ACTIVE MEMBERS SUMMARY PLAN DESCRIPTION

Transcription

1 ACTIVE MEMBERS SUMMARY PLAN DESCRIPTION Teamsters Unin 25 Health Services & Insurance Plan

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3 A Letter frm the Bard f Trustees Dear Member: The Bard f Trustees is pleased t prvide yu with this Answerbk an updated descriptin f yur TeamstersCare benefits. The benefits described in this bklet, althugh authrized by the Trustees and administered by ur TeamstersCare staff, are benefits that yu have earned and cntinue t earn ver the curse f yur wrking years. The Trustees are cmmitted t prviding yu and yur eligible family members with high quality healthcare cverage as well as weekly disability and ther benefits. Besides these basic cverages, yu and yur family have access t lcal TeamstersCare in huse clinical services at ur Charlestwn, Chelmsfrd, and Stughtn facilities. Services include the Emplyee Assistance Prgram (EAP), prescriptin drug, dental, and audilgy services in supprtive surrundings and at the hands f ur wn dedicated TeamstersCare healthcare prfessinals. Yur new Answerbk is a Summary Plan Descriptin (SPD), a dcument designed t utline the basic details f yur TeamstersCare benefits. The Bard f Trustees is the Plan Spnsr and Plan Administratr f the benefits accrding t the terms f this SPD and the Agreement and Declaratin f Trust f the Teamsters Unin 25 Health Services & Insurance Plan. The Answerbk describes the benefits and services available if yu r ne f yur eligible dependents is sick r injured, needs preventive care, r suffers an unexpected lss. Please read this bklet carefully and make certain yur family understands hw they can use the Answerbk t find imprtant infrmatin, bth rutinely and in case f emergency. If yu have questins n any aspect f yur benefits visit us in persn at any f ur facilities, check ur website at r cntact TeamstersCare thrugh Charlestwn Member Services, at the fllwing numbers: lcal: , ext 2, Remember: tll free in MA: , ext 2, tll free utside MA: , ext 2. N questin yu r a dependent may have is t basic t ask r t much truble fr us t answer. Sincerely, Bard f Trustees

4 Table f Cntents TABLE OF CONTENTS... 2 INTRODUCTION... 7 THE PATIENT PROTECTION AND AFFORDABLE CARE ACT... 7 Grandfathered Plan under the Affrdable Care Act... 7 Participatin in the Early Retiree Reinsurance Prgram... 8 UNITED PARCEL SERVICE (UPS) PART TIME BENEFIT MEMBERS... 9 UPS Part time Benefits... 9 UPS Part time Eligibility... 9 ELIGIBILITY MEMBER ELIGIBILITY HOW YOU FIRST BECOME ELIGIBLE HOW YOU CONTINUE TO REMAIN ELIGIBLE BUYING UP HOURS HOW TO REINSTATE LOST ELIGIBILITY SUPPLEMENTAL REINSTATEMENT/ELIGIBILITY RULES Cnstructin Industry Rules Mvie Industry Rules Oil Industry Rules DEPENDENT ELIGIBILITY When Yur Dependents Are Eligible Defining Eligible Children Defining Disabled Children CONTINUING TEAMSTERSCARE COVERAGE Cntinuing TeamstersCare Cverage under COBRA Dependent Cverage when Eligibility Ends Family Cverage in Case f Yur Death Cntinuing Cverage if Yu re Disabled Cntinuing Cverage fr Yur Spuse after Legal Separatin r Divrce Cverage n Returning frm Military Duty Cverage thrugh Medicaid and the Children s Health Insurance Prgram (CHIP) Page 2

5 HOW TO ENROLL IN TEAMSTERSCARE BENEFITS Infrmatin Yu Must Prvide t Enrll in TeamstersCare Benefits Change in Family Status Ntificatin SUSPENSION OF BENEFITS TEAMSTERSCARE BENEFITS MEDICAL BENEFIT TeamstersCare HMO Blue New England: TeamstersCare Blue Care Elect Preferred Out f Area Optin Blue Crss Blue Shield Behaviral Health Benefit CLINICAL BENEFITS PHARMACY BENEFITS Optin #1: TeamstersCare In Huse Pharmacies Optin #2: Mail Order Prescriptin Service Optin #3: Use yur Express Scripts/Medc Prescriptin Drug card at an Express Scripts Netwrk Pharmacy Optin #4: Nn Netwrk Retail Pharmacies Generic vs. Brand New Maintenance Medicatin at ur In huse Pharmacies Medicatins Requiring Prir Authrizatin Specialty Medicatin Prgram Prescriptin Drug Csts Chart Prescriptins Cvered Prescriptins Nt Cvered DENTAL BENEFITS Optin #1: TeamstersCare Dentists Making Appintments Optin #2: Delta Dental PPO Netwrk Dentists Optin #3: Nn Netwrk Dentists Csts fr Delta Dental PPO Netwrk and Nn Netwrk Dental Services Orthdntics Dental Treatment in the Hspital Dental Expenses Nt Cvered Pre Treatment Dental Estimates Filing a Dental Claim Crdinating with Other Dental Plans Page 3

6 VISION BENEFIT Davis Visin Netwrk Yur TeamstersCare Visin Benefit Eyewear Yu Can Select Making an Appintment TEAMSTERSCARE EMPLOYEE ASSISTANCE PROGRAM (EAP) R.A.F.T HEARING CARE BENEFITS Hearing Care Benefits Outside f New England OTHER BENEFITS WEEKLY DISABILITY BENEFIT Yur Disability Cverage Disability Waiting Perid Mre Than One Perid f Disability Cntinuing TeamstersCare Medical Cverage While Disabled Nn Wrk Related Disability Wrk Related Disability Disputed Wrk Related Disability Cntinuing Life Insurance While Disabled Disability TeamstersCare Des Nt Cver Disability Resulting frm Mtr Vehicle and Mtrcycle Accidents Other Disability Settlements Filing a Weekly Disability Claim Infrmatin Yu Must Prvide t be Eligible fr Weekly Disability Benefits LIFE INSURANCE Life Insurance Benefit Amunt Naming Yur Beneficiary Accelerated Death Benefit Optin Dependent Life Insurance Cnverting TeamstersCare Life Insurance t an Individual Plicy Life Insurance Benefits if Yu re Disabled Filing a Life Insurance Claim ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE AD&D Basic Benefits Page 4

