your annual salary is over $250,000 $4,100 Family (cumulative Out-of-Pocket Maximum) If your annual salary is under $100,000 $6,700 If your annual salary is $100,000 to $250,000 $7,800 If your annual salary is over $250,000 $8,200 Fertility Medications Maintenance Medications through Walgreens or CVS Retail (90 day supply) 2 Contact WINFertility directly ( ) to preauthorize fertility medications prior to receiving treatment. Failure to contact WINFertilty will result in denial of claims for these medications. Day Supply 1-31 Generic - 25% of the Prescription Order or Refill but not less than $10 and not more than $20 Preferred Brand -25% of the Prescription Order or Refill but not less than $40 and not more than $60 Non-Preferred Brand -25% of the Prescription Order or Refill but not less than $60 and not more than $80 Day Supply Generic - 25% of the Prescription Order or Refill but not less than $20 and not more than $40 5 SECTION 2 PLAN HIGHLIGHTS

9 Covered Services 1 Prescription Drug Cost Payable by You Network Prescription Drug Cost Payable by You Non-Network Preferred Brand -25% of the Prescription Order or Refill but not less than $80 and not more than $120 Non-Preferred Brand-25% of the Prescription Order or Refill but not less than $120 and not more than $160 Day Supply Generic- 25% of the Prescription Order or Refill but not less than $30 and not more than $60 Preferred Brand -25% of the Prescription Order or Refill but not less than $120 and not more than $180 Non-Preferred Brand -25% of the Prescription Order or Refill but not less than $180 and not more than $240 1You, your Physician or your pharmacist must notify the Claims Administrator to receive full Benefits for certain Prescription Drugs. Otherwise, you may pay more out-of-pocket. See Notification Requirements in this section for details. For compound drugs to be covered under the Plan, they must satisfy certain requirements. In addition to being medically necessary and not experimental or investigative, compound drugs must not contain any ingredient on a list of excluded ingredients. Furthermore, the cost of the compound must be determined by Express Scripts to be reasonable (e.g. if the cost of any ingredient has increased more than 5% every other week or more than 10% annually), the cost will not be considered reasonable. Any denial of coverage a compound drug may be appealed in the same manner as any other drug claim denial under the Plan. 2 For Maintenance Medications as defined by the Claims Administrator Pharmacy Targeted Maintenance Medication List, as written by the provider, up to a consecutive 90- day supply of a Prescription Drug Product (for the payment of up to three Copayments), unless adjusted based on the drug manufacturer's packaging size. In order to receive the maximum Benefit, you should ask your provider to write your Prescription Order or Refill for the full 90 days. You are not responsible for paying a Copayment and/or Coinsurance for Preventive Care Medications. If you are enrolled in a High Deductible Health Plan, non-preventive prescription drugs are subject to the annual deductible. Preventive medications (as defined by the Standard Preventive Drug List) are not subject to the annual deductible. You can contact Express Scripts using the number on your ID card to confirm if a drug is on the Standard Preventive list or go to 6 SECTION 2 PLAN HIGHLIGHTS

10 Note: The Coordination of Benefits provision described in the Accenture US Participating Medical Plan Summary Plan Description applies to covered Prescription Drugs as described in this section. Benefits for Prescription Drugs will be coordinated with those of any other health plan in the same manner as Benefits for Covered Health Services described in the medical plan SPD s for each respective medical plan carrier. 7 SECTION 2 PLAN HIGHLIGHTS

