First Data 2016 Prescription Drug Plan Highlights

Transcription

1 First Data 2016 Prescription Drug Plan Highlights Prescription Drug Benefits AFTER you have met the deductible: Retail You pay $8 for generic drugs (up to a 30-day supply) You pay 30% of cost for brand-name formulary drugs, up to $100 maximum per prescription You pay 45% of cost for brand-name non-formulary drugs, up to $120 maximum per prescription Mail Order You pay $16 for generic drugs (up to a 90-day supply) You pay 30% of cost for brand-name formulary drugs, up to $250 maximum per prescription You pay 45% of cost for brand-name non-formulary drugs, up to $300 maximum per prescription Note that the copayment and coinsurance amounts shown above only apply after the in-network medical deductible has been met for the Enhanced, Standard, or Out-of-Area medical plans. Enhanced & Standard Medical Plans With these plans, you are enrolled in a consumer-directed high-deductible health plan, which provides medical and prescription coverage. The plans also include a health savings account (HSA) and an annual deductible (the amount that you, and if applicable, your dependents pay for healthcare services before the plan begins to share costs with you). For questions about your medical benefit, please call the member services number on your United Healthcare or Aetna medical ID card. Your medical carrier is United Healthcare, if you reside or work in Colorado, Florida, Illinois, Iowa, Kentucky, Nebraska, New York, New Jersey or Virginia. Aetna is the medical carrier for all other states. Express Scripts is the prescription benefit administrator for Aetna and United Healthcare participants. The Out of Area medical plan generally mirrors the in-network level for covered services under the Standard medical plan. The table below illustrates the design summaries for each medical plan: Annual Deductible - Individual - Family Medical Coinsurance (employee / employer) Individual (Self Only) Coverage Annual Out-of-Pocket Maximum (Varies by Salary) - <$40,000 - $40,001 - $85,000 - $85,001 - $125,000 - $125,001- $200,000 Enhanced Plan In-Network Out-of- Network Standard Plan In-Network Out-of- Network $1,300 $3,900 $2,000 $2,600 $7,800 $4,000 10% / 90% 50% / 50% 20% / 80% 50% / 50% $3,000 $3,500 $4,000 $5,000 $9,000 $10,500 $15,000 $3,000 $3,500 $4,000 $5,000 $9,000 $10,500 $15,000

2 - $200,001 + Family Annual Out-of-Pocket Maximum (Varies by Salary) - <$40,000 - $40,001 - $85,000 - $85,001 - $125,000 - $125,001 - $200,000 - $200,001 + For Family coverage, family OOP maximum must be met before any family member receives Plan 100% coverage. However, the OOP maximum will be no greater than $6,850 for any individual family member (overall family OOP maximum applies; not applicable to salary level 1) - $7,000 $8,000 $10,000 $21,000 $24,000 $30,000 $36,000 $7,000 $8,000 $10,000 $21,000 $24,000 $30,000 $36,000 Health Savings Account (HSA) Your payroll contributions into a health savings account are pre-tax dollars, which you can use to pay for your prescription and medical expenses. Unlike a general purpose flexible spending account, your HSA is not a use it or lose it account. Contributions to the HSA account accumulate will roll over year to year. Any HSA money that you don t spend stays in your account and can earn interest. If you are enrolled in either the Enhanced or Standard plan, First Data also makes a contribution to most employees HSAs in 2016 as follows (prorated per paycheck): Annual Salary Enhanced Plan Standard Plan Individual Family Individual Family <$40,001 $500 $1,000 $500 $1,000 $40,0001- $85,000 $300 $600 $300 $600 $85,001 - $125,000 $150 $300 $150 $300 $125,001 - $200,000 $150 $300 $150 $300 $200,001 + None None None None In addition, when you are enrolled in the Enhanced or Standard medical plan with an HSA, any applicable HealthyFirst wellness incentives will be deposited as a lump sum to the HSA in January The HealthyFirst incentives are as follows (2016 new-hires will be prorated quarterly and deposited shortly after enrollment) $150 Health Screening Incentive $400 Wellness Results Incentive $350 Tobacco Free Incentive Employees are encouraged to consider making pre-tax contributions to the HSA as well to help fund their out-of-pocket healthcare expenses until the deductible is satisfied. For questions about your health savings account, please contact your HSA administrator, PayFlex, at

