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TSN995FormularyWelcomeLetter

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Toll-free: 1-800-361-4542                                                              Fax: 330-405-8081

October 14, 2011

Dear Teamsters Local 995 member:

Effective November 1, 2011, your prescription drug benefit will be administered by EnvisionRxOptions. Headquartered in
Twinsburg, Ohio, EnvisionRxOptions has been providing pharmacy benefit management services nationally since 2001.
Additional information about EnvisionRxOptions and your prescription benefit can be found by registering at
www.envisionrx.com. The following information is an overview of the Teamsters Local 995 Security Fund for Southern
Nevada prescription drug benefit being administered by EnvisionRxOptions.

Your new prescription drug card is enclosed with this letter. Should you find any errors on your card, please contact
Zenith Administrators at (702) 734 - 8601.

Your prescription drug benefit features a formulary drug list. A formulary is a list of preferred medications organized into
groups or “Tiers”. Enclosed is a pocket formulary which lists the most frequently prescribed medications. For a full
formulary listing please visit www.envisionrx.com.

Copays, the portion of the drug cost that you are responsible to pay, are listed in the table below. Please note that if you
purchase a brand name medication that has a generic equivalent available, a penalty will be added to your applicable
brand copayment. This penalty is the difference in price between the brand name medication and its available generic.

                                                      30-Day Retail
                             Tier 1               Tier 2                                Tier 3
                            Generic           Formulary Brand                     Non-Formulary Brand
               Copay        $0.00                                              Greater of 45% andor $45.00
                                        Greater of 20% andor $20.00
                                                      90-Day Retail
                             Tier 1               Tier 2                                Tier 3
                            Generic           Formulary Brand                     Non-Formulary Brand
               Copay        $0.00       Greater of 20% andor $60.00           Greater of 45% andor $135.00

                                              90-Day Costco Mail Order
                             Tier 1               Tier 2                                Tier 3
                            Generic           Formulary Brand                     Non-Formulary Brand
               Copay        $0.00                  $30.00                                $60.00


Your benefit plan may have certain restrictions regarding refills. Please refer to the Summary Benefit Plan provided by
your plan or contact your Plan Administrator. You may also call our Customer Service Help Desk at 1-800-361-4542.

To access our Pharmacy Locator, please visit www.envisionrx.com. You may also call the EnvisionRxOptions Help Desk
at 1-800-361-4542 to see if your pharmacy is in the network.

Costco Mail Order/Online Pharmacy

Costco Mail Order/Online Pharmacy is your new mail order service provider. Prescriptions with available refills will be
transferred from your previous mail order vendor to Costco Mail Order/Online Pharmacy. Please note that prescriptions
for controlled substances are unable to be transferred. Only members utilizing controlled substances will need to
obtain new prescriptions from their physicians for a 90-day supply. Some examples of controlled substances
include: narcotics, pain medications, sleep aids, ADD/ADHD medications, and muscle relaxers. If you need to start
your medication immediately, or do not have a two (2) week minimum supply on hand, request two prescriptions from your
physician; one for a short-term supply to fill at a local retail pharmacy and one for a 90-day supply (including refills) that
can be submitted to Costco Mail Order/Online Pharmacy.

To best use this service, please review the enclosed Costco Mail Order/Online pharmacy brochure. You have 2 options
for using this service. 1) Traditional mail order service – where all orders are placed through the mail or by phone. 2)
Online order service – where orders can be placed online at www.pharmacy.costco.com.

If you have questions on how to get started using the Costco Mail Order/Online Pharmacy please visit
www.pharmacy.costco.com or contact the pharmacy at 1-800-607-6861; Monday-Friday 5am – 7pm (PST) and Saturday
9:30am – 2pm (PST).

Please read the brochure included with this mailing for details on the best way to utilize Costco Mail Order
Pharmacy’s traditional mail order service and information on how to request refills

Costco Specialty Services
Costco Specialty Services is the exclusive provider for your specialty medications as part of your prescription drug plan.
What this means for you is that you and those covered under your benefit will receive the personalized care and expertise
of Costco Specialty Services’ dedicated pharmacists, which is essential to successful therapy. This is because Costco
Specialty Services goes beyond traditional retail pharmacy services, helping you get the most from your specialty
medication therapy.

Because specialty medications can be more difficult to manage, Costco Specialty Services offers the following patient
support services at no charge:

            Personalized support to help you achieve the best results from your prescribed therapy
            Convenient delivery to your home or prescriber’s office
            Easy access to a Care Team who can answer medication questions, provide educational materials about your
             condition, help you manage any potential medication side effects, and provide confidential support—all with
             one toll-free phone call
            Assistance with your specialty medication refills

If you have any questions, or to begin to take advantage of these complimentary patient support services, please call
Costco Specialty Services toll free at 1-866-443-0060.

Glucometer Replacement

EnvisionRxOptions has a program available to members that allows them to receive a free glucometer. Call
                                                                                       ®
1-866-224-8892 for an Abbott Diabetes Care Glucometer (FreeStyle and the Precision Xtra Blood Glucose & Ketone
                                                                                                ®        ®
Monitoring Systems) or 1-877-229-3777 for a Bayer HealthCare, Diabetes Care Glucometer (Ascensia CONTOUR and
         ®           ®
Ascensia BREEZE ). Please identify EnvisionRxOptions as your pharmacy benefits administrator, and Abbott or
Bayer will take care of the rest. There is a limit of one glucometer per member.

Complaints and Appeals

If you have a complaint or need assistance, please call our Customer Service Help Desk at 1-800-361-4542. Please refer
to the Summary Benefit Plan provided by your plan or contact your Plan Administrator for instructions on how to file a
grievance with your plan or appeal a coverage determination.

If you have any questions regarding your prescription drug benefit, please call the EnvisionRxOptions Customer Service
Help Desk at 1-800-361-4542.


Sincerely,
EnvisionRxOptions

				
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