11 SECTION 3 - ADDITIONAL COVERAGE DETAILS What this section includes: Benefits available for Prescription Drugs; How to utilize the retail and mail order service for obtaining Prescription Drugs; and Any benefit limitations and exclusions that exist for Prescription Drugs. Identification Card (ID Card) Network Pharmacy You must either show your ID card at the time you obtain your Prescription Drug at a Network Pharmacy or you must provide the Network Pharmacy with identifying information that can be verified by the Claims Administrator during regular business hours. If you don t show your ID card or provide verifiable information at a Network Pharmacy, you will be required to pay the Usual and Customary Charge for the Prescription Drug at the pharmacy. Benefit Levels Benefits are available for outpatient Prescription Drugs that are considered Covered Health Services. The Plan includes a list of preferred drugs that are either more effective at treating a particular condition than other drugs in the same class of drugs, or as effective as and less costly than similar medications. Non-preferred drugs may also be covered under the prescription drug program, but at a higher cost-sharing tier. Collectively, these lists of drugs make up the Plan s Formulary. The Plan s Formulary is updated periodically and subject to change, so to get the most up-to-date list go online to Drugs that are excluded from the Plan s Formulary are not covered under the Plan unless approved in advance through a Formulary exception process managed by Express Scripts on the basis that the drug requested is (1) medically necessary and essential to the Covered Person s health and safety and/or (2) all Formulary drugs comparable to the excluded drug have been tried by the Covered Person. If approved through that process, the applicable Formulary co-pay would apply for the approved drug based on the Plan s cost share structure. Absent such approval, Covered Persons selecting drugs excluded from the Formulary will be required to pay the full cost of the drug without any reimbursement under the Plan. If the Covered Person s Physician believes that an excluded drug meets the requirements described above, the Physician should take the necessary steps to initiate a Formulary exception review. The Formulary will continue to change from time to time. For example: A drug may be moved to a higher or lower cost-sharing Formulary tier. Additional drugs may be excluded from the Formulary. A restriction may be added on coverage for a Formulary-covered drug (e.g. prior authorization). A Formulary-covered brand name drug may be replaced with a Formulary-covered generic drug. 8 SECTION 3 ADDITIONAL COVERAGE DETAILS

12 Please be sure to check before the drug is purchased to make sure it is covered on the Formulary, as you may not have received notice that a drug has been removed from the Formulary. Certain drugs even if covered on the Formulary will require prior authorization in advance of receiving the drug. Other Formulary-covered drugs may not be covered under the Plan unless an established protocol is followed first; this is known as Step-Therapy. As with all aspects of the Formulary, these requirements may also change from time to time. Prior Authorization requirements may apply to some drugs. Included among prescription drugs subject to Prior Authorization are expensive new drugs entering the marketplace, drugs that have potential for off label use, and drugs that are effective only for people with certain genetic profiles. To find out if a drug your doctor prescribes for you requires Prior Authorization, you or your doctor may contact Express Scripts at the number on the back of your ID card or visit the Express Scripts website at If your physician wants to request coverage for a prescription drug or related supply for which Prior Authorization is required, your physician must call If your physician does not request Prior Authorization, Express Scripts will advise the pharmacy of the requirement at the time you present your prescription. If a request is denied, you and your physician will be notified. If a prescription requiring Prior Authorization is approved by Express Scripts, the authorization is generally valid for the duration of your prescription need or one year, whichever time period ends first. Please note that the Prior Authorization program is subject to change at any time. Step Therapy is a program that applies to more expensive drugs that have lower cost alternatives, for conditions such as arthritis, asthma, or high blood pressure. Generally, when your doctor prescribes a drug for you that is subject to Step Therapy, you will be required to begin treatment with a front-line drug as a first step. Drugs that are subject to Step Therapy will require Prior Authorization if the Step Therapy requirements are not met when the pharmacist attempts to transmit your prescription. To find out if a drug your doctor prescribes for you requires Step Therapy, you or your doctor may contact Express Scripts at the number on the back of your ID card or visit the Express Scripts website at Please note that the Step Therapy program is subject to change at any time. Drugs covered by the Plan are assigned a Copay or coinsurance depending on where they fall on the formulary. Here is how medications are classified: Generic Drug: A drug that is chemically equivalent to a brand drug for which the patent has expired. The color and shape of the drug may be different, but the active ingredients are the same. Generic medications, created after the patent expires on an original, patented drug, are required to meet the same quality standards as brand drugs. These drugs are generally your lowest Copay option. Preferred Brand: A brand-name drug (an original, patented drug created by a single manufacturer) listed on your formulary. These drugs are your middle Copay option. Non-Preferred Brand: A brand-name drug (an original, patented drug created by a single manufacturer) that is not listed on your formulary. These drugs are your highest copay option. Coinsurance for a Prescription Drug at a non-network Pharmacy is a percentage of the Predominant Reimbursement Rate. 9 SECTION 3 ADDITIONAL COVERAGE DETAILS