7 Airbag Benefit Seat Belt Benefit Childcare Benefit Child Educatin Benefit Cma Benefit Felnius Assault Benefit Naming Yur Beneficiary Exclusins Hw t File an AD&D Claim ADMINISTRATION CONTINUING YOUR HEALTH COVERAGE UNDER COBRA Types f Cverage The Perid fr Making Yur Decisin Abut COBRA Cverage Cst f Cntinued Cverage Qualifying Events When COBRA Cntinued Cverage Ends If Yu Dn t Elect COBRA Cverage If Yu Have Questins abut COBRA YOUR RIGHTS UNDER HIPAA Privacy & Ntice f TeamstersCare Privacy Plicies Hw TeamstersCare May Use r Disclse Yur Prtected Health Infrmatin When TeamstersCare May Nt Use r Disclse Yur Prtected Health Infrmatin Statement f Yur Health Infrmatin Rights YOUR RIGHTS UNDER THE NEWBORNS AND MOTHERS HEALTH PROTECTION ACT YOUR RIGHTS UNDER THE WOMEN S HEALTH AND CANCER RIGHTS ACT COORDINATION OF BENEFITS General COB Guidelines Crdinating Cverage fr Children Crdinating Cverage with Medicare Prescriptin Drug Cverage under Medicare THIRD PARTY LIABILITY N Fault Aut Insurance Wrkers Cmpensatin YOUR RIGHTS AS A PLAN MEMBER UNDER ERISA Page 5

8 Prudent Actins by Plan Fiduciaries Help With Yur Questins INFORMATION ABOUT TEAMSTERS UNION 25 HS&IP Plan Spnsr/Plan Administratr/Named Fiduciary The Bard f Trustees Plan Year Emplyer and Plan Identificatin Numbers Plan Cntributins Benefit Payment Eligibility fr Benefits Financial Infrmatin Agent fr Service f Legal Prcess Plan Authrity CLAIMS AND APPEALS Submitting a Claim CLAIM DETERMINATIONS AND APPEALS Timing f Ntificatin f Claim Determinatins Manner and Cntent f Ntificatin f an Adverse Benefit Determinatin Appeal f Adverse Benefit Determinatins t the TeamstersCare Bard f Trustees FINAL NOTES IMPORTANT ADDRESSES AND PHONE NUMBERS INDEX Page 6

9 Intrductin The Teamsters Unin 25 Health Services & Insurance Plan, mre cmmnly called TeamstersCare, ffers yu and yur family the security f quality health care and a measure f financial prtectin thrugh disability, life, and accident insurance plans. If yu re an eligible TeamstersCare member, yu, yur spuse and yur dependent children have the fllwing health benefits: medical care and hspitalizatin behaviral health benefits pharmacy and prescriptin drugs dental care visin care hearing care emplyee assistance prgram (EAP) As a member, yu als have the additinal financial prtectin prvided by these TeamstersCare benefits: weekly disability benefits!replacement incme if yu can t wrk because yu re sick r injured!fr the member life insurance!fr the member and dependents accidental death and dismemberment (AD&D) insurance!extra life and accident prtectin!fr the member Certain bargaining agreements may prvide different benefits. If yu are cvered under ne f these agreements, yu ll receive additinal infrmatin specific t yur benefits. As a reference, this bklet cntains quite a bit f detail abut yur benefits. Yu shuld share the infrmatin in this bklet with yur family. If yu have questins regarding specific benefits that yu can t find described in this benefit bklet, dn t hesitate t call Charlestwn Member Services. See page 75 fr these and ther imprtant phne numbers. The Patient Prtectin and Affrdable Care Act In March 2010, Cngress passed and the President signed int law the Affrdable Care Act. As a result f the Act, TeamstersCare is required t prvide yu with certain health care cverages and infrmatin. Grandfathered Plan under the Affrdable Care Act TeamstersCare believes that ur plan is a grandfathered health plan under the Patient Prtectin and Affrdable Care Act. A grandfathered health plan can preserve certain basic health cverage that was already in effect when the law was enacted. Being a grandfathered plan means that TeamstersCare may nt include certain cnsumer prtectins f the Act that apply t ther plans. Fr example, we are nt required t fllw the prvisin f preventive health services withut any cst sharing. Hwever, grandfathered health plans must cmply with certain ther cnsumer prtectins in the Act, such as the eliminatin f lifetime dllar limits fr benefits. Page 7

10 Questins regarding which prtectins apply and which prtectins d nt apply t a grandfathered health plan and what might cause the plan t change status can be directed t the TeamstersCare Executive Directr, at ext Yu may als cntact the Emplyee Benefits Security Administratin, US Department f Labr at r This website has a table summarizing which prtectins d and d nt apply t grandfathered health plans. Participatin in the Early Retiree Reinsurance Prgram Yu are a plan participant, r are being ffered the pprtunity t enrll as a plan participant, in an emplyment based health plan (TeamstersCare) that is certified fr participatin in the Early Retiree Reinsurance Prgram (ERRP). The Early Retiree Reinsurance Prgram is a Federal prgram that was established under the Affrdable Care Act. Under the Prgram, the Federal gvernment reimburses a plan spnsr f an emplyment based health plan fr sme f the csts f health care benefits paid n behalf f, r by, early retirees and certain family members f early retirees participating in the plan. By law, the prgram expires n January 1, Under the Early Retiree Reinsurance Prgram, TeamstersCare may chse t use any reimbursements it receives frm this prgram t reduce r ffset increases in early retiree plan participants premium cntributins, c payments, deductibles r ther ut f pcket csts. If TeamstersCare chses t use the ERRP reimbursements this way, yu, as a plan participant, may experience changes that may be advantageus t yu, in yur health plan cverage terms and cnditins, fr s lng as the reimbursements under this prgram are available and TeamstersCare chses t use the reimbursements fr this purpse. TeamstersCare may als use the ERRP reimbursements t reduce r ffset increases in its wn csts fr maintaining yur health benefits cverage, which may increase the likelihd that it will cntinue t ffer health benefits cverage t its retirees and emplyees and their families. Page 8

