Prescription Drugs About This SPD HMO and PPO Prescription Drugs The Prescription Drug Program is a component program in the Tenet Employee Benefit Plan (TEBP). The TEBP is a comprehensive welfare benefits program intended to qualify as a cafeteria plan within the meaning of Internal Revenue Code (IRC) section 125. This information summarizes key provisions of the Prescription Drug Program and serves as part of the summary plan description (SPD) for the TEBP. You can obtain more information about the Prescription Drug Program, the TEBP and the other component programs offered under the TEBP by reviewing the complete SPD for the TEBP. If there is any discrepancy between this online SPD and the official plan documents for the TEBP, the official plan documents will control. For more information on obtaining the official plan documents, see Other Information. MODESTO/MANTECA EMPLOYEES: For information on your Prescription Drug Program for the HMO, see the HMO Medical Plan Details. Plan Highlights You must be enrolled in a Tenet medical plan to receive prescription drug coverage. Your choice of medical plan determines your Prescription Drug Program options. If you enroll in the HDHP, your prescription drug coverage is part of your medical plan and you will not have a choice about your Prescription Drug Program option. See your HDHP Medical Plan Details for more information. Prescription drug benefits under the HDHP are not described this Prescription Drug Program section of the SPD. If you enroll in an HMO or a PPO, you choose Prescription Drug Program coverage separately from your medical plan. You will choose from two prescription drug options — Rx I and Rx III. Each has a different deductible and coverage level. FOR MODESTO/MANTECA EMPLOYEES: If you enroll in an HMO in Modesto/Manteca, see the HMO Medical Plan Details. Prescription drug benefits under the Modesto/Manteca HMO are not described in this Prescription Drug Program section of the SPD. The Prescription Drug Program offers an easy and convenient way to save on short- and long-term medication. The program includes a formulary feature that can help you manage your prescription drug expenses. A “formulary” is a list of commonly prescribed medications — both generic and brand name — that have been found to be clinically effective, as well as cost effective. By asking your doctor to prescribe formulary medications when appropriate and discussing with your doctor the use of a generic medication, you can help keep your out-of-pocket costs lower while maintaining high- quality care. The list of formulary drugs can be accessed by clicking the Prescription Drugs link from the My Benefit Links box. There are two components to the Prescription Drug Program: Retail Prescription Drug Allows you to purchase up to a 30-day supply of medication at Program participating retail pharmacies Mail-Order Program A more cost-effective way for you to purchase up to a 90-day supply of maintenance medication by having your prescription drugs sent to you in the mail — and you don’t have to satisfy the deductible first when ordering by mail Profile: Tony and Sara Tony and Sara are a young couple who have just started a family with the arrival of their son, Ryan. Tony works for Tenet, while Sara has a part-time job at a daycare facility. Sara’s employer doesn’t offer medical or prescription drug benefits to part-time employees, so Tony has elected family coverage in the PPO. Because he knows they’ll be using brand-name prescriptions on a regular basis for his medical condition, Tony goes online to model his prescription drug coverage and determines that Rx III is the most cost effective plan for his family. Quick Facts Who You Can Cover Your coverage category for prescription drugs is determined by your coverage category for your medical plan. You (and your family members) must be enrolled under an HMO or one of the Tenet PPO medical plan options by the date indicated on your Enrollment Worksheet to be covered under the Prescription Drug Program. Cost of Coverage Your contribution to the cost of your prescription drug coverage is separate from the premium you pay for medical coverage. Premium information is provided to you during annual enrollment or on your Enrollment Worksheet. When Coverage Begins On the 31st day after you begin employment in a full-time or part-time benefit eligible position, provided you’ve enrolled in a Tenet medical plan option by the date indicated on your Enrollment Worksheet. When Coverage Ends Your (or your family member’s) coverage under the Prescription Drug Program ends on the earlier of (1) the date you (or your family member) lose(s) coverage under your Tenet medical plan option or (2) the date the Prescription Drug Program is terminated. If you (or your family member) lose(s) coverage under the Medical Program, you (or your family member) may be eligible in some circumstances to continue medical (and therefore, prescription drug) coverage under the Consolidated Omnibus Reconciliation Act of 1985 (COBRA), as amended. For more information on COBRA coverage, please see Other Information. How the Retail Program Works A Look at the Basics The Retail Prescription Drug Program, administered by Medco, allows you to purchase up to a 30- day supply of medication. You simply present your medical identification (ID) card (or prescription drug card if a separate one is sent) at a participating Medco pharmacy when you have your prescription filled. Annual Deductible If you have a deductible, you must meet it before the plan begins paying benefits. Your annual prescription drug deductible depends on your Rx choice. There is no deductible for Rx I. For Rx III, the deductible is $25 per covered individual. This deductible is separate from any annual deductible you’re required to satisfy under your medical plan option. It also applies to EACH covered family member. Retail Deductible Rx I Rx III Annual Deductible $0 $25 per covered individual Copays and Coinsurance Once the applicable deductible is satisfied, the copay or coinsurance for each prescription filled follows: Retail Coverage Rx I Rx III Generic Drugs $5 copay $10 copay after deductible Benefit-Based* Brand-Name Drugs 20% up to a maximum copay Not covered Included on the Formulary List of $75 Brand-Name Drugs Included on 35% up to a maximum copay $30 copay after deductible the Formulary List of $75 Brand Name Drugs Not Included 50% up to a maximum copay $45 copay after deductible on the Formulary List of $125 *If you have an ongoing condition for which you take medication — asthma, diabetes, coronary artery disease (CAD) or congestive heart failure (CHF) — benefit-based drugs offer lower coinsurance for certain maintenance medications. If you request a brand-name drug when a generic is available, you’ll pay the generic copay or coinsurance, plus the cost difference between the brand-name and generic drug. You’ll pay any deductible amount, copay or coinsurance at the participating pharmacy. As prescriptions for each family member are filled, the participating pharmacy will track on Medco’s computer system when covered family members meet their prescription deductible. Most chain drugstores are participating pharmacies. For assistance in locating a participating pharmacy near you, click on the Prescription Drugs link in the My Benefit Links box or call Medco Member Services at 1-800-455-8350. You’ll need your member number (included on your medical ID card) and ZIP code. Formulary Drugs Can Save You Money This cost-saving feature allows your doctor to prescribe appropriate commonly used brand-name medications, which are more cost effective than other brand-name medications that treat the same condition. For a list of the brand-name drugs included on the formulary list, click on the Prescription Drugs link in the My Benefit Links box or call Medco Member Services at 1-800-455-8350. Save Money by Requesting Generic Drugs Brand-name drugs often have generic counterparts. Generic drugs have the same active ingredients as brand-name drugs and are subject to the same FDA standards for quality, strength and purity. Because generic drugs cost less to produce, it’s more cost effective to use the generic form. The Prescription Drug Program pays higher benefits for generic drugs than for brand-name drugs. If you request a brand-name drug when a generic equivalent is available, you’ll pay the generic copay or coinsurance, plus the price difference between the brand-name and generic drug. You should always discuss with your doctor or pharmacist whether a generic form of the prescribed drug exists and is appropriate for you. Unless your doctor has specifically indicated “dispense as written,” the pharmacist can make the generic substitution upon your request. You should consult with your doctor regarding the medical implications, if any, of using a generic medication. Profile: Tony and Sara When Ryan was six months old, he caught an infection from one of the other children in his daycare center. Sara received a prescription from his pediatrician and went to fill it at a participating pharmacy. She was told that the total cost for Ryan’s medication was $70. After Sara showed her medical ID card to the pharmacist, her prescription benefits were verified on the computer. Then the pharmacist applied Sara’s prescription benefit to the total cost (see example below). Because this was the first prescription filled for Ryan this year, he first needed to satisfy his annual prescription drug deductible. Here’s how the cost for Ryan’s medication was determined: FOR RYAN’S FIRST PRESCRIPTION ... Generic prescription drug cost $70 Prescription drug deductible for