13 For Prescription Drugs at a retail Network Pharmacy, you are responsible for paying the lower of: the applicable Copay; or the Network Pharmacy s Usual and Customary Charge for the Prescription Drug; For Prescription Drugs from a mail order Network Pharmacy, you are responsible for paying the lower of: the applicable Copay; or the Prescription Drug cost for that particular Prescription Drug. Retail The Plan has a Network of participating retail pharmacies, which includes many large drug store chains. You can obtain information about Network Pharmacies by contacting the Claims Administrator at the toll-free number on your ID card or by logging onto To obtain your prescription from a retail pharmacy, simply present your ID card and pay the Copay. The Plan pays Benefits for certain covered Prescription Drugs: as written by a Physician; up to a consecutive 31-day supply, unless adjusted based on the drug manufacturer's packaging size or based on supply limits; when a Prescription Drug is packaged or designed to deliver in a manner that provides more than a consecutive 31-day supply, the Copay that applies will reflect the number of days dispensed. Note: Pharmacy Benefits apply only if your prescription is for a Covered Health Service, and not for Experimental or Investigational, or Unproven Services. Otherwise, you are responsible for paying 100% of the cost. 10 SECTION 3 ADDITIONAL COVERAGE DETAILS

14 Mail Order The mail order service may allow you to purchase up to a 90-day supply of a covered maintenance drug through the mail from a Network Pharmacy. Maintenance drugs help in the treatment of chronic illnesses, such as heart conditions, allergies, high blood pressure, and arthritis. To use the mail order service, all you need to do is complete a patient profile and enclose your prescription order or refill. Your medication, plus instructions for obtaining refills, will arrive by mail about 14 days after your order is received. If you need a patient profile form, or if you have any questions, you can reach the Claims Administrator toll-free at the number on your ID card. The Plan pays mail order Benefits for certain covered Prescription Drugs: as written by a Physician; and up to a consecutive 90-day supply, unless adjusted based on the drug manufacturer's packaging size or based on supply limits. These supply limits do not apply to Specialty Prescription Drugs. Specialty Prescription Drugs from a mail order Network Pharmacy are subject to the supply limits stated below under the heading Specialty Prescription Drugs. You may fill an initial Prescription Drug order and obtain 3 refills through a retail pharmacy. However, after that you must use a mail order Network Pharmacy, Walgreens or CVS Retail. If you choose not to obtain your Prescription Drug order or refill from a mail order Network Pharmacy, Walgreens or CVS Retail, no Benefits will be paid and you will be responsible for paying all charges Note: To maximize your benefit, ask your Physician to write your prescription order or refill for a 90-day supply, with refills when appropriate. You will be charged the mail order Copay for any prescription order or refill if you use the mail order service, regardless of the number of days' supply that is written on the order or refill. Be sure your Physician writes your mail order or refill for a 90-day supply, not a 30-day supply with three refills. Maintenance Medications through Walgreens or CVS Retail (90 day supply) When a Maintenance Medication is dispensed by Walgreens or CVS, the supply limit is up to a 90 day supply of a Prescription Drug, unless adjusted based on the drug manufacturer s packaging size or any additional supply limits. 11 SECTION 3 ADDITIONAL COVERAGE DETAILS

15 Benefits for Preventive Care Medications Benefits under the Prescription Drug Plan include those for Health Care Reform Preventive Care Medications as defined under Section 7 Glossary. You may determine whether a drug is a Health Care Reform Preventive Care Medication through the internet at or by calling the Claims Administrator at the toll-free telephone number on your ID card. Benefits for Standard Preventive Care Medications Preventive medications are used to prevent the occurrence of a disease/condition for individuals with risk factors, or to prevent the recurrence of a disease/condition, and do not include drugs used to treat an existing illness, injury or condition. Examples of preventive medications are those used for high blood pressure and high cholesterol. If you are enrolled in a High Deductible Health Plan, non-preventive prescription drugs are subject to the annual deductible. Preventive medications (as defined by the Standard Preventive Drug List) are not subject to the annual deductible. You can contact Express Scripts using the number on your ID card to confirm if a drug is on the Standard Preventive list or go to Specialty Prescription Drugs Accredo, Express Scripts specialty pharmacy, has been selected to serve your Specialty Prescription needs. Specialty Prescription Drugs* are generally covered only if filled through Accredo. If you choose not to obtain your Specialty Prescription Drugs from Accredo, no Benefits will be paid and you will be responsible for paying all charges. Call to reach Accredo Specialty Pharmacy. *An injectable, an oral, or an inhaled medication is most often considered a specialty medication if it has: Frequent dosing adjustments Intensive clinical monitoring Intensive patient training Limited or exclusive distribution Specialized handling and administration Please see Section 7, Glossary for definitions of Specialty Prescription Drug and Accredo. 12 SECTION 3 ADDITIONAL COVERAGE DETAILS

