inVentiv Health, Inc. Prescription Benefit Plan for Participants in the Medical Choice Fund Open Access Plus HSA Plan
Your Summary Plan Description for the Prescription Benefit Plan
Effective January 1, 2016
inVentiv Health, Inc.
This booklet summarizes the main provisions of the Prescription Benefit Plan made available to participants in the inVentiv Health Medical Choice Fund Open Access Plus HSA Plan, effective January 1, 2016, and serves as the ERISA-required summary plan description (SPD) for the Prescription Benefit Plan. It describes the prescription benefits as they apply to eligible employees. A separate SPD describes the medical benefits available to you through the Medical Choice Fund Open Access Plus HSA Plan.
We encourage you to read this SPD carefully and share it with your family members. If you have any questions about your benefits, please contact the Benefits Group or Express Scripts, our prescription drug benefit administrator, directly.
This document is intended to serve as both the SPD and the legal plan document for the Prescription Benefit Plan. This plan does not have a separate formal plan document.
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Table of Contents
Page
ABOUT YOUR PARTICIPATION ...... 1 Who Is Eligible for Prescription Coverage ...... 1 Employee Eligibility...... 1 Dependent Eligibility ...... 1 About Domestic Partner Eligibility ...... 1 When Prescription Benefit Coverage Begins ...... 2 Coverage Levels ...... 2 Paying for Prescription Benefit Coverage ...... 3 Making Changes During the Year ...... 3 HIPAA Special Enrollment Rights ...... 7 Loss of Eligibility for Other Medical Coverage ...... 7 When Coverage Begins...... 8 Gaining a New Dependent ...... 8 When Coverage Begins...... 9 Loss or Gain of Eligibility for a State Children's Health Insurance Program (CHIP) or Medicaid ...... 9 When Coverage Begins...... 9
EMPLOYER CHILDREN’S HEALTH INSURANCE PLAN (CHIP) NOTICE ...... 10 Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP) ...... 10
WHEN PRESCRIPTION COVERAGE ENDS ...... 13 Other Events Ending Your Coverage...... 13 Coverage for a Disabled Child ...... 14 Continuing Coverage When It Might Otherwise End ...... 14
TERMS YOU SHOULD KNOW...... 15
EXPRESS SCRIPTS PRESCRIPTION DRUG BENEFITS...... 16 How the Prescription Benefit Plan Works ...... 16 More About Your Deductible ...... 17 Prescription Drug Copayments...... 17 Your ID Card...... 19 When You Need to Fill a Prescription...... 19 Express Scripts Annual Out-of-Pocket Maximum...... 19 Using Your HSA for Prescription Drug Costs ...... 20 Retail Pharmacies ...... 20 Express Scripts Pharmacy for Mail Order ...... 20 Using the Express Scripts Pharmacy Program for the First Time ...... 20 Covered Medications ...... 21 Preventive Drugs Covered at 100% ...... 22 Preventive and Other Drugs Covered Under HDHP and HSA Rules ...... 23 Express Scripts Compound Management Program ...... 30
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Express Scripts Specialty Pharmacy Services ...... 31 When You Need to File a Claim Form ...... 31 Limitations ...... 31 Supply Limits ...... 31 Quantity Management ...... 33 Prior Authorization ...... 33 Step Therapy Requirements...... 34 Drugs That Are Not Covered ...... 35 Drug Coverage Provided by your inVentiv Health Medical Plan ...... 35
ADDITIONAL RULES THAT APPLY TO THIS PRESCRIPTION BENEFIT PLAN ...... 36 Breast Reconstruction Benefits...... 36 Maternity Admissions ...... 36 Qualified Medical Child Support Order (QMCSO) ...... 37 Subrogation and Right of Reimbursement ...... 37 Coordination of Benefits If You Are Covered by More Than One Medical Plan ...... 37 Circumstances That May Result in Denial, Loss, Forfeiture or Rescission of Benefit ...... 37
HOW TO REACH YOUR PROVIDER ...... 38
CONTINUATION OF YOUR MEDICAL COVERAGE...... 39 Continuation Coverage Rights Under COBRA ...... 39 Introduction ...... 39 What Is COBRA Continuation Coverage ...... 39 COBRA Qualifying Events ...... 40 Giving Notice that a COBRA Qualifying Event (or Second Qualifying Event) Has Occurred ...... 40 How Is COBRA Continuation Coverage Provided ...... 41 Duration of COBRA Continuation Coverage ...... 41 Electing COBRA Continuation Coverage ...... 43 Paying for COBRA Continuation Coverage ...... 44 Trade Act of 2002 ...... 44 When COBRA Continuation Coverage Ends ...... 45 If You Have Questions...... 46 Keep Your Plan Informed of Address Changes...... 46 Plan Contact Information ...... 46 Continuation of Coverage for Employees in the Uniformed Services (USERRA)...... 46 Continuation of Coverage While on a Family and Medical Leave (FMLA) ...... 47 HIPAA Certificate of Creditable Coverage ...... 48
CLAIMS PROCEDURES ...... 49 Non-Urgent Claims ...... 49 Urgent Claims (Expedited Reviews) ...... 49 Non-Urgent Appeal ...... 50 Urgent Appeal (Expedited Review) ...... 52 External Review Procedures...... 53 Non-Urgent External Review ...... 54 Urgent External Review ...... 54
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YOUR RIGHTS UNDER ERISA ...... 55 Receive Information About Your Plan and Benefits ...... 55 Continue Group Health Plan Coverage ...... 55 Prudent Actions by Plan Fiduciaries ...... 56 Enforce Your Rights ...... 56 Assistance With Your Questions ...... 56
PLAN ADMINISTRATION...... 57 Plan Administrator’s Discretionary Authority to Interpret the Plan ...... 58 The Company’s Right to Amend or Terminate the Plan ...... 58 Limitation on Assignment ...... 58
YOUR EMPLOYMENT ...... 59
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About Your Participation
This section includes important information about your participation in the Prescription Benefit Plan (the “plan”), including eligibility information, when to enroll, when you can make election changes, paying for coverage and when coverage ends.
Who Is Eligible for Prescription Coverage
Employee Eligibility You are eligible to participate in the Prescription Benefit Plan if you are covered under the inVentiv Health Medical Choice Fund Open Access Plus HSA Plan and you are a full-time, hourly or salaried employee who is regularly scheduled to work at least 30 hours per week. If you are regularly scheduled to work less than 30 hours a week, you are considered a part-time employee and are not eligible for the benefits described in this SPD.
Dependent Eligibility Your eligible dependents can also participate in the Prescription Benefit Plan if you elect medical coverage for them. Eligible dependents include:
l Your spouse to whom you are legally married or your domestic partner
l Your or your domestic partner’s dependent child(ren) who is under age 26 including a natural child, a stepchild, a legally adopted child, a child placed for adoption or a child for whom you or your spouse or domestic partner are the legal guardian, regardless of whether the child resides with you, is dependent upon you for support, is a student or is married. Note that you may enroll a child(ren) as an eligible dependent under this plan, even if you cannot claim the child(ren) as a tax dependent for tax filing purposes.
l Your or your domestic partner’s unmarried dependent child(ren), regardless of age, who is mentally or physically disabled and incapable of earning his or her own living.
To be eligible for coverage under the plan, a dependent must reside within the United States.
About Domestic Partner Eligibility For this plan, your domestic partner is an individual of the same or opposite sex with whom you have established a domestic partnership as described below.
A domestic partnership is a relationship between you and one other person of the same or opposite sex. Both persons must:
l Not be so closely related that marriage would otherwise be prohibited
l Not be legally married to, or the domestic partner of, another person under either statutory or common law
l Be at least 18 years old
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l Live together and share the common necessities of life l Be mentally competent to enter into a contract, and l Be financially interdependent.
You and your domestic partner must jointly sign an affidavit of domestic partnership provided by the Benefits Group upon your request. Coverage for your domestic partner and children cannot begin until you return the affidavit.
Dependent children of your domestic partner are also eligible for medical coverage. You can elect coverage for children of your domestic partner even if you do not elect coverage for your domestic partner.
When Prescription Benefit Coverage Begins
Your coverage under the Prescription Benefit Plan begins when your inVentiv Health medical plan coverage begins.
If you are a new employee enrolling during the year, medical coverage for you and your eligible dependents will begin as of the first day of the month on or after your date of hire as long as you enroll with the Benefits Group within 31 days of when you first become eligible. Your initial election will run through December 31 of your first year in the plan. If you do not enroll in medical coverage within 31 days, you will need to wait until the next annual Open Enrollment to make your benefit elections.
If you enroll during the Open Enrollment period, coverage for you and your eligible dependents will begin on January 1 and remain in effect through December 31. According to IRS rules, you can change your election during the year only if you have a qualified change in status or if you experience a different event permitting a mid-year election change.
Coverage for your eligible dependents will start on the date your coverage begins, provided you have enrolled them in a timely manner.
Coverage for a spouse or dependent stepchild that you acquire through marriage becomes effective the first day of the month following the date the Benefits Group receives notice of your marriage, provided you notify the Benefits Group within 31 days of your marriage. Coverage for dependent children acquired through birth, adoption or placement for adoption is effective the date of the family status change, provided you notify the Benefits Group within 90 days of the birth, adoption or placement.
Coverage Levels
You may choose from four different coverage levels under your inVentiv Health medical plan: l You only l You and your legal spouse or domestic partner
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l You and your dependent child(ren) and/or your domestic partner’s dependent child(ren) l You and your legal spouse or domestic partner and your dependent child(ren) and/or your domestic partner’s dependent child(ren).
Whatever level of coverage you elect under your medical plan will apply to the Prescription Benefit Plan as well.
Paying for Prescription Benefit Coverage
The cost of the Prescription Benefit Plan is included in the cost of the inVentiv medical plan you choose. You and inVentiv Health share in the cost of your coverage. Your portion of the cost is generally deducted from your paycheck on a before-tax basis before federal — and, in most cases, state — income taxes and FICA taxes are withheld. Expected costs and contributions are group rates — that is, they are determined by the total cost of providing medical coverage to all plan participants.
The Internal Revenue Service generally does not consider domestic partners and their children eligible dependents. Therefore, the value of inVentiv Health’s cost to cover a domestic partner may be imputed to you as income. To reduce your imputed income, you may elect to pay your share of the cost of coverage for a domestic partner and his or her children through after-tax payroll deductions.
Making Changes During the Year
Because you pay for your medical and prescription drug coverage with before-tax dollars, you may make changes during the year only if you have a change in your family status (referred to as a “family status change”) or if you experience a different event permitting a mid-year election change. Examples of approved qualified family status changes under this plan may include: l Your marriage, divorce, legal separation or annulment l Registering a domestic partner l The birth, adoption, placement for adoption or legal guardianship of a child l A change in your spouse’s or domestic partner’s employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan l Loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis l The death of a dependent l Your dependent child no longer qualifying as an eligible dependent
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l A change in your or your spouse’s or domestic partner’s position or work schedule that impacts eligibility for health coverage l A significant change in the cost you pay for coverage. (This is true even if you or your eligible dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer.) l You and your eligible dependent who were enrolled in an HMO no longer live or work in that HMO's service area and no other benefit option is available to you or your eligible dependent l Benefits are no longer offered by the plan to a class of individuals that include you or your eligible dependent l Termination of your or your dependent’s Medicaid or Children’s Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact the Benefits Group within 60 days of termination) l You or your dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact the Benefits Group within 60 days of determination of subsidy eligibility) l A strike or lockout involving you or your spouse, or l A court or administrative order.
Unless otherwise noted above, if you wish to change your elections, you must contact the Benefits Group within 31 days of the change in family status. Otherwise, you will need to wait until the next annual Open Enrollment.
While some of these changes in status are similar to qualifying events under COBRA, you, or your eligible dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible dependent if COBRA is elected.
Note: Any child under age 26 who is placed with you for adoption will be eligible for coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all medical plan and prescription benefit plan coverage for the child will end when the placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.
Any election change you make during the year as a result of one of the above-events must be permitted by law and consistent with the event. Election changes are consistent with a family status change event only if the election change is on account of and corresponds with an event that affects eligibility for either you, your spouse/domestic partner or your dependent under this plan or the medical plan of your spouse’s/domestic partner’s or dependent’s employer. For example, if the qualified change in status event is your divorce, the death of your spouse or dependent, or a dependent ceasing to satisfy the medical plan’s eligibility requirements, the corresponding election change would be to drop medical coverage for (a) the spouse involved in the divorce (in the case of your divorce), (b) the deceased spouse or dependent (in the case of
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your spouse’s or dependent’s death), or (c) the dependent that ceased to satisfy the medical plan’s eligibility requirements. In addition, if you, your spouse, and/or your dependent become eligible for medical coverage under your spouse’s employer plan or your dependent’s employer plan as a result of a change in marital or employment status, you may drop medical (and prescription) coverage for any individual (including yourself) but only if the individual actually becomes covered under the other employer’s medical plan. You must notify the company of the qualified change in status within 31 days of the event.
Other permissible mid-year election changes include: l Changes consistent with the special enrollment rights under the Health Insurance Portability and Accountability Act (HIPAA). See the section “HIPAA Special Enrollment Rights.” l Changes required by a judgment, decree or order, including a qualified medical child support order (QMCSO), resulting from a divorce, legal separation, annulment or change in legal custody that require medical coverage for your child (or foster child who is your dependent). If the order directs you to cover the child, you may enroll the child (and yourself) in the medical plan and the Prescription Benefit Plan. If the order directs someone other than you (e.g., your spouse or former spouse) to cover the child, you may drop medical coverage (and prescription coverage) for the child, but only if the other coverage is actually provided. See the section “Qualified Medical Child Support Order (QMCSO)” for further details. l Changes due to entitlement (or loss of entitlement) to Medicare or Medicaid. If you, your spouse/domestic partner or a covered dependent becomes entitled to Medicare or Medicaid (i.e., becomes enrolled), you may drop or reduce medical coverage for that individual. If you, your spouse/domestic partner or a dependent loses entitlement to Medicare or Medicaid, you may enroll in or increase medical coverage for that individual (and yourself) in the plan. l Changes consistent with taking leave under the Family and Medical Leave Act (FMLA). If you take leave under the FMLA, you may revoke your election under the medical plan and this Prescription Benefit Plan and make such other election for the remaining portion of the period of coverage as may be provided for under the FMLA. See the “Continuation of Coverage While on a Family and Medical Leave (FMLA)” section for further details. l Significant cost or coverage changes. l Cost changes: A cost increase or decrease as described below refers to an increase or decrease in the amount of your elective contributions. This is regardless of whether the increase or decrease results from action taken by you (such as switching from full-time to part-time status), or from action taken by inVentiv Health (such as reducing the amount of employer contributions for a class of employees).