11 United Parcel Service (UPS) Part time Benefit Members If yu are an eligible United Parcel Service (UPS) part time emplyee, yur Teamsters Unin 25 Health Services & Insurance Plan cverage differs frm the cverage fr ther members in tw basic ways: the benefits yu receive and yur eligibility rules. UPS Part time Benefits If yu wrk 225 hurs r mre fr UPS in a three mnth eligibility determinatin perid, but fewer than 400 hurs, yu are eligible fr the fllwing TeamstersCare benefits: medical behaviral health pharmacy and prescriptin drugs dental care visin care hearing care emplyee assistance prgram (EAP) Hwever, yu are nt eligible fr: weekly disability life insurance dependent life insurance AD&D insurance UPS Part time Eligibility As a UPS part time emplyee, the same eligibility rules apply t yu as t full time emplyees, except that yu have t wrk 225 hurs, rather than 400 hurs, in a three mnth eligibility determinatin perid. If yu re a UPS part time emplyee, and yu wrk 400 r mre hurs in a fixed three mnth eligibility determinatin perid, then yu receive the same benefits as a full time emplyee during the crrespnding three mnth benefit cverage perid. Fr mre infrmatin n eligibility rules, see the descriptin immediately fllwing in the Eligibility sectin, keeping in mind that yur eligibility is based n 225 hurs rather than 400 hurs. Page 9

12 Eligibility Member Eligibility Yu becme eligible fr TeamstersCare benefits in ne f tw ways: " yu begin wrking fr an emplyer wh is already participating with Teamsters Lcal 25 (r sme ther participating Lcal r rganizatin) and wh is cntributing t Teamsters Unin 25 Health Services & Insurance Plan (TeamstersCare) in this case, yu becme an active participant as sn as yu fulfill the eligibility requirements r " yu are already wrking fr an emplyer wh begins participating with Teamsters Lcal 25 (r sme ther participating Lcal r rganizatin) and begins cntributing t TeamstersCare in this case, yu becme an active participant when yur emplyer cntributes t TeamstersCare an amunt equal t the remittance rate times the required number f hurs and yu fulfill the eligibility requirements. Hw Yu First Becme Eligible T becme eligible fr benefits nce yu re cvered by a cntract requiring cntributins n yur behalf, yu have t wrk and yur emplyer must have remitted cntributins fr a ttal f 400 r mre hurs ver a perid f any three cnsecutive mnths. When yu reach 400 hurs during that three mnth perid, yu becme eligible t enrll in the Plan. After yu enrll, cverage fr yu and yur eligible dependents begins n the first day f the next mnth fllwing the accumulatin f the 400 hurs. Initial Eligibility Example: If yu wrk and yur emplyer cntributes n yur behalf 110 hurs fr March, 200 hurs fr April and 160 hurs fr May, yu are eligible t enrll fr benefits beginning June 1. Imprtant Nte : In this Answerbk, anytime the wrd wrk is used as it relates t eligibility, it means credited with required cntributins accrding t the Cllective Bargaining Agreement r by law. In this cntext, required cntributins means cntributins wed t the Fund fr thse hurs# r part f hurs#fr which wages are paid r due figured t the nearest quarter hur, as well as hurs fr paid vacatin, paid hliday, and ther hurs fr which pay is due r received by the member. Hw Yu Cntinue t Remain Eligible After yu ve becme eligible fr the first time (regardless f what mnth yur eligibility starts), yu remain eligible thrugh the next January 31, r April 30, r July 31, r Octber 31 whichever date cmes first. These dates are called eligibility review dates and they are used t determine yur cntinuing eligibility. Imprtant Nte : Under a special Plan prvisin, the first time yu becme eligible, yu re entitled t n less than three mnths cverage. Thus, if the perid between the day yu first becme eligible t enrll and the fllwing eligibility review date is less than three mnths, yur eligibility autmatically extends t the next fllwing eligibility review date. Page 10

13 On each eligibility review date, we lk at the number f hurs yu ve wrked during a fixed three mnth perid. S lng as yu wrked 400 r mre hurs during that fixed three mnth eligibility determinatin perid, yu cntinue t be eligible, frm the review date n, fr the next three mnths ging frward. If yu d nt have 400 r mre hurs, yu may cntinue eligibility if yur emplyer has made cntributins f 1800 r mre hurs in the previus 12 mnths, and yu have wrked at least ne hur in the current eligibility determinatin perid, and we have prf that yu cntinue t wrk fr a cntributing TeamstersCare emplyer. Here s hw the eligibility cycle wrks: Yur eligibility is reviewed n: If yu wrked at least 400 hurs during the preceding: Or, if yu wrked 1800 hurs during the preceding 12 mnths*: Yu cntinue t be eligible fr the next: January 31 Oct., Nv. & Dec. Jan. 1 thru Dec. 31 February, March, & April April 30 Jan., Feb. & March April 1 thru March 31 May, June, & July July 31 April, May & June July 1 thru June 30 August, Sept., & Oct. Octber 31 July, Aug. & Sept. Oct. 1 thru Sept. 30 Nvember, Dec., & Jan. *Yu must prvide prf f cntinued emplyment in either the mnth befre the eligibility cverage perid r the first mnth f the new eligibility cverage perid t be eligible fr the 1800 hur lk back rule. Imprtant Nte: If yu re a UPS part timer and yu wrk at least 225 hurs (but less than 400) in a fixed three mnth perid, yu re eligible fr all TeamstersCare benefits except weekly disability, life, dependent life, and AD&D. If yu wrk 400 r mre hurs, yu re eligible fr all benefits in the crrespnding three mnth cverage perid, just as thugh yu were a full time emplyee. Buying up Hurs If Yu Fall Shrt f 400 Hurs in a Fixed Three Mnth Perid, r Yu D Nt Have 1800 hurs in the 12 mnth Lk Back perid, we check t see if yu wrked mre than the required 400 hurs in each f three cnsecutive calendar quarters, but then fell shrt f 400 hurs in the mst recent quarter. If this happens, yu re eligible t cntinue cverage by buying up the number f hurs yu need t remain eligible. T be eligible fr the buy up, the fllwing cnditins must apply: " yu must have wrked at least 400 hurs in each f the three cnsecutive quarters immediately preceding the quarter in which yu have the shrtfall; " yu must wrk at least ne hur in the quarter yu re buying up; " yu must prvide prf f cntinued emplyment in either the mnth befre the eligibility cverage perid r the first mnth f the new eligibility cverage perid; " the buy up rate is yur emplyer s cntracted hurly remittance rate that is in place during the quarter yu have the shrtfall; " the amunt yu pay is yur buy up rate times the number f hurs yu fall shrt f the required 400 hurs; " there s a $1,000 maximum n the amunt yu re required t pay in rder t buy up in any given quarter nce yu reach this $1,000 cap, yu d nt have t pay any additinal amunt fr that quarter; and " yu pay fr yur hurs directly t TeamstersCare by check r mney rder. Page 11