16 Assigning Prescription Drugs to the Formulary The Claims Administrator s Pharmacy and Therapeutics Committee makes the final approval of Prescription Drug placement on the formulary. In its evaluation of each Prescription Drug, the Pharmacy and Therapeutics Committee takes into account a number of factors including, but not limited to, clinical and economic factors. Clinical factors may include: evaluations of the place in therapy; relative safety and efficacy; and whether supply limits or prior authorization should apply. Economic factors may include: the acquisition cost of the Prescription Drug; and available rebates and assessments on the cost effectiveness of the Prescription Drug. When considering a Prescription Drug for formulary placement, the Pharmacy and Therapeutics Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician. The Pharmacy and Therapeutics Committee may periodically change the formulary placement of a Prescription Drug. Prescription Drug, Formulary, and Pharmacy and Therapeutics Committee are defined in Section 7, Glossary. Formulary The Formulary is a tool that helps guide you and your Physician in choosing the medications that allow the most effective and affordable use of your Prescription Drug benefit. 13 SECTION 3 ADDITIONAL COVERAGE DETAILS

17 Notification Requirements Network Pharmacy Notification When Prescription Drugs are dispensed at a Network Pharmacy, the prescribing provider, the pharmacist, or you are responsible for notifying the Claims Administrator. Non-Network Pharmacy Notification When Prescription Drugs are dispensed at a non-network Pharmacy, you or your Physician are responsible for notifying the Claims Administrator. If the Claims Administrator is not notified before the Prescription Drug is dispensed, you may pay more for that Prescription Drug order or refill. You will be required to pay for the Prescription Drug at the time of purchase. The contracted pharmacy reimbursement rates (the Prescription Drug Cost) will not be available to you at a non-network Pharmacy. If the Claims Administrator is not notified before you purchase the Prescription Drug, you can request reimbursement after you receive the Prescription Drug - see Claims Procedures, for information on how to file a claim. When you submit a claim on this basis, you may pay more because you did not notify the Claims Administrator before the Prescription Drug was dispensed. The amount you are reimbursed will be based on the Prescription Drug Cost (for Prescription Drugs from a Network Pharmacy) or the Predominant Reimbursement Rate (for Prescription Drugs from a non-network Pharmacy), less the required Copayment and/or Coinsurance, Ancillary Charge and any Deductible that applies. To determine if a Prescription Drug requires notification, either visit or call the toll-free number on your ID card. The Prescription Drugs requiring notification are subject to the Claims Administrator s periodic review and modification. Benefits may not be available for the Prescription Drug after the Claims Administrator reviews the documentation provided and determines that the Prescription Drug is not a Covered Health Service or it is an Experimental or Investigational or Unproven Service. For compound drugs to be covered under the Plan, they must satisfy certain requirements. In addition to being medically necessary and not experimental or investigative, compound drugs must not contain any ingredient on a list of excluded ingredients. Furthermore, the cost of the compound must be determined by Express Scripts to be reasonable (e,g. if the cost of any ingredient has increased more than 5% every other week or more than 10% annually), the cost will not be considered reasonable. Any denial of coverage a compound drug may be appealed in the same manner as any other drug claim denial under the Plan. 14 SECTION 3 ADDITIONAL COVERAGE DETAILS