– Automatic changes. If the cost of your medical plan (including this Prescription Benefit Plan) increases (or decreases) during a period of coverage, and the plan administrator, in its sole discretion, determines that the cost increase (or decrease) is not significant, the plan administrator may, on a reasonable and consistent basis, automatically make a prospective increase (or decrease) in your elective contributions for the plan.
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– Significant cost changes. If the cost charged to you for a medical plan option (including this Prescription Benefit Plan) significantly increases or decreases during a period of coverage, you may make a corresponding medical plan election change. For example, you can begin participation in the medical plan option with a decrease in cost. In the case of a cost increase, you can: (a) revoke your election for that medical plan option and receive coverage going forward under another medical plan option providing similar coverage; or (b) drop coverage if no other medical plan option providing similar coverage is available.
Coverage changes
– Significant curtailment without loss of coverage. If you or your spouse/domestic partner or dependent has a significant curtailment of medical coverage under your plan that is not a loss of coverage as described below, you may revoke your election for that medical plan option and elect to receive coverage going forward under another medical plan option providing similar coverage. A significant curtailment without a loss of coverage includes a significant increase in the deductible, the copay or the out-of-pocket cost sharing limit. Because medical coverage under the plan will be considered significantly curtailed only if there is an overall reduction in coverage provided under the plan so as to constitute reduced coverage generally, in most cases the loss of one particular physician in a network will not constitute a significant curtailment.
– Significant curtailment with loss of coverage. If you or your spouse/domestic partner or dependent has a significant curtailment that is a loss of medical coverage under the plan, you may revoke your election for that medical plan option (including the Prescription Benefit Plan described in this SPD) and elect to either: (a) receive coverage going forward under another medical plan option providing similar coverage; or (b) drop coverage if no similar medical plan option is available. A loss of coverage means a complete loss of medical coverage under the medical plan option or other medical plan option such as: the elimination of a medical plan option, an HMO’s ceasing to be available in the area where an individual resides, or an individual’s losing all coverage under the option due to an overall lifetime or annual limitation. In addition, the plan administrator, in its discretion, may treat the following as a loss of coverage:
l A substantial decrease in the medical care providers available under the medical plan option (such as a major hospital ceasing to be a member of a preferred provider network or a substantial decrease in the number of physicians participating in a preferred provider network or an HMO).
l A reduction in benefits for a specific type of medical condition or treatment with respect to which you, your spouse or your dependent is currently in a course of treatment.
l Any other similar fundamental loss of coverage.
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– Addition or improvement of a medical plan option. If a new medical plan option or other medical coverage option is added under the plan, or if coverage under an existing medical plan option is significantly improved during a period of coverage, you may revoke your medical plan election (including your coverage under this Prescription Benefit Plan) and elect coverage going forward under the new or improved medical plan option. This provision applies whether or not you have previously made an election under the medical plan or have previously elected the medical plan option.
Change in coverage under another employer plan: You may make a prospective election change that is on account of and corresponds with a change made under another employer plan if either:
l The other cafeteria plan or medical plan permits its participants to make an election change that would be permitted under applicable IRS mid-year election change regulations; or
l This plan permits you to make an election for a plan year which is different from the plan year under the other cafeteria plan or medical plan (i.e., different open enrollment period).
Loss of coverage under other group health coverage: You may make a mid-year election change to add coverage under the plan for you, your spouse/domestic partner or dependent if you, your spouse/domestic partner or dependent loses coverage under any group health coverage sponsored by a governmental institution, including the following:
l A state’s children’s health insurance program (SCHIP);
l A medical care program of an Indian Tribal government, the Indian Health Service, or a tribal organization;
l A state health benefits risk pool; or
l A foreign government group health plan.
HIPAA Special Enrollment Rights
Loss of Eligibility for Other Medical Coverage
l If you are declining medical plan enrollment, and, as a result, enrollment in this Prescription Benefit Plan, for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage and you submitted the written verification described below at the time coverage was declined, you may be able to enroll yourself and your dependents in a medical plan, or switch medical benefit options under an inVentiv Health medical plan, if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other non-COBRA coverage). However, you must request enrollment within 31 days after the date your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). Loss of eligibility for coverage includes:
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l Loss of eligibility as a result of legal separation, divorce, cessation of dependent status (such as attaining the maximum age to be eligible as a dependent child under the plan), death of an employee, termination of employment, reduction in the number of work hours of employment,
l (In the case of coverage offered through an HMO or other arrangement in the individual or group market that does not provide benefits to individuals who no longer reside, live or work in the service area) Loss of coverage because an individual no longer resides, lives or works in the service area (whether or not it was the individual’s choice), and with respect to an HMO in the group market, no other benefit package is available to the individual,
l A situation in which a plan no longer offers any benefits to the class of similarly situated individuals that includes the individual, and
l In the case of an individual who has COBRA continuation coverage, at the time the COBRA continuation coverage is exhausted.
However, loss of eligibility for other coverage does not include a loss of coverage due to:
l The failure of the employee or dependent to pay premiums on a timely basis
l Voluntary disenrollment from a plan, or
l Termination of coverage for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan).
When Coverage Begins If you enroll yourself, your spouse/domestic partner and/or your eligible dependent child(ren) in an inVentiv Health medical plan (and, as a result, receive coverage in this Prescription Benefit Plan) due to a “loss of eligibility for coverage” event as described above, prescription coverage under this plan will begin the first day of the first calendar month after the completed special enrollment form is received.
Written verification requirement: To preserve your right and/or your dependents’ right to special enrollment when the events described above occur, you must verify in writing that medical plan coverage is being declined due to having other health coverage. If you do not submit this written verification at the time coverage under this plan is being declined, you and/or your dependents will not be eligible to enroll later under the plan’s special enrollment provisions described above.
Gaining a New Dependent If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents in an inVentiv Health medical plan or switch medical coverage options. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
In addition, if you are not enrolled in the plan as an employee, you also must enroll in the plan when you enroll any of these dependents. And, if your spouse is not enrolled in the medical plan, you may enroll him or her in the plan when you enroll a child due to birth, adoption or placement
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for adoption. Written verification of the reason you or your spouse previously declined coverage under the medical plan is not required if a special enrollment period occurs under the “Gaining a New Dependent” section.
When Coverage Begins In the case of marriage, coverage will begin on the first day of the first calendar month after the completed enrollment form is received. In the case of birth, adoption or placement for adoption, coverage is retroactive to the date of birth, adoption or placement for adoption.
Loss or Gain of Eligibility for a State Children's Health Insurance Program (CHIP) or Medicaid
If you (the employee) are eligible for, but not enrolled in, an inVentiv Health medical plan (or your dependent is eligible for, but not enrolled in, an inVentiv Health medical plan), you (and your dependent) may enroll in a medical plan (and automatically receive coverage under this Prescription Benefit Plan) or switch medical benefit options, if either of the following conditions is met:
l You or your dependent is covered under CHIP or Medicaid and such coverage is terminated as a result of loss of eligibility, and you request coverage under the medical plan not later than 60 days after the date of termination of such CHIP or Medicaid coverage; or
l You or your dependent becomes eligible for CHIP or Medicaid premium assistance subsidy assistance with respect to coverage under an inVentiv Health medical plan, if you request coverage under the medical plan not later than 60 days after the date you or your dependent is determined to be eligible for such premium assistance subsidy.
When Coverage Begins If you enroll yourself, your spouse and/or your eligible dependent child(ren) in an inVentiv Health medical plan (and automatically receive coverage under this Prescription Benefit Plan) due to a loss or gain of eligibility for coverage event described above, coverage under this plan will begin the first day of the first calendar month after the completed special enrollment form is received.
To request special enrollment or obtain more information, contact:
inVentiv Health Benefits Group [email protected]
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Em ployer Children’s Health In s u ra n c e Plan (C HIP) Notice
Premium Assistance under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit https://www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at http://www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2015. Contact your State for more information on eligibility
State – Program Contact Information ALABAMA – Website: http://www.myalhipp.com/ Medicaid Phone: 1-855-692-5447 ALASKA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529 COLORADO – Medicaid Website: http://www.colorado.gov/hcpf Medicaid Medicaid Customer Contact Center: 1-800-221-3943 FLORIDA – Medicaid Website: https://www.flmedicaidtplrecovery.com/ Phone: 1-877-357-3268 GEORGIA – Website: http://dch.georgia.gov/ Medicaid Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1-404-656-4507
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State – Program Contact Information INDIANA – Medicaid Website: http://www.in.gov/fssa Phone: 1-800-889-9949 IOWA – Medicaid Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562 KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884 KENTUCKY – Website: http://chfs.ky.gov/dms/default.htm Medicaid Phone: 1-800-635-2570 LOUISIANA – Website: http://new.dhh.louisiana.gov/index.cfm/subhome/1/n/331 Medicaid Phone: 1-888-695-2447 MAINE – Medicaid Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740 TTY 1-800-977-6741 MASSACHUSETTS Website: http://www.mass.gov/MassHealth – Phone: 1-800-462-1120 Medicaid and CHIP MINNESOTA – Website: http://www.dhs.state.mn.us/id_006254 Medicaid Click on Health Care, then Medical Assistance Phone: 1-800-657-3739 MISSOURI – Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Medicaid Phone: 573-751-2005 MONTANA – Website: http://medicaid.mt.gov/member Medicaid Phone: 1-800-694-3084 NEBRASKA – Website: www.ACCESSNebraska.ne.gov Medicaid Phone: 1-855-632-7633 NEVADA – Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900 NEW HAMPSHIRE – Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Medicaid Phone: 603-271-5218 NEW JERSEY – Medicaid Website: Medicaid and CHIP http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 NEW YORK – Website: http://www.nyhealth.gov/health_care/medicaid/ Medicaid Phone: 1-800-541-2831 NORTH CAROLINA Website: http://www.ncdhhs.gov/dma – Medicaid Phone: 919-855-4100 NORTH DAKOTA – Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Medicaid Phone: 1-800-755-2604 OKLAHOMA – Website: http://www.insureoklahoma.org Medicaid and CHIP Phone: 1-888-365-3742 OREGON – Medicaid Website: http://www.oregonhealthykids.gov
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State – Program Contact Information http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075 PENNSYLVANIA – Website: http://www.dhs.state.pa.us/hipp Medicaid Phone: 1-800-692-7462 RHODE ISLAND – Website: http://www.eohhs.ri.gov/ Medicaid Phone: 401-462-5300 SOUTH CAROLINA Website: http://www.scdhhs.gov – Medicaid Phone: 1-888-549-0820 SOUTH DAKOTA – Website: http://dss.sd.gov Medicaid Phone: 1-888-828-0059 TEXAS – Medicaid Website: http://gethipptexas.com/ Phone: 1-800-440-0493 UTAH – Medicaid Website: and CHIP Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-866-435-7414 VERMONT– Website: http://www.greenmountaincare.org/
Medicaid Phone: 1-800-250-8427 VIRGINIA – Medicaid Medicaid Website: and CHIP http://www.coverva.org/programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282 WASHINGTON – Website: Medicaid http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx Phone: 1-800-562-3022 ext. 15473 WEST VIRGINIA – Website: www.dhhr.wv.gov/bms/ Medicaid Phone: 1-877-598-5820, HMS Third Party Liability WISCONSIN – Website: Medicaid https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002 WYOMING – Website: https://wyequalitycare.acs-inc.com/ Medicaid Phone: 307-777-7531 To see if any more states have added a premium assistance program since July 31, 2015, or for more information on special enrollment rights, you can contact either:
U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/ebsa 1-866-444-EBSA (3272)
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
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When Prescription Coverage Ends
In general, coverage under this Prescription Benefit Plan will end when your inVentiv Health Choice Fund Open Access Plus HSA Plan coverage ends.
Your entitlement to benefits automatically ends on the date that coverage ends, even if you are hospitalized or are otherwise receiving medical treatment on that date.
When your coverage ends, inVentiv Health will still pay claims for covered prescription drugs that you received before your coverage ended. However, once your coverage ends, benefits are not provided for prescription drugs that you receive after coverage ended, even if the underlying medical condition occurred before your coverage ended.
Your coverage under the plan will end on the earliest of: l The last day of the month your employment with the company ends l The date the plan ends l The last day of the month Express Scripts receives written notice from inVentiv Health to end your coverage, or the date requested in the notice, if later, or l The last day of the month you retire or are pensioned under the plan, unless specific coverage is available for retired or pensioned persons and you are eligible for that coverage.
Coverage for your eligible dependents will end on the earliest of: l The date your coverage ends l The last day of the month you stop making the required contributions l The last day of the month Express Scripts receives written notice from inVentiv Health to end your coverage, or the date requested in the notice, if later, or l The last day of the month your dependents no longer qualify as dependents under this plan.
Other Events Ending Your Coverage
The plan will provide prior written notice to you that your coverage will end on the date identified in the notice if: l You commit an act, practice or omission that constituted fraud, or an intentional misrepresentation of a material fact including, but not limited to, false information relating to another person’s eligibility or status as a dependent, or l You commit an act of physical or verbal abuse that imposes a threat to inVentiv Health’s staff, Express Scripts’ staff, a provider or another covered person.
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Note: inVentiv Health has the right to demand that you pay back benefits inVentiv Health paid to you, or paid in your name, during the time you were incorrectly covered under the plan.
Coverage for a Disabled Child
If an unmarried enrolled dependent child with a mental or physical disability reaches an age when coverage would otherwise end, the plan will continue to cover the child, as long as: l The child is unable to be self-supporting due to a mental or physical handicap or disability l The child depends mainly on you for support l You provide to inVentiv Health proof of the child’s incapacity and dependency within 31 days of the date coverage would have otherwise ended because the child reached a certain age, and l You provide proof, upon inVentiv Health’s request, that the child continues to meet these conditions.
The proof might include medical examinations at inVentiv Health's expense. However, you will not be asked for this information more than once a year. If you do not supply such proof within 31 days, the plan will no longer pay benefits for that child.
