#10 – Amendment to Health Benefit Plan – Human Resources

The Health Benefit Plan has been amended. The changes affecting the Plan are set forth in this Summary of Material Modifications and are effective as of July 1, 2022.

Prescription Drug Benefit

The PRESCRIPTION DRUGS benefit will be deleted from the SCHEDULE OF MEDICAL BENEFITS – BLACK PLAN section of the Plan document. In place of this benefit, the following new section will be added to the Plan document:

SCHEDULE OF PRESCRIPTION DRUG BENEFITS – BLACK PLAN PRESCRIPTION DRUGS

Prescription Drug Card Program

Co-payment per generic prescription drug $10
Co-payment per brand-name prescription drug $20
Co-payment per Specialty Prescription Drug $25
A Covered Person may fill a prescription for up to and including a 30-day supply for the above-stated co-payment amounts. If a prescribing Physician requests more than a 30-day supply of a drug, a 60- to 90-day supply of a covered prescribed medication can be purchased at a participating pharmacy for the applicable Mail Service Program co-payment specified below. However, Specialty Prescription Drug purchases will always be limited to a 30-day dispensing supply.

Mail Service Program

Co-payment per generic prescription drug $20
Co-payment per brand-name prescription drug $40
Co-payment per Specialty Prescription Drug $25
The Mail Service Program is specifically designed to provide the Covered Person with maintenance drugs for up to and including a 90-day supply. However, Specialty Prescription Drug purchases will always be limited to a 30-day dispensing supply.

Prescription Drug Notes

The pharmacy will dispense generic drugs unless the prescribing Physician requests “Dispense as Written” (DAW) or a generic equivalent is not available. If the Covered Person refuses an available generic equivalent and the prescribing Physician has not requested DAW, the Covered Person must pay the applicable co-payment plus the difference in price between the brand-name drug and its generic equivalent.
Certain over-the-counter drugs will be covered under the Plan and shall be subject to the generic co-payments shown above. A Physician’s prescription for these products is required.
In accordance with the requirements of Health Care Reform, the Plan provides coverage for certain preventive care medications without any cost-sharing provisions such as medical Deductibles or prescription drug co-payments. Preventive care medications include, but are not limited to, certain FDA-approved contraceptive agents, certain smoking cessation intervention products when prescribed by a Physician, and breast cancer medications that lower the risk of cancer or slow its development. For more information about eligible preventive care medications, Covered Persons can contact the Pharmacy Benefits Manager (PBM) at the telephone number on the front of the identification card.
Certain immunizations administered at a pharmacy within the designated network, including any injection/administration fees charged by the pharmacy, will be covered by the Plan through the Prescription Drug Card Program at 100% (no prescription drug co-payment will be applied). Covered Persons can contact the PBM for more information on how to find a pharmacy within the designated network that administers
these immunizations.
The Plan requires that specific criteria be met before certain high-cost brand-name medications are covered. The Covered Person must have tried a lower-cost PBM-approved equivalent medication before the Plan will cover the brand-name drug. Alternatively, a brand-name drug may be covered if the Covered Person’s Physician contacts the PBM and provides evidence of the prior utilization or proof of failed therapy and the PBM authorizes the brand-name medication. If a Covered Person chooses to fill a prescription for certain brand-name drugs without first trying a PBM-approved equivalent medication or getting an authorization from the PBM, coverage may be denied and the Covered Person may have to pay the full cost of the drug.
Eligible prescriptions for a Specialty Prescription Drug must be filled through the designated specialty pharmacy network or that drug purchase will generally not be eligible for coverage under the Plan. Contact the PBM or OptiMed Specialty Pharmacy for more information about this program. As used in this benefit, the term “Specialty Prescription Drug” means a prescription drug identified on the drug list maintained by the PBM that includes drugs typically used to treat complex medical conditions. Specialty Prescription Drugs may be injectable medications, high-cost medications, or medications with special delivery and storage requirements (e.g., they may require refrigeration). Specialty Prescription Drug purchases will be limited to a 30-day dispensing supply.
Certain prescription drugs may be acquired through the Plan’s International Prescription Program vendor and may be available to Covered Persons with reduced or no cost-sharing provisions such as prescription drug co-payments. For more information about prescription drugs available through the International Prescription Program vendor, including the co-payment that will be charged or other special coverage terms that will apply, the covered person can contact the PBM using the information on his/her identification card.
For any Covered Person who meets the necessary individual qualifications to receive external assistance through variable program benefits for prescribed medication(s), the Plan has the right, at its sole discretion, to require the use of a particular, preferred, or mandated program(s). When utilizing the Plan’s preferred (or mandated) procurement avenue, the Covered Person’s financial liability may be variable, reduced, or eliminated as determined by the Employer. Therefore, any whole or partial benefit for which a Covered Person individually qualifies is not a covered benefit under the Plan.

