Elmira School District Health and Dental Plan Plan Amendment

Transcription

1 Elmira School District Health and Dental Plan Plan Amendment The Elmira School District has adopted and amended the following provision for the self-funded Health and Dental Plan, restated April 28, 2005: Amendment Number: 003 Amendment Effective Date: January 1, 2006 Nature of Amendment: To 1) revise deductibles, coinsurance, and prescription coverage for ESSAC retired employees, ETA active and retired employees, Non-Unit active and retired employees, and CMCW active and retired employees; 2) require eligible Non-Unit retiree enrollment in Medicare Provisions Affected: Section I Summary of, subsection A. Summaries of Medical Expense, certain categories in paragraph 10. Schedules of Medical Expense are amended as shown. INDEMNITY PLAN ESSAC/NON-UNIT Unit members employed before September 1, 1996, may choose between their current ESSAC Health Benefit Plan (Indemnity Plan) and Preferred Provider Organization. All Administrators hired after September 1, 1996 shall be covered by the Option A Plan only, with unit members hired after July 1, 1999 eligible for coverage under the Option B plan only. Plan Features Active Retired Major Medical Major Medical Deductible Calendar Year None $50 per individual $100 per Family A deductible of $150 per individual and $300 per family applies under the separate Retiree Prescription Drug Program. Common Accident Deductible Yes Yes Carry-over Deductible Yes Yes Percentage Coinsurance charges up to $5,000, 100% thereafter 100% of covered charges after annual deductible is met Copayments N/A N/A 1

2 INDEMNITY PLAN ESSAC/NON-UNIT Unit members employed before September 1, 1996, may choose between their current ESSAC Health Benefit Plan (Indemnity Plan) and Preferred Provider Organization. All Administrators hired after September 1, 1996 shall be covered by the Option A Plan only, with unit members hired after July 1, 1999 eligible for coverage under the Option B plan only. Plan Features Active Retired Major Medical Out of Pocket Maximum Per Person (does not include deductible) $1000 None for Major Medical expenses. An out-of-pocket maximum of $1000 applies under the separate Retiree Prescription Drug Program. Lifetime Maximum $1,000,000 $1,000,000 Prescription Drug Coverage Refer to your current collective bargaining agreement or contact the Business Office for applicable copayments. The Plan pays charges up to $5,000 after the annual deductible of $150 per individual and $300 per family is met, 100% thereafter; see separate Retiree Prescription Drug Program for details Non-participating Retail Pharmacy: The Plan reimburses cost minus the copayment up to the amount that would have been paid at a participating pharmacy. Non-participating Retail Pharmacy: The Plan reimburses cost minus the copayment up to the amount that would have been paid at a participating pharmacy. 2

3 OPTION A Option A - Active Option A - Retired Plan Features Major Medical Deductible per Calendar Year (a separate deductible applies to in-network and out-of-network charges) Common Accident Deductible Major Medical Expense ETA, CMCW, ISEA, and CWA Active Employees and their Covered Dependents $150 per individual $300 per Family $150 per individual $300 per Family ESSAC and Non-Unit Active Employees and their Covered Dependents - Applies to Prescription Drug Expenses only $400 per Family Yes $400 per Family ISEA and CWA Retirees and their Covered Dependents $150 per individual $300 per Family $150 per individual $300 per Family ESSAC, ETA, Non-Unit, and CMCW Retirees and their Covered Dependents $50 per individual $100 per Family $50 per individual $100 per Family (A deductible of $150 per individual and $300 per family applies under the separate Retiree Prescription Drug Program for ESSAC, ETA, Non-Unit, and CMCW Retirees.) Carry-over Deductible Yes Yes Percentage Coinsurance ISEA Active and Retired Employees: charges up to $4,000 after annual deductible is met, 100% thereafter charges until the outof-pocket maximum is reached after annual deductible is met, 100% thereafter charges up to $4,000 after annual deductible is met, 100% thereafter Yes charges until the outof-pocket maximum is reached after annual deductible is met, 100% thereafter CWA Active Employees and Retirees; Non-Unit Active Employees; ESSAC Active Employees; ETA Active Employees; CMCW Active Employees; and their Covered Dependents ESSAC, ETA, Non- Unit, and CMCW Retirees and their Covered Dependents charges up to $5,000 after annual deductible is met, 100% thereafter charges until the outof-pocket maximum is reached after annual deductible is met, 100% thereafter charges up to $5,000 after annual deductible is met, 100% thereafter 100% of covered charges after annual deductible is met charges until the outof-pocket maximum is reached after annual deductible is met, 100% thereafter 100% of covered charges after annual deductible is met 3