3 Deductible A deductible is the amount you must pay before the Plan begins paying for a portion of your medical and prescription costs. See the design summary above for each medical plan s annual deductibles Eligible medical and prescription drug expenses are applied to the medical plan deductible Out-of-network coverage/deductible does not apply to the prescription drug benefit The annual deductible starts over every January 01 (no deductible carryover). When enrolled in Individual coverage (covering self-only), you must satisfy the Individual deductible before copayments or coinsurance applies to your prescription drug coverage. When enrolled in Family coverage (covering self and one or more family members), the Family deductible must be met before any family member receives cost-share from the Plan. The Family deductible can be met in one of two ways: One family member has high healthcare expenses, so he/she reaches the family deductible for all family members. Several different family members have smaller expenses and the family deductible is met when these smaller expenses added together reach the family deductible. Coinsurance Coinsurance is the percentage of eligible medical and pharmacy claims you pay after the deductible has been fulfilled. See the design summary above for your brand-name drug coinsurance coverage amount. Copayment (Copay) Copays are a flat dollar amount you pay for generic prescriptions after the deductible has been fulfilled. See the design summary above for your generic drug copayment coverage amounts. Out-Of-Pocket Maximum Your share of out-of-pocket expense (i.e., deductible, coinsurance, and copayments for medical and prescription drugs) each year is limited by an out-of-pocket maximum. Once you meet the out-of-pocket maximum, the Plan pays 100% of covered medical and prescription drug expenses for the rest of the Plan year. See the design summary above for the medical plan s out-of-pocket maximum limit Out-of-Pocket maximums vary by annual benefits salary Eligible medical and prescription drug expenses apply to the medical out-of-pocket maximum Your out-of-pocket maximum limit starts over on January 01 (no carryover). When enrolled in Individual coverage (covering self-only), you must satisfy the Individual out-of-pocket maximum limit before the Plan begins to cover your expenses at 100%. When enrolled in Family coverage (covering self and one or more family member), the Family out-of-pocket maximum must be met before any family member receives 100% coverage from the Plan. However, the OOP maximum will be no greater than $6,850 for any individual family member (the overall family maximum continues to apply; does not apply to salary band level 1).

4 Mandatory Generics If you opt to take a brand-name prescription when a generic equivalent is available, you will pay more. Only the amount you would have paid for the generic prescription will apply to your annual deductible and out-of-pocket maximum. Many brand-name drugs have generic equivalents. Generic drugs are required by the Food and Drug Administration (FDA) to have the exact same active ingredients and meet the same quality standards as the brand drug. In addition, generics cost on average six times less than brand, yet are just as safe and effective. If you have a reason for not using the generic equivalent, such as an allergy to an ingredient, you may submit an appeal to Express Scripts. Mail Order Incentive Program This program encourages employees to obtain long-term medications (taken for 3 months or more) through the Express Scripts by Mail Pharmacy service. Long-term medications include, but aren't limited to, drugs such as those used to treat high blood pressure, high cholesterol, or allergies. You will pay your mail order copayment or coinsurance when you use the mail service for your long-term drugs. When you receive a prescription for medication that will be taken on a long-term basis, you will be encouraged to obtain these prescriptions through mail order to avoid paying more at retail. If you decide to purchase your long-term drugs at a participating retail pharmacy, you will pay more. Once you satisfy your in-network deductible, you may purchase a long-term medication at a participating retail pharmacy 3 times at your regular 30-day supply copayment or coinsurance. Beginning with the 4th time you fill that long-term medication at retail, you will pay a higher amount for a 30 day supply: $16 for generics, 50% for brand-name formulary (up to $250 maximum per prescription) or 100% for brand-name non-formulary (up to $300 maximum per prescription). Once you satisfy l your in-network deductible, and after your 2 nd fill of a long-term medication at a retail pharmacy, you will receive a reminder letter from Express Scripts about the mail-order incentive program and at periodic times thereafter if you continue to fill long-term medications at retail pharmacies. 90 Day Supply Through the Mail Order Service, you can purchase up to a 90-day supply of most prescription medications. There may be limitations on some prescriptions, such as controlled medications, subject to state and federal dispensing limitations. Preventive Drugs The annual deductible is waived for certain specified preventive medications (as defined by Express Scripts Standard Plus list) when purchased through mail order under the Enhanced, Standard, and Outof-Area plans. For specific questions on coverage, please call the phone number on your Express Scripts ID card or visit and use the Price a Drug tools. All medications will require a prescription. Member cost share for eligible preventive medications (with a waived deductible) purchased through mail order will be determined by the plan s drug coverage and formulary:

5 Generic: $16 copay Brand Formulary: 30% ($250 maximum per prescription) Brand Non-Formulary: 45% ($300 maximum per prescription) The same preventive medications purchased through a retail pharmacy will be subject to the plan s deductible and typical cost share outlined in above. The plan will provide certain preventive medications as designated by the Affordable Care Act (ACA) in the drug categories below at no member cost share (i.e., 100% coverage from the Plan) specific to age and gender requirements. All medications will require a prescription. Drug or Drug Category Aspirin (to prevent cardiovascular events) Generic Over The Counter (OTC) 81 mg and 325 mg Aspirin for Preeclampsia generics OTC 81 mg Fluoride Generic OTC and prescription products Folic Acid Generic OTC and prescription products mg Iron Supplements - Generic Rx and Generic OTC Smoking Cessation - Generic Rx and Generic OTC, plus brand Chantix Women s Contraceptives Barrier contraceptive methods (i.e. diaphragms / cervical cap) Hormonal contraceptive methods (i.e. oral, transdermal, injectable) Emergency contraceptive methods (i.e. Ella and Plan B) Implantable medications Intrauterine contraceptives OTC contraceptives with prescriptions (except male condoms) Vaccines Vitamin D and some Vitamin D combinations Generic OTC and Generic Rx Bowel preparation for colonoscopy screening Generic OTC and Generic Rx Criteria Men ages 45 to 79 years and women ages 55 to 79 years Women through 55 years Children 6 months through 5 years old Women through age 50 years Children 6 months through 12 months Patients 18 years or older Women through age 50 Various childhood and adult vaccines are covered under the Plan, in accordance with age restrictions based on vaccine Patients 65 years or older Women and men, age 50 through 75 years. Limited to 2 prescriptions in 365 days.