14 Once yu buy up fr a particular quarter, yu cannt cunt that same quarter as the first in a new series f cnsecutive three mnth perids. In ther wrds, nce yu buy up fr ne quarter, yu must then wrk and have remittances paid n yur behalf by yur emplyer fr three cnsecutive quarters befre yu again have the pprtunity t buy up. If yu are nt eligible under the 400 hur rule, the 1800 hur lk back r the buy up ptin, yu may have the ptin t cntinue cverage under COBRA. Hw t Reinstate Lst Eligibility If fr sme reasn yu d nt meet the eligibility requirements and yu are nt eligible t buy up (r yu decline), then yu lse TeamstersCare cverage. In rder t reinstate yur eligibility, yu must wrk at least 400 hurs in a rlling three mnth reinstatement perid that ccurs either befre r within 12 mnths after yu ve lst cverage. Once yu re ineligible fr mre than 12 mnths, yu have t reinstate just as thugh yu were a new member. (See Hw Yu First Becme Eligible n page 10.) When reinstating, yu can wrk yur 400 hurs befre r after the date n which yur eligibility ends. The number f mnths yu lse cverage, and the number f mnths f eligibility yu earn when yu reinstate, bth depend n the relatinship between the date yu lse eligibility and the three mnth rlling reinstatement perid when yu wrk yur 400 hurs. Once yu becme ineligible, yu must always lse at least ne mnth f cverage befre yu can regain eligibility. Reinstatement Example. If yu lse yur eligibility n April 30th, regardless f hw r when yu reinstate, yu must lse cverage fr at least the mnth f May. The earliest three mnth perid yu can use t reinstate is February/March/April. S, n April 30th, yu lk back at thse three mnths; if yu reached 400 hurs during that perid, yu lse cverage fr May, but reinstate as f June 1st. Hwever, if yu dn t make yur 400 hurs in February/March/April, yu then rll frward t the next three mnth perid, March/April/May. On May 31st, yu lk back n that perid t see if yu ve wrked 400 r mre hurs. If yes, yur eligibility reinstates n June 1st; if n, then yu rll frward t the next three mnth perid, April/May/June...and s n, frm ne three mnth perid t the next, until yu wrk 400 r mre hurs in any three cnsecutive mnth perid. Supplemental Reinstatement/Eligibility Rules Cnstructin Industry Rules When a TeamstersCare member wrks fr a cnstructin industry emplyer with a Cllective Bargaining Agreement requiring that the emplyer cntribute fr all hurs wrked, up t 2080 hurs in a calendar year, and the member reaches 2080 hurs f cntributins in that calendar year, eligibility cntinues fr the February, March and April eligibility perid f the fllwing year. Mvie Industry Rules Due t the cntractual hurs remitted in the mvie industry (up t 65 hurs/week) members in the Mvie Referral System (senirity r casual list), wh have received at least 65 hurs f mvie cntributins in the Page 12

15 past twelve mnths, are granted eligibility fr the buy up rule and fr the 1800 hur extended cverage rule and d nt need t shw prf f cntinued emplyment. Oil Industry Rules Members wrking fr the il industry wh lse eligibility n Octber 31 st can reinstate cverage December 1 st if they wrk 100 r mre hurs in Octber. The member must lse ne mnth f cverage (Nvember); all cntributin hurs must be frm a TeamstersCare il industry emplyer; and the member must cntinue t wrk each mnth f the next quarter. This rule des nt supersede the 1800 hur r buy up prvisin rules. When Yur Dependents Are Eligible Dependent Eligibility Once yur wn eligibility begins, yur dependents als becme eligible fr TeamstersCare medical, prescriptin drug, dental, visin, hearing, and behaviral health benefits. Imprtant Nte: Fr purpses f TeamstersCare eligibility, nce yur dependent is enrlled, and s lng as yur dependent meets the Plan s definitin f eligible dependent, yu cannt terminate cverage fr that dependent. Eligible dependents include: " yur current spuse, r an ex spuse wh was cvered by the Plan when yu divrced, r an exspuse wh was an eligible and enrlled dependent when a new emplyer begins cntributing t the Plan, in cases where: # yu have a divrce decree requiring yu t cver yur ex spuse, and # yu decline cverage fr yur current spuse (in rder t maintain cverage fr yur ex spuse) and yur current spuse agrees in writing t waive all current and future cverage frm Teamsters Unin 25 Health Services & Insurance Plan and prvides prf f ther cverage. (Nte: new members wrking fr a regular cntributing emplyer cannt cver an ex spuse if the member was divrced r legally separated befre jining the Plan) " yur children, up t age 26 prvided they are nt eligible fr an emplyer prvided health plan " yur unmarried children wh are incapable f self care because f a physical r mental disability, prvided they: # depend n yu fr supprt, and # first became disabled befre turning 26 and were cvered by the Plan at that time. Defining Eligible Children Eligible children include yur natural children; dependent children f yur dependent; legally adpted children; children placed with yu fr adptin; stepchildren; children fr whm the member has been appinted legal guardian; fster children. TeamstersCare als cvers member s children named under a Page 13

