1 Prescription Drug Summary Plan Description About This Summary Plan Description (SPD) The Prescription Drug Program is a component program in the Tenet Employee Benefit Plan (TEBP). The TEBP is a comprehensive welfare benefits program intended to qualify as a cafeteria plan within the meaning of Internal Revenue Code (IRC) section 125. This information summarizes key provisions of the Prescription Drug Program and serves as part of the summary plan description (SPD) for the TEBP. You can obtain more information about the Prescription Drug Program, the TEBP and the other component programs offered under the TEBP by reviewing the complete SPD for the TEBP. If there is any discrepancy between this online SPD and the official plan documents for the TEBP, the official plan documents will control. For more information on obtaining the official plan documents, see the Other Information section of the TEBP SPD. Plan Highlights You must be enrolled in a medical coverage option under the Tenet Medical Benefit Program to receive prescription drug coverage. Your medical plan option, and whether or not you are covered under a collective bargaining agreement, determines your Prescription Drug Program. Health & Saving Plan enrollees are automatically enrolled in the Rx IV program. Health & Reimbursement Plan, PPO or EPO enrollees, not covered by a collective bargaining agreement, are automatically enrolled in the Rx I program. PPO or EPO enrollees, covered by a collective bargaining agreement, will be enrolled in either the Rx VII or Rx VIII programs, depending on their specific collective bargaining agreement. Contact your local HR representative for more information. The Prescription Drug Program offers an easy and convenient way to save on short- and long-term medication. The program includes a formulary feature that can help you manage your prescription drug expenses. A formulary is a list of commonly prescribed medications both generic and brand name that have been found to be clinically effective, as well as cost effective. By asking your doctor to prescribe formulary medications when appropriate and discussing with your doctor the use of a generic medication, you can help keep your out-of-pocket costs lower while maintaining high quality care. The list of formulary drugs can be accessed by clicking the Prescription Drugs link from the My Benefit Links box. There are two components to the Prescription Drug Program: Retail Prescription Drug Program Mail-Order Program Allows you to purchase up to a 30-day supply of medication at participating retail pharmacies A more cost-effective way for you to purchase up to a 90-day supply of maintenance medication by having your prescription drugs sent to you in the mail
2 Introduction to the Prescription Drug Program This section of the SPD includes: Quick Facts: Who You Can Cover, Cost of Coverage, When Coverage Begins, and When Coverage Ends The factors that impact your cost of coverage Instructions and timeframes for enrolling yourself and your eligible dependents in the Medical and Prescription Drug Benefit Programs When you can make coverage changes under the Medical Benefit Program Quick Facts Who You Can Cover Cost of Coverage When Coverage Begins When Coverage Ends You (and your family members) must be enrolled under the Tenet Health & Savings Plan, Health & Reimbursement Plan, PPO or EPO medical plan options to be covered under the Prescription Drug Program. Your coverage category for prescription drugs is determined by your coverage category for your medical plan, and whether or not you are covered by a collective bargaining agreement. Your contribution to the cost of your prescription drug coverage is included in the premium you pay for medical coverage. Your (or your dependent s) coverage under the Prescription Drug Program begins on the day your (or your dependent s) coverage under the Tenet Medical Benefit Program begins. If you (or your dependents) are not enrolled in the Tenet Medical Benefit Program, then you (or your dependents) will not be covered under the Prescription Drug Program. Coverage for newly eligible dependents begins on the date they become eligible under the Tenet Medical Benefit Program and dependent documentation has been received and verified (through birth, adoption, etc.), provided you enroll them within 31 days (as applicable, see the Life Events section of the TEBP SPD for more information) of the date they become eligible. When coverage ends is dependent on various factors. Please refer to When Coverage Ends in the Eligibility and Enrollment section of the TEBP SPD, for detailed information on when coverage for you and your dependents ends. In some circumstances, you or your dependents may be eligible to continue medical coverage (and the corresponding prescription drug coverage) under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended. For more information on COBRA coverage, please see the Other Information section of this TEBP SPD.
