Aldine Independent School District 2011 Prescription Drug Plan Your prescription drug benefit program is administered by Caremark, Inc. (Caremark) – the nation’s largest independent provider of health improvement services. Your Choices If you are enrolled in any of the District’s medical plan options, you are eligible for prescription drug coverage. When you need prescription drugs, you must use: A retail network pharmacy, or Caremark’s mail order pharmacy.
Participating pharmacies have agreed to be part of Caremark’s retail pharmacy network. To locate a participating retail pharmacy in your area, access the Pharmacy or call Caremark at 1-800-378-8651. You must use a network pharmacy to receive plan benefits. The plan doesn’t cover prescriptions purchased at out-of-network pharmacies. The retail pharmacy program is typically for the purchase of short-term use medications that you need to purchase immediately, such as antibiotics or certain pain medications. You may receive up to a 30-day supply of medication at a time. You must present your Caremark ID card to the pharmacist when purchasing a prescription. If you are enrolled in a District medical plan, your Aetna ID card can also be used for prescription drugs. The amount of your copay depends on whether you purchase generic, preferred brand, or non-preferred brand drugs. Ask your doctor to consider prescribing a generic drug whenever possible since you can get the same quality as a brand-name drug at a lower cost.
The mail order program can save you money if you have a condition that requires maintenance medication, if you take regular medication, or you have a long-term illness. Through this program, you may purchase up to a 90-day supply of most prescribed medications. The amount of your copay again depends on whether you purchase generic, preferred brand, or non-preferred brand drugs. Your copays apply to each prescription you and your dependents purchase. The first time you are prescribed a medication, ask your doctor for two prescriptions, one for a long-term supply (up to 90 days) and another for immediate use (up to 30 days). You can fill the short-term prescription at a participating retail pharmacy and send in the long-term prescription to the mail order program. What is Covered For the Consumer plans, there is a $50 per person annual deductible for prescription drugs. Once the deductible is met, the copay amount you pay for this prescription drug coverage depends on whether you purchase generic, preferred brand, non-preferred brand-name, or specialty drugs. Your copays apply to each prescription you and your dependents purchase. 2011 Prescription Drug Benefits Through Caremark Plan Features Consumer Basic – Choice Consumer Plus – Limited Consumer Plus – Choice Retail 30-Day Supply Mail Order 90-Day 2011 Prescription Drug Benefits Through Caremark Choice POS II Choice POS II Plan Features High (TRS-3) Low (Catastrophic) Retail 30-Day Supply Mail Order 90-Day Supply 1 The prescription deductible only applies once per year per person and a copay may also be requested 2 Specialty drug is up to a 30-day supply Note: All non-sedating antihistamines (Clarinex, Allegra D) are paid at the Non-preferred Brand copay level Generic drugs will be dispensed whenever possible. Brand-name drugs will be dispensed only when: There is no equivalent generic drug available for substitution, or Your physician specifically requests a brand-name drug. However, if you request a brand name drug
when a generic alternative is available (unless your physician writes “Dispense as Written”), your total out-of-pocket cost for your prescription will be considerably higher. You will pay the brand name drug copay plus the drug cost difference between the brand name medicine and the generic medicine.
A comprehensive program has been designed for you if you have chronic conditions including hypertension, hyperlipidemia (high cholesterol) or diabetes. The prescription drug copay for generic drugs prescribed to treat your hypertension or hyperlipidemia are waived. Waiving these copays makes it easier for you to follow your doctor’s directions by taking prescribed medications and renewing them on time to manage your conditions. In addition, copays for generic diabetic drugs and injectable Insulin are waived when you are compliant with your Diabetes America treatment plan. Diabetes America can provide you all the necessary care to help you effectively manage your diabetic
condition and live a healthier life. The program is offered at each of Diabetes America's Houston locations with all the care you and/or your adult dependent needs - including laboratory, medical, educational, exercise, and nutrition services - under one roof. Through this program and along with separate medical plan incentives, you will receive special prescription incentives.
Copays will be waived for generic diabetes-related prescriptions and injectable Insulin, when
prescribed by Diabetes America and dispensed through your CVS Caremark mail order prescription benefit, as long as you remain compliant with your Diabetes America treatment plan (costs for testing supplies will not be waived, but are part of your normal pharmacy benefit)
Because Diabetes America works hand in hand with your primary care physician, this program does not replace that regular physician, but compliments them and reinforces the plan of care you might have with your primary care physician.