16 Qualified Medical Child Supprt Order, prvided a cpy f this rder is filed with Teamsters Unin 25 Health Services & Insurance Plan, 16 Sever Street, Charlestwn, MA Call Charlestwn Member Services at ext. 2 fr a cpy f TeamstersCare s prcedures regarding Qualified Medical Child Supprt Orders. Defining Disabled Children Under certain circumstances, TeamstersCare may cntinue t prvide medical benefits fr a disabled child beynd the date dependent eligibility wuld nrmally have ended. Fr cverage t be extended, the child must be first disabled befre they turn age 26 and, at that time, they must be: # cvered by the Plan # currently unmarried, and # mentally r physically disabled s as nt t be able t earn his r her wn living n the date eligibility wuld nrmally end. In rder fr yur dependent t be eligible fr cntinued medical cverage, yu must prvide TeamstersCare with prf f the disability within 30 days after the disabled child turns 26. Peridically, as required by the Medical Review Cmmittee yu will need t prvide medical dcumentatin r ther infrmatin fr review. The Cmmittee will evaluate this infrmatin and determine whether the dependent is still eligible fr cntinuing TeamstersCare cverage. Failure t prvide medical dcumentatin when requested may cause yur dependent t lse eligibility. Fr further details, cntact Charlestwn Member Services at ext. 2. Imprtant Nte: If yu have a disabled dependent when yu as a member first becme eligible fr TeamstersCare cverage, the Plan may prvide medical benefits fr that dependent s lng as yu submit prf f disability, t the TeamstersCare Medical Review Cmmittee, within 30 days f the date yu becme eligible. Cntinuing TeamstersCare Cverage Cntinuing TeamstersCare Cverage under COBRA In certain cases where yu r yur dependents wuld therwise lse healthcare benefits, yu may be able t cntinue medical cverage under the Federal law knwn as COBRA (see page 46 fr details n COBRA cverage). Dependent Cverage when Eligibility Ends Yur dependents lse cverage at the same time yur wn eligibility ends. Individual dependents can als lse cverage if they n lnger meet the definitin f an eligible dependent; hwever they may be able t cntinue medical cverage thrugh COBRA (see page 48 fr details n COBRA cverage fr dependents). Family Cverage in Case f Yur Death If yu die while cvered by the TeamstersCare Prgram, TeamstersCare will cntinue t prvide yur family with medical, behaviral health, prescriptin drug, dental, visin, hearing, and the Emplyee Assistance Prgram. These extended benefits can apply fr up t three mnths beynd the benefit cverage perid when yur dependents wuld therwise lse eligibility. After three mnths, yur family will have the ptin f cntinuing cverage under COBRA, r, if eligible, may be able t jin a Page 14

17 TeamstersCare Retiree Prgram. When extending benefits under any f these ptins, certain cnditins may apply. Fr mre infrmatin, call Charlestwn Member Services at ext. 2. Cntinuing Cverage if Yu re Disabled If yu re disabled and are receiving either TeamstersCare Weekly Disability benefits (fr a nn wrkrelated disability) r Wrkers Cmpensatin (fr a wrk related disability), yu may be able t cntinue receiving TeamstersCare medical benefits during the perid f yur disability. In either case, yu must meet all f the Plan s eligibility rules. If yur disability is caused by a jb related sickness r injury and yu re receiving Wrkers Cmpensatin benefits, yur emplyer may be required t cntribute t TeamstersCare at a rate f 32 hurs a week fr up t 12 mnths, if specified in yur Cllective Bargaining Agreement (CBA). Cntinuing Cverage fr Yur Spuse after Legal Separatin r Divrce In the event f divrce r legal separatin, a curt might rder yu t prvide medical cverage fr yur frmer spuse and eligible dependents. In certain cases, TeamstersCare may extend the same cverage t which yur ex spuse had been previusly entitled, except fr life insurance. T be eligible, yur exspuse must have been cvered by the Plan at the time f yur divrce. Yu will need t prvide Charlestwn Member Services with the effective date f the divrce and dcumentatin f the curt rder within 30 days f yur divrce becming final. If cverage is extended, but yur ex spuse subsequently remarries, then the extended cverage ends n the date f remarriage. Yu, as the member, are respnsible fr ntifying TeamstersCare within 31 days f this change in family status. If yu remarry, yu may elect t cntinue cverage fr yur ex spuse instead f yur new spuse prvided yur new spuse agrees in writing t waive all current and future cverage frm Teamsters Unin 25 Health Services & Insurance Plan and prvides prf f ther health cverage. Under the Plan, yu cannt cver a spuse and an ex spuse at the same time. If, upn divrce, yu are nt required t prvide cverage fr yur ex spuse, he/she may be eligible t purchase temprary extended healthcare cverage under COBRA fr up t 36 mnths (see page 48 fr details f COBRA cverage fr dependents). Yu, as the member, are respnsible fr ntifying an ex spuse f all benefit infrmatin including benefit changes, reinstatements, prviding ID cards, etc. The Plan is respnsible fr ntifying an ex spuse f COBRA cverage upn terminatin f health care benefits. Imprtant Nte: Divrce r legal separatin is a change in family status, which in rder t ensure cverage fr yur eligible dependents yu must reprt t TeamstersCare within 31 days f the change. If yu fail t d s, TeamstersCare cannt ensure cntinuus r timely cverage fr any claims yu may incur beynd that 31 day perid. Cverage n Returning frm Military Duty If yu return t yur jb within 90 days f authrized military duty, yur TeamstersCare cverage is reinstated immediately, prvided: yu were eligible fr benefits at the time yu went n duty yu wrk at least ne hur fr a cntributing emplyer after returning t wrk yur emplyer prvides TeamstersCare with dcumentatin that yu have returned t wrk, and yu prvide prf f military service listing yur discharge date Page 15

18 Yur reinstated cverage cntinues fr the remainder f the eligibility determinatin perid during which yu were reinstated thrugh the subsequent benefit cverage perid, accrding t the fllwing schedule: Eligibility Determinatin Perid January, February, March April, May, June July, August, September Octber, Nvember, December Benefit Cverage Perid May, June, July August, September, Octber, Nvember, December, January, February, March, April Fr example, if yu return t wrk n August 20, and wrk at least ne hur, then cverage fr yu and yur eligible dependents begins n August 20 and cntinues thrugh January 31. While yu are in the military, yu and yur dependents have the right t elect cntinued benefit cverage under COBRA fr up t 24 mnths (see page 46 fr details n COBRA cverage). Cverage thrugh Medicaid and the Children s Health Insurance Prgram (CHIP) If yu are unable t affrd the premiums, sme States have premium assistance prgrams that can help pay fr cverage. These States use funds frm their Medicaid r CHIP prgrams t help peple wh are eligible fr emplyer spnsred health cverage, but need assistance in paying their health premiums. If yu r yur dependents are already enrlled in Medicaid r CHIP, yu can cntact yur State Medicaid r CHIP ffice t find ut if premium assistance is available. If yu r yur dependents are NOT currently enrlled in Medicaid r CHIP, and yu think yu r any f yur dependents might be eligible fr either f these prgrams, yu can cntact yur State Medicaid r CHIP ffice r dial KIDS NOW r t find ut hw t apply. If yu qualify, yu can ask the State if it has a prgram that might help yu pay the premiums fr an emplyerspnsred plan. G t the TeamstersCare website fr a list by state with cntact infrmatin fr the Medicaid and CHIP Offices. Hw t Enrll in TeamstersCare Benefits Infrmatin Yu Must Prvide t Enrll in TeamstersCare Benefits Once yu are eligible, in rder t enrll in TeamstersCare benefits, we must have cmplete, accurate, and up t date infrmatin fr yu and yur eligible dependents. Yu re respnsible fr prviding this infrmatin and fr keeping the infrmatin updated. Once yu have wrked the required number f hurs and yur emplyer has made the crrespnding cntributins, Charlestwn Member Services will send yu an Enrllment Package. Yu must cmplete the Enrllment Frm and return it t Charlestwn Member Services with the required dcumentatin (i.e. marriage license and birth certificate fr each dependent child) within 31 days f receiving the package. Page 16

