Columbia University in the City of New York
Optum Rx Prescription Drug Plan for Officers,
Support Staff, Post-Doctoral Fellows, Obama
Scholars, Pre and Post 65 Retirees
Effective: January 1, 2021
Group Number: 712790
Summary Plan Description
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Guidelines and tips
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Summary Plan Description | Columbia Human Resources, Exercises of Surgical Pathology
Columbia University is pleased to provide you with this Summary Plan ... Prescription drug coverage is included in the cost of the Medical Plan that you ...
Typology: Exercises
2022/2023
1 / 75
This page cannot be seen from the preview
Don't miss anything!
Related documents
Partial preview of the text
Download Summary Plan Description | Columbia Human Resources and more Exercises Surgical Pathology in PDF only on Docsity!
Columbia University in the City of New York
Optum Rx Prescription Drug Plan for Officers,
Support Staff, Post-Doctoral Fellows, Obama
Scholars, Pre and Post 65 Retirees
Effective: January 1, 20 21
Group Number: 712790
Summary Plan Description
- SECTION 1 - WELCOME TABLE OF CONTENTS
- SECTION 2 - INTRODUCTION.........................................................................................................
- Eligibility
- Cost of Coverage
- How to Enroll
- When Coverage Begins
- Changing Your Coverage............................................................................................................
- SECTION 3 - OUTPATIENT PRESCRIPTION DRUGS....................................................................
- Benefits for Prescription Drug Products..................................................................................
- What You Must Pay.....................................................................................................................
- Identification Card (ID Card) – In-Network Pharmacy
- Benefit Levels
- Retail
- Mail Order.....................................................................................................................................
- Benefits for Preventive Care Medications
- Specialty Prescription Drug Products
- Assigning Prescription Drug Products to the Prescription Drug List (PDL)
- Limitation on Selection of Pharmacies
- Supply Limits
- Special Programs
- Prescription Drug Products Prescribed by a Specialist Physician
- Rebates and Other Discounts
- Coupons, Incentives and Other Communications
- SECTION 4 – PLAN HIGHLIGHTS - OUTPATIENT PRESCRIPTION DRUGS
- Schedule of Benefits - Outpatient Prescription Drugs.........................................................
- SECTION 5 - EXCLUSIONS AND LIMITATIONS: WHAT THE PLAN WILL NOT COVER
- Drugs
- Experimental or Investigational or Unproven Services
- Providers
- Services Provided under Another Plan ii TABLE OF CONTENTS
- All Other Exclusions
- SECTION 6 - CLAIMS PROCEDURES
- Prescription Drug Benefit Claims
- If Your Provider Does Not File Your Claim.........................................................................
- Claim Denials and Appeals
- Federal External Review Program
- Limitation of Action
- SECTION 7 - COORDINATION OF BENEFITS (COB)
- Determining Which Plan is Primary
- When This Plan is Secondary
- When a Covered Person Qualifies for Medicare
- Medicare Crossover Program...................................................................................................
- Right to Receive and Release Needed Information
- Overpayment and Underpayment of Benefits.......................................................................
- SECTION 8 - WHEN COVERAGE ENDS
- Coverage for a Disabled Child
- Continuing Coverage Through COBRA
- When COBRA Ends
- Uniformed Services Employment and Reemployment Rights Act
- SECTION 9 - OTHER IMPORTANT INFORMATION
- Qualified Medical Child Support Orders (QMCSOs)
- Your Relationship with OptumRx and Columbia University
- Relationship with Providers
- Relationship with Providers
- Interpretation of Benefits
- Your Relationship with Providers
- Information and Records..........................................................................................................