3 Cost of Coverage Your contribution to the cost of your prescription drug coverage is included in the premium you pay for medical coverage, and depends on the medical care option you select and the family members you choose to enroll. You and Tenet share in the cost of the Medical Benefit Program. Your contributions are typically deducted from your paychecks on a before-tax basis. Before-tax dollars come out of your pay before federal income and Social Security taxes are withheld - and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you. Your contributions for Domestic Partner coverage will be deducted from your paychecks on an after-tax basis unless your Domestic Partner qualifies as your federal tax dependent within the meaning of IRC section 152 (determined without regard to IRC sections 152(b)(1), (b)(2), and (d)(1)(b)). For more information in determining whether your Domestic Partner qualifies as your federal tax dependent, contact your tax advisor. Your contributions are subject to review and Tenet reserves the right to change your contribution amount from time to time. You can obtain current contribution rates by calling the MyBenefits Customer Support Center at or accessing your personal enrollment information from HealthyatTenet.com. How to Enroll 1. Enroll online at HealthyatTenet.com or call the MyBenefits Customer Support Center at Complete an enrollment transaction within 31 days of the date you first become eligible for coverage under the Tenet Medical Benefit Program. If you do not enroll within 31 days, you will need to wait to make your benefit elections until the next Annual Enrollment period or the date you incur a change of family status or HIPAA special enrollment event entitling you to a mid-year enrollment. For more information on change of family status and HIPAA special enrollment events, see the Life Events section of the TEBP SPD. Each year during Annual Enrollment, you have the opportunity to review, change, or cancel your healthcare coverage. All changes made during the Annual Enrollment period will take effect on January 1 of the following calendar year. Important If you wish to change your benefit elections following your marriage, birth or adoption of a child, or other family status change or HIPAA special enrollment event, you must complete your enrollment transaction online at HealthyatTenet.com or call the MyBenefits Customer Support Center at within 31 days of the event and request your change. Otherwise, you will need to wait until the next Annual Enrollment period to change your elections. Changing Your Coverage Please refer to the Life Events section of the TEBP SPD for more information on making coverage changes outside of an Annual Enrollment period. PROFILE: Tony and Sara Tony and Sara are a young couple who have just started a family with the arrival of their son, Ryan. Tony works for Tenet, while Sara has a part-time job at a daycare facility. Sara s employer doesn t offer medical or prescription drug benefits to part-time employees, so Tony has elected family coverage in the PPO. Because he knows they ll be using brand-name prescriptions on a regular basis for his medical condition, Tony goes online to model his prescription drug coverage and determines that Rx I is the best plan for his family.
4 How the Retail Program Works A Look at the Basics The Retail Prescription Drug Program allows you to purchase up to a 30-day supply of medication. You simply present your prescription identification (ID) card a participating pharmacy when you have your prescription filled. Annual Deductible In certain cases you must meet a deductible before the plan begins paying benefits. With the Health & Savings Plan, your preventive prescription drugs are covered without a deductible. However, you must meet your medical plan deductible for any non-preventive prescription drugs. With a Health & Reimbursement Plan, PPO or EPO (except for individuals under the Rx VIII program) your preventive and non-preventive prescription drugs are covered without a deductible. For Rx VIII program enrollees, the deductible is $25 per covered individual. This deductible is separate from any annual deductible you re required to satisfy under your medical program option. It also applies to EACH covered family member. Retail Deductible Annual Deductible Health & Savings Plan Health & Reimbursement Plan, PPO or EPO PPO or EPO Cypress Fairbanks Nurses Only Rx IV Rx I Rx VII Rx VIII Applies with medical $0 $0 $25 per covered individual Co-pays and Co-insurance Once the applicable deductible is satisfied, the co-pay or co-insurance for each prescription filled follows: Retail Deductible Generic Drugs Health & Savings Plan* Health & Reimbursement Plan, PPO or EPO PPO or EPO Cypress Fairbanks Nurses Only Rx IV Rx I Rx VII Rx VIII $5 co-pay after deductible $5 co-pay $5 co-pay $10 co-pay after deductible Benefit-Based** Brand-Name Drugs Included on the Formulary List Not covered Not covered 20% up to a maximum co-pay of $75 Not covered Brand-Name Drugs Included on the Formulary List 35% after deductible with $30 minimum / $100 maximum 35% with $30 minimum / $100 maximum 35% up to a maximum co-pay of $75 $30 co-pay after deductible Brand Name Drugs Not Included on the Formulary List 50% after deductible with $40 minimum / $150 maximum 50% with $40 minimum / $150 maximum 50% up to a maximum co-pay of $125 $45 co-pay after deductible * Under the Health & Savings Plan certain preventive medications will be paid at the co-pay/ co-insurance levels prior to the satisfaction of the deductible. Access HealthyatTenet.com and follow the Medical and Prescription Drug link for more information.