19 Imprtant Nte: TeamstersCare cannt activate yur benefits, which means yu and yur family will nt have access t TeamstersCare cverage, until we have received a cmplete and accurate Enrllment Frm and crrespnding dcumentatin. If the Enrllment Frm is nt received within 31 days frm when we send the package, eligibility fr benefits will be activated n the first day f the mnth that the Enrllment Frm and dcumentatin is received. Change in Family Status Ntificatin A change in family status is any event that affects the recrds we currently have n file fr yu and yur dependents. This includes, but is nt limited t, the fllwing: mving ut f the gegraphic area cvered by yur medical ptin a change in yur address r the address f an eligible dependent marriage, divrce r legal separatin, r the mandate f a curt rder adding a new dependent by: birth, adptin, r placement fr adptin; marriage; the mandate f a Qualified Medical Child Supprt Order (QMCSO) death f an eligible participant lss f dependent eligibility; change in physically r mentally disabled status returning t wrk after a disability any change in yur wn r yur dependent s emplyment related healthcare cverage eligibility fr Medicare and/r Scial Security disability status cverage fr yu and/r any f yur dependents under any grup benefit plans ther than TeamstersCare Imprtant Nte: If yu have a change in family status yu r smene acting n yur behalf must ntify Charlestwn Member Services by telephne r in writing within 31 days f the change (see page 75 fr cntact infrmatin). If yu fail t d s, TeamstersCare cannt ensure cntinuus r timely cverage f any claims incurred beynd that 31 day time perid. TeamstersCare may require that yu submit certain changes in writing r prf f yur change in family status, at the time yu ntify us f the change. TeamstersCare manages all eligibility and enrllment issues. Anytime yu prvide us with eligibilityrelated infrmatin, we ll ntify all the vendrs n yur behalf. Suspensin f Benefits There are certain instances where, althugh yu may be therwise eligible fr TeamstersCare benefits, yur benefits and thse f yur dependents culd be suspended until such time as the situatin causing yur suspensin is remedied. A member s suspensin culd result frm: nt respnding t a request t repay an verpayment f a disability claim nt repaying a lien after yu receive a mnetary award nt repaying the Plan after yu have received prceeds frm a third party nt respnding t a request fr infrmatin nt submitting an Enrllment Frm when TeamstersCare requires yu t d s enrlling an ineligible dependent cmmitting fraud r misrepresenting infrmatin t TeamstersCare a check fr a buy up, COBRA payment, r TeamsterShare Payment is returned frm yur bank as unpaid A member, wh is suspended n the date a qualifying event is sustained, will nt be extended COBRA cverage. Page 17

20 TeamstersCare Benefits Medical Benefit TeamstersCare prvides medical benefits thrugh an HMO and an Out f Area Optin: " TeamstersCare HMO Blue New England Optin " TeamstersCare Blue Care Elect Preferred Out f Area Optin Each f these ptins ffers a wide range f health services, including cverage f dctrs visits, hspitalizatin, surgery, maternity care, behaviral health and many ther medical prducts and services. Yur chice depends n where yu live. T participate in the HMO, yu must live within that HMO s netwrk service area. If yu r any ne f yur eligible dependents permanently lives in an area nt cvered by the HMO, then yu and all yur dependents will autmatically be cvered by the TeamstersCare Blue Care Elect Preferred Out f Area Optin. Yu cannt elect the Out f Area Optin if yu and all yur eligible dependents permanently reside in the TeamstersCare HMO Blue New England service area. If yu re a member f TeamstersCare HMO Blue New England, yu will need t select a Primary Care Physician (PCP) fr yurself and fr each cvered family member. Yur individual PCP will crdinate all yur rutine care and guide yu thrugh any referrals yu may need fr specialized services. If yu re a member f the Out f Area Optin, yu d nt have t select a PCP. When yu use a participating netwrk prvider, the Out f Area Optin cvers mst services in full, after yu make certain cpays. If yu use a nn netwrk prvider, mst expenses are cvered at 80% f reasnable and custmary amunts after a $250 individual/$500 family deductible. The ut f netwrk calendar year cinsurance maximum is $1,000 per individual/$2,000 per family. If yu re currently enrlled in TeamstersCare s HMO Blue New England, and yu r an eligible dependent permanently mves ut f the HMO s service area, r yu are enrlled in the Blue Care Elect Preferred Out f Area Optin and yu and all yur dependents permanently live in the New England area, then yu must call Charlestwn Member Services t discuss changing yur medical benefit ptin. The nly exceptin t this rule is if a dependent (fr example a cllege student) temprarily mves ut f the HMO service area. In this case, yur dependent will cntinue t be cvered by yur HMO ptin. TeamstersCare HMO Blue New England: Fr specific details f yur HMO cverages, refer t yur HMO bklet. In general: " Yu ll select a Primary Care Physician (PCP) the individual prfessinal wh s principally respnsible fr crdinating yur medical care. Check nline at fr physicians in yur area. Yur current dctr might already be a PCP in the Blue Crss netwrk. " Each f yur family members chses a PCP and receives medical care frm his r her individual PCP. " When specialized care is needed, yur PCP crdinates all referrals t practitiners within the HMO netwrk. It s especially imprtant t be in cntact with yur PCP. Page 18