SCHEDULE OF PRESCRIPTION DRUG BENEFITS – ORANGE PLAN PRESCRIPTION DRUGS

The PRESCRIPTION DRUGS benefit will be deleted from the SCHEDULE OF MEDICAL BENEFITS – ORANGE PLAN section of the Plan document. In place of this benefit, the following new section will be added to the Plan document:

Prescription Drug Card Program

Co-payment per generic prescription drug $10
Co-payment per brand-name prescription drug $20
Co-payment per Specialty Prescription Drug $25

A Covered Person may fill a prescription for up to and including a 30-day supply for the above-stated co-payment amounts. If a prescribing Physician requests more than a 30-day supply of a drug, a 60- to 90-day supply of a covered prescribed medication can be purchased at a participating pharmacy for the applicable Mail Service Program co-payment specified below. However, Specialty Prescription Drug purchases will always be limited to a 30-day dispensing supply.

Mail Service Program

Prescription Drug Notes

The pharmacy will dispense generic drugs unless the prescribing Physician requests “Dispense as Written” (DAW) or a generic equivalent is not available. If the Covered Person refuses an available generic equivalent and the prescribing Physician has not requested DAW, the Covered Person must pay the applicable co-payment plus the difference in price between the brand-name drug and its generic equivalent.
Certain over-the-counter drugs will be covered under the Plan and shall be subject to the generic co-payments shown above. A Physician’s prescription for these products is required.
In accordance with the requirements of Health Care Reform, the Plan provides coverage for certain preventive care medications without any cost-sharing provisions such as medical Deductibles or prescription drug co-payments. Preventive care medications include, but are not limited to, certain FDA-approved contraceptive agents, certain smoking cessation intervention products when prescribed by a Physician, and breast cancer medications that lower the risk of cancer or slow its development. For more information about eligible preventive care medications, Covered Persons can contact the Pharmacy Benefits Manager (PBM) at the telephone number on the front of the identification card.
Certain immunizations administered at a pharmacy within the designated network, including any injection/administration fees charged by the pharmacy, will be covered by the Plan through the Prescription Drug Card Program at 100% (no prescription drug co-payment will be applied). Covered Persons can contact the PBM for more information on how to find a pharmacy within the designated network that administers
these immunizations.
The Plan requires that specific criteria be met before certain high-cost brand-name medications are covered. The Covered Person must have tried a lower-cost PBM-approved equivalent medication before the Plan will cover the brand-name drug. Alternatively, a brand-name drug may be covered if the Covered Person’s Physician contacts the PBM and provides evidence of the prior utilization or proof of failed therapy and the PBM authorizes the brand-name medication. If a Covered Person chooses to fill a prescription for certain brand-name drugs without first trying a PBM-approved equivalent medication or getting an authorization from the PBM, coverage may be denied and the Covered Person may have to pay the full cost of the drug.
Eligible prescriptions for a Specialty Prescription Drug must be filled through the designated specialty pharmacy network or that drug purchase will generally not be eligible for coverage under the Plan. Contact the PBM or OptiMed Specialty Pharmacy for more information about this program. As used in this benefit, the term “Specialty Prescription Drug” means a prescription drug identified on the drug list maintained by the PBM that includes drugs typically used to treat complex medical conditions. Specialty Prescription Drugs may be injectable medications, high-cost
medications, or medications with special delivery and storage requirements (e.g., they may require refrigeration). Specialty Prescription Drug purchases will be limited to a 30-day dispensing supply.
Certain prescription drugs may be acquired through the Plan’s International Prescription Program vendor and may be available to Covered Persons with reduced or no cost-sharing provisions such as prescription drug co-payments. For more information about prescription drugs available through the International Prescription Program vendor, including the co-payment that will be charged or other special coverage terms that will apply, the covered person can contact the PBM using the information on his/her identification card.
For any Covered Person who meets the necessary individual qualifications to receive external assistance through variable program benefits for prescribed medication(s), the Plan has the right, at its sole discretion, to require the use of a particular, preferred, or mandated program(s). When utilizing the Plan’s preferred (or mandated) procurement avenue, the Covered Person’s financial liability may be variable, reduced, or eliminated as determined by the Employer. Therefore, any whole or partial benefit for which a Covered Person individually qualifies is not a
covered benefit under the Plan.

Prescription Drug Benefit

PRESCRIPTION DRUG CARD PROGRAM

Charges are covered under this benefit for eligible drugs that are prescribed in writing by a Physician, Physician’s Assistant, or Nurse Practitioner within the legally appointed scope of his/her license. Benefits are paid in excess of the co-payment per prescription listed in the Schedule of Benefits. The Plan Administrator may establish other procedures to administer this benefit. If the Plan Administrator has issued an identification card for prescription drug benefits, the Covered Person must either destroy that card or surrender it to the Plan Administrator when his or her coverage terminates. The Plan will allow the Covered Person to fill a prescription for up to and including a 30-day supply (or a 60- to 90-day supply for certain drugs as determined by the Pharmacy Benefits Manager [PBM]), subject to the Prescription Agreement between the Employer and the PBM.

