Microsoft word - medco_spd2010.doc

A Plan Designed to Provide
Security for Employees of

Lee Enterprises,
Incorporated

Appendix to the Lee Enterprises Low, Mid and High Deductible Plans Summary Plan Description

Prescription
Drug
Coverage


Lee Enterprises intends to continue this Plan, but reserves the right, in its sole discretion, to modify,
change, revise, amend or terminate the Plan at any time, for any reason, and without prior notice. This
SPD Appendix is not to be construed as a contract of or for employment. If there should be an
inconsistency between the contents of this summary and the contents of the Plan, your rights shall be
determined under the Plan and not under this summary.

SCHEDULE OF BENEFITS

If drugs are prescribed to treat you or one of your dependents, Lee Enterprises, Inc (the
“Company”) will pay Prescription Drug benefits for covered charges as described below:
The following chart shows your maximum prescription drug costs under the Low- and Mid-
Deductible Plans. These costs are in addition to any costs you incur for medical
expenses.
Drug Category
Your Cost-Sharing Your Maximum
Your Maximum
Prescription for 30- Prescription for 90-
day Retail Supply
day Mail Order
Supply
Preferred Brand
Non Preferred
Out-of-Pocket Maximum $2,000 Individual/ $4,000 Family
If the amount you pay for covered charges in any one calendar year reaches the Out of
Pocket Expense Maximum shown above, Prescription Drug benefits will be payable at
100% of covered charges. The Out of Pocket Expense Maximum for Retail and Mail
Order Drugs is a combined maximum.
The following chart shows your maximum prescription drug costs under the High-Deductible Plan. These costs apply toward the medical plan deductible, cost-sharing and maximum out-of-pocket amounts. What You Pay
Deductible
Cost-sharing
Maximum Cost-sharing Out of Pocket

Generic Substitution for the Low, Mid and High Deductible Plans
If there is a generic equivalent and you choose to receive the brand name medication,
in addition to the cost of the generic you will pay the difference in the cost between the
generic and brand. The difference in cost will not apply to your deductible or out-of-
pocket maximum.
COVERED CHARGES
The following are covered benefits unless listed as an exclusion:
disposable blood/urine glucose/acetone testing agents (e.g. Chemstrips, Clinitest tablets, Diastix strips, and Tes-Tape); legend oral contraceptives, NuvaRing, and Ortho Evra; compounded medications in which at least one ingredient is a Prescription Legend Drug; and any other drug or medicine that can be legally dispensed only upon the written prescription of a physician.
NON-COVERED CHARGES
No benefits will be paid for the following Prescription Drug charges:
• drugs that are not for medically necessary care; • drugs dispensed by a hospital, skilled nursing facility, rest home, or other institution in which you or one of your dependents is confined; • drugs delivered or administered by the prescriber; • drugs prescribed or dispensed by any person in your immediate family or any person in your dependent's immediate family; • drugs (other than insulin) that can be purchased without a physician's prescription; • any prescription drug with an over the counter (OTC) equivalent; • therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medicinal substances, regardless of intended use (except as described under covered charges); • contraceptives (non-oral dosage forms); infertility drugs, immunization agents, blood, blood plasma, or self-injectables (except as described under covered charges); • administration or injection of any drug or medicine; • any prescription or refill in excess of the number directed by the physician or any refill dispensed more than one year after the prescription date; • drugs for which you or your dependent has no financial liability or that would be provided at no charge in the absence of coverage; • drugs that are paid for or furnished by the United States Government or one of its agencies (except as required under Medicaid provisions or Federal law); • drugs provided as the result of a sickness or injury that is due to war or act of war or to participation in criminal activities; • drugs provided as the result of a sickness that is covered by a Workers' • drugs provided as the result of an injury arising out of or in the course of any • drugs labeled "Caution--limited by Federal law to investigational use," or experimental, even though a charge is made to the individual; • cosmetic hair removal products (e.g. Vaniqa); • any drugs covered under the Lee Comprehensive Medical Plan.