Coverage will continue as long as the enrolled dependent is incapacitated and dependent upon you unless coverage is otherwise terminated in accordance with the terms of the plan.
Continuing Coverage When It Might Otherwise End
If you lose your inVentiv Health medical plan coverage, you may have the right to extend it under the Consolidated Budget Reconciliation Act of 1985 (COBRA). If you elect to extend your medical plan coverage through COBRA, your coverage under the Prescription Benefit Plan is also extended. See the “Continuation of Coverage Rights Under COBRA” section later in this SPD for more information.
You also may be able to continue coverage if you are on military leave (see the “Continuation of Coverage for Employees in the Uniformed Services (USERRA)” section or if you are on an approved Family and Medical Leave Act (FMLA) leave (see the “Continuation of Coverage While on a Family and Medical Leave” section).
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Term s You Should Know
Annual out-of-pocket maximum: The most you will pay out-of-pocket for covered services, supplies and drugs each year combined under your inVentiv Health medical plan and this Prescription Benefit Plan. The amount includes your annual deductible, your coinsurance and your copays. The annual out-of-pocket maximum does not include charges you pay for non- covered health services, any reductions in benefits you incur by not notifying Personal Health Support or by not using generic and preferred drugs and the Express Scripts Pharmacy and any amounts that are above the reasonable and customary (R&C) charge. Once you reach the out-of- pocket maximum, both your medical plan and this Prescription Benefit Plan pay 100% of any remaining eligible charges for that year.
Claims Administrator: Express Scripts and its affiliates who provide certain claim administration services for the plan.
Company – inVentiv Health.
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA): A federal law that requires employers to offer continued health insurance coverage to certain employees and their dependents whose group health insurance has been terminated.
Copayment (or “copay”): The flat dollar amount you must pay for prescription drugs. This SPD describes which covered prescription drugs are subject to a copayment. You will be asked to provide your copayment when you fill a prescription.
Formulary: A list of FDA-approved generic and brand-name prescription drugs that are covered by the Prescription Benefit Plan. Plans may have their own formularies.
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Express Scripts Prescription Drug Benefits
When you enroll in the inVentiv Health Medical Choice Fund Open Access Plus HSA Plan, you are automatically enrolled in the Express Scripts Prescription Benefit Plan. You do not need to make a separate election to receive prescription drug benefits.
Under this plan, your cost is lower for generic and preferred brand-name prescription drugs which are subsidized at a higher percentage rate. Express Scripts has contracts with most chain and independent pharmacies nationwide.
Under the Prescription Benefit Plan, you can obtain prescription drugs in three ways: either through your local participating pharmacy, through a custom retail network of pharmacies or through the Express Scripts Pharmacy for mail order service. You also have the option to submit paper claims.
How the Prescription Benefit Plan Works
Once you have met your medical plan deductible, the Prescription Benefit Plan requires that you pay a copayment for each prescription covered under the Plan when you receive a prescription at participating Express Scripts retail pharmacies, through the custom retail network or through the Express Scripts Pharmacy. However, there are exceptions for preventive medications. Preventive medications subject to the Patient Protection and Affordable Care Act (PPACA), which include some over-the-counter medications and contraceptives for women, are not subject to the deductible, are fully covered by the plan and are available at no cost to you. Other medications that are used to prevent certain diseases or disease complications available under the High Deductible Health Plan (HDHP) and Health Savings Account (HSA) are also not subject to the deductible, but do require a copayment. Please refer to the section Preventive Drugs Covered at 100% for a list of the PPACA mandated drugs and to the section Preventive and Other Drugs Covered Under HDHP and HSA Rules for a list of the HSA covered drugs. The list of preventive drugs covered under HDHP and HSA rules is periodically updated, so please contact Express Scripts if you have questions on a specific drug.
After you reach the annual out-of-pocket maximum for your inVentiv Health medical plan, the Prescription Benefit Plan will pay the full cost of all your covered prescriptions for the year.
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More About Your Deductible As a participant in the inVentiv Health Medical Choice Fund Open Access Plus HSA Plan, you must satisfy the following annual deductible before the medical or prescription drug plans pay benefits. The deductible includes all your out-of-pocket medical and prescription drug expenses that would otherwise be covered under the plans.
Combined Annual Deductible* Individual $1,750
Individual plus one dependent $3,250 (spouse or child)
Family** $3,250
* The annual deductible includes all your out-of-pocket medical and prescription drug expenses that would have otherwise been covered under the plans had your deductible been satisfied. The only exception to this rule is for preventive prescription drugs that are not subject to the deductible. For a list of preventive drugs not subject to the deductible, refer to the section Preventive Drugs Covered at 100% and the section Preventive and Other Drugs Covered Under HDHP and HSA Rules. Copays for preventive drugs that are not covered at 100% do count towards the deductible. ** The plans do not require that you or a covered dependent meet the single deductible in order to satisfy the family deductible. If more than one person in a family is covered under the plan, the single coverage deductible shown above does not apply individually. Instead, the higher deductible applies and no one in the family is eligible to receive benefits until that higher deductible is satisfied.
Prescription Drug Copayments Until you meet your annual deductible, you will need to pay the full cost of your prescriptions. Once you have met that deductible (by paying medical and prescription drug expenses out of pocket), you will pay the applicable copayment for each prescription drug you have filled (except for certain preventive and other drugs shown in the section Preventive Drugs Covered at 100%) as shown in the following table.
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Express Scripts Retail Custom Retail Network* or
Pharmacy Network Express Scripts Pharmacy
For short-term medications For long-term medications
(up to a 30-day supply) (up to a 90-day supply) Where For a list of participating Three options: pharmacies, go to Express- Go to a Custom Retail Network Scripts.com and click on “Locate pharmacy location a Pharmacy” or call Member Services at 1-800-341-4576 Mail your original prescription and the mail service order form to Express Scripts Pharmacy and your prescription will be mailed to you
OR
Have your physician fax in your prescription to 1-888-327-9791 Tier 1 – Generic Medications $7 for a generic prescription after $17.50 for a generic prescription Ask your doctor or other you have met your deductible after you have met your prescriber if there is a generic deductible available, as these generally cost less Tier 2 – Preferred Brand-Name $45 for a preferred brand-name $112.50 for a preferred brand- Medications prescription after you have met name prescription after you have If a generic is not available or your deductible met your deductible appropriate, ask your doctor or healthcare provider to prescribe from your plan’s preferred drug list Tier 3 – Non-Preferred Brand- $70 for a non-preferred brand- $175 for a non-preferred brand- Name Medications name prescription after you have name prescription after you have You will pay the most for met your deductible met your deductible medications not on your plan’s preferred drug list Specialty Medications 5% after deductible (minimum $75) Subject to annual deductible and annual out-of-pocket maximum
Refill Limit One initial fill plus 2 refills for None maintenance medications Web Services Register at Express-Scripts.com to access tools to help you save money and manage your prescription benefits. You will need your prescription card when you register Member Services Call 1-800-341-4576 to reach Member Services
* The custom retail network pharmacies include Wal-Mart, CVS, K-Mart and Kroger.
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Your ID Card When you first enroll in your inVentiv Health Choice Fund Open Access Plus HSA Plan, you will receive prescription drug identification cards from Express Scripts. If you need additional cards (for instance, if your child is attending college out of town), you can request them by calling Express Scripts Member Services at 1-800-341-4576. In an emergency, you are able to print a temporary identification card from Express Scripts’ website, Express-Scripts.com. It is important to remember to use your Prescription Benefit Plan ID card at the pharmacy rather than your medical plan insurance card.
When You Need to Fill a Prescription When you need to fill a prescription, you can choose to go to your local participating retail pharmacy or your custom retail pharmacy or, for mail order, use the Express Scripts Pharmacy. If your prescription is for a 30-day supply of a medication or less, one of the retail options is best. If you are filling a maintenance medication that you are expecting to take for a longer period of time, the Express Scripts Pharmacy or one of the custom retail network pharmacies – Wal-Mart, CVS, K-Mart or Kroger – is your best choice.
Regardless of whether you choose a local retail pharmacy or the Mail Service Pharmacy, generic drugs are used to fill prescriptions whenever possible unless your doctor specifies otherwise. The pharmacist may contact your doctor to suggest that a preferred brand-name drug be substituted with a comparable drug from Express Scripts’ formulary list. Your doctor decides whether or not to switch to the formulary medication.
Express Scripts also provides “safety checks” at both its retail and mail service pharmacies. Examples include checking for possible drug allergies or adverse interactions, incorrect dosage or strength and age- and sex-appropriate drugs. If there are any problems, Express Scripts contacts your doctor. Express Scripts, and not the plan, is solely responsible for these safety checks.
Express Scripts Annual Out-of-Pocket Maximum There is a combined annual out-of-pocket maximum for your covered medical and prescription drug expenses. If you participate in the Medical Choice Fund Open Access Plus HSA Plan, the annual out-of-pocket maximums are:
Combined Annual Out-of-Pocket Maximum* Individual $3,000
Family** $6,000
* Both your annual deductible and preventive care copays count toward your annual out-of-pocket maximum. In addition brand/generic difference and retail refill allowance penalties apply to your annual out-of-pocket maximum. ** The plans do not require that you or a covered dependent meet the single out-of-pocket maximum in order to satisfy the family out-of-pocket maximum. If more than one person in a family is covered under the plan, the single coverage out-of-pocket maximum shown above does not apply individually. Instead, the higher out-of-pocket maximum applies.
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This means that once you reach your out-of-pocket amount for medical services and supplies and Express Scripts prescription drug copayments, your prescriptions will be filled at no additional charge to you for the remainder of that calendar year.
Using Your HSA for Prescription Drug Costs If you are participating in the inVentiv Health Medical Choice Fund Open Access Plus HSA Plan, you have the opportunity to open a Health Savings Account (HSA) to pay eligible health care expenses for yourself and your eligible dependents with before-tax money. Prescription drug costs including copayments under the plan are considered qualified health expenses and can be covered with HSA funds. Qualified health expenses must only include your and your eligible dependents’ related expenses. For HSA purposes, only your spouse and any other family members whom you are allowed to claim as dependents on your federal tax return can be considered your dependents.
If you have elected to contribute to an HSA, you can use the money in your HSA to cover your out-of-pocket prescription drug costs including costs you must pay until you meet your deductible and your copayments on a tax-advantaged basis.
For information about your HSA, visit irs.gov. You may want to contact your tax advisor for information on HSA rules and how they might affect your personal situation.
Retail Pharmacies
Express Scripts has contracted with nearly 60,000 retail pharmacies, including most major drug stores. These retail pharmacies in the Express Scripts network are referred to as “participating pharmacies.” To locate a participating pharmacy close to your home or other location, you can call Express Scripts Member Services at 1-800-341-4576 or check Express Scripts’ website at Express-Scripts.com. You can purchase up to a 30-day supply at one time at any retail pharmacy.
You may obtain a 90-day supply of a maintenance medication through the custom retail network including your local Wal-Mart, CVS, K-Mart or Kroger retail pharmacies.
Express Scripts Pharmacy for Mail Order
Express Scripts offers the Express Scripts Pharmacy to fill your long-term prescriptions through mail order. When you use the Express Scripts Pharmacy, your copayment for a 90-day supply will be lower than what you would have paid at a local (non-custom retail network) pharmacy. You will also have the convenience of having your medications delivered right to you. You have the option of taking your prescription for long-term medications to one of the pharmacies that is part of the custom retail network (Wal-Mart, CVS, K-Mart or Kroger). The copayment you pay for the 90-day supply will be the same whether you use the Express Scripts Pharmacy or one of the local custom retail network pharmacies.
Using the Express Scripts Pharmacy Program for the First Time First-time users of the Express Scripts Pharmacy can sign up for the program either online or by telephone. To register online:
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l Register or log into Express-Scripts.com l Select “Activate Your Account” and fill out the required information l To order a prescription, select “My Prescriptions” l Select “Fill a New Prescription.”
To register for the program by telephone: l Call Express Scripts at 1-888-327-9791 l Speak with a Member Services representative who will help you with your request.
You will receive your prescription within 7 - 10 days of when your order is placed.
You may want to ask your doctor to write you a prescription for a 30 day supply of medication to be filled at a retail pharmacy and one for a 90 day supply to be filled through the Express Scripts Pharmacy so that you have medication on hand while your mail service prescription is being filled.
Refilling Prescriptions Using the Mail Service Program: You can have your prescriptions refilled by phone, mail or through the Internet. Be sure to reorder your prescription at least three weeks before you expect to run out of your medication. If you miss this deadline, you may ask your doctor to write you a prescription for a 30 day supply of medication to be filled at a retail pharmacy while you wait for your prescription from the Express Scripts Pharmacy.
You have the option of registering for Worry Free Fills through Express-Scripts.com to have your refills automatically shipped when they are due to ensure you have your medication on time.
Covered Medications
The Prescription Benefit Plan provides coverage for federal legend drugs which are drug products bearing the legend, “Caution: Federal law prohibits dispensing without a prescription.” The plan also covers certain prescription supplies, oral contraceptives and some compound medications which contain at least one federal legend drug in a therapeutic amount.
For the Prescription Benefit Plan to cover a prescription, the prescribed item must meet the following requirements: l It must be a prescription written by a licensed physician and not have exceeded the accepted date range of validity. Prescriptions for all drugs other than controlled substances are valid for one year from the date they were written. Controlled substance prescriptions are valid for six months from the date they are written. l It must be approved by the Federal Food and Drug Administration (FDA). l It must be dispensed by a pharmacy.
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l It must not be listed as an exclusion under this plan.
Prescription drugs covered by the plan are classified as either generic or brand-name drugs. Brand-name drugs are then considered either preferred brand-name or non-preferred brand- name.