18 Prescription Drug Benefit Claims For Prescription Drug claims procedures, please refer to Claims Procedures. Limitation on Selection of Pharmacies If the Claims Administrator determines that you may be using Prescription Drugs in a harmful or abusive manner, or with harmful frequency, your selection of Network Pharmacies may be limited. If this happens, the Claims Administrator may require you to use a single Network Pharmacy that will provide and coordinate all future pharmacy services. Benefits will be paid only if you use the designated single Network Pharmacy. Supply Limits Some Prescription Drugs are subject to supply limits that may restrict the amount dispensed per Prescription Order or Refill, you may receive a Prescription Drug Product up to the stated supply limit. To determine if a Prescription Drug has been assigned a maximum quantity level for dispensing, either visit or call the toll-free number on your ID card. Whether or not a Prescription Drug has a supply limit is subject to the Claims Administrator s periodic review and modification. Note: Some products are subject to additional supply limits based on criteria that the Plan Administrator and the Claims Administrator have developed, subject to periodic review and modification. The limit may restrict the amount dispensed per prescription order or refill and/or the amount dispensed per month s supply. If a Brand-name Drug Becomes Available as a Generic If a Brand-name Prescription Drug becomes available as a Generic drug, the formulary placement of the Brand-name Prescription Drug Product may change. As a result, your Copay or Coinsurance may change. You will pay the Copay or Coinsurance applicable for the formulary placement to which the Prescription Drug Product is assigned. Special Programs Accenture LLP and the Claims Administrator may have certain programs in which you may receive an enhanced or reduced benefit based on your actions such as adherence/compliance to medication or treatment regimens, and/or participation in health management programs. You may access information on these programs through the Internet at or by calling the number on the back of your ID card. Rebates and Other Discounts The Claims Administrator and Accenture LLP may, at times, receive rebates for certain drugs on the formulary. The Claims Administrator does not pass these rebates and other discounts on to you, nor are they applied to the Annual Drug Deductible or taken into account in determining your Copays or Coinsurance. Rebates and discounts are used to reduce the overall cost of the plan for Accenture and employees. 15 SECTION 3 ADDITIONAL COVERAGE DETAILS

19 Coupons, Incentives and Other Communications The Claims Administrator and a number of its affiliated entities, conduct business with various pharmaceutical manufacturers separate and apart from this Prescription Drug section. Such business may include, but is not limited to, data collection, consulting, educational grants and research. Amounts received from pharmaceutical manufacturers pursuant to such arrangements are not related to this Prescription Drug section. The Claims Administrator is not required to pass on to you, and does not pass on to you, such amounts. 16 SECTION 3 ADDITIONAL COVERAGE DETAILS

20 SECTION 4 - EXCLUSIONS: WHAT THE PRESCRIPTION DRUG PLAN WILL NOT COVER What this section includes: Services, supplies and treatments that are not Covered Health Services, except as may be specifically provided for in Section 3, Additional Coverage Details. Medications that are: for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received; any Prescription Drug for which payment or benefits are provided or available from the local, state or federal government (for example Medicare) whether or not payment or benefits are received, except as otherwise provided by law; Pharmaceutical Products for which Benefits are provided in your medical benefits plan; This exclusion does not apply to Depo Provera and other injectable drugs used for contraception. available over-the-counter that do not require a prescription order or refill by federal or state law before being dispensed, unless the Plan Administrator has designated over-thecounter medication as eligible for coverage as if it were a Prescription Drug and it is obtained with a prescription order or refill from a Physician. Prescription Drugs that are available in over-the-counter form or comprised of components that are available in over-the-counter form or equivalent. Certain Prescription Drugs that the Plan Administrator has determined are Therapeutically Equivalent to an over-the-counter drug. The Plan Administrator may decide at any time to reinstate Benefits for a Prescription Drug that was previously excluded under this provision. For compound drugs to be covered under the Plan, they must satisfy certain requirements. In addition to being medically necessary and not experimental or investigative, compound drugs must not contain any ingredient on a list of excluded ingredients. Furthermore, the cost of the compound must be determined by Express Scripts to be reasonable (e.g. if the cost of any ingredient has increased more than 5% every other week or more than 10% annually), the cost will not be considered reasonable. Any denial of coverage a compound drug may be appealed in the same manner as any other drug claim denial under the Plan. dispensed outside of the United States, except in an Emergency; Durable Medical Equipment (prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered); 17 SECTION 4 EXCLUSIONS