4 OPTION A Option A - Active Option A - Retired Plan Features Major Medical Out of Pocket Maximum Per Person (does not include deductible) ISEA Active and Retired Employees: CWA Active Employees and Retirees; Non-Unit Active Employees; ESSAC Active Employees; ETA Active Employees; CMCW Active Employees; and their Covered Dependents ESSAC, ETA, Non- Unit, and CMCW Retirees and their Covered Dependents $800 $1,600 plus 20% of the next $4,000 (total $2400) $1,000 $1,600 plus 20% of the next $4,000 (total $2400) $800 $1,600 plus 20% of the next $4,000 (total $2400) $1,000 $1,600 plus 20% of the next $4,000 (total $2400) None for Major Medical Expenses None for Major Medical Expenses An out-of-pocket maximum of $1000 applies under the separate Retiree Prescription Drug Program. Lifetime Maximum $1,000,000 $1,000,000 Prescription Drug Coverage Refer to your current collective bargaining agreement or contact the Business Office for applicable copayments. ISEA and CWA Retirees: 80% of cost after deductible Non-participating Retail Pharmacy: The Plan reimburses cost minus the copayment up to the amount that would have been paid at a participating pharmacy. ESSAC, ETA, Non-Unit and CMCW Retirees: The Plan pays charges up to $5,000 after annual deductible of $150 per individual and $300 per family is met, 100% thereafter; see separate Retiree Prescription Drug Program for details. Non-participating Retail Pharmacy: The Plan reimburses cost minus the copayment up to the amount that would have been paid at a participating pharmacy. 4

5 OPTION B Option B Active Option B Retiree Plan Features Major Medical Deductible Calendar Year (a separate deductible applies to in-network and out-ofnetwork charges) Major Medical Expense ETA, CMCW, ISEA, and CWA Active Employees and their Covered Dependents: $100 per individual $200 per Family $600 per Family ESSAC and Non-Unit Active Employees and their Covered Dependents - Applies to Prescription Drug Expenses only $400 per Family $400 per Family ISEA and CWA Retirees and their Covered Dependents: $100 per individual $200 per Family $600 per Family ESSAC, ETA, Non-Unit, and CMCW Retirees and their Covered Dependents $50 per individual $100 per Family $50 per individual $100 per Family (A deductible of $150 per individual and $300 per family applies under the separate Retiree Prescription Drug Program for ESSAC, ETA, Non-Unit, and CMCW Retirees.) Common Accident Yes Yes Deductible Carry-over Deductible Yes Yes Percentage Coinsurance CWA Active Employees and Retirees; Non-Unit Active Employees; ESSAC Active Employees; ETA Active Employees; CMCW Active Employees; ISEA Active Employees and Retirees, and their Covered Dependents ESSAC, ETA, Non-Unit, and CMCW Retirees and their Covered Dependents charges up to $5,000 after annual deductible, 100% thereafter charges up to $5,000 after annual deductible, 100% thereafter charges up to $5,000 after annual deductible, 100% thereafter 100% of covered charges after annual deductible is met charges up to $5,000 after annual deductible, 100% thereafter 100% of covered charges after annual deductible is met 5

6 OPTION B Option B Active Option B Retiree Plan Features Major Medical Out of Pocket Maximum Per Person (does not include deductible) CWA Active Employees and Retirees; Non-Unit Active Employees; ESSAC Active Employees; ETA Active Employees; CMCW Active Employees; ISEA Active Employees and Retirees, and their Covered Dependents ESSAC, ETA, Non-Unit, and CMCW Retirees and their Covered Dependents $1,000 $1,000 $1,000 $1,000 None for Major Medical Expenses None for Major Medical Expenses An out-of-pocket maximum of $1000 applies under the separate Retiree Prescription Drug Program. Lifetime Maximum $2,500,000 $1,000,000 $2,500,000 $1,000,000 Prescription Drug Coverage Refer to your current collective bargaining agreement or contact the Business Office for applicable copayments. Non-participating Retail Pharmacy: The Plan reimburses cost minus the copayment up to the amount that would have been paid at a participating pharmacy. ISEA and CWA Retirees: 80% of cost after deductible ESSAC, ETA, Non-Unit, and CMCW Retirees: The Plan pays charges up to $5,000 after annual deductible of $150 per individual and $300 per family is met, 100% thereafter; see separate Retiree Prescription Drug Program for details. Non-participating Retail Pharmacy: The Plan reimburses cost minus the copayment up to the amount that would have been paid at a participating pharmacy. 6