Preventive Drugs Covered at 100% To comply with the Patient Protection and Affordable Care Act (PPACA), the Prescription Drug Plan will cover the following drugs (with the limitations shown), in full, not subject to your deductible: l Aspirin – For patients 45 and older – Generic only – Over-the-counter requires a prescription l Iron Supplements – For children age 1 or younger – No prior authorization – Brand and generic – Over-the-counter requires a prescription l Oral Fluorides – For children age 6 or younger – Brand and generic only – Over-the-counter is not covered – Prescription products only l Folic Acid – Women age 55 or younger – Generic only – Over-the-counter requires a prescription l Tobacco Cessation Products – Prescription and over-the-counter drugs require prescription – Product must be on the Express Scripts defined drug list. – No quantity limits for members utilizing smoking cessation products at a $0 co-pay. l Breast Cancer Preventative Medication – Generic Tamoxifen, Raloxifene and Soltamox at a $0 co-pay for women 35 or older. l Vaccines/Immunizations – Vaccines for children and adults currently contained in the Recommendations of the Advisory Committee on Immunization Practices (ACIP) – Coverage for ages based on ACIP/CDC “General Recommendations on Immunization” l Contraceptives – Coverage of FDA-approved contraceptive methods prescribed for a woman, through age 50 years l Bowel Preparation Agents – Screening for colorectal cancer using colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years l Vitamin D
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– Vitamin D and select Vitamin D combinations in adults age 65 or older
Preventive and Other Drugs Covered Under HDHP and HSA Rules To comply with HSA rules, the Prescription Benefit Plan will cover the following drugs (with some limitations), in full after you pay your applicable copayment. These copays are subject to both your deductible and annual out-of-pocket maximum. This list is effective as of January 1, 2016 and may be updated periodically. Please contact Express Scripts to check on the status of a drug you are prescribed.
Please note that brand names are shown in larger upper case italics in each category. Coverage prior to the deductible being met may not be provided for every dosage form of a listed drug. This is not an all-inclusive list; only examples of medicines in each category are listed.
ANEMIA IN CHILDREN CELONTIN METHSUXIMIDE FERROUS SULFATE LIQUID DROPS FOR TRILEPTAL INFANTS (SUCH AS FER-IN-SOL) OXCARBAZEPINE ANTICONVULSANTS LUMINAL SODIUM PHENOBARBITAL SODIUM FOSPHENYTOIN SODIUM DILANTIN, PHENYTEK LEVETIRACETAM, LEVETIRACETAM-NACL PHENYTOIN, PHENYTOIN SODIUM OXCARBAZEPINE MYSOLINE PRIMIDONE PRIMIDONE TIAGABINE HCL BANZEL CARBATROL, EPITOL, EQUETRO, RUFINAMIDE TEGRETOL, TEGRETOL XR GABITRIL CARBAMAZEPINE, CARBAMAZEPINE TIAGABINE HCL ER, CARBAMAZEPINE XR TOPAMAX, TOPIRAGEN ONFI TOPIRAMATE CLOBAZAM DEPACON KLONOPIN VALPROATE SODIUM CLONAZEPAM STAVZOR DIASTAT, DIASTAT ACUDIAL VALPROIC ACID DIAZEPAM DEPAKENE DEPAKOTE, DEPAKOTE ER, VALPROIC ACID, VALPROATE SODIUM DEPAKOTE SPRINKLE SABRIL DIVALPROEX SODIUM, DIVALPROEX VIGABATRIN SODIUM ER ZARONTIN ANTIPSYCHOTICS ETHOSUXIMIDE PEGANONE CHLORPROMAZINE HCL ETHOTOIN FLUPHENAZINE DECANOATE POTIGA FLUPHENAZINE HCL PERPHENAZINE EZOGABINE QUETIAPINE FUMARATE FELBATOL THIORIDAZINE HCL FELBAMATE THIOTHIXENE VIMPAT TRIFLUOPERAZINE HCL LACOSAMIDE ZIPRASIDONE HCL LAMICTAL, LAMICTAL ODT, ABILIFY, ABILIFY DISCMELT LAMICTAL XR ARIPIPRAZOLE LAMOTRIGINE SAPHRIS KEPPRA, KEPPRA XR ASENAPINE MALEATE LEVETIRACETAM EQUETRO MEBARAL CARBAMAZEPINE MEPHOBARBITAL CLOZARIL, FAZACLO
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CLOZAPINE, CLOZAPINE ODT MOMETASONE/FORMOTEROL HALDOL, HALDOL DECANOATE, SINGULAIR HALOPERIDOL LACTATE MONTELUKAST HALOPERIDOL ACCOLATE FANAPT ZAFIRLUKAST ILOPERIDONE ZYFLO CR LATUDA ZILEUTON LURASIDONE HCL LOXITANE BONE DISEASE AND FRACTURES LOXAPINE SUCCINATE FOSAMAX, FOSAMAX PLUS D MOBAN ALENDRONATE MOLINDONE HCL FORTICAL, MIACALCIN SYMBYAX CALCITONIN OLANZAPINE/FLUOXETINE HCL PROLIA, XGEVA INVEGA, INVEGA SUSTENNA DENOSUMAB PALIPERIDONE BONIVA ORAP IBANDRONATE PIMOZIDE EVISTA SEROQUEL, SEROQUEL XR RALOXIFENE QUETIAPINE FUMARATE ACTONEL RISPERDAL, RISPERDAL CONSTA, RISEDRONATE RISPERDAL M-TAB, RISPERIDONE RECLAST ODT ZOLEDRONIC ACID RISPERIDONE NAVANE BREAST CANCER RECURRENCE THIOTHIXENE TAMOXIFEN ZYPREXA, ZYPREXA RELPREVV, ZYPREXA ARIMIDEX ZYDIS OLANZAPINE ANASTROZOLE GEODON AROMASIN EXEMESTANE ZIPRASIDONE MESYLATE FEMARA AROMATASE INHIBITORS LETROZOLE ARIMIDEX CANCER TREATMENT, ANASTROZOLE SIDE EFFECTS FROM AROMASIN EXEMESTANE ARANESP FEMARA DARBOETIN ALFA LETROZOL EPOGEN, PROCRIT EPOETIN ALFA ASTHMA NEUPOGEN FILGRASTIM FLUNISOLIDE DEPO-PROVERA QVAR MEDROXYPROGESTERONE BECLOMETHASONE MESNEX PULMICORT, PULMICORT MESNA FLEXHALER NEULASTA BUDESONIDE PEGFILGRASTIM SYMBICORT LEUKINE BUDESONIDE/FORMOTEROL SARGRAMOSTIM INTAL CROMOLYN SODIUM CAVITIES FLOVENT HFA, FLOVENT DISKUS PEDIATRIC FLUORIDE RX AND OTC FLUTICASONE ADVAIR HFA, ADVAIR DISKUS PREVIDENT FLUTICASONE/SALMETEROL SODIUM FLUORIDE ASMANEX MOMETASONE DULERA
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CHEMICAL DEPENDENCY ZOLOFT SERTRALINE CAMPRAL PARNATE ACAMPROSATE CALCIUM TRANYLCYPROMINE SUBOXONE, SUBUTEX SURMONTIL BUPRENORPHINE HYDROCHLORIDE TRIMIPRAMINE ANTABUSE MALEATE, MULTAQ DISULFIRAM DRONEDARONE HYDROCHLORIDE DEPADE RYTHMOL, RYTHMOL SR NALTREXONE HYDROCHLORIDE, REVIA PROPAFENONE HCL VIVITROL ZONEGRAN NALTREXONE MICROSPHERES ZONISAMIDE EFFEXOR COLONOSCOPY PREPARATION VENLAFAXINE VIIBRYD COLYTE, GOLYTELY, HALFLYTELY, VILAZODONE NULYTELY, TRILYTE, MOVIPREP POLYETHYLENE GLYCOL DIABETES, COMPLICATIONS VISICOL, OSMOPREP, SUPREP OF SODIUM PHOSPHATE SALTS INSULINS: DEPRESSION NOVOLOG, NOVOLOG 70/30 AMITRIPTYLINE ASPART, ASPART PROTAMINE MIX AMOXAPINE LEVEMIR DOXEPIN HCL DETEMIR MAPROTILINE HCL LANTUS, LANTUS SOLOSTAR PHENELZINE SULFATE GLARGINE APLENZIN ER HUMULIN, NOVOLIN BUPROPION INSULIN CELEXA HUMALOG, 50/50, 75/25 CITALOPRAM LISPRO, LISPRO PROTAMINE MIX ANAFRANIL CLOMIPRAMINE HCL NON-INSULIN MEDICINES: NORPRAMIN DESIPRAMINE BYETTA PRISTIQ EXENATIDE DESVENLAFAXINE AMARYL CYMBALTA GLIMEPIRIDE DULOXETINE GLUCOTROL, METAGLIP LEXAPRO GLIPIZIDE AND COMBINATIONS ESCITALOPRAM DIABETA, GLYNASE, GLUCOVANCE PROZAC GLYBURIDE AND COMBINATIONS FLUOXETINE TRADJENTA TOFRANIL LINAGLIPTIN IM IPRAMINE FORTAMET, GLUCOPHAGE, MARPLAN GLUMETZA, RIOMET ISOCARBOXAZID METFORMIN REMERON STARLIX MIRTAZAPINE NATEGLINIDE PAMELOR ACTOS, DUETACT, ACTOPLUS MET NORTRIPTYLINE PIOGLITAZONE AND COMBINATIONS PAXIL, PEXEVA SYMLIN PAROXETINE PRAMLINTIDE NARDIL PRANDIN PHENELZINE REPAGLINIDE VIVACTIL AVANDIA, AVANDAMET, PROTRIPTYLINE HCL AVANDARYL EMSAM ROSIGLITAZONE AND COMBINATIONS SELEGILINE ONGLYZA, KOMBIGLYZE XR
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SAXAGLIPTIN AND COMBINATIONS DILATRATE-SR, ISOCHRON, JANUVIA, JANUMET ISORDIL, ISORDIL SITAGLIPTIN AND COMBINATIONS ISOSORBIDE DINITRATE IMDUR, ISMO, MONOKET SUPPLIES: ISOSORBIDE MONONITRATE MINITRAN, NITRO-BID, BLOOD GLUCOSE MONITORS
BLOOD GLUCOSE, KETONE, AND URINE NITRO-DUR, NITROGLYCERIN TEST STRIP CONTROL SOLUTIONS NITRO-TIME LANCETS NITROGLYCERIN LANCET DEVICES ANTIARRHYTHMIC AGENTS: ESTROGEN REPLACEMENT AND OTHER HORMONES MULTAQ DRONEDARONE PREMARIN RYTHMOL CONJUGATED ESTROGEN TABLETS PROPAFENONE PREMPRO, PREMPHASE ZONEGRAN CONJUGATED ESTROGEN/ ZONISAMIDE MEDROXYPROGESTERONE ESTRACE ANTICOAGULANT: ESTRADIOL TABLETS CLIMARA PRADAXA ESTRADIOL TRANSDERMAL DABIGATRAN ESTRADERM IPRIVASK ESTRADIOL TRANSDERMAL DESIRUDIN VIVELLE DOT ESTRADIOL TRANSDERMAL BLOOD THINNER MEDICINES: DIVIGEL ASPIRIN, 81 MG OR 325 MG ESTRADIOL, GEL HEPARIN EVAMIST AGGRENOX ESTRADIOL, TRANSDERMAL SPRAY ASA/DIPYRIDAMOLE COMBIPATCH PLAVIX ESTRADIOL/NORETHINDRONE, CLOPIDOGREL TRANSDERMAL FRAGMIN MAKENA DALTEPARIN HYDROXYPROGESTERONE CAPROATE LOVENOX PROVERA ENOXAPARIN MEDROXYPROGESTERONE ARIXTRA CRINONE, PROMETRIUM FONDAPARINUX PROGESTERONE EFFIENT CENESTIN PRASUGREL SYNTHETIC CONJUGATED ESTROGENS, A XARELTO ENJUVIA RIVAROXABAN SYNTHETIC CONJUGATED ESTROGENS, B BRILINTA TICAGRELOR GOUT COUMADIN, JANTOVEN ZYLOPRIM WARFARIN ALLOPURINOL COLCRYS CHOLESTEROL LOWERING COLCHICINE MEDICINES GUM DISEASE HMG-COA REDUCTASE ARESTIN MINOCYCLINE INHIBITORS: LIPITOR HEART DISEASE AND STROKE ATORVASTATIN ANTIANGINAL AGENTS MEVACOR, ALTOPREV (ORAL,TRANSDERMAL, TOPICAL): LOVASTATIN
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PRAVACHOL CANDESARTAN PRAVASTATIN TEVETEN, TEVETEN HCT CRESTOR EPROSARTAN ROSUVASTATIN AVAPRO, AVALIDE ZOCOR IRBESARTAN SIMVASTATIN COZAAR, HYZAAR LOSARTAN OTHER AGENTS: BENICAR, BENICAR HCT OLMESARTAN
PREVALITE, QUESTRAN MICARDIS, MICARDIS HCT CHOLESTYRAMINE TELMISARTAN WELCHOL DIOVAN, DIOVAN HCT COLESEVELAM VALSARTAN COLESTID
COLESTIPOL ZETIA BETA BLOCKERS EZETIMIBE AND COMBINATIONS: VYTORIN TENORMIN, TENORETIC EZETIMIBE/SIMVASTATIN ATENOLOL FENOGLIDE, LIPOFEN, TRICOR, ZEBETA, ZIAC ANTARA, TRIGLIDE BISOPROLOL FENOFIBRATE LOPRESSOR, TOPROL XL TRILIPIX METOPROLOL FENOFIBRIC ACID BYSTOLIC LOPID NEBIVOLOL GEMFIBROZIL INDERAL LA, INNOPRAN XL NIACOR, NIASPAN ER PROPRANOLOL NIACIN ADVICOR CALCIUM CHANNEL BLOCKERS: NIACIN/LOVASTATIN SIMCOR NORVASC NIACIN ER/SIMVASTATIN AMLODIPINE LOVAZA CARDIZEM, CARDIZEM LA, OMEGA-3-ACID ETHYL ESTERS CARTIA XT, TIAZAC ER DILTIAZEM ADALAT CC, PROCARDIA HIGH BLOOD PRESSURE NIFEDIPINE MEDICINES SULAR NISOLDIPINE ACE INHIBITORS CALAN, COVERA HS, ISOPTIN SR, AND COMBINATIONS: VERELAN VERAPAMIL LOTENSIN, LOTENSIN HCT BENAZEPRIL VASOTEC, VASERETIC DIURETICS AND COMBINATIONS: ENALAPRIL HYDROCHLOROTHIAZIDE MONOPRIL, MONOPRIL HCT INDAPAMIDE FOSINOPRIL MIDAMOR PRINIVIL, PRINZIDE, ZESTRIL, AMILORIDE ZESTORETIC ZAROXOLYN LISINOPRIL METOLAZONE ACCUPRIL, ACCURETIC ALDACTONE QUINAPRIL SPIRONOLACTONE DYAZIDE, MAXZIDE ACE RECEPTOR BLOCKERS TRIAMTERENE-HCTZ
AND COMBINATIONS: HIGH BLOOD PRESSURE EDARBI MEDICINES, MISCELLANEOUS: AZILSARTAN ATACAND, ATACAND HCT HYDRALAZINE
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MINOXIDIL BENEFIX TEKTURNA, TEKTURNA HCT, FACTOR IX HUMAN RECOMBINANT TEKAMLO, AMTURNIDE, CORIFACT VALTURNA FACTOR XIII ALISKIREN AND COMBINATIONS LOTREL HEREDITARY DISORDERS AMLODIPINE/BENAZEPRIL AMITRIPTYLINE HCL AZOR AMOXAPINE AMLODIPINE/OLMESARTAN DESIPRAMINE HCL TRIBENZOR DOXEPIN HCL AMLODIPINE/OLMESARTAN/ IM IPRAMINE HCL HYDROCHLOROTHIAZIDE IM IPRAMINE PAMOATE TWYNSTA MAPROTILINE HCL AMLODIPINE/TELMISARTAN PHENELZINE SULFATE EXFORGE PROTRIPTYLINE HCL TRIMIPRAMINE MALEATE AMLODIPINE/VALSARTAN ANAFRANIL EXFORGE HCT CLOMIPRAMINE HCL AMLODIPINE/VALSARTAN/ HYDROCHLOROTHIAZIDE NORPRAMIN DESIPRAMINE HCL COREG, COREG CR CARVEDILOL TOFRANIL, TOFRANIL-PM CATAPRES, CLORPRES IMIPRAMINE CLONIDINE MARPLAN CARDURA ISOCARBOXAZID DOXAZOSIN REMERON HYTRIN MIRTAZAPINE TERAZOSIN PAMELOR NORTRIPTYLINE HCL HEMATOLOGIC AGENTS NARDIL PHENELZINE SULFATE ADVATE, ADVATE H, ADVATE L, VIVACTIL ADVATE M, ADVATE SH, PROTRIPTYLINE HCL ADVATE UH EMSAM ANTIHEMOPH.FVIII PLAS/ALB FREE SELEGILINE ALPHANATE PARNATE