21 the amount dispensed (days supply or quantity limit) which exceeds the supply limit; prescribed, dispensed or intended for use during an Inpatient Stay; Prescription Drugs, including new Prescription Drugs or new dosage forms, that Accenture LLP determines do not meet the definition of a Covered Health Service; Prescription Drugs that contain (an) active ingredient(s) available that is Therapeutically Equivalent to another covered Prescription Drug; Prescription Drugs that contain (an) active ingredient(s) which is (are) a modified version of and Therapeutically Equivalent to another covered Prescription Drug; typically administered by a qualified provider or licensed health professional in an outpatient setting (This exclusion does not apply to Depo Provera and other injectable drugs used for contraception); unit dose packaging of Prescription Drugs; used for conditions and/or at dosages determined to be Experimental or Investigational, or Unproven, unless Express Scripts and Accenture LLP have agreed to cover an Experimental or Investigational or Unproven treatment, as defined in Section 7, Glossary; used for cosmetic purposes; Prescription Drug as a replacement for a previously dispensed Prescription Drug that was lost, stolen, broken or destroyed; and vitamins, except for the following which require a prescription: - prenatal vitamins; - vitamins with fluoride; and - single entity vitamins. 18 SECTION 4 EXCLUSIONS

22 SECTION 5 - CLAIMS PROCEDURES What this section includes: How Network and non-network claims work; and What to do if your claim is denied, in whole or in part. Prescription Drug Benefit Claims If you wish to receive reimbursement for a prescription, you may submit a post-service claim as described in this section if: you are asked to pay the full cost of the Prescription Drug when you fill it and you believe that the Plan should have paid for it; or you pay a Copay or Coinsurance and you believe that the amount of the Copay or Coinsurance was incorrect If a pharmacy (retail or mail order) fails to fill a prescription that you have presented and you believe that it is a Covered Health Service, you may submit a pre-service request for Benefits as described in this section. How to File Your Claim You can obtain a claim form by visiting or calling the toll-free number on your ID card. If you do not have a claim form, simply attach a brief letter of explanation to the bill, and verify that the bill contains the information listed below. If any of these items are missing from the bill, you can include them in your letter: your name and address; the patient's name, age and relationship to the Employee; the number as shown on your ID card; Failure to provide all the information listed above may delay any reimbursement that may be due you. When filing a claim for Outpatient Prescription Drug Benefits, your claims should be submitted to the pharmacy benefit manager claims address noted on your ID card. After the Claims Administrator has processed your claim, you will receive payment for Benefits that the Plan allows. It is your responsibility to pay the non-network provider the charges you incurred, including any difference between what you were billed and what the Plan paid. 19 SECTION 5 - CLAIMS PROCEDURES

23 Important All claim forms must be submitted within 12 months after the date of service. Otherwise, the Plan will not pay any Benefits for that Eligible Expense. This 12-month requirement does not apply if you are legally incapacitated. Claim Denials and Appeals A member has the right to request that a medication be covered or be covered at a higher benefit (e.g. lower copay, higher quantity, etc.). The first request for coverage is called an initial coverage review. Express Scripts reviews both clinical and administrative coverage review requests: Clinical coverage review request: A request for coverage of a medication that is based on clinical conditions of coverage that are set by the Plan. For example, medications that require a prior authorization. Administrative coverage review request: A request for coverage of a medication that is based on the Plan s benefit design. How to request an initial coverage review: The preferred method to request an initial clinical coverage review is for the prescriber to submit the prior authorization request electronically. Alternatively, the prescriber or dispensing Pharmacist may call the Express Scripts Coverage Review Department at or the prescriber may submit a completed coverage review form and Fax to Forms may be obtained online at Home Delivery coverage review requests are automatically initiated by the Express Scripts Home Delivery pharmacy as part of filling the Prescription. To request an initial administrative coverage review, the member or his or her representative must submit the request in writing to Express Scripts Attn: Benefit Coverage Review Department, PO Box St Louis, MO If the patient s situation meets the definition of urgent under the law, an urgent review may be requested and will be conducted as soon as possible, but no later than 72 hours from receipt of request. In general, an urgent situation is one which, in the opinion of the attending provider, the patient s health may be in serious jeopardy or the patient may experience pain that cannot be adequately controlled while the patient waits for a decision on the review. If the patient or provider believes the patient s situation is urgent, the expedited review must be requested by phone at How to Request a Level 1 Appeal or Urgent Appeal after an Initial Coverage Review has been Denied When an initial coverage review has been denied (adverse benefit determination), a request for appeal may be submitted by the member or authorized representative within 180 days from receipt of notice of the initial adverse benefit determination. To initiate an appeal, the following information must be submitted by mail or fax to the appropriate department for clinical or administrative review requests: 20 SECTION 5 - CLAIMS PROCEDURES