Specialty pharmacy services provide clinical support and ongoing interaction and education that enable patients to manage and live with their chronic or complex condition resulting in optimal outcomes and reduced overall healthcare costs. Caremark Specialty Pharmacy Services provide end to end support of physicians and participants – hassle-free benefits verification, patient-centric care and engagement, improved adherence, access to over 99% of all specialty medications and understands the unique needs of patients. Specialty pharmaceuticals are produced through DNA technology or biological processes and target chronic or complex disease states. They require more frequent monitoring, training, unique handling, distribution, and/or administration. Prescriptions are limited to a 30 day supply at a Specialty copay. Call Caremark’s customer service at 1-800-378-8651 for questions related to Specialty therapies and services. What’s Not Covered The prescription drug plan does not cover the following products because they are either: 1) covered under the medical plan, 2) intended solely for cosmetic appearance, 3) self care products, or 4) available over-the-counter (OTC): Cosmetic Products Nutritional Supplements Prescription devices other than Respiratory Vaccines/Toxoids Excluded Drugs Over The Counter Drugs Contraceptive Devices Lunelle Erectile Dysfunction Fertility Medications Anabolics (oral and injectable) Androgens Diet Medications Smoking Cessation Alcohol Wipes Glucose Monitors Respiratory Therapy Supplies Blood Factors/Clotting Factors Exubera Discount Rx Program If you waive District medical coverage, you may enroll in the Discount Rx program at any time throughout the year, but you must enroll to receive a card. The program entitles you to a cash discount through Caremark participating pharmacies and mail service. The Discount Rx card is not insurance, and you do not have a copay amount. You are responsible for paying 100% of the discounted Caremark price and any dispensing fee. It is simply a discount program. Caremark will provide you an ID card when you choose to enroll. About Generic, Preferred Brand, and Non-preferred Brand Drugs A generic drug includes the same ingredients as its brand-name equivalent, but at a lower cost. A generic drug is named for its contents, while a brand-name drug is named by the manufacturer for marketing purposes. Most health care professionals believe that generic drugs are as safe and effective as brand- name drugs.
A preferred brand drug is a brand-name drug that has been selected for its clinical appropriateness (i.e. safety and efficacy) and cost effectiveness.
Non-preferred brand drugs are those which generally have generic equivalents and/or have one or more preferred brand name drugs within the same therapeutic category. These medications are typically covered at the highest copay.
Drug manufacturers must comply with Food and Drug Administration (FDA) standards, whether they are producing brand-name or generic drugs. These standards guarantee that generics are equivalent to their brand-name counterparts in substance and body absorption rates.
Understanding the Caremark Clinical Programs Managed Drug Limitations (or Quantity Limits)
In an effort to continue to offer a comprehensive prescription drug program, your benefit provider has put in place certain drug limits. In doing this, your benefit provider can better manage the high cost of certain drugs, yet not eliminate their coverage all together. Only when you have exceeded your benefit limit will you pay the full cost of your medication. This program is used to assure an appropriate quantity is dispensed in keeping with the manufacturer’s and the FDA’s recommendation and accepted medical practices. The limits on these drug classes only affect the amount your plan will pay for, not whether you can obtain greater quantities. Antiemetic AntiMigraine Intra-Nasal Corticosteroids Proton Pump Inhibitors Sedatives/hypnotics For certain drug classes (noted below), there is a limit on the quantity of that medication that the Plan will cover. However, if your physician determines that a greater quantity of a specific medication is appropriate for your treatment; your physician can call Caremark Prior Authorization at 1-800-626-3046. Antiemetics – Aloxi, Anzemet, Emend, Kytril, Zofran, Sancuso, Cesamet, Marinol AntiMigraine – Amerge, Axert, Frova, Imitrex, Alsuma, Maxalt, Maxalt MLT, Relpax, Sumavel,