ANTIHEMOPHILIC FACTOR/VWF TRANYLCYPROMINE SULFATE RECOMBINATE SURMONTIL
ANTIHEMOPHILIC FACTOR, HUM REC TRIMIPRAMINE MALEATE WILATE ANTIHEMOPHILIC FACTOR/VWF XYNTHA, XYNTHA SOLOFUSE HEREDITARY ANGIOEDEMA ANTIHEMOPH.FVIII PLAS/ALB FREE AGENTS FEIBA NF, FEIBA VH IMMUNO CINRYZE ANTI-INHIBITOR COAGULANT COMP HELIXATE FS, KOGENATE FS C1 ESTERASE INHIBITOR ANTIHEMOPHILIC FACTOR, HUM IMMUNIZING AGENTS RECTE FS HUMATE-P CYTOGAM ANTIHEMOPHILIC FACTOR/VWF CYTOMEGALOVIRUS IMMUNE HEMOFIL-M, KOATE-DVI, GLOBULIN INTRAVENOUS HUMAN MONOCLATE-P INFECTION ANTIHEMOPHILIC FACTOR, HUMAN NOVOSEVEN, NOVOSEVEN RT FUNGAL COAGULATION FACTOR VIIA RECOMB ALPHANINE SD, MONONINE MEPRON ATOVAQUONE FACTOR IX BEBULIN, BEBULIN VH IMMUNO, NEBUPENT, PENTAM PROFILNINE SD PENTAMIDINE NOXAFIL FACTOR IX COMPLEX HUMAN
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POSACONAZOLE DOLASETRON MALARIA MARINOL DRONABINOL PRIMAQUINE SANCUSO COARTEM GRANISETRON ARTEMETHER/LUMEFANTRINE ANTIVERT MALARONE MECLIZINE ATOVAQUONE/PROGUANIL ZOFRAN, ZOFRAN ODT PLAQUENIL ONDANSETRON HYDROXYCHLOROQUINE TRANSDERM-SCOP, SCOPACE DARAPRIM SCOPOLAMINE PYRIMETHAMINE VIRUS OBESITY AMANTADINE DIETHYLPROPION ZOVIRAX XENICAL ACYCLOVIR ORLISTAT FAMVIR BONTRIL FAMCICLOVIR PHENDIMETRAZINE FOSCAVIR ADIPEX-P, IONAMIN FOSCARNET PHENTERMINE CYTOVENE GANCICLOVIR ORGAN TRANSPLANT REJECTION TAMIFLU IMURAN, AZASAN OSELTAMIVIR VALTREX AZATHIOPRINE NULOJIX VALACYCLOVIR VALCYTE BELATACEPT SANDIMMUNE, NEORAL VALGANCICLOVIR RELENZA CYCLOSPORINE CELLCEPT ZANAMIVIR MYCOPHENOLATE MOFETIL KIDNEY DISEASE, MYFORTIC HIGH PHOSPHATE LEVELS MYCOPHENOLIC ACID RAPAMUNE PHOSLO, PHOSLYRA SIROLIMUS CALCIUM ACETATE PROGRAF FOSRENOL TACROLIMUS LANTHANUM RENVELA, RENAGEL PREGNANCY SEVELAMER BIRTH CONTROL MEDICINES MULTIPLE SCLEROSIS TAKEN BY MOUTH BIRTH CONTROL DEVICES: GLIENYA DIAPHRAGMS, SKIN PATCH SYSTEMS, FINGOLIMID INJECTABLE BIRTH CONTROL, COPAXONE INTRAUTERINE SYSTEMS, AND GLATIRAMER ACETATE IMPLANTS AVONEX, BETASERON, EXTAVIA, RESPIRATORY DISORDERS REBIF INTERFERON BETA BROVANA AUBAGIO ARFORMOTEROL TARTRATE TERIFLUNOMIDE FORADIL, PERFOROMIST FORMOTEROL FUMARATE NAUSEA AND DIZZINESS XOLAIR PROCHLORPERAZINE OMALIZUMAN PROMETHAZINE DALIRESP EMEND ROFLUMILAST APREPITANT SEREVENT DISKUS ANZEMET SALMETEROL XINAFOATE
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RHEUMATOID ARTHRITIS, PYLERA PROGRESSION OF BISMUTH/METRONIDAZOLE/ TETRACYCLINE ORENCIA CARAFATE ABATACEPT SUCRALFATE HUMIRA PROTON PUMP INHIBITORS: ADALIMUMAB RIDAURA NEXIUM AURANOFIN ESOMEPRAZOLE ENBREL PREVACID ETANERCEPT LANSOPRAZOLE REMICADE PROTONIX INFLIXIMAB PANTOPRAZOLE RHEUMATREX, TREXALL ACIPHEX METHOTREXATE RABEPRAZOLE CUPRIMINE PENICILLAMINE VACCINES ACTEMRA VACCINES: TOCILIZUMAB DIPHTHERIA, PERTUSSIS, TETANUS, HAEMOPHILUS INFLUENZAE B, SMOKING-CESSATION THERAPY HEPATITIS A AND B, HUMAN PAPILLOMAVIRUS, INFLUENZA, ZYBAN MEASLES, MENINGOCOCCAL, BUPROPION MUMPS, PNEUMOCOCCAL, NICOTROL POLIOVIRUS, ROTAVIRUS, RUBELLA, NICOTINE PRODUCTS AND VARICELLA CHANTIX VARENICLINE VITAMINS OR MINERALS, LOW LEVELS OF ULCER DISEASE CALCIUM H2-ANTAGONISTS: FOLIC ACID, 0.4 TO 0.8 MG CIMETIDINE IRON PEPCID MAGNESIUM FAMOTIDINE MULTIVITAMIN PRODUCTS AXID POTASSIUM BICARBONATE/CITRIC ACID POTASSIUM CHLORIDE NIZATIDINE ZANTAC PRESCRIPTION PRENATAL VITAMINS VITAMINS: A, B, B1, B6, B12, D, K RANITIDINE ZINC MISCELLANEOUS AGENTS:
Express Scripts Compound Management Program According to the FDA, compounding is the practice in which a licensed pharmacist combines, mixes, or alters ingredients in response to a prescription to create a medication tailored to the medical needs of an individual patient. The active ingredients within the compound are FDA approved, but the FDA does not approve the quality, safety and efficacy of the compound with multiple ingredients.
Effective 9/15/2014, inVentiv implemented a compound management program which excludes some of these compound medications from the prescription benefit plan. If any ingredient in the compound is on the list of excluded ingredients, the compound will not be covered. The list of excluded compound ingredients is subject to change as reviewed by Expressed Scripts.
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Express Scripts Specialty Pharmacy Services
Specialty medications are drugs that are used to treat complex conditions such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis and rheumatoid arthritis. Accredo Health Group, Inc., an Express Scripts specialty pharmacy, is composed of therapy-specific teams that provide an enhanced level of individual service to patients with special therapy needs. Counseling, scheduled delivery and safety checks are just a few of the services that Accredo provides.
When You Need to File a Claim Form
If you obtain a prescription drug from a non-participating retail pharmacy (i.e., a pharmacy that is not in the Express Scripts network or in the custom retail network), you must pay the non- participating pharmacy the full cost of the prescription. Then, you may submit a paper claim form along with original receipts directly to Express Scripts for reimbursement of the covered expenses.
To obtain a claim form, call Express Scripts’ toll-free Member Services number 1-800-341-4576 or visit Express-Scripts.com to access and print claim forms. You should submit your claim form to:
Express Scripts P.O. Box 1711 Lexington, KY 40512
Your claim will be reimbursed according to the cost-sharing provisions of your prescription drug coverage applicable to prescriptions purchased at an Express Scripts retail pharmacy.
To find out if your pharmacy is affiliated with Express Scripts, for instructions on filing claims, for refills and for status of an order call Express Scripts member Services at 1-800-341-4576.
Limitations
If you are uncertain whether the drug that your physician has prescribed is covered by the Prescription Benefit Plan and Express Scripts, please call Express Scripts at 1-800-341-4576 to confirm.
Supply Limits Some prescription drug medications are subject to supply limits based on Express Scripts’ criteria. Supply limits, which are subject to periodic review and modification by Express Scripts, may restrict the amount dispensed per prescription order or refill and/or the amount dispensed for each month’s supply. Limits are based on manufacturer suggested prescribing guidelines and may change from time to time. This does not affect the day supply limits which are part of the plan design and would only change if the plan design is changed. Currently the days supply limit in place is a 30-day supply at retail and, for maintenance drugs, a 90-day supply by mail through Express Scripts Pharmacy (or at a local pharmacy participating in the custom retail network – Wal-Mart, CVS, K-Mart and Kroger). You may obtain information on maximum dispensing limits by either visiting Express-Scripts.com or by contacting Express Scripts at 1-800-341-4576.
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Quantity Management To help promote safe and effective drug therapy consistent with plan limits, certain covered medications may have quantity restrictions. These quantity restrictions are based on product labeling or clinical guidelines and are subject to periodic review and change. Examples include anti-migraine drugs, rheumatoid arthritis and osteoarthritis drugs, impotence drugs, sleep aids and pain management drugs. Examples of these medications include, but are not limited to: l Erectile dysfunction agents (Caverject®, Edex®, Muse®, Cialis®, Levitra®, Viagra®, Staxyn®) l Hormones (Samsca®) l Migraine agents (Amerge®, Axert®, Frova®, Imitrex®, Maxalt®, Migranal® NS, Relpax®, Sumavel DosePro™, Treximet®, Zomig®) l Non-narcotic analgesics (Mobic and Ketorolac ).
Prior Authorization For certain medications, the Prescription Benefit Plan requires a coverage review or “prior authorization” by Express Scripts before benefits will be paid. This review uses plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective.
There are other medications that may be covered, but with limits (for example, only for a certain amount or for certain uses), unless you receive approval through a coverage review. During this review, Express Scripts asks your doctor for more information than what is on the prescription before the medication may be covered under your plan.
The list of medications that require prior authorization will change from time to time, and drugs that do not require prior authorization may require it in the future. To find out whether a medication requires a coverage review, log in to Express-Scripts.com anytime, select “Price a Medication” from the left-hand menu and search for your medication. On the pricing results page, select “View Coverage Notes” to see coverage details.
Prior authorizations are typically approved for a one year period, unless otherwise noted.
Your physician may call Express Scripts at 1-800-753-2851 to request a prior authorization approval.
Current prior authorization drugs include: l Appetite and weight loss (Adipex®, Bontril®, Didrex®, Sanorex®, Suprenza®, Tenuate®, Xenecal®) l Anti-narcolepsy agents (Provigil®, Nuvigil®) l Cancer therapy (Afinitor®, Caprelsa®, Gleevec®, Revlimid®, Tarceva®, Temodar®) l Non-cosmetic Botulinum toxin (Botox®, Dysport®, Myobloc®, Xeomin®)
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l Acne (Retin-A®, Tazorac®)
l Growth hormones (Genotropin®, Humatrope®, Increlex®Norditropin®, Nutropin®, Omnitrope®, Saizen®, Serostim®, TevTropin®, Zorptive®)
l Miscellaneous Specialty (Incivek®, Victrelis®, Epogen®, Procrit®, Neupogen®, Avonex®, Rebif®, Betaseron®, Copaxone®, Tysabri®, Ampyra®, Cimzia®, Enbrel®, Humira®, Kineret®, Orencia®, Remicade®, Rituxan®, Simponi®, Xolair®).
The following medications may also require a coverage review (prior authorization) based on:
l Whether certain criteria have been met, such as age, sex or condition, and/or
l Whether treatment of an alternate therapy or course of treatment has failed or is not appropriate.