24 Member ID and Name of patient Phone Number The drug name for which benefit coverage has been denied Brief description of why the claimant disagrees with the initial adverse benefit determination Any additional information that may be relevant to the appeal, including prescriber statements/letters, bills or any other documents Clinical review Requests: Express Scripts Attn: Clinical Appeals Department, PO Box 66588, St Louis, MO Fax Administrative review Requests: Express Scripts Attn: Administrative Appeals Department, PO Box 66587, St Louis, MO Fax An urgent appeal may be submitted if in the opinion of the attending provider, the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function or would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Urgent appeals must be submitted by phone or fax Claims and appeals submitted by mail will not be considered for urgent processing unless a subsequent phone call or fax identifies the appeal as urgent. How to Request a Level 2 Appeal after a Level 1 Appeal has been Denied When a Level 1 appeal has been denied (adverse benefit determination), a request for a Level 2 appeal may be submitted by the member or authorized representative within 60 days from receipt of notice of the Level 1 appeal adverse benefit determination. To initiate a Level 2 appeal, the following information must be submitted by mail or fax to the appropriate department for clinical or administrative review requests: Member ID and Name of Patient Phone Number The drug name for which benefit coverage has been denied Brief description of why the claimant disagrees with the adverse benefit determination Any additional information that may be relevant to the appeal, including prescriber statements/letters, bills or any other documents. 21 SECTION 5 - CLAIMS PROCEDURES

25 Clinical review Requests: Express Scripts, Attn: Clinical Appeals Department, PO Box 66588, St Louis, MO Fax Administrative review Requests: Express Scripts, Attn: Administrative Appeals Department, PO Box 66587, St Louis, MO Fax An urgent Level 2 appeal may be submitted if in the opinion of the attending provider, the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the patient or the patient s ability to regain maximum function or would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Urgent appeals must be submitted by phone or fax Claims and appeals submitted by mail will not be considered for urgent processing unless a subsequent phone call or fax identifies the appeal as urgent. 22 SECTION 5 - CLAIMS PROCEDURES

26 Federal External Review Program When and How to request an External Review The right to request an independent external review may be available for an adverse benefit determination involving medical judgment, rescission, or a decision based on medical information, including determinations involving treatment that is considered experimental or investigational. Generally, all internal appeal rights must be exhausted prior to requesting an external review. The external review will be conducted by an independent review organization with medical experts that were not involved in the prior determination of the claim. To submit an external review, the request must be mailed or faxed to: MCMC LLC Attn: Express Scripts Appeal Program, 300 Crown Colony Drive. Suite 203, Quincy, MA Phone: ext Fax: and the request must be received within 4 months of the date of the final Internal adverse benefit determination (If the date that is 4 months from that date is a Saturday, Sunday or holiday, the deadline will be the next business day). How an External Review is Processed Standard External Review: MCMC will review the external review request within 5 business days to determine if it is eligible to be forwarded to an Independent Review Organization (IRO) and the patient will be notified within 1 business day of the decision. If the request is eligible to be forwarded to an IRO, the request will randomly be assigned to an IRO and the appeal information will be compiled and sent to the IRO within 5 business days of assigning the IRO. The IRO will notify the claimant in writing that it has received the request for an external review and if the IRO has determined that the claim involves medical judgment or rescission, the letter will describe the claimant s right to submit additional information within 10 business days for consideration to the IRO. Any additional information the claimant submits to the IRO will also be sent back to the claims administrator for reconsideration. The IRO will review the claim within 45 calendar days from receipt of the request and will send the claimant, the plan and Express Scripts written notice of its decision. If the IRO has determined that the claim does not involve medical judgment or rescission, the IRO will notify the claimant in writing that the claim is ineligible for a full external review. Urgent External Review: Once an urgent external review request is submitted, the claim will immediately be reviewed to determine if it is eligible for an urgent external review. An urgent situation is one where in the opinion of the attending provider, the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health or the ability for the patient to regain maximum function or would subject the patient to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. If the claim is eligible for urgent processing, the claim will immediately be reviewed to determine if the request is eligible to be forwarded to an IRO, and the claimant will be notified of the decision. If the request is eligible to be forwarded to an IRO, the request will randomly be assigned to an IRO and the appeal information will be compiled and sent to the IRO. The IRO will review the claim within 72 hours from receipt of the request and will send the claimant written notice of its decision. 23 SECTION 5 - CLAIMS PROCEDURES