7 Plan Features Deductible per calendar year Percentage Coinsurance Out of Pocket Maximum Per Person (does not include deductible) $150 per individual $300 per Family Retiree Prescription Drug Program Indemnity, Options A and B Retirees Applies to ESSAC, ETA, Non-Unit, and CMCW Retirees and their Covered Dependents Participating Retail Pharmacy - 20% copayment of discounted cost after deductible The Plan pays charges up to $5,000 after annual deductible is met, 100% thereafter $1,000 Section IV - Covered Services, subsection I. Miscellaneous Covered Expense Provisions, paragraph 8. is amended to read: 8. Prescription Drug Expenses (Retired Employees and their Covered Dependents only) are subject to deductible and coinsurance. The prescription drug exclusions described below under subsection J.7. apply. Please note: ESSAC, ETA, Non-Unit, and CMCW Retirees are eligible for prescription coverage as described under K. Retiree Prescription Drug Expense below. Section IV - Covered Services, the subsection K. header for Dental Expense is amended to read K. Retiree Prescription Drug Expense Benefit. Further, Section IV - Covered Services, the former subsection K. header for Dental Expense is amended to read L. Dental Expense. K. Retiree Prescription Drug Expense (Applies to ESSAC, ETA, Non-Unit, and CMCW Retirees, and their Covered Dependents) You and your Dependents may purchase drugs from any Pharmacy. However, if you or your Dependents choose a Network Retail Pharmacy or if you use the Mail Service pharmacy for maintenance drugs, you save on prescription costs for yourself and the District. The following is a brief summary. 1. Covered Prescription Drug Expenses. The quantity of each Covered drug purchased at a retail Pharmacy is limited to a maximum of a 31-day to 90-day supply. Mail service drugs will be limited to a maximum quantity of a 90-day supply. Nitroglycerin and natural thyroid products will be covered for a maximum quantity of 100 doses. Prescription refills will be paid for up to one (1) year from the date of the original prescription. All drugs must be obtainable only by prescription, ordered by the attending Physician, and found to be Medically Necessary unless certain drugs are specifically included by name. Please refer to Prescription Drug Exclusions shown later under this benefit. Unless a drug is otherwise excluded, Plan benefits are available for medications that are Federal legend drugs, or insulin. 2. Prior Authorization is required for some medications. For example, Lovenox 7

8 (anticoagulant), biotech drugs (Copaxone), Betaseron and Avonex (immune response modifiers), Toradol (for short-term pain management), and cosmetic agents for a patient after age 18. Weight loss medications and oral contraceptives must be Medically Necessary to be authorized. 3. Generic Drug Substitution Program. As part of a continuing effort to control costs and preserve the quality of the Plan, you are encouraged to use generic drugs whenever appropriate for your condition. A generic drug is a drug that is chemically equivalent to the original brand name drug. The only difference is that the patent on the brand name medication has expired, allowing other manufacturers to sell the drug. As a result, the generic manufacturer does not incur research costs and can charge significantly less for the drug. Since generic drugs cost less than brand name drugs, cost savings may result for you and the District when you substitute the lower priced drug. If you have any questions about generic drugs, ask your Physician or your pharmacist. 4. Deductible. An annual deductible will apply to prescription drugs purchased through Pharmacare. Please refer to the appropriate Summary of for the deductible amount. 5. Network Pharmacy. A Network Pharmacy has an agreement with the prescription drug Claims Administrator to accept the Plan benefit as payment in full after any applicable Copayment. The copayments do not apply toward either the prescription or Major Medical deductibles or coinsurance limits. If you or your Dependents use a Network Retail Pharmacy, you will be required to pay only the following Copayments: a. Copayments. Please refer to the appropriate Summary of or collective bargaining agreement for the copayment amount. b. Plan Identification Card. You can use your Plan identification card at any Network Pharmacy. The Pharmacy may display the participation logo or you may ask the pharmacy if it participates as a Network Pharmacy. You may also call the Claims Administrator s customer service department for information on Network pharmacies located near you. c. Obtaining Network Pharmacy Drugs. To obtain your Covered drug or supply at Network Provider costs, you need only present your Plan identification card, the written prescription, and any applicable Copayment amount to the Network pharmacist. The Pharmacy will bill the drug Claims Administrator and will receive its payment directly from them. 6. Out-of-Network Pharmacy. If you or your Dependents purchase Covered drugs at an Outof-Network Pharmacy, or do not present your Plan identification card, or you are coordinating benefits this Plan with another health plan, you must submit a claim to Pharmacare. The Plan will reimburse the cost minus the copayment and deductible up to the amount that would have been paid under the Plan. 7. Mail Service for Maintenance Drugs. You or your Dependents may obtain up to a 90-day supply of maintenance drugs from the Mail Service. You need only pay the applicable copayment; the mail service bills the Plan for the balance. The copayments do not apply toward the deductible or coinsurance limits. This service delivers the drug directly to your home. Maintenance drugs are those medications to treat chronic disorders such as hypertension, heart disease, thyroid disease, and diabetes. 8