If an eligible prescription is filled at a pharmacy within the designated network, the Covered Person will be responsible only for the co-payment amount when purchasing the drug. If an eligible prescription is purchased at a pharmacy that is not within the designated network, the Covered Person must pay the purchase price in full and then must submit the charge directly to the PBM for reimbursement.

Claims for prescription drugs must include the name of the prescribed medication, the patient’s full name, the date that services were rendered or purchases made, and the cost per item. If the PBM permits a Covered Person to directly submit expenses for reimbursement, a qualifying receipt and the PBM’s designated claim form must be submitted directly to the PBM for processing. Reimbursement will be made based on a formula determined by the PBM and agreed to by the Employer; the amount received may be less than the difference between the purchase price and the co-payment amount.

MAIL SERVICE PROGRAM

Charges are covered under this benefit for eligible drugs that are provided through the Mail Service Program and that are prescribed in writing by a Physician, Physician’s Assistant, or Nurse Practitioner within the legally appointed scope of his/her license. Each prescription purchase is subject to the co-payment stated in the Schedule of Benefits. The Mail Service Program is specifically designed to provide the Covered Person with maintenance drugs for up to and including a 90-day supply.

SPECIALTY PHARMACY PROGRAM

The Plan generally provides coverage for certain Specialty Prescription Drugs designated as covered by the PBM or Plan Administrator that are prescribed in writing by a Physician, Physician’s Assistant, or Nurse Practitioner within the legally appointed scope of his/her license. The Plan will allow the Covered Person to fill a prescription for up to and including a 30-day supply of an eligible Specialty Prescription Drug. In general, if a prescription for a Specialty Prescription Drug is not filled through either the designated specialty pharmacy network or via the International Prescription Program vendor, that drug purchase will not be eligible for coverage under the Plan. Contact the PBM for more information about this program.

Covered Products

Compounded medications
Contraceptives (all FDA-approved methods designated as covered by the PBM, including emergency kits, but excluding abortifacient agents)
Diabetic supplies designated as covered by the PBM
Federal legend drugs (unless specifically designated as excluded by the PBM)
Immunizations designated as covered by the PB< (e.g. flu shots)
Injectables, self-administered (unless specifically designated as excluded by the PBM)
Medications related to the diagnosis of gender dysphoria
over-the-counter products designated as covered by the PBM (Physicians prescriptions is required)
Products and medications listed as covered under the Prescription Agreement between Employer and the PBM
Smoking cessation products
Specialty Prescription Drugs designated as covered by the PBM or Plan Administrator (oral and injectable forms; coverage for certain products may be limited based on cost, use of the designated specialty pharmacy, and alternative sourcing opportunities available)

Excluded Products

Cosmetic drugs (unless specifically designated as covered by the PBM)
Infertility drugs
Injectables, office-based (unless specifically designated as covered by the PBM)
Medical devices or appliances (unless specifically designated as covered by the PBM)
Over-the-counter products (unless specifically designated as covered by the PBM)
Products and medications listed as excluded under the Prescription Agreement between the Employer and the PBM

Notes

Quantity limits, a prior authorization requirement, or other coverage limitations may apply to some drugs. To obtain more information about the Plan’s prescription drug benefit, including information about the coverage status or the co-payment amount applicable to a particular drug, the Covered Person can call the PBM’s telephone umber listed on the health plan identification card.
In accordance with the requirements of Health Care Reform, the Plan provides coverage for certain preventive care medications without any cost-share provisions such as Deductibles or co-payments. For more information about eligible preventive care medications, Covered Persons can contact the PBM at the telephone number on the health plan identification card. In the event a conflict arises between this provision and the information stated under the Excluded Products subsection above, the terms of this provision will rule.

Exclusions and Limitations

In the General Plan Exclusion and Limitations section of the Plan document, the Travel to Foreign Countries for Specific Treatment provision will be revisions to read as follows:

Travel to Foreign Countries for Specific Treatment

Charges incurred outside the United States if the Covered Person traveled to such a location for the primary purpose of obtaining medical services, drugs or supplies. This exclusion does not apply to prescription drugs acquired through the Plan’s International Prescription Program vendor, or to otherwise eligible charges if the location was closer to, or substantially more accessible from, the Covered Person’s residence (or if an emergency exists, the place where the Covered Person suffered the Illness or Injury) than the nearest location within the United States that was adequately equipped to deal with, and was available for treatment of, the Covered Person’s Illness or Injury

All other provisions of the Plan shall remain in effect and unchanged.

Signed copies of this amendment are available in the Human Resources office upon request.