- Incentives to You
- Workers' Compensation Not Affected
- Future of the Plan
- Plan Document iii TABLE OF CONTENTS
- Medicare Eligibility
- Policies Review and Determine Benefits in Accordance with UnitedHealthcare Reimbursement
- SECTION 10 - GLOSSARY
- SECTION 11 - IMPORTANT ADMINISTRATIVE INFORMATION: ERISA
- ATTACHMENT I - HEALTH CARE REFORM NOTICES
- Patient Protection and Affordable Care Act ("PPACA")
- ATTACHMENT II - LEGAL NOTICES
- Women's Health and Cancer Rights Act of
- Statement of Rights under the Newborns' and Mothers' Health Protection Act
- ATTACHMENT III – NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS
- ATTACHMENT IV – GETTING HELP IN OTHER LANGUAGES OR FORMATS
2 SECTION 1 - WELCOME
How To Use This SPD ■ Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference. ■ Many of the sections of this SPD are related to other sections. You may not have all the information you need by reading just one section. ■ You can find copies of your SPD and any future amendments at www.hr.columbia.edu or request printed copies by contacting the number on the back of your ID card. ■ Capitalized words in the SPD have special meanings and are defined in Section 1 0 , Glossary. ■ If eligible for coverage, the words "you" and "your" refer to Covered Persons as defined in Section 1 0 , Glossary. ■ Columbia University is also referred to as University. ■ If there is a conflict between this SPD and any benefit summaries (other than Summaries of Material Modifications) provided to you, this SPD will control.
3 SECTION 2 - INTRODUCTION
SECTION 2 - INTRODUCTION
Eligibility
You are generally eligible for prescription drug health benefit coverage under the Plan on the same terms and conditions that apply to your medical coverage under the Plan. For detailed summary of those terms and conditions, including special enrollment rights and COBRA continuation coverage, please refer to your medical benefit coverage summary and the wrap document of the Plan. Your eligible Dependents may also participate in the Plan. An eligible Dependent is considered to be: ■ Your Spouse/same-sex Domestic Partner, as defined in Section 1 0 , Glossary. ■ Your or your Spouse's/same-sex Domestic Partner’s child who is under age 26, including a natural child, stepchild, a legally adopted child, a child placed for adoption or a child for whom you or your Spouse are the legal guardian. ■ An unmarried child age 26 or over who is or becomes disabled and dependent upon you.
Note: Your Dependents may not enroll in the Plan unless you are also enrolled. If you and
your Spouse are both covered under a Columbia University plan, you may each be enrolled as an Employee or be covered as a Dependent of the other person, but not both. In addition, if you and your Spouse are both covered under a Columbia University plan, only one parent may enroll your child as a Dependent. A Dependent also includes a child for whom health care coverage is required through a Qualified Medical Child Support Order or other court or administrative order, as described in Section 9 , Other Important Information.
Cost of Coverage
Prescription drug coverage is included in the cost of the Medical Plan that you select. Please refer to your Medical Plan coverage for contribution amounts, if applicable. You may not elect Prescription drug coverage only..
Note: The Internal Revenue Service generally does not consider Domestic Partners and
their children eligible Dependents. Therefore, the value of Columbia University's cost in covering a same-sex Domestic Partner may be imputed to the Employee as income. In addition, the share of the Employee's contribution that covers a same-sex Domestic Partner and their children may be paid using after-tax payroll deductions. Your contributions are subject to review and Columbia University reserves the right to change your contribution amount from time to time. You can obtain current contribution rates by logging onto www.hr.columbia.edu.
5 SECTION 2 - INTRODUCTION
Changing Your Coverage
You may make coverage changes during the year only if you experience a change in family status. The change in coverage must be consistent with the change in status (e.g., you cover your Spouse following your marriage, your child following an adoption, etc.). The following are considered family status changes for purposes of the Plan: ■ Your marriage, divorce, legal separation or annulment. ■ Registering a same-sex Domestic Partner. ■ The birth, legal adoption, placement for adoption or legal guardianship of a child. ■ A change in your Spouse's employment or involuntary loss of health coverage (other than coverage under the Medicare or Medicaid programs) under another employer's plan. ■ Loss of coverage due to the exhaustion of another employer's COBRA benefits, provided you were paying for premiums on a timely basis. ■ Your death or the death of a Dependent. ■ Your Dependent child no longer qualifying as an eligible Dependent. ■ A change in your or your Spouse's position or work schedule that impacts eligibility for health coverage. ■ Contributions were no longer paid by the employer (this is true even if you or your eligible Dependent continues to receive coverage under the prior plan and to pay the amounts previously paid by the employer). ■ You or your eligible Dependent who were enrolled in an HMO no longer live or work in that HMO's service area and no other benefit option is available to you or your eligible Dependent. ■ Benefits are no longer offered by the Plan to a class of individuals that include you or your eligible Dependent. ■ Termination of your or your Dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage as a result of loss of eligibility (you must contact OptumRx at the number on the back of your ID card within 60 days of termination). ■ You or your Dependent become eligible for a premium assistance subsidy under Medicaid or CHIP (you must contact OptumRx at the number on the back of your ID card within 60 days of the date of determination of subsidy eligibility). ■ A strike or lockout involving you or your Spouse. ■ A court or administrative order. Unless otherwise noted above, if you wish to change your elections, you must log onto CUBES at www.hr.columbia.edu within 31 days of the change in family status. Otherwise, you will need to wait until the next annual Open Enrollment. While some of these changes in status are similar to qualifying events under COBRA, you, or your eligible Dependent, do not need to elect COBRA continuation coverage to take advantage of the special enrollment rights listed above. These will also be available to you or your eligible Dependent if COBRA is elected.