In either of these instances, Express Scripts pharmacists will review the prescription to ensure that all criteria required for a certain medication have been met. If the criteria have not been met, a coverage review will be required. If so, Express Scripts will automatically notify the pharmacist, who in turn will tell you that the prescription needs to be reviewed for prior authorization. Categories of medications included in this program are:
l COX-2 inhibitor (Celebrex)®)
l Lipid and cholesterol lowering agents (Altoprev®, Lescol XL®, Livalo®)
l Narcotic analgesics (Actiq®, Fentora®, Onsolis®)
l Osteoporosis (Forteo®)
l Angiotensin II receptor blockers (Atacand®, Atacand HCT®, Edarbi®, Micardis®, Micardis HCT®, Teveten®, Teveten HCT®)
l Hypnotic agents (Edluar®, Lunesta®, Rozerem®, Zolpimist®)
l Intranasal steroids (Beconase AQ®, Omnaris®, Rhinocort Aqua®, Veramyst®)
l Osteoporosis (Actonel®, Actonel with Calcium®)
l Migraine treatment (Axert®, Frova®, Treximet®, Zomig ZMT®)
l Proton pump inhibitors (Nexium®, Zegerid®, Prilosec® packets, Prevacid® packets and solutabs, Protonix® packets, Aciphex®, Dexilant®)
Step Therapy Requirements Step therapy is a program designed to help people with certain health conditions that require maintenance medications to save money by using the most cost effective treatments. It requires that newly diagnosed individuals first try a generic drug to treat their medical condition. Then,
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based on your doctor’s review, if necessary, move to a brand name drug. However, if a brand drug is dispensed and there is a generic available you will pay the cost difference between the generic and the brand drug. Some of the drugs listed in the “Prior Authorization” section fall into this step therapy program. Please contact Express Scripts Member Services at 1-800-753-2851 for more specific information on the program.
Drugs That Are Not Covered The following are not covered under the Prescription Benefit Plan:
l Therapeutic devices or appliances, including hypodermic needles, syringes (except those used for diabetes management), support garments, ostomy supplies, durable medical equipment and non-medical substances regardless of intended use
l Any over-the-counter medicine, unless otherwise specified
l Blood products, blood serum
l Experimental medicines do not have NDC numbers and therefore, are not covered
l Drugs used for cosmetic purposes.
Drug Coverage Provided by your inVentiv Health Medical Plan Prescription drugs that are dispensed to you while in a hospital, either as an inpatient or as an outpatient at an approved outpatient facility, or while a patient in your doctor’s office are covered under your inVentiv Health medical plan. You must follow normal medical claim procedures for reimbursement for these drugs.
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Additional Rules that Apply to th is Prescription Benefit Plan
Breast Reconstruction Benefits
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under The Women’s Health and Cancer Rights Act (“WHCRA”) of 1998.
If you (or a covered dependent) are receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: l All stages of reconstruction of the breast on which the mastectomy was performed l Surgery and reconstruction of the other breast to produce a symmetrical appearance l Prostheses, and l Treatment of physical complications of the mastectomy, including lymphedemas.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.
If you would like more information, contact your plan administrator by email at [email protected].
Maternity Admissions
Under federal law, group health plans and health insurance issuers generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to (a) less than 48 hours following a vaginal delivery, (b) or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and health care issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
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Qualified Medical Child Support Order (QMCSO)
The Prescription Benefit Plan will comply with all the terms of a qualified medical child support order (QMCSO). A QMCSO is an order or judgment from a court or administrative body that directs the plan to cover a child of a participant under a medical plan, and, as a result, under the Prescription Benefit Plan. Federal law provides that a medical child support order must meet certain form and content requirements in order to be a qualified medical child support order. When an order is received, each affected participant and each child (or the child’s representative) covered by the order will be given notice of the receipt of the order and a copy of the plan’s procedure for determining if the order is valid. Coverage under the plan pursuant to a medical child support order will not become effective until the plan administrator determines that the order is a QMCSO. If you have any questions or if you would like to receive a copy of the written procedure for determining whether a QMCSO is valid, please contact the Benefits Group.
Subrogation and Right of Reimbursement
The plan has a right to subrogation and reimbursement as defined in the medical plan SPD. Please refer to that SPD or contact your plan administrator for more information.
Coordination of Benefits If You Are Covered by More Than One Medical Plan
In situations where you have other primary coverage, the Prescription Benefit Plan has a provision to ensure that payments from all of your group medical plans do not exceed the amount the Prescription Benefit Plan would pay if it were your only coverage.
The coordination of benefits rules described in your inVentiv medical plan SPD will also apply to the Prescription Benefit Plan. Please refer to that document or contact the plan administrator at [email protected] for more information on coordinating other coverage you may have.
Circumstances That May Result in Denial, Loss, Forfeiture or Rescission of Benefit
Under certain circumstances, plan benefits may be denied or reduced from those described in this SPD. Cancellation or discontinuance of coverage is permitted if it has only a prospective effect on coverage, or is effective retroactively due to failure to pay required premiums or contributions. For instance:
Rescission of coverage is cancellation or discontinuance of coverage retroactively for reasons other than failure to pay required premiums or contributions. For example, rescission of coverage may be permitted in limited circumstances such as fraud or the intentional misrepresentation of a material fact. If coverage is subject to rescission, all affected participants must be provided with a written notice at least 30 days prior to the date of rescission.
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How to Reach Your Pro v id e r
Plan Telephone Number Website Address Prescription Benefit Plan 1-800-341-4576 Express-Scripts.com
inVentiv Health Choice Fund 1-855-281-1204 mycigna.com Open Access Plus HSA HSA Trustee – HSA Bank 1-855-281-1204 hsabank.com
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Continuation of Your Medical Coverage
You may be able to continue coverage under the Prescription Benefit Plan under certain conditions if you choose to continue your inVentiv Health medical plan coverage. Medical plan coverage may be continued under certain circumstances under the federal Consolidated Omnibus Reconciliation Act of 1985 (COBRA).
Continuation Coverage Rights Under COBRA
Introduction This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your covered spouse and dependent children, and what you need to do to protect the right to receive it. inVentiv Health has also decided to offer COBRA-like continuation coverage to eligible domestic partners and the dependent children of domestic partners who are covered at the time of a qualifying event. You must elect COBRA continuation coverage for your inVentiv Medical Choice Fund Open Access Plus HSA Plan to also continue your Prescription Benefit Plan coverage. You cannot make a separate COBRA election to continue only Prescription Benefit Plan coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose coverage under the plan. It can also become available to your spouse and dependent children who are covered under the plan when they would otherwise lose such coverage.
What Is COBRA Continuation Coverage COBRA continuation coverage is a continuation of plan coverage when you would otherwise lose such coverage because of a life event known as a “qualifying event.” Specific qualifying events are listed below. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if covered under the plan at the time of a qualifying event, and such coverage is lost because of the qualifying event. Additionally, a child who is born to or adopted or placed for adoption with you (the covered employee) during the COBRA continuation coverage period is also considered a qualified beneficiary, provided that you elected COBRA continuation coverage for yourself. Under the plan, qualified beneficiaries must pay for the COBRA continuation coverage they elect, as described in the “Paying for COBRA Continuation Coverage” section.
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COBRA Qualifying Events If you are an employee, you will become a qualified beneficiary if you lose coverage under the plan because either of the following qualifying events happens:
l Your hours of employment are reduced
l Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose coverage under the plan because any of the following qualifying events happens:
l Your spouse dies
l Your spouse’s hours of employment are reduced
l Your spouse’s employment ends for any reason other than his or her gross misconduct
l You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the plan because any of the following qualifying events happens:
l The parent-employee dies
l The parent-employee’s hours of employment are reduced
l The parent-employee’s employment ends for any reason other than his or her gross misconduct
l The parents become divorced or legally separated
l The child stops being eligible for coverage under the plan as a “dependent child.”
For this purpose, “lose coverage” means to cease to be covered under the same terms and conditions as in effect immediately before the qualifying event. For example, any increase in the premium or contribution that must be paid by you (or your covered spouse or dependent children) for coverage under the plan that results from the occurrence of a qualifying event is a loss of coverage.
Giving Notice that a COBRA Qualifying Event (or Second Qualifying Event) Has Occurred The plan will offer COBRA continuation coverage to qualified beneficiaries only after the plan administrator has been timely notified that a qualifying event has occurred. When the qualifying event is the employee’s termination of employment (other than for gross misconduct) or reduction of work hours, or death of the employee, the employer must notify the plan administrator of the qualifying event.
Important Note: For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the plan administrator in writing within 60 days after the later of: 1) the date of qualifying event (or
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second qualifying event) or 2) the date the qualified beneficiary loses (or would lose) coverage under the plan as a result of the qualifying event (or second qualifying event). You must provide this notice to ADP COBRA administration at www.benefitsdirect.adp.com or call 1-800-526-2720.
How Is COBRA Continuation Coverage Provided Once the plan administrator receives timely notice that a qualifying event has occurred, COBRA continuation coverage will be offered (through a “COBRA Continuation Coverage Election Notice”) to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.
If coverage under the plan is changed for active employees, the same changes will apply to individuals receiving COBRA continuation coverage. Qualified beneficiaries also may change their coverage elections during the annual enrollment periods or at other times under the plan to the same extent that active employees may do so.
Duration of COBRA Continuation Coverage COBRA continuation coverage is a temporary continuation of health coverage. When the qualifying event is the employee’s termination of employment (other than for gross misconduct) or reduction of work hours, COBRA continuation coverage for the employee and the employee’s covered spouse and dependent children generally lasts for only up to a total of 18 months.
When the qualifying event is the death of the employee, or your divorce or legal separation, COBRA continuation coverage for the employee’s spouse and/or dependent children (but not the employee) lasts for up to a total of 36 months. Also, the employee’s dependent children are entitled to COBRA continuation coverage for up to 36 months after losing eligibility as a dependent child under the terms of the plan.
There are three ways in which the 18-month period of COBRA continuation coverage due to the employee’s termination of employment or reduction of work hours can be extended. l Employee’s Medicare Entitlement Occurs Before a Qualifying Event That Is Employee’s Termination of Employment or Reduction of Work Hours: When the qualifying event is the employee’s termination of employment (other than for gross misconduct) or reduction of work hours, and the employee became entitled to (i.e., enrolled in) Medicare benefits less than 18 months before the qualifying event (even if Medicare entitlement was not a qualifying event for the employee’s spouse or dependent children because their coverage was not lost), COBRA continuation coverage for qualified beneficiaries other than the employee lasts for up to 36 months after the date of the employee’s Medicare entitlement. For example, if the employee becomes entitled to Medicare eight months before the date his or her employment terminates, COBRA continuation coverage for the employee’s covered spouse and dependent children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). l Disability Extension: If you, your spouse or any of your dependent children covered under the plan is determined by the Social Security Administration (SSA) to be disabled on the date of the employee’s termination of employment or reduction of work hours, or at any time during
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the first 60 days of COBRA continuation coverage due to such qualifying event, each qualified beneficiary (whether or not disabled) may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. To qualify for this disability extension, you must notify the plan administrator in writing of the person’s disability status BOTH: 1) within 60 days after the latest of: i) the date of the disability determination by the SSA, ii) the date on which the qualifying event occurs, iii) the date on which you lose (or would lose) coverage under the plan, or iv) the date on which you are informed of both the responsibility to provide this notice and the plan’s procedures for providing such notice to the plan administrator, AND 2) before the original 18-month COBRA continuation coverage period ends. Also, if Social Security determines that the qualified beneficiary is no longer disabled, you are required to notify the plan administrator in writing within 30 days after this determination. If these procedures are not followed or if the notice is not provided in writing to the plan administrator within the required period, you will not receive a disability extension of COBRA continuation coverage. l Second Qualifying Event Extension: If the employee’s spouse and/or dependent children experience a second qualifying event while receiving the initial 18 months of COBRA continuation coverage, the employee’s spouse and dependent children (but not the employee) can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months from the initial qualifying event, if timely notice of the second qualifying event is given to the plan. This extension may be available to the employee’s spouse and any dependent children receiving COBRA continuation coverage if the employee or former employee dies, or gets divorced or legally separated, or if the dependent child stops being eligible under the plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the plan had the first qualifying event not occurred. If a second qualifying occurs at any time during the 29-month disability continuation period (as described above), then each qualified beneficiary who is the employee’s spouse or dependent child (whether or not disabled) may further extend COBRA continuation coverage for seven more months, for a total of up to 36 months from the employee’s termination of employment or reduction of work hours. (See the “Giving Notice That a COBRA Qualifying Event (or Second Qualifying Event) Has Occurred” section for important details on the proper procedures and timeframes for giving this notice to the plan administrator.) If these procedures are not followed or if the notice is not provided to the plan administrator within the required 60-day period, you will not receive an extension of COBRA continuation coverage due to a second qualifying event.
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The table below provides a summary of the COBRA provisions outlined in this section.
Maximum Continuation Period
Qualifying Events That Result in Loss of Coverage Employee Spouse Child
Employee’s reduction of work hours (e.g., full-time to part-time) 18 months 18 months 18 months
Employee’s termination of employment for any reason (other 18 months 18 months 18 months than gross misconduct) Employee or employee’s covered spouse or dependent child is 29 months 29 months 29 months disabled (as determined by the Social Security Administration) at the time of the qualifying event, or becomes disabled within the first 60 days of COBRA continuation coverage that begins as a result of termination of employment or reduction of work hours Employee dies N/A 36 months 36 months
Employee and spouse legally separate or divorce N/A 36 months 36 months
Employee becomes entitled to Medicare within 18 months N/A 36 months1 36 months1 before termination of employment or reduction in work hours (even if such Medicare entitlement was not a qualifying event for the covered spouse or dependent child because their coverage was not lost) Child no longer qualifies as a dependent child under the terms N/A N/A 36 months of the plan
1 36-month period is counted from the date the employee becomes entitled to Medicare.
Electing COBRA Continuation Coverage You and/or your covered spouse and dependent children must choose to continue coverage within 60 days after the later of the following dates:
l The date you and/or your covered spouse and dependent children would lose coverage under the plan as a result of the qualifying event, or
l The date inVentiv Health notifies you and/or your covered spouse and dependent children (through a “COBRA Continuation Coverage Election Notice”) of your right to choose to continue coverage as a result of the qualifying event.
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Paying for COBRA Continuation Coverage Cost: Generally, each qualified beneficiary is required to pay the entire cost of COBRA continuation coverage. The cost for continuing Prescription Benefit Plan coverage under COBRA is included in the COBRA cost of the continuing inVentiv Health medical plan you elect.