Sedative/hypnotics – Ambien, Ambien CR, Lunesta, Rozerem, Sonata Proton Pump Inhibitors – Aciphex, Nexium, Prilosec, Prevacid, Protonix, Zegerid If you have any further questions about these prescription drug management programs, please contact Caremark customer service at 1-800-378-8651. Specialty Guideline Management (SGM) The Specialty Guideline Management (SGM) program supports safe, clinically appropriate and cost- effective use of specialty medications. Programs are based on FDA-approved labeling, compendia uses, current medical literature, and nationally recognized guidelines. The Caremark clinical team proactively works with the physician’s office to obtain the required clinical information. If the participant meets the guidelines, Caremark will approve the case and notify the prescribing physician of the approval as well as ship the medication to the participant. If the participant does not meet the guidelines, Caremark will send a denial letter to the prescribing physician and participant. Specialty therapies requiring utilization management include: Allergic Asthma – Xolair Age Related Macular Degeneration – Lucentis, Macugen, Visudyne Alpha-1 Antitrypsin Deficiency – Aralast, Prolastin, Zemaira Blood Modifiers – Leukine, Neulasta, Neupogen, Aranesp, Epogen, Procrit Cystic Fibrosis – Pulmozyme, TOBI Enzyme Replacement – Aldurazyme, Ceredase, Cerezyme, Elaprase, Fabrazyme, Myozyme,
Growth Hormone and related disorders – Genotropin, Humatrope, Increlex, Norditropin, Nutropin,
Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive
Hemophilia – Advate, Alphanate, Alphanine SD, Bebulin VH, Benefix, Feiba VH, Helixate FS,
Hemofil-M, Humate-P, Koate-DVI, Kogenate FS, Monarc-M, Monoclate-P, Mononine, Novoseven, Profilnine SD, Proplex T, Recombinate, Refacto, Stimate
Hepatitis C – Copegus, Infergen, Intron A, Pegasys, Peg-Intron, Rebetol, Ribasphere, Ribavirin,
HIV – Fuzeon Hormonal Therapies – Eligard, Lupron, Lupron Depot, Trelstar, Vantas, Viadur, Zoladex IBD – Humira, Remicade Immune Therapies – Baygam, Carimune NF, Cytogam, Flebogamma, Gamastan-SD, Gammagard,
Gammar-P, Gamunex, Iveegam EN, Octagam, Panglobulin, Polygam-SD, Venoglobulin-S, Vivaglobin
Multiple Sclerosis – Avonex, Betaseron, Copaxone, Novantrone, Rebif, Tysabri Oncology – Gleevec, Intron A, Iressa, Nexavar, Rituxan, Revlimid, Sprycel, Sutent, Tarceva,
Temodar, Thalomid, Tykerb, Xeloda, Zolinza
Osteoarthritis – Euflexxa, Hyalgan, Orthovisc, Supartz, Synvisc Osteoporosis - Forteo Psoriasis – Amevive, Enbrel, Humira, Remicade Pulmonary Arterial Hypertension – Flolan, Letairis, Remodulin, Revatio, Tracleer, Ventavis Renal - Sensipar RSV – Synagis Rheumatoid Arthritis – Enbrel, Humira, Kineret, Orencia, Remicade, Rituxan Prior Authorization Required Certain medications may require prior authorization before they are covered by Aldine Independent School District (Aldine ISD)’s plan to ensure they are used for appropriate situations and conditions. If your doctor prescribes a prescription drug that requires a prior authorization, your pharmacist will
inform you to notify your doctor that he/she must contact the Caremark Prior Authorization Unit toll-free at 1-800-626-3046 prior to receiving your prescription.
After your doctor contacts Caremark, the drug is reviewed for clinical appropriateness and either
approved or denied. – If approved, your pharmacist can fill the prescription. – In the event the prior authorization is not approved, you and the doctor will receive a letter. The
letter will explain the reason for the denial. You can still choose to have the prescription filled, but you will pay 100% of the pharmacy charge.
Prior Authorization applies to the following drug class: Acne medications (for participants 26 YO & older) – Azelex, Finevin, Differin, Retin-A, Tazorac ADHD/Narcolepsy (for participants 19 YO & older) - Concerta, Daytrana, Focalin, Focalin XR,
Metadate, Methylin, Ritalin, Adderall, Adderall XR, Desoxyn, Dexedrine, Dextrostat, Vyvanse, Strattera
Oral Antifungal - Diflucan (except 150mg), Lamisil, Sporanox Narcolepsy – Provigil, Nuvigil, Xyrem GI Motility – Amitiza, Lotronex Oral Fentanyl – Actiq, Fentora, Onsolis, Abstral
Appeal Overview Once a participant or their representative is notified that a claim is wholly or partially denied, they have the right to appeal. The internal appeals process begins in the CVS Caremark Customer Service department. Once a
participant or participant’s representative (requestor) contacts CVS Caremark with a request to appeal, they are instructed on how to submit an appeal.
Acceptable submission methods would include fax or mail. In the case of Urgent appeals, the
participant’s physician may make the request by phone.