5 ** If you have an ongoing condition for which you take medication asthma, diabetes, coronary artery disease (CAD) or congestive heart failure (CHF) benefit-based drugs offer lower co-insurance for certain maintenance medications. If you request a brand-name drug when a generic is available, you ll pay the generic co-pay or coinsurance, plus the cost difference between the brand-name and generic drug. This will occur even if your doctor adds a Dispense As Written note on the prescription. You ll pay any deductible amount, co-pay or co-insurance at the participating pharmacy. As prescriptions for each family member are filled, the participating pharmacy will track on the pharmaceutical carrier s system when covered family members meet their prescription deductible. Most chain drugstores are participating pharmacies. For assistance in locating a participating pharmacy near you, click on the Prescription Drugs link in the My Benefit Links box or call the pharmaceutical carrier directly. You ll need your member number (included on your medical ID card or prescription drug card) and ZIP code. FORMULARY DRUGS CAN SAVE YOU MONEY This cost-saving feature allows your doctor to prescribe appropriate commonly used brand-name medications, which are more cost effective than other brand-name medications that treat the same condition. For a list of the brand-name drugs included on the formulary list, click on the Prescription Drugs link in the My Benefit Links box or call the pharmaceutical carrier directly. SAVE MONEY BY REQUESTING GENERIC DRUGS Brand-name drugs often have generic counterparts. Generic drugs have the same active ingredients as brand-name drugs and are subject to the same FDA standards for quality, strength and purity. Because generic drugs cost less to produce, it s more cost effective to use the generic form. The Prescription Drug Program pays higher benefits for generic drugs than for brand-name drugs. If you request a brand-name drug when a generic equivalent is available, you ll pay the generic co-pay or co-insurance, plus the price difference between the brand-name and generic drug. You should always discuss with your doctor or pharmacist whether a generic form of the prescribed drug exists and is appropriate for you. Unless your doctor has specifically indicated dispense as written, the pharmacist can make the generic substitution upon your request. You should consult with your doctor regarding the medical implications, if any, of using a generic medication. PROFILE: Tony and Sara When Ryan was six months old, he caught an infection from one of the other children in his daycare center. Sara received a prescription from his pediatrician and went to fill it at a participating pharmacy. She was told that the total cost for Ryan s medication was $70. After Sara showed her medical ID card to the pharmacist, her prescription benefits were verified on the computer. Then the pharmacist applied Sara s prescription benefit to the total cost (see example below).
6 Here s how the cost for Ryan s medication was determined: FOR RYAN S FIRST PRESCRIPTION... Generic prescription drug cost $70 THE COST FOR RYAN S FIRST PRESCRIPTION IS... Co-pay - $5 Under the Rx I option, the cost for generic drugs is a $5 co-pay. Sara pays this amount for Ryan s prescription Remaining cost = $65 The plan picks up this cost. After several months, Sara needs to fill another prescription for Ryan. Again, Sara shows her medical ID card at the participating pharmacy. This time, Ryan s doctor has prescribed a brand-name medication that doesn t have a generic equivalent but is included on the formulary list. The cost of the brand-name drug is $125. FOR RYAN S SECOND PRESCRIPTION... Brand-name prescription drug cost $125 THE COST FOR RYAN S SECOND PRESCRIPTION IS... Co-pay - $37.50 The co-pay for brand-name drugs on the formulary list is 35% with a $30 minimum and $100 maximum. The calculation is: $125 x.35 = $ Sara pays this amount for Ryan s prescription. Remaining cost = $87.50 The plan picks up this cost. It Pays to Use Participating Pharmacies When you use a participating pharmacy, you receive the highest level of benefits. You can also choose to have your prescriptions filled at non-participating pharmacies; however, non-participating pharmacies usually charge more than the contracted network rates for prescription drugs charged by participating pharmacies. These contracted network rates also apply to Health & Savings Plan participants who use participating pharmacies though you pay the full contracted price for the prescription until you meet your medical deductible, you still are taking advantage of participating pharmacy discounts. Using Non-Participating Pharmacies With non-participating pharmacies, you pay the full cost of the prescription at the time of purchase. For reimbursement, you ll receive the contracted network cost for a 30-day supply, minus the appropriate co-pay or co-insurance. You must complete a claim form to receive reimbursement from the pharmaceutical carrier. Be sure to follow all directions on the claim form and attach original receipts. You can get claim forms by clicking on the Prescription Drugs link in the My Benefit Links box.