The cost of COBRA continuation coverage is 102% of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving COBRA continuation coverage. With regards to the 11-month disability extension of COBRA continuation coverage, the cost of coverage for the 19th through 29th months of coverage is: 1) 150% of the cost of group health plan coverage for all family members participating in the same coverage option as the disabled individual’s, and 2) 102% for any family members participating in a different coverage option from the disabled individual’s, except as provided in the next sentence. If a second qualifying event occurs during the first 18 months of coverage, the 102% rate applies to the full 36 months even if the qualified beneficiary is disabled. However, if a second qualifying event occurs during the otherwise applicable disability extension period (that is, during the 19th through 29th months), then the cost of coverage for the 19th through 36th months of coverage is 1) the 150% rate for all family members participating in the same coverage option as the disabled qualified beneficiary’s, and 2) the 102% rate for any family members in a different coverage option from the disabled qualified beneficiary’s.
Premium Due Dates: If you elect COBRA continuation coverage, you must make your initial payment for continuation coverage (including all premiums due but not paid) no later than 45 days after the date of your election. (This is the date the COBRA Election Notice is post-marked, if mailed.) If you do not make your initial payment for COBRA continuation coverage within 45 days after the date of your election, you will lose all COBRA continuation coverage rights under the plan. Payment is considered made on the date it is sent to the plan.
After you make your initial payment for COBRA continuation coverage, you will be required to make periodic payments for each subsequent coverage period. The premium due date and exact amount due each coverage period for each qualified beneficiary will be shown in the COBRA Election Notice you receive. Although periodic payments are due on the dates shown in the COBRA Election Notice, you will be given a grace period of 30 days after the first day of the coverage period to make each periodic payment. Your COBRA continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment.
If you elect COBRA continuation coverage but then fail to make an initial or periodic payment before the end of the 45- or 30-day grace period respectively for that coverage period, you will lose all rights to COBRA continuation coverage under the plan, and such coverage will be terminated retroactively to the last day for which timely payment was made (if any).
Trade Act of 2002 The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for Trade Adjustment Assistance (TAA) because their employment is adversely affected by international trade and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC) (eligible individuals). Under these tax provisions, TAA-eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including COBRA continuation coverage. If you
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have questions about these tax provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866- 626-4282. More about the Trade Act is also available at www.doleta.gov\\tradeact.
If you are an employee eligible to receive TAA or Alternative Trade Adjustment Assistance (ATAA) benefits, and you (i) lost group health plan coverage due to a job loss that resulted in eligibility for TAA/ATAA benefits, and (ii) failed to elect COBRA during your original 60-day COBRA election period (as described above), you may be eligible for a second 60-day COBRA election period. The second election period begins on the first day of the month in which you are certified for TAA/ATAA benefits provided this second election is made within six months of the initial loss of group health coverage.
If you elect COBRA under this second election period, your maximum period of continuation coverage will be based on the date of your original qualifying event, not on the date of your election. However, your coverage will begin on the first day of the second election period and not on the date your group health coverage was originally lost.
When COBRA Continuation Coverage Ends COBRA continuation coverage for any person will end when the first of the following occurs: l The applicable 18-, 29- or 36-month COBRA continuation coverage period ends l Any required premium is not paid on time l After the date COBRA continuation coverage is elected, a qualified beneficiary first becomes covered (as an employee or otherwise) under another group health plan (not offered by inVentiv Health) that does not contain any exclusion or limitation affecting a qualified beneficiary’s preexisting condition, or the other group health plan’s preexisting condition limit or exclusion does not apply or is satisfied because of the HIPAA rules l After the date COBRA continuation coverage is elected, a qualified beneficiary first becomes entitled to (i.e., enrolled in) Medicare benefits (under Part A, Part B, or both). This does not apply to other qualified beneficiaries who are not entitled to Medicare l In the case of extended COBRA continuation coverage due to a disability, there has been a final determination, under the Social Security Act, that the qualified beneficiary is no longer disabled. In such a case, the COBRA continuation coverage ceases on the first day of the month that begins more than 30 days after the final determination is issued, unless a second qualifying event has occurred during the first 18 months l For newborns and children adopted by or placed for adoption with you (the employee) during your COBRA continuation coverage, the date your COBRA continuation coverage period ends unless a second qualifying event has occurred l inVentiv Health ceases to provide any group health plan for its employees and retirees.
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COBRA continuation coverage may also be terminated for any reason the plan would terminate coverage of a participant or beneficiary not receiving COBRA continuation coverage (such as fraud).
If You Have Questions Questions concerning your plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address Changes In order to protect your rights as well as the rights of your spouse and dependent children, you should keep the plan administrator informed of any address changes for your spouse and/or dependent children. You should also keep a copy for your records of any notices you send to the plan administrator.
Plan Contact Information inVentiv Health, Inc. Plan Administrator 500 Atrium Drive Somerset, NJ 08873 [email protected]
Continuation of Coverage for Employees in the Uniformed Services (USERRA)
The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) guarantees certain rights to eligible employees who enter military service. The terms “Uniformed Services” or “Military Service” mean the Armed Forces (i.e., Army, Navy, Air Force, Marine Corps, Coast Guard), the reserve components of the Armed Services, the Army National Guard and the Air National Guard when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of war or national emergency.
Upon reinstatement, you are entitled to the seniority, rights and benefits associated with the position held at the time employment was interrupted, plus any additional seniority, rights and benefits that you would have attained if employment had not been interrupted.
If your military leave is for less than 31 days, you may continue your medical and prescription drug coverage by paying the same amount charged to active employees for the same coverage. If your leave is for a longer period of time, you will be charged up to the full cost of coverage plus a 2% administrative fee.
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The maximum period of continuation coverage available to you and your eligible dependents is the lesser of (a) 24 months after the leave begins or (b) the period running from the day the leave begins through the day the leave ends.
When you go on military leave, your work hours are reduced. As a result, you and your covered dependents may become eligible for COBRA. Any COBRA continuation period for which you are eligible will run concurrently with any USERRA continuation period for which you are eligible.
If you choose not to continue your medical coverage, and along with it, your prescription drug coverage, while on military leave, you are entitled to reinstated health coverage with no waiting periods or exclusions (however, an exception applies to service-related disabilities) when you return from leave.
In general, to be eligible for the rights guaranteed by USERRA, you must: l Return to work on the first full, regularly scheduled workday following your leave, safe transport home, and an eight-hour rest period, if you are on a military leave of less than 31 days l Return to or reapply for employment within 14 days of completion of such period of duty, if your absence from employment is from 31 to 180 days l Return to or reapply for employment within 90 days of completion of your period of duty, if your military service lasts more than 180 days.
Continuation of Coverage While on a Family and Medical Leave (FMLA)
Under the federal Family and Medical Leave Act (FMLA), updated as of March 8, 2013, employees are generally allowed to take up to 12 weeks of unpaid leave for certain family and medical situations and continue their elected medical coverage benefits during this time. The company is required to maintain group health insurance coverage for an employee on FMLA leave: a) if the employee had such insurance before taking the leave, and b) on the same terms as if the employee had continued to work. If applicable, employees may need to make arrangements to pay their share of health insurance premiums while on leave. In some instances, the company may recover premiums it paid to maintain health coverage for an employee who fails to return to work from FMLA leave. Please refer to your inVentiv Health medical plan SPD for information on paying for your medical coverage during your period of leave. If you elect to continue your medical plan coverage under those rules, your Prescription Benefit Plan coverage continues automatically.
If you are eligible, you can take up to 12 weeks of unpaid leave in a 12-month period for the following reasons: l For the birth and care of your newborn child or a child that is placed with you for adoption or foster care l For the care of a spouse, child, or parent who has a serious health condition l For your own serious health condition
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l For “any qualifying exigency” (a qualifying urgent situation or pressing need) arising out of the fact that the spouse, son, daughter or parent of the employee is on active duty or called to active duty status as a member of the regular Armed Forces, the National Guard or Reserves in support of a contingency operation. For all qualifying exigency leave, the military member must be deployed to a foreign country; or l For any qualifying exigency for parental care leave to provide care necessitated by the covered active duty of the military member for the military member’s parent who is incapable of self-care.
In addition, an eligible employee who is the spouse, son, daughter, parent or next of kin (that is, nearest blood relative) of a covered service member who is recovering from a serious illness or injury sustained in the line of duty on active duty is entitled to up to 26 weeks of leave in a single 12-month period to care for the service member. An eligible employee can also take leave to care for certain veterans with a serious injury or illness incurred or aggravated in the line of duty while on active duty and that manifested before or after the veteran left active duty. Military caregiver leave is also allowed for an eligible employee to care for current service members with serious injuries or illnesses that existed prior to service and that were aggravated by service in the line of duty on active duty.
This military caregiver leave is available during “a single 12-month period” during which an eligible employee is entitled to a combined total of 26 weeks for all types of FMLA leave. See U.S. Department of Labor, Employment Standards Administration, Wage and Hour Division, for Fact Sheets #28 and #28A, which provide further details on FMLA (http://www.dol.gov/compliance/laws/comp-fmla.htm).
Depending on the state where you live, the number of weeks of unpaid leave available to you for family and medical reasons may vary based on state law requirements.
HIPAA Certificate of Creditable Coverage
If you lose your coverage under your inVentiv Health medical plan (including this Prescription Benefit Plan), you may request a HIPAA certificate of creditable coverage showing how long you had been covered under the medical plan up to 24 months after your coverage has ended. You may also request a HIPAA certificate of creditable coverage at any time while covered under the plan.
To request a HIPAA certificate of creditable coverage you may contact the inVentiv Health Benefits Group by email at [email protected].
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Cla im s Pro c e d u re s
You must use and exhaust this plan’s administrative claims and appeals procedure before bringing a suit in either state or federal court. Similarly, failure to follow the plan’s prescribed procedures in a timely manner will also cause you to lose your right to sue regarding an adverse benefit determination.
Non-Urgent Claims
A pre-service claim is a request for coverage of a medication when your plan requires you to obtain approval before a benefit will be payable. For example, a request for prior authorization is considered a pre-service claim. For these types of claims (unless urgent as described below) you will be notified of the decision not later than 15 days after receipt of a pre-service claim that is not an urgent care claim, provided you have submitted sufficient information to decide your claim. A post-service claim is a request for coverage or reimbursement when you have already received the medication. For post-service claims, you will be notified of the decision no later than 30 days after receipt of the post-service claim, as long as all needed information was provided with the claim.
If sufficient information to complete the review has not been provided, you will be notified that the claim is missing information within 15 days from receipt of your pre-service claim and 30 days from receipt of your post-service claim. You will have 45 days to provide the information. If all of the needed information is received within the 45-day time frame, you will be notified of the decision not later than 15 days after the later of receipt of the information or the end of that additional time period. If you don’t provide the needed information within the 45-day period, your claim is considered “deemed” denied and you have the right to appeal as described below.
If your claim is denied, in whole or in part, the denial notice will include information to identify the claim involved, the specific reasons for the decision, the plan provisions on which the decision is based, a description of applicable internal and external review processes and contact information for an office of consumer assistance or ombudsman (if any) that might be available to assist you with the claims and appeals processes and any additional information needed to perfect your claim. You have the right to a full and fair impartial review of your claim. You have the right to review your file and the right to receive, upon request and at no charge, the information used to review your claim. If you do not speak English well and require assistance in your native language to understand the letter or your claims and appeals rights, please call 1-800-753-2851. In addition, you may also have the right to request a written translation of your letter if 10 percent or more of the people in the county where notification is mailed do not speak English well and are fluent in the same non-English language (e.g., Spanish, Chinese, Navajo or Tagalog). If you are not satisfied with the decision on your claim (or your claim is deemed denied), you have the right to appeal as described below.
Urgent Claims (Expedited Reviews)
An urgent care claim is defined as a request for treatment when, in the opinion of your attending provider, the application of the time periods for making non-urgent care determinations could
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seriously jeopardize your life or health or your ability to regain maximum function or would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of your claim. In the case of a claim for coverage involving urgent care, you will be notified of the benefit determination within 72 hours of receipt of the claim provided there is sufficient information to decide the claim.
If the claim does not contain sufficient information to determine whether, or to what extent, benefits are covered, you will be notified within 24 hours after receipt of your claim that information is necessary to complete the claim. You will then have 48 hours to provide the information and will be notified of the decision within 48 hours of receipt of the information. If you don’t provide the needed information within the 48-hour period, your claim is considered “deemed” denied and you have the right to appeal as described below.
If your claim is denied, in whole or in part, the denial notice will include information to identify the claim involved, the specific reasons for the decision, the plan provisions on which the decision is based, a description of applicable internal and external review processes and contact information for an office of consumer assistance or ombudsman (if any) that might be available to assist you with the claims and appeals processes and any additional information needed to perfect your claim. You have the right to a full and fair impartial review of your claim. You have the right to review your file and the right to receive, upon request and at no charge, the information used to review your claim. If you do not speak English well and require assistance in your native language to understand the letter or your claims and appeals rights, please call 1-800-753-2851. In addition, you may also have the right to request a written translation of your letter if 10 percent or more of the people in the county where notification is mailed do not speak English well and are fluent in the same non-English language (e.g., Spanish, Chinese, Navajo or Tagalog). If you are not satisfied with the decision on your claim (or your claim is deemed denied), you have the right to appeal as described below.
Non-Urgent Appeal
If you are not satisfied with the decision regarding your benefit coverage or you receive an adverse benefit determination following a request for coverage of a prescription benefit claim (including a claim considered “deemed” denied because missing information was not timely submitted), you have the right to appeal the adverse benefit determination in writing within 180 days of receipt of notice of the initial coverage decision. An appeal may be initiated by you or your authorized representative (such as your physician). To initiate an appeal for coverage, provide in writing: l Your name l Member ID l Phone number l The prescription drug for which benefit coverage has been denied, and l Any additional information that may be relevant to your appeal.