27 Timing of Appeals Determinations Coverage Review Type of Claim Standard Pre-Service* Timing 15 days (Retail) 5 days (home delivery) Standard Post-Service* Urgent 30 days 72 hours** * If the necessary information needed to make a determination is not received from the prescriber within the decision timeframe, a letter will be sent to the patient and prescriber informing them that the information must be received within 45 days or the claim will be denied. ** Assumes all information necessary is provided. If necessary information is not provided within 24 hours of receipt, a 48 hour extension will be granted. 24 SECTION 5 - CLAIMS PROCEDURES

28 Level 1 or Urgent Appeals Type of Appeal Standard Pre-Service Standard Post-Service Urgent* Timing 15 days 30 days 72 Hours *If new information is received and considered or relied upon in the review of the appeal, such information will be provided to the patient and prescriber together with an opportunity to respond prior to issuance of any final adverse determination. The decision made on an urgent appeal is final and binding. In the urgent care situation, there is only one level of appeal prior to an external review. Level 2 Appeal Type of Appeal Standard Pre-Service Standard Post-Service Urgent* Timing 15 days 30 days 72 Hours *If new information is received and considered or relied upon in the review of the appeal, such information will be provided to the patient and prescriber together with an opportunity to respond prior to issuance of any final adverse determination. 25 SECTION 6 - OTHER IMPORTANT INFORMATION

29 Limitation of Action You cannot bring any legal action against Accenture LLP or the Claims Administrator to recover reimbursement until 90 days after you have properly submitted a request for reimbursement as described in this section and all required reviews of your claim have been completed. If you want to bring a legal action against Accenture LLP or the Claims Administrator, you must do so within three years from the expiration of the time period in which a request for reimbursement must be submitted or you lose any rights to bring such an action against Accenture LLP or the Claims Administrator. You cannot bring any legal action against Accenture LLP or the Claims Administrator for any other reason unless you first complete all the steps in the appeal process described in this section. After completing that process, if you want to bring a legal action against Accenture LLP or the Claims Administrator you must do so within three years of the date you are notified of our final decision on your appeal or you lose any rights to bring such an action against Accenture LLP or the Claims Administrator. 26 SECTION 6 - OTHER IMPORTANT INFORMATION

30 SECTION 6 - OTHER IMPORTANT INFORMATION What this section includes: Your relationship with the Claims Administrator and Accenture LLP; Relationships with providers; Interpretation of Benefits; Information and records; Incentives to providers and you; The future of the Plan; and How to access the official Plan documents. Your Relationship with Express Scripts and Accenture LLP In order to make choices about your health care coverage and treatment, Accenture LLP believes that it is important for you to understand how the Claims Administrator interacts with the Plan Sponsor's benefit Plan and how it may affect you. Express Scripts (Claims Administrator) administers the claims for the Plan Sponsor's benefit plan in which you are enrolled. The Claims Administrator does not provide medical services or make treatment decisions. This means: Accenture LLP and the Claims Administrator do not decide what care you need or will receive. You and your Physician make those decisions; The Claims Administrator communicates to you decisions about whether the Plan will cover or pay for the health care that you may receive (the Plan pays for Covered Health Services, which are more fully described in this SPD); and the Plan may not pay for all treatments you or your Physician may believe are necessary. If the Plan does not pay, you will be responsible for the cost. Accenture LLP and the Claims Administrator may use individually identifiable information about you to identify for you (and you alone) procedures, products or services that you may find valuable. Accenture LLP and the Claims Administrator will use individually identifiable information about you as permitted or required by law, including in our operations and in our research. Accenture LLP and the Claims Administrator will use de-identified data for commercial purposes including research. Relationship with Providers The relationships between Accenture LLP, the Claims Administrator and Network providers are solely contractual relationships between independent contractors. Network providers are not Accenture LLP s agents or employees, nor are they agents or employees of the Claims Administrator. Accenture LLP and any of its employees are not agents or employees of 27 SECTION 6 - OTHER IMPORTANT INFORMATION