7 How the Mail-Order Program Works To save even more money, you can use the Mail-Order Program for long-term and maintenance prescription drugs. It allows you to purchase up to a 90-day supply of generic or brand-name medications, which are mailed directly to your home. You ll get a larger supply of medications for less money than using the Retail Prescription Drug Program. Mail-Order Coverage Health & Savings Plan* Health & Reimbursement Plan, PPO or EPO PPO or EPO Cypress Fairbanks Nurses Only Rx IV Rx I Rx VII Rx VIII Annual Deductible Applies with medical $0 $0 $25 co-pay Generic Drugs $10 co-pay after deductible $10 co-pay Free $25 co-pay Benefit-Based** Brand-Name Drugs Included on the Formulary List Not covered Not covered 20% with a maximum co-pay of $150 Not covered Brand-Name Drugs Included on the Formulary List 35% after deductible with $75 minimum / $200 maximum 35% with $75 minimum / $200 maximum 35% with a maximum co-pay of $150 $63 co-pay Brand-Name Drugs Not Included on the Formulary List 50% after deductible with $100 minimum / $300 maximum 50% with $100 minimum / $300 maximum 50% with a maximum co-pay of $250 $100 co-pay * Under the Health & Savings Plan certain preventive medications will be paid at the co-pay/ co-insurance levels prior to the satisfaction of the deductible. Access HealthyatTenet.com and follow the Medical and Prescription Drug link for more information. ** If you have an ongoing condition for which you take medication asthma, diabetes, coronary artery disease (CAD) or congestive heart failure (CHF) benefit-based drugs offer lower co-insurance for certain maintenance medications.
8 PROFILE: Tony and Sara Tony has been diagnosed with high cholesterol. In addition to eating right and exercise, Tony s doctor has told him that he will need medication over the long term to control his cholesterol level and has prescribed a brand-name drug that is on the formulary list. FOR TONY S PRESCRIPTION... Brand-Name prescription drug $ The retail price for Tony s prescription is $175 for a 30-day supply, compared to the Mail Order price of $ A 90 day Mail Order supply, before insurance applies, costs $ THE COST FOR TONY S PRESCRIPTION IS... Tony s cost -$ Mail Order Calculation: The co-pay for brand-name drugs on the formulary list is 35% with a $75 minimum and $200 maximum. The calculation is: $ x.35 = $ Retail Calculation: Had Tony chosen to fill the prescription at retail each month the co-pay would have been 35% with $30 minimum / $100 maximum. The calculation is: $175 x.35 = $61.25 x 3 months = $ My using the mail order service Tony saves $18.37 over the course of 3 months / $73.48 over 12 months. Remaining cost =$ The plan picks up this cost. Please Be Aware... The pharmaceutical carrier may require that some medications be dispensed through the Mail-Order Program. If your medication falls into that category, the pharmaceutical carrier will contact you. It takes approximately two to three weeks from the time you send in your order form to receive your prescription drugs in the mail. Order forms for the Mail-Order Program can be obtained by contacting the pharmaceutical carrier. Additional forms can be obtained by clicking on the Prescription Drugs link in the My Benefit Links box. If your prescription indicates refills, the mail-order pharmacy will send you a reorder form with your initial prescription and each subsequent refill. You can then order your refill by mail or you can call the pharmaceutical carrier. You can also process your refill by clicking on the Prescription Drugs link in the My Benefit Links box to access the pharmaceutical carrier s website. Online orders are usually processed within 7 10 days.