21 " Except fr life threatening emergencies and ther specific circumstances, HMO s pay benefits fr services nly when prvided r referred by an individual s PCP. " HMO s will nt cver the expense f any nn emergency services yu receive utside the HMO s netwrk. " Yu d nt have t pay deductibles r cinsurance r fill ut claim frms thugh in mst cases yu will be respnsible fr making a cpay. Imprtant Nte: If yu re a new Plan member, yur HMO cverage begins n the date yu becme eligible t enrll fr TeamstersCare benefits as lng as we receive yur cmpleted Enrllment Frm and dcumentatin within 31 days f the date we sent yur Enrllment Package. Yur eligible dependents are cvered as f that same date unless yu enrll a dependent at a later date. If the Enrllment Frm is nt received within 31 days frm when we send the package, eligibility fr benefits will be activated n the first day f the mnth that the Enrllment Frm and dcumentatin is received. TeamstersCare Blue Care Elect Preferred Out f Area Optin If yu r yur eligible dependents permanently reside utside the HMO s service area, TeamstersCare prvides yur basic medical cverage thrugh Blue Care Elect Preferred. Fr mre details n the Blue Care Elect Preferred prvider netwrk and facilities, call r visit When yu r a dependent receives cvered medical services frm a Blue Care Elect Preferred prvider, in mst cases yur nly cst will be the cpay yu make directly t yur prvider. Nn Netwrk Medical Cverage under the Out f Area Optin If yu d nt have cnvenient access t a Blue Care Elect Preferred prvider, yu can g t any ther nnnetwrk prvider f yur chice. In this case, TeamstersCare will pay 80% f reasnable and custmary csts fr cvered services, after a $250 individual /$500 family annual deductible, and yu will be respnsible fr the balance. The ut f netwrk calendar year cinsurance maximum is $1,000 per individual /$2,000 per family. (These are the maximum amunts yu will pay ut f yur pcket each year.) If yu re a new Plan member, yur Out f Area cverage begins n the same date that yu becme eligible fr TeamstersCare cverage. Yur eligible dependents are cvered as f that same date. TeamstersCare must have a cmpleted Enrllment Frm and required dcumentatin befre yur benefits can be activated. If yu change t the Blue Care Elect Preferred Out f Area Optin due t a qualifying event, then yur cverage in this ptin begins the first f the fllwing mnth after yu ntify us. Fr mre infrmatin n specific cverages under the Blue Care Elect Preferred ptin, claims related questins, and limitatins that might apply t services call the Blue Care Elect Preferred Plan at Page 19

22 Blue Crss Blue Shield Behaviral Health Benefit Cunseling and treatment are available fr emtinal difficulties, mental illness, substance abuse, family and marital prblems, childhd and adlescent cncerns. Benefits als include a variety f prgrams and services with case managers available t help members living with chrnic behaviral health cnditins. T access utpatient behaviral health services, n referral r pre authrizatin is necessary; yu simply make an appintment t see any in netwrk prvider and pay a $15 cpay fr services. Fr new episdes f utpatient care, up t the first 12 visits are autmatically authrized. If mre than 12 visits are needed, yur in netwrk prvider will cntact Blue Crss Blue Shield fr additinal authrizatin, with n actin needed by yu. If yu experience a behaviral health emergency situatin r are in need f acute hspital care, yu can wrk with yur prvider t determine an apprpriate plan f care; when that s nt practical, yu shuld prceed t any Emergency Rm. N authrizatin is needed fr emergency care, and if a hspital admissin is necessary, the facility will cntact Blue Crss Blue Shield fr authrizatin. Members and dependents can call the Blue Crss Behaviral Health Crdinatin line at (the phne number is listed n yur I.D. card) and a Blue Crss Member Service Assciate will assist yu. Yu can als access their web site at and g t the Find A Dctr directry t lcate a prvider. Imprtant Nte: Regardless f which TeamstersCare Medical Optin yu enrll in, yur prescriptin, dental, visin, audilgy, and Emplyee Assistance Prgram services, are prvided t yu thrugh TeamstersCare, nt thrugh the HMO r the Out f Area Optin. Page 20

23 Clinical Benefits Yur family has access t a variety f imprtant healthcare services prvided directly by TeamstersCare thrugh its wn dedicated facilities r thrugh specialized prviders. These services include: " pharmacy and prescriptin drugs " dental care " visin care " hearing care " emplyee assistance prgram (EAP) Imprtant Nte: These services are made available t yu thrugh TeamstersCare nt thrugh the HMO r the Out f Area Optin. Pharmacy Benefits Under the TeamstersCare plan, yu and yur eligible dependents have fur ptins when yu need prescriptin drug services. Optin #1: TeamstersCare In Huse Pharmacies The TeamstersCare Pharmacies at Charlestwn and Stughtn dispense prescriptins (fr up t a 90 day supply) fr yu and yur family fr a $5 (generic)/$15 (brand name) TeamsterShare Payment per prescriptin. The TeamstersCare in huse pharmacies ffer yu an easy, cst effective way t fill prescriptins, including thse yu use n an nging basis, such as heart r bld pressure medicatin and diabetic supplies. T have a prescriptin filled by the TeamstersCare Pharmacies, yu may: " take yur prescriptin t the TeamstersCare Pharmacy in Charlestwn r Stughtn " have yur dctr call in the prescriptin t the TeamstersCare Pharmacy " have yur dctr fax the prescriptin t the TeamstersCare Pharmacy " ask the TeamstersCare Pharmacist t call yur dctr n yur behalf Refilling Yur Prescriptin at TeamstersCare is Easy Call ahead using Telemanager an autmated telephne system, available t refill a prescriptin at the Stughtn ( ) r Charlestwn ( ) TeamstersCare Pharmacies. Simply fllw the phne prmpts and use the keypad n yur telephne t submit the infrmatin required t refill a prescriptin. Be sure t have yur ld prescriptin available, as yu will need the 6 digit refill number. G nline using Refill Netmanager available t refill yur prescriptins at either f ur TeamstersCare Pharmacies. Simply g t and click n the TeamstersCare Pharmacy Benefit icn n the left side f the screen. This will bring yu t the Refill Netmanager system where yu can Page 21

