Index

About Medicare Supplement

Eligibility and Enrollment

Other Plan Provisions

Accepting Assignment

Covered Expenses

Exclusions

Coordination of Benefits

Claims

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

The Prescription Drug Program

Q. Does the Plan cover outpatient prescription drugs?

A. Yes, but only if you are not enrolled in Medicare Part D or a Medicare Part C plan that provides a Medicare prescription drug benefit. The Plan's prescription drug benefits offer you two cost-saving ways to buy outpatient prescription drugs:

• A network of local participating retail pharmacies for short-term prescriptions.
• The mail-order service for long-term or maintenance prescriptions.

No deductible is required.

Note: Prescription medications, including injections, provided in a hospital or in a doctor's office are covered as other medical expenses, see page 26.

Short-Term Prescriptions

A short-term prescription is written for a drug taken for a limited period of time, such as an antibiotic for a specific illness or if your doctor wants you to try the prescription before having a long-term prescription filled. The Plan provides benefits for up to a 34-day supply. See page 16 for limitations.

You have the choice of filling your prescriptions at:

• A local participating retail pharmacy (part of Medco's extensive network of retail pharmacies), where you will pay your share — a percentage co-payment — of the discounted cost. There are no claims to file.
• A non-participating pharmacy of your choice, where you will pay the full retail price and file a claim for partial reimbursement of the cost.

To receive the discounted price:

• Present your prescription and either your prescription drug identification card or the primary participant's identification number at a participating network pharmacy.
• The pharmacist enters the prescription and the primary participant's identification number into the pharmacy's computer system to confirm:
  • That you are a participant or dependent covered by this option.
  • That it is a covered prescription.
  • Your share of the prescription's cost.
• You do not file a claim.

The term primary participant refers to the participant whose identification number is used for identification purposes. The primary participant is the retiree, survivor or individual who elected COBRA coverage. Covered dependents use the primary participant's identification number to access all medical benefits. Be sure to give identification cards or the primary participant's identification number to your spouse and any covered dependents who may live away from home.

Note: Dependents who elect COBRA coverage must use their own identification number after the date they enroll as a COBRA participant.

Co-Payments
For prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs.

Examples:

 

page 12

Retail Refill Limitation
For the third and subsequent refills of a long-term or maintenance drug, which is a drug you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, a heart condition or high blood pressure, you will pay an additional 25% percentage co-payment. The additional 25% co-payment does not apply to your annual prescription drug out-of-pocket maximum.

For example, the percentage co-payment for a generic maintenance drug purchased at a retail network pharmacy is 55%.

Retail Pharmacy Percentage Co-Payment for the third and subsequent refill of a long-term maintenance drug:

• Generic drugs 55%

• Formulary preferred brand name drugs 55%

• Formulary non-preferred brand name drugs 75%

Using a Non-Participating Pharmacy or Not Identifying Yourself as a Medco Participant
You are not eligible for a discounted price if you:

• Have your prescription filled at a non-participating pharmacy; or
• Do not identify yourself as a Medco participant at a network pharmacy.

In either case:

• You pay the full non-discounted price of the prescription at the time of purchase.

• You must submit a completed Direct Reimbursement Claim Form to Medco. You may obtain a claim form by calling Medco at the number shown in the front of this SPD.
• You will be responsible for:
  • 100% of the difference between the non-discounted and discounted cost of the prescription (the ineligible cost);
    PLUS
  • your percentage co-payment portion of the discounted cost.

This example shows how you would save money when you use a network pharmacy and show your prescription ID card. In this case, you would save $10.

Long-Term Prescriptions

A long-term or maintenance drug is one you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, heart condition or high blood pressure. The Plan generally provides benefits for up to a 90-day supply through the mail-order prescription service. See page 16 for limitations.

Medco By Mail — Mail-Order Pharmacy
With Medco By Mail, the mail-order pharmacy, you save money and have the convenience of home delivery. Ask the doctor to write a prescription for up to a 90-day supply with appropriate refills. Enclose your original prescription(s) and payment of your percentage co-payment in an envelope. If you are paying via check or money order, you may obtain a calculation of your percentage co-payment from the Medco web site or by calling Medco directly. If you are paying via credit card, Medco will deduct the appropriate percentage co-payment and you will receive notification of the deduction with your medication.

For each prescription filled, you pay:

Type of Drug:	Medco By Mail  Percentage Co-Payment:
Generic drugs	25%
Preferred brand name drugs	25%
Non-preferred brand name drugs	45%

Your prescription will be delivered to the address on your order form within 14 working days. By law, prescriptions may not be sent outside the U.S.

page 14

Refills
You may order refills by calling Medco or sending in the refill label provided with your previous order. You may also order refills through Medco's Web site. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used at least 75% of the previous prescription based on the prescribed dosage.

Comparing Retail Pharmacy with Medco By Mail

This example shows how you can save money by purchasing long-term medication through the mail-order pharmacy.

Assume you purchase a 90-day supply of a preferred brand name drug:

At a Participating Retail Pharmacy:		Through Medco By Mail:
$108.00	Cost of preferred brand name drug (30-day supply)	$324.00	Cost of preferred brand name drug (90-day supply)
x 30%	Percentage co-payment	x 25%	Percentage co-payment
$32.40	Your co-payment or $97.20 for a 90-day supply	$81.00	Your co-payment
		You pay $81.00.