9 Purchasing Diabetic Supplies Through the Mail-Order Program If you or a covered family member is diabetic, you can purchase over-the-counter diabetic supplies,*including lancets and test strips, through the Mail-Order Program. Keep the following in mind when purchasing these supplies: Prescriptions Are Required Prescriptions Need to State the Quantity and the Number of Refills A Co-pay or Coinsurance Is Required for Each Order It Takes Approximately 2-3 Weeks to Fill Mail-Order Prescriptions Refills Are Easy Your physician needs to write a prescription for over-the-counter diabetic supplies. (Please note that the pharmaceutical carrier always requires a prescription, even if you live in a state where prescriptions aren t required for over-the-counter diabetic supplies.) Your doctor needs to indicate the quantity (90-day maximum) and the number of refills allowed (if any) on your prescription. If your doctor doesn t state the quantity, the pharmacy will send the minimum order, which is one box. Please note that the manufacturers don t package lancets and test strips in equal numbers. Co-pays or co-insurance for over-the-counter diabetic supplies are at the brandname formulary and non-formulary level. For example, with the Rx VIII option, you will pay $63 per order for formulary or $100 per order for non-formulary (either new prescriptions or refill). Lancets and test strips are considered separate orders; therefore, when ordering both, your total payment with the Rx VIII option will be $126 for formulary and $200 for non-formulary (two times the formulary or non-formulary cost for each). Therefore, be sure you take this timing into consideration when mailing in your order. If you need an immediate supply, you can purchase a 30-day supply through the Retail Prescription Drug Program at any participating pharmacy. Please note that the Retail Prescription Drug Program also requires a prescription from your doctor, and you ll be required to satisfy applicable deductibles if you haven t already. So be sure to get two prescriptions from your doctor. If your prescription includes refills, you ll receive a refill order slip with your initial order, and with each subsequent order, until all refills have been sent then you can expect to receive a renewal reminder once a new prescription is needed. Refills can be ordered over the telephone, by mailing in your refill order slip or online by clicking on the Prescription Drugs link in the My Benefit Links box to access the pharmaceutical carrier s website. Please note: To cut down on paperwork, members with open home delivery refills and a history of requesting refills online or by phone will not receive order forms, business and customer reply envelopes or refill slips in their home delivery packages. However, they will continue to receive renewal reminders. * Subject to formulary guidelines. Please contact the pharmaceutical carrier to see if your supplies are part of the formulary. If they aren t, have your physician contact the pharmaceutical carrier to see if one of the formulary supply options will work for you.
10 PROFILE: Randall Randall has diabetes and manages his costs carefully. He takes advantage of ordering over-thecounter diabetic supplies through the Mail-Order Program. He knows he needs separate prescriptions for his lancets and test strips and that each of those orders requires separate co-pay. That s why he makes sure his doctor writes prescriptions for formulary supplies. Under Rx VIII, Randall pays a total of $126 for formulary lancets and test strips ($63 per order) instead of $200 for non-formulary supplies. Pre-Packaged Prescription Drugs Certain prescription drugs are pre-packaged in supplies greater than the 30-day benefit normally filled at retail pharmacies. Some drugs are pre-packaged in two-, three-, four- and six-month supplies and the quantities cannot be cut back. For pre-packaged drugs filled at retail pharmacies: 1- to 30-day supplies will be one co-pay (or appropriate percentage of the total package), 31- to 60-day supplies will be two co-pays (or appropriate percentage of the total package), 61- to 90-day supplies will be three co-pays (or appropriate percentage of the total package), 91- to 120-day supplies will be four co-pays (or appropriate percentage of the total package) and so on. For pre-packaged drugs filled through mail-order: 91-day or greater supplies will never be charged more than the 90-day co-pay. Specialty Pharmacy The specialty pharmacy is designed to help you meet the particular needs and challenges of using certain medications, many of which require injection or special handling. If you are using a specialty pharmacy medication, you will be eligible to receive additional services when you fill your specialty prescriptions with the specialty pharmacy. These additional services include: Support and guidance from nurses and pharmacists who are trained in these medications, their side effects and the conditions they treat Expedited delivery of all your specialty prescription medications Supplemental supplies, such as needles and syringes that are required to administer the medication, at no additional charge Scheduling of refills and coordination of services with home care providers, case managers and doctors or other health care professionals