24 cmplete the Online Prescriptin Refill Frm. Be sure t have yur ld prescriptin available, as yu will need the 6 digit refill number. Please nte that the hurs f peratin fr ur tw TeamstersCare in huse Pharmacies are slightly different. The hurs are subject t change: Charlestwn hurs: Walk in Service " Mnday thrugh Thursday 8:00 a.m. t 6:00 p.m. " Friday 8:00 a.m. t 4:00 p.m. " Saturday 8:00 a.m. t 4:00 p.m. " Lcal phne: Tll free: Fax: Stughtn hurs: Walk in Service " Mnday, Tuesday, Thursday, Friday & Saturday 8 a.m. t 4 p.m. " Wednesday 8 a.m. t 6 p.m. " Lcal phne: Fax: Call ahead whenever pssible s yur medicatin will be available and ready when yu arrive. Optin #2: Mail Order Prescriptin Service Yu can have yur lng term and maintenance medicatins filled by mail frm the Express Scripts/Medc Pharmacy. The Express Scripts/Medc Pharmacy will mail up t a 90 day supply via UPS r the U.S. mail fr a $5 (generic)/$15 (brand name) cpayment. Effective April 2012, Medc is a part f the Express Scripts family f pharmacies. " T get started, cmplete an Express Scripts/Medc Pharmacy mail rder frm and submit it with yur prescriptins. " Yu can register at t # view plan infrmatin # use MY RX Chices t cmpare prices n line # quickly refill yur mail rder prescriptins # enrll in e checks payments Fr mre infrmatin r t speak with an Express Scripts/Medc Specialist Pharmacist, call Express Scripts/Medc Member Services tll free at Optin #3: Use yur Express Scripts/Medc Prescriptin Drug card at an Express Scripts Netwrk Pharmacy Yu can use a retail netwrk pharmacy but yu ll have t pay a higher cpay and, in sme instances, cinsurance. Yu are limited t the lesser f a 30 day supply r 100 units. (See page 24 fr a Prescriptin Drug Csts Chart detailing drug csts at a retail netwrk pharmacy). " Generic Medicatin: $15 cpay up t a 30 day supply " Brand Name Medicatin, when n generic is available: $25 cpay up t a 30 day supply " Brand Name Medicatin, when a generic is available: $25 cpay, plus the difference between the cst f the brand name and generic...up t a 30 day supply Page 22

25 Optin #4: Nn Netwrk Retail Pharmacies Yu can use a nn netwrk retail pharmacy, but yu ll be required t pay the full amunt f yur prescriptin at the pint f sale, including the apprpriate cpay. Yu shuld then: " Submit a claim frm within 12 mnths with an itemized receipt listing the amunt paid t Express Scripts/Medc, PO Bx 14711, Lexingtn KY " Express Scripts/Medc will send yu a check fr the Plan s share f the cst based n the retail netwrk rate, less the amunt f yur cpay. Generic vs. Brand Yu will pay less fr a generic prescriptin than fr a brand name. Be sure t ask yur dctr, whenever yu get a new prescriptin, if the prescriptin is a generic. If it s nt, ask if there s a generic alternative available that might wrk just as well fr yu. In sme states retail pharmacies dn t always make generic substitutins, particularly if the pharmacy desn t have a generic n hand. As a way f hlding dwn Plan csts and yur csts as well TeamstersCare pharmacies as well as the Express Scripts/Medc mail rder pharmacy, will fill prescriptins fr brand name drugs nly when there is n generic equivalent fr a given medicatin. If a generic equivalent fr yur prescriptin exists, but yu want the brand name, yu ll have t g t a retail netwrk pharmacy, r t sme ther nn netwrk retail pharmacy. In either case, yu ll need t pay sme share f the cst. Therapeutic generic alternatives are nw available fr virtually every majr class f brand name medicatin. New Maintenance Medicatin at ur In huse Pharmacies Available nly at the TeamstersCare Walk in Pharmacies! When a new maintenance medicatin is prescribed, usually fr 90 days, it may nt wrk as anticipated. Yu may chse t receive up t a 30 day supply at n cst t yu. If the medicatin wrks fr yu, yu can fill the balance f the prescriptin, up t a 60 day supply, fr a $5 (generic)/$15 (brand name) TeamsterShare Payment. If the medicatin desn t wrk fr yu, and yur dctr switches yu t anther dsage r a new medicatin, yu haven t paid a TeamsterShare Payment fr the initial prescriptin. Medicatins Requiring Prir Authrizatin Sme medicatins require Prir Authrizatin (PA) befre cverage is prvided. The drug s prescribed use is evaluated against certain criteria. Ask ne f ur TeamstersCare Pharmacy staff abut the prcess fr btaining a medicatin PA. In mst cases, yur dctr will have t fax a cmpleted PA Frm t TeamstersCare at with certain infrmatin needed t make a determinatin. Frms are available n ur website r at ur TeamstersCare Pharmacies. The list f drugs requiring Prir Authrizatin is subject t change. The fllwing are examples f medicatins that currently require prir authrizatin: Page 23

26 " Aciphex " Btx " Crestr " Daytrana " Grwth Hrmne " Lescl " Lvaza " Prtnix " Nexium " Slareze Imprtant Ntes: New drugs are intrduced int the marketplace daily. As the FDA apprves new drugs fr use in the United States, TeamstersCare will assess the feasibility f cvering these drugs and cnsider the applicability f any restrictins and/r limitatins. Specialty Medicatin Prgram TeamstersCare has a dedicated prgram fr specialty medicatins. These are certain high cst prescriptin medicatins that treat cmplex cnditins. A list f these medicatins is available n ur website r by asking a TeamstersCare Pharmacist. These specialty medicatins are available at TeamstersCare Pharmacies fr pick up r thrugh Accred Specialty Pharmacy (mail rder nly). These medicatins require a $15 cpay fr each 30 day supply. They are nt available at retail pharmacies. If yu use the Accred Specialty Pharmacy t fill yur prescriptin, they will mnitr the shipment f yur medicatin, cntact yu via telephne t be sure yu will be hme t accept the shipment, and they will be available fr cnsultatin regarding yur medicatin 24 hurs a day, 7 days a week. Yu r yur dctr can reach them by telephne at Prescriptin Drug Csts Chart If yur prescriptin is written fr: Yu Pay: The Plan Pays: at Charlestwn and Stughtn TeamstersCare Pharmacies (up t 90 day supply) at Express Scripts/Medc Pharmacy mail rder (up t 90 day supply) generic medicatin $5 brand name medicatin and n $15 100% f the remaining cst generic is available brand name medicatin and this ptin nt available at generic is available TeamstersCare in huse Pharmacies r mail rder at a Retail Netwrk pharmacy (up t 30 day supply) generic medicatin $15 brand name medicatin and n generic is available $25 100% f the remaining cst brand name medicatin and generic is available $25 + cst difference between brand name & generic 100% f the remaining cst fr the generic at a Nn netwrk retail pharmacy When yu use a nn netwrk pharmacy, yu pay the full amunt f yur prescriptin at the pint f sale, including the apprpriate cpay. Then, within 60 days, yu submit a claim frm and itemized receipt t Express Scripts/Medc; They will send yu a check, based n the retail netwrk rate, less the amunt f yur cpay. Page 24