the Rx III plan - $25 Remaining cost $45 The copay gets applied to the remaining cost. THE COST FOR RYAN’S FIRST PRESCRIPTION IS ... Copay $10 Under the Rx III option, the cost for generic drugs is a $10 copay. Prescription drug deductible for the Rx III plan + $25 Remaining cost $35 The total cost for Ryan’s first prescription is $35 ($25 annual deductible + $10 copay). After several months, Sara needs to fill another prescription for Ryan. Again, Sara shows her medical ID card at the participating pharmacy. This time, Ryan’s doctor has prescribed a brand-name medication that doesn’t have a generic equivalent but is included on the formulary list. The cost of the brand-name drug is $125. FOR RYAN’S SECOND PRESCRIPTION … Brand-name prescription drug cost $125 Prescription drug deductible (already paid) - $0 Remaining cost $125 THE COST FOR RYAN’S SECOND $30 The cost for brand-name drugs on the formulary PRESCRIPTION IS … list is a $30 copay. It Pays to Use Participating Pharmacies When you use a participating pharmacy, you receive the highest level of benefits. You can also choose to have your prescriptions filled at non-participating pharmacies; however, non-participating pharmacies usually charge more than the contracted network rates for prescription drugs charged by Medco participating pharmacies. Using Non-Participating Pharmacies With non-participating pharmacies, you pay the full cost of the prescription at the time of purchase. For reimbursement, you’ll receive the contracted network cost for a 30-day supply, minus the appropriate copay or coinsurance. You must complete a claim form to receive reimbursement from Medco. Be sure to follow all directions on the claim form and attach original receipts. You can get claim forms by clicking on the Prescription Drugs link in the My Benefit Links box. How the Mail-Order Program Works To save even more money, you can use the Mail-Order Program for long-term and maintenance prescription drugs. It allows you to purchase up to a 90-day supply of generic or brand-name medications, which are mailed directly to your home. You’ll get a larger supply of medications for less money than using the Retail Prescription Drug Program. Mail-Order Coverage Rx I Rx III Annual Deductible $0 $0 Generic Drugs $0 $25 copay Benefit-Based* Brand-Name Drugs 20% up to a maximum copay of $150 Not covered Included on the Formulary List Brand-Name Drugs Included on the 35% up to a maximum copay of $150 $63 copay Formulary List Brand-Name Drugs Not Included on 50% up to a maximum copay of $250 $100 copay the Formulary List *If you have an ongoing condition for which you take medication — asthma, diabetes, coronary artery disease (CAD) or congestive heart failure (CHF) — benefit-based drugs offer lower coinsurance for certain maintenance medications. For example, if a brand-name drug is on the formulary list, and the copay through the Rx III option is $25 for a 30-day supply, you’ll pay only $63 for a 90-day supply. You’ll get part of your medication free! Please Be Aware... Medco may require that some medications be dispensed through the Mail-Order Program. If your medication falls into that category, Medco will contact you. It takes approximately two to three weeks from the time you send in your order form to receive your prescription drugs in the mail. Order forms for the Mail-Order Program are included in your Medco information packet. Additional forms can be obtained by clicking on the Prescription Drugs link in the My Benefit Links box. If your prescription indicates refills, the mail-order pharmacy will send you a reorder form with your initial prescription and each subsequent refill. You can then order your refill by mail or you can call Medco Member Services toll free at 1-800-455-8350. You can also process your refill by clicking on the Prescription Drugs link in the My Benefit Links box to access the Medco site. Online orders are usually processed within 7–10 days. Purchasing Diabetic Supplies Through the Mail-Order Program If you or a covered family member is diabetic, you can purchase over-the-counter diabetic supplies,* including lancets and test strips, through the Mail-Order Program. Keep the following in mind when purchasing these supplies: Prescriptions Are Required Your physician needs to write a prescription for over-the-counter diabetic supplies. (Please note that Medco always requires a prescription, even if you live in a state where prescriptions aren’t required for over-the-counter diabetic supplies.) Prescriptions Need to State Your doctor needs to indicate the quantity (90-day maximum) and the the Quantity and the Number number of refills allowed (if any) on your prescription. If your doctor of Refills doesn’t state the quantity, the pharmacy will send the minimum order, which is one box. Please note that the manufacturers don’t