11 Days of Therapy Through the Specialty Pharmacy Medications will be dispensed for up to a 90-day supply when appropriate. Certain medications dispensed through the specialty pharmacy may only be available for up to a 30-day supply based on dosing, safety, frequent change in therapy, or need to minimize waste for that particular drug. There are other classes of medications that may be limited to a smaller quantity (up to a 30-day supply) early in your treatment to allow for potential changes in dose. Once therapy has been stabilized, you will be offered up to a 90-day supply. For example: Hemophilia drugs will always be limited to a maximum of a 30-day supply. Erythroid stimulants (Epogen, Aranesp ) and agents for rheumatoid arthritis (Enbrel, Humira ) will be limited to a maximum of a 30-day supply early in treatment. For those medications that are only limited early in therapy, a pharmacist will contact you regarding your past history with the medication to determine whether a larger supply is appropriate for you. Your co-pay will also be automatically adjusted for any medication that has a limited-day supply and you will not be responsible for a full 90-day co-pay. If you have any questions regarding specialty pharmacy medications, please call the specialty pharmacy directly. Some Medications Require Authorization or Review The pharmaceutical carrier requires a prior authorization or coverage review for certain medications. This applies both to new prescriptions and to continue coverage on certain medications. Traditional Prior Authorization (TPA) The following medications require prior authorization to ensure appropriate coverage decisions (e.g., patient diagnosis, what the prescribed drug is being used for, recommended dosage, how long the medication is to be used, possible drug interactions and other safety concerns): Alzheimer s Therapy Androgens & Anabolic Steroids Anti-Narcoleptic Agents (Nuvigil, Provigil) Antiviral Agents - Incivek, Victrelis, Ribavirin Cancer Therapy Oncology agents Dermatologicals (Isotretinoin) Dermatologicals (Retin A/Tazorac) Dermatologicals / Misc. (Regranex gel) Dermatologicals / Misc. (Solodyn) Erythroid Stimulants Growth Hormones Immune Globulins (IVIG) Interferons Miscellaneous Specialty Hormones: (Interleukins / Misc. (Arcalyst/Ilaris); Acthar Gel, Kuvan, Sensipar, Somavert, Zavesca, Cerezyme, Vpriv) Multiple Sclerosis Therapy Myeloid Stimulants and Hemostatics Neurological Agents/Misc. (Xenazine)
12 Ophthalmic Agents - Retisert Parkinson's Therapy (Apokyn) PNH Agents (Soliris) Psoriasis Therapy (Stelara, Amevive) Pulmonary Agents Berinert/Cinryze/Kalbitor Pulmonary Agents/Misc. (Pulmozyme) Pulmonary Agents/Misc. (Xolair) Pulmonary Arterial Hypertension (All Agents) Rheumatological Agents (such as Enbrel, Humira, Simponi, Cimzia, etc.) RSV Agents Synagis/Respigam The list of medications requiring prior authorization is subject to change. Your doctor should contact the pharmaceutical carrier before issuing a prescription to you. A Managed Prior Authorization pharmacist will discuss the necessary drug criteria with your doctor before issuing the authorization. If you don t receive authorization before picking up your prescription at the pharmacy, your pharmacist will receive a message from the pharmaceutical carrier indicating that prior authorization is necessary and instruct him or her to contact the pharmaceutical carrier s managed prior authorization service. This could result in a delay in receiving your medication. Smart Prior Authorization (SPA) Step Therapy Protocol The pharmaceutical carrier automatically tracks each prescription and monitors the standard maximum dosage and quantities for certain types of drugs. They also review other medications you have taken in the past, your age and other patient factors. If your doctor has prescribed a medication in excess of the quantity usually allowed or the usual dose of medication over time, or in cases when evidence of prior therapy in a step approach is not found, your doctor will need to obtain authorization from the pharmaceutical carrier. Examples of medications that require authorization and/or quantity limits: Anti-Convulsant Agents (Topamax and Zonegran) Atypical Antipsychotics (Abilify) CNS Stimulants (such as Ritalin, Metadate, Adderall) Gout Therapy (example, Uloric) Antiinfluenza Agents Osteoporosis Therapy (Forteo) Anti-Emetics Anti-Fungal Agents Hypnotic/ Sleep agents (such as Zolpidem) Migraine Therapy (such as Imitrex, Maxalt, Relpax) Ophthalmic Agents - Retisert Pain Management (Celebrex, Stadol, Toradol) Proton Pump Inhibitors (such as Omeprazole, Nexium, lansoprazole)