MAIL ORDER INCENTIVE PROGRAM

You will pay more for long-term medications (such as those used to treat high blood
pressure or high cholesterol) if you continue to purchase them at a participating retail
pharmacy rather than through Medco By Mail, Medco’s mail-order pharmacy. Medco By
Mail is a convenient, low-cost way of receiving up to a 90-day supply of long-term
medications through the mail.
To give you time to take advantage of Medco By Mail, the first three times you purchase
each long-term drug at a participating retail pharmacy, you will pay only the amounts
shown in the Schedule of Benefits. Starting with the 4th retail fill, you will pay the full cost
of the drug if you purchase long-term medications at a participating retail pharmacy. The
cost for continuing to fill a maintenance drug at a retail pharmacy does not apply to your
deducible or annual out of pocket maximums. By using Medco By Mail, you will continue to
pay only your portion of the cost outlined in the Schedule of Benefits.
You should continue to get all your short-term medications, such as antibiotics, at a
participating retail pharmacy.
To determine which medications you are taking are affected by this change, please visit
the “Price a Medication” section of www.medco.com. If you are a first-time visitor to the
site, take a minute to register. Please have your member ID number and a recent
prescription number handy when you register. You may also call Member Services at 1-
800-987-5248.
HOW TO UTILIZE YOUR BENEFITS AT A RETAIL PHARMACY
You may want to use a participating retail pharmacy for short-term prescriptions (such as
antibiotics to treat infections). Be sure to show your United Healthcare ID card to the
pharmacist to only pay your portion of the cost as outlined in the Schedule of Benefits.
If you use a nonparticipating retail pharmacy, you must pay the entire cost of the
prescription and then submit a reimbursement claim to Medco. The claim form can be
found at link.lee.net. You will be reimbursed the amount the drug would have cost at a
participating retail pharmacy minus your 40% coinsurance.

HOW TO ORDER FROM MEDCO BY MAIL
Utilizing the mail order program is easy, with various options to submit and refill prescription orders: • Point-and-click ordering system available at Medco's website, www.medco.com. Medco will email your physician to request a mail order prescription. • Order refills by telephone through the automated system by calling 1-888-327- • A Medco by Mail Order form is available at link.lee.net or medco.com to obtain a new prescription or refill a prescription via mail or fax. PRESCRIPTION DRUG COVERAGE MANAGEMENT PROGRAMS
The following information explains a feature of your prescription drug plan known as
coverage management. Coverage management determines how your prescription drug
plan will cover certain medications.
Lee utilizes coverage management programs to help control rising drug costs and provide
you with the coverage you need. Each program is administered by Medco.
The Coverage Review Process
For your prescription drugs that need special authorization, you, your doctor, or your
pharmacist may initiate the review process by calling Medco at 1-800-753-2851.
Your doctor will be sent a Coverage Management Review Fax Form to fill out and fax
back to Medco. Medco will contact you and your doctor by phone or letter confirming
whether or not coverage has been approved (usually within 2 business days of
receiving the necessary information).
If coverage is approved, you simply pay your normal co-payment for the medication. If
coverage is not approved, you will be responsible for the full cost of the medication.
NOTE: You have the right to appeal the decision. Information about the appeal process
will be included in the notification letter that you receive.
For more information on medication coverage or limitations, please visit
www.medco.com, log in and click "Price a medication" in the left navigation menu under
"Prescriptions & benefits", search for your medication, then click "review coverage
notes". If you are a first-time visitor to medco.com, take a moment to register. Please
remember to have your member ID number and a recent prescription number handy.
You can also call Medco Member Services at 1-800-939-3781.
Prior Authorization
Some medications are not covered unless you receive pre-approval, or prior
authorization. Prior authorization requires that you obtain pre-approval through a
coverage review. The review will determine whether your plan covers your prescribed
medication.

Quantity Limitations
For some medications, your plan may cover a limited quantity within a specified period of
time. A coverage review may be necessary to have additional quantities of these
medications covered by your plan. This program alerts the pharmacist when the total
quantity of a medication exceeds the amount allowed.
CLAIMS APPEAL PROCESS

For all claims other than member submitted paper claims:

In the event you receive an adverse determination following a request for coverage of a
prescription benefit claim, you have the right to appeal the adverse benefit
determination in writing within 180 days of receipt of notice of the initial coverage
decision. To initiate an appeal for coverage, you or your authorized representative (such
as your physician), must provide in writing, your name, member ID, phone number, the
prescription drug for which benefit coverage has been denied and any additional
information that may be relevant to your appeal. This information should be mailed to
Medco Health, 8111 Royal Ridge Parkway, Irving, TX 75063, ATTN: Coverage
Reviews. A decision regarding your appeal will be sent to you within 15 days of receipt
of your written request. The notice will include the specific reasons for the decision and
the plan provisions on which the decision is based. You have the right to receive, upon
request and at no charge, the information used to review your appeal.
If you are not satisfied with the coverage decision made on appeal, you may request in
writing, within 90 days of the receipt of notice of the decision, a second level appeal. To
initiate a second level appeal, you or your authorized representative (such as your
physician), must provide in writing, your name, member ID, phone number, the
prescription drug for which benefit coverage has been denied and any additional
information that may be relevant to your appeal. This information should be mailed to
Medco Health, 8111 Royal Ridge Parkway, Irving, TX 75063, ATTN: Coverage
Reviews. A decision regarding your request will be sent to you in writing within 15 days
of receipt of your written request for appeal. You have the right to receive, upon request
and at no charge, the information used to review your second level appeal. The decision
made on your second level appeal is final and binding.
If you are not satisfied with the decision of the second level appeal, you also have the
right to bring a civil action under section 502(a) of the Employee Retirement Income
Security Act of 1974 (ERISA) if your second level appeal is denied.
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. An urgent care claim is
any claim for treatment with respect to which the application of the time periods for
making non-urgent care determinations could seriously jeopardize the life or health of
the claimant or the ability of the claimant to regain maximum function, or in the opinion
of a physician with knowledge of the claimant's medical condition, would subject the
claimant to severe pain that cannot be adequately managed. 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, of the
information 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.
You have the right to request an urgent appeal of an adverse determination if you
request coverage of a claim that is urgent. Urgent appeal requests may be oral or
written. You or your physician may call 800-987-5248 or send a written request to
Medco Health, 8111 Royal Ridge Parkway, Irving, TX 75063, ATTN: Coverage
Reviews. 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. This
coverage decision is final and binding. You have the right to receive, upon request and
at no charge, the information used to review your appeal. You also have the right to
bring a civil action under section 502(a) of ERISA if your final appeal is denied.
For member submitted paper claims:
Your plan provides for reimbursement of prescriptions when you pay 100% of the
prescription price at the time of purchase. This claim will be processed based on your
plan benefit. You will receive an explanation of benefits within 30 days of receipt of your
claim. If you are not satisfied with the decision regarding your benefit coverage, you
have the right to appeal this decision in writing within 180 days of receipt of notice of the
initial decision. To initiate an appeal for coverage, you or your authorized
representative (such as your physician), must provide in writing, your name, member ID,
phone number, the prescription drug for which benefit coverage has been reduced or
denied and any additional information that may be relevant to your appeal. This
information should be mailed to Medco Health, 8111 Royal Ridge Parkway, Irving, TX
75063, ATTN: Coverage Reviews. A decision regarding your appeal will be sent to you
within 30 days of receipt of your written request. The notice will include the specific
reasons for the decision and the plan provision on which the decision is based. You
have the right to receive, upon request and at no charge, the information used to review
your appeal.
If you are not satisfied with the coverage decision made on appeal, you may request in
writing, within 90 days of the receipt of notice of the decision, a second level appeal. To
initiate a second level appeal, you or your authorized representative (such as your
physician), must provide in writing, your name, member ID, phone number, the
prescription drug for which benefit coverage has been reduced or denied and any
additional information that may be relevant to your appeal. This information should be
mailed to Medco Health, 8111 Royal Ridge Parkway, Irving, TX 75063, ATTN:
Coverage Reviews. A decision regarding your request will be sent to you in writing
within 30 days of receipt of your written request for appeal. The decision made on your
second level appeal is final and binding.
If you are not satisfied with the decision of the second level appeal, you also have the
right to bring a civil action under section 502(a) of the Employee Retirement Income
Security Act of 1974 (ERISA) if your second level appeal is denied.
DEFINITIONS

Because the writing of an insurance plan is like writing a legal contract, specific technical
words must be used to make areas of coverage and terms clear. Because of this, we
have included a list of words and definitions to help you understand more fully the extent of
your coverage under the Lee Prescription Drug Plan.
Brand Name Prescription Drug; Brand Name Drug: a drug that is customarily
recognized throughout the pharmaceutical profession as the original or trademarked
preparation of a drug entity and for which the Food and Drug Administration (FDA) has
given general marketing approval.
Coinsurance: the amount, calculated using a fixed percentage, you pay each time you
receive certain prescription drugs.
Company: Lee Enterprises, Incorporated.
Generic Prescription Drugs: biologically equivalent pharmaceutical products manu-
factured and sold under their chemical, common, or official name or a drug that is
classified as generic by First DataBank/Medispan.
Network Pharmacy: any pharmacy which has entered into an agreement with Medco
Non-Network Pharmacy: any pharmacy which has not entered into an agreement with
Medco.
Out of Pocket Expense Maximum: is the maximum amount you pay out of pocket in a
calendar year, in Coinsurance amounts, for prescription drugs.
Pharmacy Benefits Manager: your Pharmacy Benefits Manager is Medco.
Prescription Legend Drugs: any medicinal substance, the label of which under the
Federal Food, Drug and Cosmetic Act is required to bear the legend, "Caution, Federal
Law prohibits dispensing without a prescription."

Source: http://www.lee.net/spd/Medco_SPD2010.pdf