package lancets and test strips in equal numbers. A Copay or Coinsurance Is Copays or coinsurance for over-the-counter diabetic supplies are at the Required for Each Order brand-name formulary and non-formulary level. For example, with the Rx III option, you will pay $63 per order for formulary or $100 per order for non-formulary (either new prescriptions or refill). Lancets and test strips are considered separate orders; therefore, when ordering both, your total payment with the Rx III option will be $126 for formulary and $200 for non-formulary (two times the formulary or non-formulary cost for each). It Takes Approximately 2–3 Therefore, be sure you take this timing into consideration when mailing Weeks to Fill Mail-Order in your order. If you need an immediate supply, you can purchase a 30- Prescriptions day supply through the Retail Prescription Drug Program at any Medco participating pharmacy. Please note that the Retail Prescription Drug Program also requires a prescription from your doctor, and you’ll be required to satisfy applicable deductibles if you haven’t already. So be sure to get two prescriptions from your doctor. Refills Are Easy If your prescription includes refills, you’ll receive a refill order slip with your initial order, and with each subsequent order, until all refills have been sent ― then you can expect to receive a renewal reminder once a new prescription is needed. Refills can be ordered over the telephone, by mailing in your refill order slip or online by clicking on the Prescription Drugs link in the My Benefit Links box to access the Medco site. Please note: To cut down on paperwork, members with open home delivery refills and a history of requesting refills online or by phone will not receive order forms, business and customer reply envelopes or refill slips in their home delivery packages. However, they will continue to receive renewal reminders. *Subject to formulary guidelines. Please contact Medco at 1-800-455-8350 to see if your supplies are part of the formulary. If they aren’t, have your physician contact Medco to see if one of the formulary supply options will work for you. Profile: Randall Randall has diabetes and manages his costs carefully. He takes advantage of ordering over-the-counter diabetic supplies through the Mail-Order Program. He knows he needs separate prescriptions for his lancets and test strips — and that each of those orders requires a separate copay. That’s why he makes sure his doctor writes prescriptions for formulary supplies. Under Rx III, Randall pays a total of $126 for formulary lancets and test strips ($63 per order) instead of $200 for non-formulary supplies. Pre-Packaged Prescription Drugs Certain prescription drugs are pre-packaged in supplies greater than the 30-day benefit normally filled at retail pharmacies. Some drugs are pre-packaged in two-, three-, four- and six-month supplies and the quantities cannot be cut back. For pre-packaged drugs filled at retail pharmacies: 1- to 30-day supplies will be one copay (or appropriate percentage of the total package), 31- to 60-day supplies will be two copays (or appropriate percentage of the total package), 61- to 90-day supplies will be three copays (or appropriate percentage of the total package), 91- to 120-day supplies will be four copays (or appropriate percentage of the total package) and so on. For pre-packaged drugs filled through mail-order: 91-day or greater supplies will never be charged more than the 90-day copay. Medco Special Care Pharmacy The Medco specialty pharmacy service is designed to help you meet the particular needs and challenges of using certain medications, many of which require injection or special handling. If you are using a specialty pharmacy medication, you will be eligible to receive additional services when you fill your specialty prescriptions using the Medco Special Care Pharmacy. These additional services include: Support and guidance from Medco nurses and pharmacists who are trained in these medications, their side effects and the conditions they treat Expedited delivery of all your specialty prescription medications Supplemental supplies, such as needles and syringes that are required to administer the medication, at no additional charge Scheduling of refills and coordination of services with home care providers, case managers and doctors or other healthcare professionals Days of Therapy Through Medco Special Care Pharmacy Medications will be dispensed for up to a 90-day supply when appropriate. Certain medications dispensed through Medco’s Special Care Pharmacy may only be available for up to a 30-day supply based on dosing, safety, frequent change in therapy or need to minimize waste for that particular drug. There are other classes of medications that may be limited to a smaller quantity (up to a 30- day supply) early