13 Preferred Drug Step Therapy In some cases you must first try a less expensive drug before a more expensive drug will be covered. The following categories of medications/conditions require Step Therapy: Angiotensin Receptor Blockers (ARBs) Depression Therapy (SSRI) Hypnotic Medications Intranasal Steroids Migraine (Triptan) Osteoporosis - Bisphosphonates Proton Pump Inhibitor Retrospective Drug Utilization Review The pharmaceutical carrier conducts a Retrospective Drug Utilization Review to identify prescribing, dispensing and consumption patterns that do not meet the established clinical practice guidelines. Physicians may be notified about clinical considerations to safeguard patients and manage plan expenses. In some cases, physicians may initiate changes in therapy. What s Not Covered by the Prescription Drug Program? Ineligible Expenses from A to Z Some prescription drugs and services aren t available through the Prescription Drug Program. Ineligible expenses include, but aren t limited to: ADMINISTERING DRUGS: Charges for the administration or injection of any drug BIRTH CONTROL DEVICES: Contraceptive devices, jellies, creams, foams, injections and implants BLOOD PRODUCTS: Immunization agents, biologicals, blood and blood plasma ERECTILE DYSFUNCTION DRUGS: Viagra, Cialis, Levitra, Caverject and Muse EXPERIMENTAL MEDICATIONS: Experimental or investigational drugs FERTILITY MEDICATIONS: Drugs used to treat infertility HAIR GROWTH MEDICATION: Drugs used to stimulate hair growth INPATIENT MEDICATIONS: Medication that is to be taken by or administered to you or a covered family member while a patient is in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home or similar institution that has the ability to dispense medications on its premises NON-SEDATING ANTIHISTAMINES OVER-THE-COUNTER DRUGS AND SUPPLIES: Any medication or supply that doesn t require a prescription, except over-the-counter diabetic supplies REFILLS: Refills that are dispensed more than one year from the date of the doctor s original order or that are in excess of the number of refills specified by the doctor SMOKING-CESSATION DRUGS: Over-the-counter smoking cessation medications Coverage provided if over 18 THERAPEUTIC DEVICES: Therapeutic devices or appliances, except blood testing machines VITAMINS: Over-the-counter vitamins, except prenatal vitamins
14 WEIGHT GAIN OR LOSS MEDICATIONS: Anorexients or obesity drugs WORK-RELATED INJURY MEDICATION: Medication for a work-related injury or illness that is covered under Workers Compensation, or for which no charge is made For information regarding eligible prescription drugs, please contact the pharmaceutical carrier. How to File a Claim Whether you need to file a claim depends on whether you go through the Retail Prescription Drug Program or the Mail-Order Program and whether you use a participating or non-participating pharmacy. In some situations, you may be required to file a claim. This section outlines the procedures for both programs. Retail Prescription Drug Program Claim forms aren t required when you use your medical ID card (or prescription drug card if a separate one is sent) to purchase prescription drugs at participating pharmacies. Simply show your ID card and pay the required deductible, co-pay or co-insurance at the time of purchase. Claim forms will be required, however, if you must purchase prescription drugs before you receive your prescription ID card or you fill a prescription at a non-participating pharmacy after you receive your prescription ID card. You can obtain claim forms by clicking on the Prescription Drugs link in the My Benefit Links box or by calling the pharmaceutical carrier. Send the completed claim form to: Claims must be filed within 12 months after you incur the expense. Mail-Order Program With this program, you need to use an order form supplied by the pharmaceutical carrier to buy prescription drugs through the mail. You can obtain claim forms by clicking on the Prescription Drugs link in the My Benefit Links box or by calling the pharmaceutical carrier. Send the completed order form to: Claims Review and Detailed Description of Claims Process If you disagree with the pharmaceutical carrier s decision regarding a claim, you can have your claim reviewed as described in the Other Information section of the TEBP SPD. The Other Information section also describes the claims appeal process in detail.