By purchasing a 90-day supply of this prescription through mail order, you would save $16.20. That is $64.80 a year for one prescription. Note this example does not include in the calculation the additional 25% co-payment for the third and any subsequent refills from a participating retail pharmacy. Actual savings may be greater.

Covered Prescriptions

The Plan covers drugs, medicines and supplies that are:

• Obtainable only with a physician's prescription or are specifically covered expenses (see Covered Expenses on page 26);
• Approved by the U.S. Food and Drug Administration for the specific diagnosis;
• Medically necessary (see page 51);
• Not experimental or investigational.

Generic Drugs
The program encourages consideration of generic alternatives, which are less expensive to you and the Plan. About half of all brand name medications have a generic equivalent available. By law, the brand name and generic medications must meet the same standards for safety, purity, strength and effectiveness. The pharmacist will only dispense generics which receive FDA approval and only if authorized by your doctor.

Note: If both generic and brand name drugs are available to treat your condition, your percentage co-payment amount will depend on which medication you select. If you purchase the brand name drug, you are responsible for paying the generic drug percentage co-payment PLUS the difference in cost between the generic drug and the brand name drug. This difference in cost will not count toward your annual prescription drug out-of-pocket maximum.

Here is an example of how you can save by choosing a generic drug at a retail pharmacy when a brand-name drug is available on the Plan's formulary list of medications.

Available Alternatives
Sometimes, a generic drug or a less expensive brand name drug which provides the same therapeutic effect at a lower cost to you may be available. If so, the network system will inform the pharmacist that a less expensive alternative medication is available to fill your prescription. A pharmacist from the network or Medco By Mail may contact your doctor to discuss the generic or less expensive brand name alternative. If the doctor authorizes a substitution, the pharmacist will dispense it based solely on your doctor's agreement. If Medco By Mail fills a prescription with a generic or an alternative brand name drug, your order will include an explanation of the doctor's change and a credit for any excess percentage co-payment.

The Network Formulary Program
A formulary is a list of commonly prescribed medications within particular therapeutic categories. The drugs on the list have been selected based on their effectiveness and cost. To be included in the formulary list, a drug must meet rigorous standards of approval by the Medco Pharmacy and Therapeutic Committee - a group of nationally recognized medical professionals.

It is always up to your doctor to decide which medications to prescribe. You may receive a copy of the network's formulary list to share with your doctor by contacting Medco.

page 16

Drug Monitoring Service
All prescriptions, both mail order and retail, are screened by the network's computerized drug monitoring service. This service analyzes all of your prescriptions in the system for potential problems such as adverse drug interactions, drug duplications and unusually high or low dosages. This service will also detect if a refill is requested too soon. If a potential problem is detected, the drug monitoring service transmits a message to the pharmacist.

The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription. Of course, your doctor makes the final decision about any change in your prescription or course of treatment.

Limitations

In most cases, the pharmacist will fill the prescription according to the doctor's written orders. However, there are some limitations:

• If the prescription is written for an amount that is greater than the Plan covers, the pharmacist will fill the prescription up to the Plan limit. You have the option to buy the additional amount at that time if purchasing at a retail pharmacy, but there is no plan benefit.
• If the medicine is a controlled substance or if there is a manufacturer's or prescription benefit manager's directive, a smaller amount may be provided.
• You must use at least 75% of the prescription, based on the dosage prescribed, before you can obtain a refill and receive plan benefits.

When a Prescription Drug Becomes Available Over the Counter
When a prescription medication becomes available over the counter, so that it can be purchased without a prescription, at the same strength and for the same use, it will no longer be covered under the Prescription Drug Program. In addition, other drugs in the same therapeutic class may be excluded from the program, but this determination will be made on a case by case basis, based on available clinical data.

Special Rules for Coordinating Benefits for Prescriptions
If you or your dependents are covered under any other group medical plan, the Plan coordinates benefits with that plan, as described on pages 31-32. In addition, information about the other coverage is provided to the outpatient prescription drug network.

When a pharmacist reviews your dependent's eligibility information in the network system, a code will indicate if your dependent has other coverage that should pay benefits first. In these cases, you must first pay according to the primary plan provisions (i.e., you cannot purchase prescriptions using the Medco card or through the mail-order prescription service). After the primary plan has paid, you may file a claim with the Plan for reimbursement of any remaining amount; the procedure is the same as when a non-participating pharmacy is used. The Plan will pay the lesser of what would have been paid if the claim was not filed with the primary plan or the amount not paid by the primary plan.

Medicare Advantage (Part C) Plans, Medicare Part D, and The Prescription Drug Program
Participants who choose to enroll in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or Medicare Part D Prescription Drug Plan will no longer be eligible for outpatient prescription drug coverage under the Plan. If you enroll in a Medicare Part C plan which provides a Medicare prescription drug benefit or Part D program and continue your Plan participation, your required contributions remain the same, but you will not be eligible for outpatient prescription drug benefits under the Plan.