in your treatment to allow for potential changes in dose. Once therapy has been stabilized, you will be offered up to a 90-day supply. For example: Hemophilia drugs will always be limited to a maximum of a 30-day supply. Erythroid stimulants (Epogen®, Aranesp®) and agents for rheumatoid arthritis (Enbrel®, Humira®) will be limited to a maximum of a 30-day supply early in treatment. For those medications that are only limited early in therapy, a Medco Special Care pharmacist will contact you regarding your past history with the medication to determine whether a larger supply is appropriate for you. Your copay will also be automatically adjusted for any medication that has a limited-day supply and you will not be responsible for a full 90-day copay. If you have any questions regarding specialty pharmacy medications, please call the Medco Special Care Pharmacy directly at 1-800-803-2523. Representatives are available Monday through Friday, 8 a.m. to 8 p.m., Eastern Time, to assist you. Some Medications Require Authorization or Review Medco requires a prior authorization or coverage review for certain medications. This applies both to new prescriptions and to continue coverage on certain medications. Traditional Prior Authorization (TPA) The following medications require prior authorization to ensure appropriate coverage decisions (e.g., patient diagnosis, what the prescribed drug is being used for, recommended dosage, how long the medication is to be used, possible drug interactions and other safety concerns): Accutane/Amnesteem/Sotret Alzheimer’s agents (IVRU — Aricept, Exelon, Cognex, Reminyl and Namenda) MS agents Interferon (alpha, beta, gamma) Erythroid stimulants Myeloid stimulants Platelet proliferation stimulants Growth hormones Growth hormone receptor antagonist IV-immune globulins (e.g., Gammar®, Iveegam®) Lupron 1mg Synarel Pulmozyme Regranex IVRU – Retin-A/Avita – all dosage forms Tazorac – all dosage forms Xolair Gleevec Iressa Raptiva Zelnorm Lotronex for females only Synagis/RespiGam Provigil Amevive Zavesca Aggrenox through age 49 The list of medications requiring prior authorization is subject to change. Your doctor should contact Medco Managed Prior Authorization Service at 1-800-753-2851 before issuing a prescription to you. An MPA pharmacist will discuss the necessary drug criteria with your doctor before issuing the authorization. If you don’t receive authorization before picking up your prescription at the pharmacy, your pharmacist will receive an online message from Medco indicating that prior authorization is necessary and instruct him or her to contact Medco Managed Prior Authorization Service. This could result in a delay in receiving your medication. Smart Prior Authorization (SPA) Medco automatically tracks each prescription and monitors the standard maximum dosage and quantities for certain types of drugs. They also review other medications you have taken in the past, your age and other patient factors. If your doctor has prescribed a medication in excess of the quantity usually allowed or the usual dose of medication over time, or in cases when evidence of prior therapy in a step approach is not found, your doctor will need to obtain authorization from Medco Managed Rx Coverage Service at 1-800-753-2851. Examples of medications that require authorization and/or quantity limits: Migraine medications such as Triptans (Imitrex, Zomig, Amerge, Maxalt), Migranal NS and Stadol NS Anti-emetics medications such as Zofran, Kytril, Anzemet and Emid Ulcer treatment medications such as Zantac, Tagamet, Pepcid, Axid, Prilosec, Prevacid and Nexium Pain management and arthritis medications such as Toradol, Celebrex and Enbrel Relenza limited to a five-day supply or 20 units, whichever is lesser per claim Tamiflu limited to a five-day supply or 10 capsules, whichever is lesser per claim Tamiflu Liquid limited to a five-day supply or 75ml (three bottles), whichever is lesser per claim Anti-fungal medication such as Diflucan and Sporanox Sleep agent medication such as Ambien, Sonata, Lunesta and Rozerem Chemotherapy medication such as Avastin and Erbitux Zonegran and Topamax for patients over age 18 and without prior use of an anticonvulsant agent Rituxan for patients age 18 and younger and for patients over age 18 without prior use of rheumatoid arthritis agent Preferred Drug Step Therapy Hypnotic medication such as Lunesta, Sonata, Rozerem and Ambien CR Osteoporosis medication such as Actonel Antidepressant (SSRIs) medication such as Lexapro Retrospective Drug Utilization Review Medco conducts a Retrospective Drug Utilization Review to identify prescribing, dispensing and consumption patterns that do not meet the established clinical practice guidelines. Physicians may be notified about clinical considerations to safeguard patients and manage plan expenses. In