15 Helpful Information about the Tenet Prescription Drug Program You can learn additional information about the Prescription Drug Program offered under the TEBP by reviewing the other sections of this online SPD. THE COMPLETE SPD INCLUDES INFORMATION ON ELIGIBILITY AND ENROLLMENT, PROCEDURES FOR APPEALING CLAIM DENIALS, QUALIFIED MEDICAL CHILD SUPPORT ORDERS, AUTHORITY TO AMEND AND TERMINATE THE TEBP AND ALL OF THE BENEFIT PROGRAMS (INCLUDING THE PRESCRIPTION DRUG PROGRAM), COBRA CONTINUATION RIGHTS AND YOUR RIGHTS UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA). Here s a list of some quick facts about the Prescription Drug Program you may need to know: EMPLOYER AND PLAN SPONSOR PLAN ADMINISTRATOR CLAIMS ADMINISTRATOR Tenet Healthcare Corporation 1445 Ross Avenue, Suite 1400 Dallas, TX Tenet Benefits Administration Committee 1445 Ross Avenue, Suite 1400 Dallas, TX CVS Caremark P.O. Box 6590 Lee s Summit, MO AGENT FOR SERVICE OF LEGAL PROCESS PRESCRIPTION DRUG PROGRAM EFFECTIVE DATE EMPLOYER IDENTIFICATION NUMBER Tenet Healthcare Corporation 1445 Ross Avenue, Suite 1400 Dallas, TX Legal process may also be served on the Plan Administrator. The Prescription Drug Program is a component program in the TEBP, which was originally effective as of October 1, 1977 and was restated January 1, The Prescription Drug Program became a component program in the TEBP effective as of January 1, PLAN NUMBER 515 PLAN YEAR January 1 through December 31 TYPE OF PLAN Welfare benefit plan offering prescription drug benefits. See the Other Information section of the TEBP SPD for more information.
16 Funding of Benefits Your benefits under the Prescription Drug Program are funded by your co-pay and co-insurance amounts and by premiums paid by you and by Tenet. Tax Consequences of Participation in the Prescription Drug Program In general, you may pay for your premiums in the Prescription Drug Program on a pre-tax basis by reducing your salary. However, premiums for coverage for a domestic partner will be paid on an aftertax basis, unless your domestic partner also qualifies as your federal tax dependent (determined without regard to IRC sections 152(b) (1), (b) (2), and (d) (1) (B), which contain certain exceptions to the definition of dependent and a gross income limitation). The test for determining whether your domestic partner qualifies as your federal tax dependent may be different than the test for determining dependent status under the plan. You should consult with your tax advisor to determine if your domestic partner qualifies as your federal tax dependent. In addition, if you are a highly compensated employee, there may be certain circumstances in which you are not eligible to exclude from gross income all or a portion of the premiums or benefits paid under the Prescription Drug Program. Neither the Plan Administrator nor your employer can guarantee that the benefits provided to you under the Prescription Drug Program will be excludable from your gross income for federal and state tax purposes. For more information on the tax consequences of participating in the Prescription Drug Program, please see your tax advisor. Your Rights Under ERISA and HIPAA For a statement explaining your rights under the Employee Retirement Income Security Act of 1974 (ERISA) and HIPAA, see the Other Information section of the TEBP SPD. Glossary Benefit Eligible Generally, you re eligible to participate in Tenet benefit plans if your facility has elected to participate and you are a full-time or part-time 1 employee. (Determination of full-time or part-time 1 status is based on scheduled hours and is not impacted by the fact that you may, on occasion, work more or less than your scheduled hours.) If you meet either of these requirements, you re considered benefit eligible. However, keep in mind that eligibility requirements may differ for each plan. Co-pay or Co-insurance This is the portion of the prescription costs you re responsible for paying under the Prescription Drug Program, a co-pay is a flat fee and co-insurance is a percentage of the cost of the drug. Deductible The deductible is the amount you need to pay each calendar year before the Prescription Drug Program begins to cover eligible retail prescription expenses. Formulary A key feature of the Prescription Drug Program, a formulary is a list of commonly prescribed medications both generic and brand name that have been found to be clinically effective, as well as cost effective. By asking your doctor to prescribe formulary medications when appropriate, you can help keep your out-of-pocket costs lower while maintaining high-quality care.
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