Appeals for Prior Authorization (PA) denials may be forwarded directly to the Appeals Department
per the directions in the PA denial letters.
A participant or their representative must submit an appeal to CVS Caremark in writing no later than
180 days after receiving an adverse decision notification.
Completed appeals forms and supporting documentation should be sent directly to the Appeals
department for processing. Call Caremark customer service to obtain a copy of the forms needed.
Appeals are to be processed within the following time frames from the date complete information is
received: – Pre-Service 15 days – Post Service 30 days – Urgent Care 72 hours
First level appeals are performed based on the Client’s prescription benefit plan and approved prior
Initial Benefit Reconsideration: (1st level appeal)
The review process includes the consideration of relevant and supporting documentation submitted by and for the claimant. Supporting documentation may include a letter written by the practitioner in support of the appeal, a copy of the denial letter sent by CVS Caremark, a copy of the participant’s payment receipt or medical records, etc. A participant or their representative must submit an appeal to CVS Caremark in writing no later than
180 days after receiving an adverse decision notification.
Appeals are to be processed within the following time frames from the date complete information is
received: – Pre-Service 15 days – Post Service 30 days – Urgent Care 72 hours
You will receive a written explanation of the final determination. Go to www.caremark.com to find these forms and CVS Caremark’s appeals process. You may request a copy of the criteria relied upon in making the determination and any other
information relevant to the determination by calling Caremark customer service.
First level appeals are performed based on the Client’s prescription benefit plan and approved prior
Upon receipt, the Appeals Analyst reviews and determines appeals relating to non-clinical benefits (e.g. eligibility determinations, copay issues, explicit exclusions under the Client’s prescription benefit plan). Appeals determinations regarding clinical knowledge (e.g. PA denials) are reviewed by the Appeals Pharmacist. All appeal determinations shall be final subject to any provisions for additional review by the Client. If the first level appeal is denied, you have the right to a second and final level appeal.
Medical Necessity Appeals/Independent Physician Specialist Review (2nd level appeal)
CVS Caremark has contracted with independent external review organizations (IRO) to conduct independent specialist physician reviews of denials of authorization of benefits when the Plan participant or beneficiary is entitled to obtain such a review. These reviews will only be performed for denials of Prior Authorization requests upheld on Initial Benefit Reconsideration (1st Level Appeal). An additional request from the participant or their representative must be made for this review to occur. For such appeals, the following will occur: CVS Caremark will forward or cause to have forwarded to the IRO applicable medical records,
documentation, Plan language and specific criteria.
Examples of supporting documentation that you may also submit to CVS Caremark can include
required lab tests, clarification from your doctor regarding the specific denial reason, clinical information regarding the medical necessity for the denied medication, etc.
The independent specialist selected by IRO to conduct the review will review documentation received
with the case. If IRO considers additional information necessary or potentially useful in its review, IRO may contact the Plan participant’s or beneficiary’s provider to request such information.
The independent specialist selected by IRO will review available medical records, review any
additional information obtained from the provider, and will write an independent rationale in support of his or her final decision.
The letter containing the rationale will be forwarded to CVS Caremark for communication to the
participant or the participant’s representative.
Appeal Determination Process Reviews are conducted within the applicable time frames listed above for the appeal type Appeal forms and associated documentation are stamped with the date and time of receipt. The appeal determination is rendered, and pertinent information is entered into the database. The determination is then communicated in writing to the participant or the participant’s
Communication is written in a manner calculated to be understood by the participant or their
representative. – Communication includes general information that states the decision rendered. – When the original determination is overturned, the communication explains the basic steps or
process that either CVS Caremark or the participant would need to follow.
When the original determination is upheld, the communication provides the specific reason for the
denial, and references the section of the prescription benefit plan on which the denial was based.
Confidentiality All participant and Client appeal documentation is handled in a confidential manner and in
accordance with applicable statutes and regulations to protect the participant’s identity and their prescription history.
To promote confidentiality of participant information, all appeal information becomes a part of a
permanent case file. Case files are then: – Prepared for each appeal, – Retained in a locked filing cabinet, and – Kept on file at CVS Caremark for a period of two years and off site for an additional five years.