some cases, physicians may initiate changes in therapy. Dose Optimization Feature Your prescription drug benefits include a dose optimization feature that identifies opportunities that can reduce the number of tablets or capsules you must take. If you are taking multiple tablets or capsules of a lower strength when a higher strength of the same medication is available, your physician may authorize a higher strength of the medication to be taken less frequently. This process increases the chances that the medication will be taken correctly and also saves you and the plan money. This type of substitution will occur only if your doctor authorizes the change and agrees that a higher strength of the same medication can be taken once a day. Upon reviewing your home delivery service prescriptions, Medco will contact your physician to see if a change in dosage is appropriate. If your physician agrees, you will receive a letter advising you that the doctor has authorized the change. Medco will also follow up with you by phone. Prescription Smoking Cessation Medication Review The Prescription Drug Program covers prescription smoking cessation medications for 180 days of therapy annually. After the initial 180 days, if your doctor believes that you need an additional supply of smoking cessation medications before the end of the year, he or she must request a coverage review. Medco will then contact the doctor to review the prescription to ensure it meets coverage requirements. What’s Not Covered by the Prescription Drug Program Ineligible Expenses from A to Z Some prescription drugs and services aren’t available through the Prescription Drug Program. Ineligible expenses include, but aren’t limited to: ADMINISTERING DRUGS: Charges for the administration or injection of any drug BIRTH CONTROL DEVICES: Contraceptive devices, jellies, creams, foams, injections and implants BLOOD PRODUCTS: Immunization agents, biologicals, blood and blood plasma ERECTILE DYSFUNCTION DRUGS: Viagra, Cialis, Levitra, Caverject and Muse EXPERIMENTAL MEDICATIONS: Experimental or investigational drugs FERTILITY MEDICATIONS: Drugs used to treat infertility HAIR GROWTH MEDICATION: Drugs used to stimulate hair growth INPATIENT MEDICATIONS: Medication that is to be taken by or administered to you or a covered family member while a patient is in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home or similar institution that has the ability to dispense medications on its premises OVER-THE-COUNTER DRUGS AND SUPPLIES: Any medication or supply that doesn’t require a prescription, except over-the-counter diabetic supplies REFILLS: Refills that are dispensed more than one year from the date of the doctor’s original order or that are in excess of the number of refills specified by the doctor SMOKING-CESSATION DRUGS: Over-the-counter smoking cessation medications THERAPEUTIC DEVICES: Therapeutic devices or appliances, except blood testing machines VITAMINS: Over-the-counter vitamins, except prenatal vitamins WEIGHT GAIN OR LOSS MEDICATIONS: Anorexients or obesity drugs WORK-RELATED INJURY MEDICATION: Medication for a work-related injury or illness that is covered under Workers’ Compensation, or for which no charge is made For information regarding eligible prescription drugs, you can call Medco Member Services at 1-800-455-8350. How to File a Claim Whether you need to file a claim depends on whether you go through the Retail Prescription Drug Program or the Mail-Order Program and whether you use a participating or non-participating pharmacy. In some situations, you may be required to file a claim. This section outlines the procedures for both programs. Retail Prescription Drug Program Claim forms aren’t required when you use your medical ID card (or prescription drug card if a separate one is sent) to purchase prescription drugs at participating pharmacies. Simply show your ID card and pay the required deductible, copay or coinsurance at the time of purchase. Claim forms will be required, however, if you must purchase prescription drugs before you receive your medical ID card or you fill a prescription at a non-participating pharmacy after you receive your medical ID card. You can obtain claim forms by clicking on the Prescription Drugs link in the My Benefit Links box or by calling Medco Member Services at 1-800-455-8350. Send the completed claim form to: Medco Health Solutions, Inc. P.O. Box 14711 Lexington, KY 40512 Claims must be filed within 12 months after you incur the expense. Mail-Order Program With this program, you need to use a Medco Order Form to buy prescription drugs through the mail. You can obtain claim forms by clicking on the Prescription Drugs link in the My Benefit Links box or by calling Medco Member Services at 1-800-455-8350. Send the completed order form to: Medco P.O. Box 650322 Dallas, TX 