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This information should be mailed to Express Scripts, P.O. Box 631850, Irving, TX 75063-0030 Attn: Appeals. A decision regarding your appeal will be sent to you within 15 days of receipt of your written request for pre-service claims or 30 days of receipt of your written request for post- service claims. If your appeal is denied, the denial notice will include information to identify the claim involved, the specific reasons for the decision, the plan provisions on which the decision is based, a description of applicable internal and external review processes and contact information for an office of consumer assistance or ombudsman (if any) that might be available to assist you with the claims and appeals processes and any additional information needed to perfect your claim. You have the right to a full and fair impartial review of your claim. You have the right to review your file and the right to receive, upon request and at no charge, the information used to review your appeal. You also have the right to request the diagnosis code and treatment code and their corresponding meanings which will be provided to you if available (i.e., if the information was submitted, relied upon, considered or generated in connection with the determination of your claim). If you do not speak English well and require assistance in your native language to understand the letter or your claims and appeals rights, please call 1-800-753-2851. In addition, you may also have the right to request a written translation of your letter if 10 percent or more of the people in the county where notification is mailed do not speak English well and are fluent in the same non-English language (e.g., Spanish, Chinese, Navajo or Tagalog).
If you are not satisfied with the coverage decision made on your appeal, you may request in writing, within 90 days of the receipt of notice of the decision, a second level appeal. A second level appeal may be initiated by you or your authorized representative (such as your physician). To initiate a second level appeal, provide in writing: l Your name l Member ID l Phone number l The prescription drug for which benefit coverage has been denied, and l Any additional information that may be relevant to your appeal.
This information should be mailed to Express Scripts, PO Box 631850, Irving, TX 75063-0030 Attn: Appeals. A decision regarding your request will be sent to you in writing within 15 days of receipt of your written request for pre-service claims or 30 days of receipt of your written request for post-service claims. If the appeal is denied, the denial notice will include information to identify the claim involved, the specific reasons for the decision, new or additional evidence, if any considered by the plan in relation to your appeal, the plan provisions on which the decision is based, a description of applicable external review processes and contact information for an office of consumer assistance or ombudsman (if any) that might be available to assist you with the claims and appeals processes. You have the right to a full and fair impartial review of your claim. You have the right to review your file, the right to receive, upon request and at no charge, the information used to review your second level appeal, and present evidence and testimony as part of your appeal. You also have the right to request the diagnosis code and treatment code and their corresponding meanings which will be provided to you if available (i.e., if the information was submitted, relied upon, considered or generated in connection with the determination of your claim). If you do not speak English well and require assistance in your native language to
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understand the letter or your claims and appeals rights, please call 1-800-753-2851. In addition, you may also have the right to request a written translation of your letter if 10 percent or more of the people in the county where notification is mailed do not speak English well and are fluent in the same non-English language (e.g., Spanish, Chinese, Navajo or Tagalog). If new information is received and considered or relied upon in the review of your second level appeal, such information will be provided to you together with an opportunity to respond prior to issuance to any final adverse determination of this appeal. The decision made on your second level appeal is final and binding.
If your second level appeal is denied and you are not satisfied with the decision of the second level appeal (i.e., your “final adverse benefit determination”) or your initial benefit denial notice or any appeal denial notice (i.e., any “adverse benefit determination notice” or “final adverse benefit determination”) does not contain all of the information required under the Employee Retirement Income Security Act of 1974, as amended (“ERISA”), you have the right to bring a civil action under ERISA section 502(a).
In addition, for cases involving medical judgment or rescission, if your second level appeal is denied and you are not satisfied with the decision of the second level appeal (i.e., your “final adverse benefit determination”) or your initial benefit denial notice or any appeal denial notice (i.e., any “adverse benefit determination notice” or “final adverse benefit determination”) does not contain all of the information required under ERISA, you have the right to an independent review by an external review organization. Details about the process to appeal your claim and initiate an external review will be described in any notice of an adverse benefit determination and are also described below. The right to an independent external review is only available for claims involving medical judgment or rescission. For example, claims based purely on the terms of the plan (e.g., plan only covers a quantity of 30 tablets with no exceptions), generally would not qualify as a medical judgment claim.
Urgent Appeal (Expedited Review)
You have the right to request an urgent appeal of an adverse benefit determination (including a claim considered denied because missing information was not timely submitted) if your situation is urgent. An urgent situation is one where in the opinion of your attending provider, the application of the time periods for making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain maximum function or would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of your claim. To initiate an urgent claim or appeal request, you or your physician (or other authorized representative) must call l-800-753-2851 or fax the request to 1-888-235-8551. Claims and appeals submitted by mail will not be considered for urgent processing unless and until you call or fax and request that your claim or appeal be considered for urgent processing. In the case of an urgent appeal (for coverage involving urgent care), you will be notified of the benefit determination within 72 hours of receipt of the claim. If the appeal is denied, the denial notice will include information to identify the claim involved, the specific reasons for the decision, new or additional evidence, if any considered by the plan in relation to your appeal, the plan provisions on which the decision is based, a description of applicable external review processes and contact information for an office of consumer assistance or ombudsman (if any) that might be available to assist you with the claims and appeals processes. You have the right to a full and fair impartial review of your claim. You have the right to review your file, the right to receive, upon request and
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at no charge, the information used to review your appeal, and present evidence and testimony as part of your appeal. You also have the right to request the diagnosis code and treatment code and their corresponding meanings which will be provided to you if available (i.e., if the information was submitted, relied upon, considered or generated in connection with the determination of your claim). If you do not speak English well and require assistance in your native language to understand the letter or your claims and appeals rights, please call 1-800-753-2851. In addition, you may also have the right to request a written translation of your letter if 10 percent or more of the people in the county where notification is mailed do not speak English well and are fluent in the same non-English language (e.g., Spanish, Chinese, Navajo or Tagalog). If new information is received and considered or relied upon in the review of your appeal, such information will be provided to you together with an opportunity to respond prior to issuance of any final adverse determination. The decision made on your urgent appeal is final and binding. In the urgent care situation, there is only one level of appeal prior to an external review.
If your appeal is denied and you are not satisfied with the decision of the appeal (i.e., your “final adverse benefit determination”) or any appeal denial notice (i.e., “adverse benefit determination notice” or “final adverse benefit determination”) does not contain all of the information required under ERISA, you have the right to bring a civil action under ERISA section 502(a).
In addition, for cases involving medical judgment or rescission, if your appeal is denied and you are not satisfied with the decision (i.e., your “final adverse benefit determination”) or your initial benefit denial notice or any appeal denial notice (i.e., your “adverse benefit determination” or “final adverse benefit determination”) does not contain all of the information required under ERISA, you have the right to an independent review by an external review organization.
In addition, in urgent situations where the appropriate timeframe for making a non-urgent care determination would seriously jeopardize your life or health or your ability to regain maximum function, you also have the right to immediately request an urgent (expedited) external review, rather than waiting until the internal appeal process, described above, has been exhausted, provided you file your request for an internal appeal of the adverse benefit determination at the same time you request the independent external review. If you are not satisfied or you do not agree with the determination of the external review organization, you have the right to bring a civil action under ERISA section 502(a).
Details about the process to appeal your claim and initiate an external review will be described in any notice of an adverse benefit determination and are also described below. The right to an independent external review is only available for claims involving medical judgment or rescission. For example, claims based purely on the terms of the plan (e.g., plan only covers a quantity of 30 tablets with no exceptions), generally would not qualify as a medical judgment claim.
External Review Procedures
The right to an independent external review is only available for claims involving medical judgment or rescission. For example, claims based purely on the terms of the plan (e.g., plan only covers a quantity of 30 tablets with no exceptions), generally would not qualify as a medical judgment claim. You can request an external review by an Independent Review Organization (IRO) as an additional level of appeal prior to, or instead of, filing a civil action with respect to your claim under Section 502(a) of ERISA. Generally, to be eligible for an independent external review, you must exhaust the internal plan claim review process described above, unless your
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claim and appeals were not reviewed in accordance with all of the legal requirements relating to pharmacy benefit claims and appeals or your appeal is urgent. In the case of an urgent appeal, you can submit your appeal in accordance with the above process and also request an external independent review at the same time, or alternatively you can submit your urgent appeal for the external independent review after you have completed the internal appeal process.
To file for an independent external review, your external review request must be received within 4 months of the date of the adverse benefit determination (If the date that is 4 months from that date is a Saturday, Sunday or holiday, the deadline is the next business day). Your request should be mailed or faxed to: Express Scripts, Attn: External Review Requests, P.O. Box 631850, Irving TX 75063-0030. Phone: 1-800-753-2851. Fax: 1-888-235-8551.
Non-Urgent External Review
Once you have submitted your external review request, your claim will be reviewed within 5 business days to determine if it is eligible to be forwarded to an Independent Review Organization (IRO) and you will be notified within 1 business day of the decision.
If your request is eligible to be forwarded to an IRO, your request will randomly be assigned to an IRO and your appeal information will be compiled and sent to the IRO within 5 business days. The IRO will notify you in writing that it has received the request for an external review and if the IRO has determined that your claim involves medical judgment or rescission, the letter will describe your right to submit additional information within 10 business days for consideration to the IRO. Any additional information you submit to the IRO will also be sent back to the claims administrator for reconsideration. The IRO will review your claim within 45 calendar days and send you, the plan and Express Scripts written notice of its decision. If you are not satisfied or you do not agree with the decision, you have the right to bring civil action under ERISA section 502(a). If the IRO has determined that your claim does not involve medical judgment or rescission, the IRO will notify you in writing that your claim is ineligible for a full external review and you have the right to bring civil action under ERISA section 502(a).
Urgent External Review
Once you have submitted your urgent external review request, your claim will immediately be reviewed to determine if you are eligible for an urgent external review. An urgent situation is one where in the opinion of your attending provider, the application of the time periods for making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain maximum function or would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of your claim.
If you are eligible for urgent processing, your claim will immediately be reviewed to determine if your request is eligible to be forwarded to an IRO, and you will be notified of the decision. If your request is eligible to be forwarded to an IRO, your request will randomly be assigned to an IRO and your appeal information will be compiled and sent to the IRO. The IRO will review your claim within 72 hours and send you, the plan and Express Scripts written notice of its decision. If you are not satisfied or you do not agree with the decision, you have the right to bring civil action under ERISA section 502(a).
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Your Rights Under ER ISA
As a participant in the Prescription Benefit Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
Receive Information About Your Plan and Benefits l Examine, without charge, at the plan administrator’s office and at other specified locations, such as work sites, all documents governing the plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. l Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies. l Receive a summary of the plan’s annual financial report. The plan administrator is required by law to furnish each participant with a copy of this summary annual report.
Continue Group Health Plan Coverage l Continue group health coverage for yourself, your spouse or your dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan for the rules governing your COBRA continuation coverage rights. Remember, if you elect COBRA continuation of your inVentiv Health medical plan, your Prescription Benefit Plan coverage will also be continued. l Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. Your group health plan or health insurance issuer should provide you with a certificate of creditable coverage, free of charge, (a) when you lose coverage under the plan, b) when you become entitled to elect COBRA continuation coverage, c) when your COBRA continuation coverage ceases, d) if you request it before losing coverage, or e) if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your coverage enrollment date.
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Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a plan benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
If you have a claim for benefits that is denied or ignored, in whole or in part, you may file a suit in a state or federal court but only after you have exhausted the plan’s claims and appeals procedure as described in the “Claims Procedures” section. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in a federal court.
If it should happen that plan fiduciaries misuse the plan’s money or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
Assistance With Your Questions
If you have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Employee Benefits Security Administration (EBSA), U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, DC 20210.
You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration at 866-444- EBSA, logging on to www.dol.gov, or contacting the EBSA field office nearest you.
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Plan Administration
This information about the administration of the plan is provided in compliance with the Employee Retirement Income Security Act (ERISA) of 1974, as amended. While you should not need these details on a regular basis, the information may be useful if you have specific questions about your plan.
DETAILS ABOUT PLAN ADMINISTRATION
Plan Sponsor/Plan inVentiv Health, Inc. Administrator ATTENTION: Vice President of Benefits 500 Atrium Drive Somerset, NJ 08873 [email protected]
Employer Identification 52-2181734 Number
Official Plan Name and inVentiv Health, Inc. Employee Health Care Program - 501 Number
Plan Year January 1 through December 31
Type of Plan Group health plan providing prescription drug benefits
Agent for Service of Legal Agent for Service of Legal Process Process inVentiv Health, Inc. Employee Health Care Program Attention: Vice President of Benefits 500 Atrium Drive Somerset, NJ 08873 [email protected]
Carrier/Vendor/Claims Express Scripts Administrator P.O. Box 14711 Lexington, KY 40512
Plan Funding The Prescription Benefit Plan is self-funded as part of the inVentiv Health Medical Choice Fund Open Access Plus HSA Plan. Benefits from this plan are paid from employee contributions, as applicable, and from the general assets of inVentiv Health, as needed. inVentiv Health has contracted with third-party administrators to administer this plan.
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Plan Administrator’s Discretionary Authority to Interpret the Plan
The administration of the plan will be under the supervision of the plan administrator. To the fullest extent permitted by law, the plan administrator will have the exclusive discretionary authority to determine all matters relating to the plan, including eligibility, coverage and benefits.
The plan administrator will also have the exclusive discretionary authority to determine all matters relating to interpretation and operation of the plan. The plan administrator may delegate any of its duties and responsibilities to one or more persons or entities. Such delegation of authority must be in writing and must identify the delegate and the scope of the delegated responsibilities. Decisions by the plan administrator, or any authorized delegate, will be conclusive and legally binding on all parties.
The Company’s Right to Amend or Terminate the Plan
It is inVentiv Health’s intent that the Prescription Benefit Plan will continue indefinitely. However, the company reserves the right to amend, modify, suspend or terminate the plan, in whole or in part. Any such action would be taken in writing and maintained with the records of the plan. Plan amendment, modification, suspension or termination may be made for any reason, and at any time, and may, in certain circumstances, result in the reduction of or elimination of benefits or other features of the plan to the extent permitted by law. inVentiv Health’s rights include the right to obtain coverage and/or administrative services from additional or different insurance carriers, HMOs, third-party administrators, etc., at any time, and the right to revise the amount of employee contributions. Employees will be notified of any material modification to the plan.
Limitation on Assignment
Your rights and benefits under the plan cannot be assigned, sold or transferred to your creditors or anyone else. However, you may assign your rights to benefits under the plan to the health provider who provided the medical services or supplies.
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Your Employment
This SPD provides detailed information about the Prescription Benefit Plan and how it works. This SPD does not constitute an implied or express contract or guarantee of employment. Similarly, your eligibility or your right to benefits under the Prescription Benefit Plan should not be interpreted as an implied or express contract or guarantee of employment. inVentiv Health’s employment decisions are made without regard to benefits to which you are entitled upon employment.
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