How to File a Claim To get a prescription filled at a retail pharmacy, you can find a participating retail pharmacy by going to mer Care. At the network pharmacy, you should present your ID card and prescription. The pharmacist will look up the benefit information online, verify coverage, and dispense the prescription to you. No claim needs to be filed. To get a prescription filled through Caremark Mail Service, you can complete a Caremark Mail Service Order Form (also available through the web site or by calling Customer Care at 1-800-378-8651) and mail it along with your prescription for a 90 day supply to Caremark. You can provide payment information when you place the order (either by check, money order, or credit card) and expect to receive the medicine in approximately 10 to 14 days. Refills can be submitted online or by mail. If you have paid for your prescription out of pocket and need to submit a paper claim, you can find the claim form on the web site, www.caremark.com, then submit it along with the receipts to:
Caremark, Inc. PO Box 686005 San Antonio, TX 78268-6005
How to Use this Document We are pleased to provide you with this Plan Description. This document describes your prescription drug benefits under the Aldine ISD prescription drug plans. These prescription drug benefits are part of the Aldine Independent School District Welfare Benefit Plan, and there is a single enrollment and single contribution for this combined Medical / Prescription drug Plan. Your eligibility and rights within this Plan are described in the medical Summary Plan Descriptions. Please refer to these SPD’s for Plan information related, but not limited to: When coverage begins Initial, Open, and Special enrollment periods When coverage ends Family Medical Leave Act (FMLA) and other leaves COBRA continuation General legal provisions Plan Description
Name of Plan: Aldine Independent School District Employee Benefit Plan Name, Address, and Telephone Number of Plan Sponsor and Named Fiduciary:
Aldine Independent School District 15010 Aldine Westfield Rd. Houston, TX 77032 281-985-6301
The Plan Sponsor retains all fiduciary responsibilities with respect to the Plan except to the extent the Plan Sponsor has delegated or allocated to other persons or entities one or more fiduciary responsibility with respect to the Plan. Employer Identification Number (EIN): 74-6001110-3 IRS Plan Number: Non-Federal Government Plan Effective Date of Plan: January 1, 2004 Type of Plan: Group health care coverage plan Name, Business address, and Business Telephone Number of Plan Administrator:
Aldine Independent School District 15010 Aldine Westfield Rd. Houston, TX 77032 281-985-6301
Claims Administrator: The company which provides certain administrative services for the Plan:
Caremark, Inc. PO Box 686005 San Antonio, TX 78268-6005
The Claims Administrator shall not be deemed or construed as an employer for any purpose with respect to the administration or provision of benefits under the Plan Sponsor’s Plan. The Claims Administrator shall not be responsible for fulfilling any duties or obligations of an employer with respect to the Plan Sponsor’s Plan. Type of Administration of the Plan: The Plan Sponsor provides certain administrative services in connection with its Plan. The Plan Sponsor may, from time to time in its sole discretion, contract with outside parties to arrange for the provision of other administrative services including arrangement of access to a Network Provider; claims processing services, including coordination of benefits and subrogation; utilization management and complaint resolution assistance. This external administrator is referred to as the Claims Administrator. The Plan Sponsor also has selected a provider network established by Caremark, Inc. The named fiduciary of Plan is Aldine Independent School District, the Plan Sponsor. Person designated as agent for service of legal process: Service of process may also be made upon the Plan Administrator. Source of contributions under the Plan: There are no contributions to the Plan. All Benefits under the Plan are paid by the Plan Sponsor. Any required employee contributions are used to partially reimburse the Plan Sponsor for Benefits under the Plan. Method of calculating the amount of contribution: Employee-required contributions to the Plan Sponsor are the employee’s share of costs is determined by Plan Sponsor. From time to time, the Plan Sponsor will determine the required employee contributions for reimbursement to the Plan Sponsor and distributed a schedule of such required contributions to employees. Date of the end of the year for purposed of maintaining Plan’s fiscal records: Plan year shall be a twelve month period ending December 31. Plan Sponsor Although the Plan Sponsor currently intends to continue the Benefits provided by this Plan, the Plan Sponsor reserves the right, at any time and for any reason or no reason at all, to change, amend, interpret, modify, withdraw, or add Benefits or terminate this Plan or this Plan Description, in whole or in part and in its sole discretion, without prior notice to or approval by Plan participants and their beneficiaries. Any change or amendment to or termination of the Plan, its benefits or its terms and condition, in whole or in part, shall be made solely in a written amendment (in the case of a change or amendment) or in a written resolution (in the case of termination), whether prospective or retroactive, to the Plan. The amendment or resolution is effective only when approved by the body or person to whom such authority is formally granted by the terms of the Plan. No person or entity has any authority to make any oral changes or amendments to the Plan. Benefits under the Plan are furnished in accordance with the Plan description issued by the Plan Sponsor, including this document.
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