Note: Any child under age 26 who is placed with you for adoption will be eligible for
coverage on the date the child is placed with you, even if the legal adoption is not yet final. If you do not legally adopt the child, all Plan coverage for the child will end when the
6 SECTION 2 - INTRODUCTION
placement ends. No provision will be made for continuing coverage (such as COBRA coverage) for the child.
Change in Family Status - Example
Jane is married and has two children who qualify as Dependents. At annual Open Enrollment, she elects not to participate in Columbia University's Benefits Plan, because her husband, Tom, has family coverage under his employer's plan. In June, Tom loses his job as part of a downsizing. As a result, Tom loses his eligibility for coverage. Due to this family status change, Jane can elect family coverage under Columbia University's Benefits plan outside of annual Open Enrollment.
8 SECTION 3 – OUTPATIENT PRESCRIPTION DRUGS
All Prescription Drug Products covered by the Plan are categorized into these three tiers on the Prescription Drug List (PDL). The tier status of a Prescription Drug Product can change periodically, generally quarterly but no more than six times per calendar year, based on the Prescription Drug List (PDL) Management Committee's periodic tiering decisions. When that occurs, you may pay more or less for a Prescription Drug Product, depending on its tier assignment. Since the PDL may change periodically, you can visit www.myuhc.com or call OptumRx at the number on your ID card for the most current information. Each tier is assigned a Copay, which is the amount you pay when you visit the pharmacy or order your medications through mail order. Your Copay will also depend on whether or not you visit the pharmacy or use the mail order service - see the table shown at the beginning of this section for further details. Here's how the tier system works: ■ Tier-1 is your lowest Copay option. For the lowest out-of-pocket expense, you should consider tier-1 drugs if you and your Physician decide they are appropriate for your treatment. ■ Tier-2 is your middle Copay option. Consider a tier-2 drug if no tier-1 drug is available to treat your condition. ■ Tier-3 is your highest Copay option. The drugs in tier-3 are usually more costly. Sometimes there are alternatives available in tier-1 or tier-2. For Prescription Drug Products at a retail In-Network Pharmacy, you are responsible for paying the lowest of: ■ The applicable Copay or deductible ■ The In-Network Pharmacy's Usual and Customary Charge for the Prescription Drug Product. ■ The Prescription Drug Charge for that Prescription Drug Product. For Prescription Drug Products from a mail order In-Network Pharmacy, you are responsible for paying the lower of: ■ The applicable Copay or deductible ■ The Prescription Drug Charge for that particular Prescription Drug.
Retail
Benefits are provided for Prescription Drug Products dispensed by a retail In-Network Pharmacy. The Plan has a network of participating retail pharmacies, which includes many large drug store chains. You can obtain information about In-Network Pharmacies by contacting OptumRx at the number on your ID card or by logging onto www.myuhc.com. Benefits are provided for Prescription Drug Products dispensed by a retail Out-of-Network Pharmacy. If the Prescription Drug Product is dispensed by a retail Out-of-Network Pharmacy, you must pay for the Prescription Drug Product at the time it is dispensed and then file a claim for reimbursement with OptumRx, as described in your SPD, Section 6 , Claims Procedures. The Plan will not reimburse you for the difference between the Predominant Reimbursement Rate and the Out-of-Network Pharmacy's Usual and
9 SECTION 3 – OUTPATIENT PRESCRIPTION DRUGS
Customary Charge for that Prescription Drug Product. The Plan will not reimburse you for any non-covered drug product. In most cases, you will pay more if you obtain Prescription Drug Products from an Out-of- Network Pharmacy. To obtain your prescription from a retail pharmacy, simply present your ID card and pay the Copay or meet the deductible first, if applicable. The following supply limits apply: ■ As written by the provider, up to a consecutive 30 - day supply of a Prescription Drug Product, unless adjusted based on the drug manufacturer's packaging size or based on supply limits. ■ As written by the provider, a 90-day supply of a Generic for which the Usual and Customary Charge does not exceed $10 - $20. ■ A one-cycle supply of an oral contraceptive. You may obtain up to three cycles at one time if you pay the Copay for each cycle supplied. When a Prescription Drug Product is packaged or designed to deliver in a manner that provides more than a consecutive 30 - day supply, the Copay that applies will reflect the number of days dispensed.