9 a. Mail Service Copayment. Please refer to the appropriate Summary of for the copayment amount. b. How to Use the Mail Service Pharmacy Program. 1) When the Physician writes a prescription for a "maintenance drug" (one taken regularly on a long-term basis), he or she should indicate the number of refills allowed (maximum three refills). 2) For your first mail service order, obtain an initial patient profile/registration form from the District s Business Office or in each District Building. Complete the form, include the original prescription(s) and the applicable copayment, and mail to the Mail Service Pharmacy. You may wish to keep a photocopy for your records. 3) A new order form and envelope will be included with each drug delivery. For subsequent original and refill prescriptions: a) Mail a completed order form with your copayment; b) and order utilizing the Internet; or c) Call the mail order pharmacy directly. 4) The medication will be delivered to you or your Dependent by first-class mail or UPS. You should allow days from the time the prescription forms are mailed to the mail service Pharmacy until delivery of your medication. However, to ensure that you or your Dependents are not left without an adequate supply of medication, you should order when you or your Dependents have a minimum of a 30-day supply remaining from the current medication. 8. Prescription Drug Expense Exclusions. In addition to limitations shown otherwise in the Plan, the following drugs or Supplies are not Covered even if only obtainable by prescription and ordered by a Physician. See also Medical Expense Exclusions shown later in this Part 1 and Part 3 - General Plan Exclusions shown later in this section. a. Non-Legend drugs/over the counter (OTC) that are obtainable without a prescription, unless otherwise specifically named for coverage; b. Weight loss drugs, anti-obesity/appetite suppressants unless Medically Necessary; c. Contraceptives or birth control medicines, drugs, or devices. However, oral contraceptive drugs which are Medically Necessary to treat an Illness are Covered; proof of Medical Necessity will be required. d. Drugs for treatment of impotency or sexual dysfunction (e.g., Viagra and Caverject); e. Therapeutic devices, equipment, and appliances; f. Injectable delivery devices (syringes) for uses other than insulin injection; g. Implantable, time-release medication unless otherwise noted h. Cosmetic medication, including but not limited to, anti-wrinkle medications, dermatological medications, hair growth medications, and any drugs FDA-approved for cosmetic use only (such as Renova, Rogaine, and Propecia). However, drugs such as Accutane, Retin-A, Differin, and Avita are Covered to age 18; prior authorization is required for Covered Persons over age 18; i. Immunization agents, vaccines, biologicals, biological serum j. Vitamins (including prenatal vitamins), minerals, fluoride prep and dental rinses, food or nutritional supplements. Single entity-vitamins to treat pernicious anemia, folic acid, and iron products are covered. k. Growth hormones and anabolic steroids; 9

10 l. Immune response modifiers other than Betaseron and Avonex; prior authorization is required for these two drugs; m. Drugs labeled Caution-limited by federal law to investigational use, Experimental drugs or drugs prescribed for Experimental (non-fda approved/unlabeled) indications; n. Charges for the administration of any medication; o. Medication which is to be taken by or administered, in whole or part, to an individual while confined in a Hospital, rest home, sanitarium, skilled nursing facility, extended care facility, convalescent Hospital, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals; p. Drugs that are not considered to be Medically Necessary for treatment of an Illness or Injury even if obtainable only by prescription and even if prescribed by a Physician. Section VI - Medicare Integration with Plan is amended to revise the last paragraph of introduction: This Medicare integration provision applies to all persons eligible for primary Medicare coverage even if the person is not actually enrolled in Medicare. If you or your Dependent are not enrolled for primary Medicare coverage, Medicare benefits will be estimated. Please note: For this Plan to be the secondary payor of benefits, retirees of ISEA and Non-Unit must enroll for Medicare. Section VI is further amended to revise subsection B. Effects of Medicare on Plan : 2. Not enrolled in Medicare. This integration will apply to persons eligible for Medicare whether or not actually enrolled in Medicare. If Medicare is primary for an eligible person who is not enrolled in Medicare Part A and Part B or in Part C, the Medicare benefit will be estimated and used to reduce Allowable Fees. This could result in significant reduction or denial of the Plan benefits. For this Plan to be the secondary payor of benefits, retirees of ISEA and Non-Unit must enroll for Medicare. Authorized Signature of the Plan Administrator (Date) * * * * * (Signature) (Title) 10