75265-0322 Claims Review and Detailed Description of Claims Process If you disagree with Medco’s decision regarding a claim, you can have your claim reviewed as described in Other Information. The Other Information section also describes the claims appeal process in detail. Helpful Information About the Tenet Prescription Drug Program You can learn additional information about the Prescription Drug Program offered under the TEBP by reviewing the other sections of this online SPD. THE COMPLETE SPD INCLUDES INFORMATION ON ELIGIBILITY AND ENROLLMENT, PROCEDURES FOR APPEALING CLAIM DENIALS, QUALIFIED MEDICAL CHILD SUPPORT ORDERS, AUTHORITY TO AMEND AND TERMINATE THE TEBP AND ALL OF THE BENEFIT PROGRAMS (INCLUDING THE PRESCRIPTION DRUG PROGRAM), COBRA CONTINUATION RIGHTS AND YOUR RIGHTS UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA). Here’s a list of some quick facts about the Prescription Drug Program you may need to know: EMPLOYER AND PLAN Tenet Healthcare Corporation SPONSOR 1445 Ross Avenue, Suite 1400 Dallas, TX 75202-2703 469-893-2000 PLAN ADMINISTRATOR Tenet Benefits Administration Committee 1445 Ross Avenue, Suite 1400 Dallas, TX 75202-2703 469-893-2000 CLAIMS ADMINISTRATOR Medco Health Solutions, Inc. P.O. Box 14711 Lexington, Kentucky 40512 1-800-455-8350 AGENT FOR SERVICE OF Tenet Healthcare Corporation LEGAL PROCESS 1445 Ross Avenue, Suite 1400 Dallas, TX 75202-2703 469-893-2000 Legal process may also be served on the Plan Administrator. PRESCRIPTION DRUG The Prescription Drug Program is a component program in the TEBP, PROGRAM EFFECTIVE which was originally effective as of October 1, 1977. The Prescription DATE Drug Program became a component program in the TEBP effective as of January 1, 2003. EMPLOYER 95-2557091 IDENTIFICATION NUMBER PLAN NUMBER 515 PLAN YEAR January 1 through December 31 TYPE OF PLAN Welfare benefit plan offering prescription drug benefits. See Other Information for more information. Funding of Benefits Your benefits under the Prescription Drug Program are funded by your copay and coinsurance amounts and by premiums paid by you and by Tenet. Tax Consequences of Participation in the Prescription Drug Program In general, you may pay for your premiums in the Prescription Drug Program on a pre-tax basis by reducing your salary. However, premiums for coverage for a domestic partner will be paid on an after-tax basis, unless your domestic partner also qualifies as your federal tax dependent (determined without regard to IRC sections 152(b) (1), (b) (2), and (d) (1) (B), which contain certain exceptions to the definition of dependent and a gross income limitation). The test for determining whether your domestic partner qualifies as your federal tax dependent may be different than the test for determining dependent status under the plan. You should consult with your tax advisor to determine if your domestic partner qualifies as your federal tax dependent. In addition, if you are a highly compensated employee, there may be certain circumstances in which you are not eligible to exclude from gross income all or a portion of the premiums or benefits paid under the Prescription Drug Program. Neither the Plan Administrator nor your employer can guarantee that the benefits provided to you under the Prescription Drug Program will be excludable from your gross income for federal and state tax purposes. For more information on the tax consequences of participating in the Prescription Drug Program, please see your tax advisor. Your Rights Under ERISA and HIPAA For a statement explaining your rights under the Employee Retirement Income Security Act of 1974 (ERISA) and HIPAA, see Other Information. Glossary Copay or Coinsurance This is the portion of the prescription costs you’re responsible for paying — under the Prescription Drug Program, a copay is a flat fee and coinsurance is a percentage of the cost of the drug. Deductible The deductible is the amount you need to pay each calendar year before the Prescription Drug Program begins to cover eligible retail prescription expenses. Enrollment Worksheet You use an Enrollment Worksheet to enroll in your Tenet benefits. The Enrollment Worksheet includes the benefit plans available to you and the premium amounts for each. The Enrollment Worksheet will be provided to you by the Plan Administrator upon your initial eligibility to participate and during annual enrollment periods. Formulary A key feature of the Prescription Drug Program, a “formulary” is a list of commonly prescribed medications — both generic and brand name — that have been found to be clinically effective, as well as cost effective. By asking your doctor to prescribe formulary medications when appropriate, you can help keep your out-of-pocket costs lower while maintaining high-quality care.
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