Note: Pharmacy Benefits apply only if your prescription is for a Covered Health Service,
and not for Experimental or Investigational, or Unproven Services. Otherwise, you are responsible for paying 100% of the cost.
Mail Order
Benefits are provided for certain Prescription Drug Products dispensed by a mail order In- Network Pharmacy. The mail order service may allow you to purchase up to a 90-day supply of a covered Prescription Drug Product through the mail. To use the mail order service, all you need to do is complete a patient profile and enclose your Prescription Order or Refill. Your medication, plus instructions for obtaining refills, will arrive by mail about 14 days after your order is received. If you need a patient profile form, or if you have any questions, you can reach OptumRx at the number on your ID card. The following supply limits apply: As written by the provider, up to a consecutive 90-day supply, unless adjusted based on the drug manufacturer's packaging size or based on supply limits. You may be required to fill an initial Prescription Drug Product order and obtain one refill through a retail pharmacy prior to using a mail order In-Network Pharmacy.
Note: To maximize your Benefit, ask your Physician to write your Prescription Order or
Refill for a 90-day supply, with refills when appropriate. You will be charged a mail order Copay for any Prescription Order or Refill if you use the mail order service, regardless of the number of days' supply that is written on the order or refill. Be sure your Physician writes your mail order or refill for a 90-day supply, not a 30-day supply with three refills.
11 SECTION 3 – OUTPATIENT PRESCRIPTION DRUGS
Refer to the Schedule of Benefits - Outpatient Prescription Drug for details on Specialty Prescription Drug Product supply limits. Please see Section 10, Glossary , in this section for definitions of Specialty Prescription Drug Product and Designated Pharmacy. Want to lower your out-of-pocket Prescription Drug Product costs? Consider tier-1 Prescription Drug Products, if you and your Physician decide they are appropriate.
Assigning Prescription Drug Products to the Prescription Drug List (PDL)
OptumRx's Prescription Drug List (PDL) Management Committee is authorized to make tier placement changes on OptumRx's behalf. The PDL Management Committee makes the final classification of an FDA-approved Prescription Drug Product to a certain tier by considering a number of factors including, but not limited to clinical and economic factors. Clinical factors may include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the Prescription Drug Product, as well as whether certain supply limits or requirements should apply. Economic factors may include, but are not limited to, the Prescription Drug Product's acquisition cost including, but not limited to, available rebates and assessments on the cost effectiveness of the Prescription Drug Product. Some Prescription Drug Products are most cost effective for specific indications as compared to others, therefore, a Prescription Drug Product may be listed on multiple tiers according to the indication for which the Prescription Drug Product was prescribed, or according to whether it was prescribed by a Specialist Physician. The PDL Management Committee may periodically change the placement of a Prescription Drug Product among the tiers. These changes generally will occur quarterly, but no more than six times per calendar year. These changes may occur without prior notice to you. When considering a Prescription Drug Product for tier placement, the PDL Management Committee reviews clinical and economic factors regarding Covered Persons as a general population. Whether a particular Prescription Drug Product is appropriate for an individual Covered Person is a determination that is made by the Covered Person and the prescribing Physician.
Note : The tier status of a Prescription Drug Product may change periodically based on the
process described above. As a result of such changes, you may be required to pay more or less for that Prescription Drug Product. Please access www.myuhc.com or call the number on your ID card for the most up-to-date tier status. Prescription Drug, Prescription Drug List (PDL), and Prescription Drug List (PDL) Management Committee are defined at the end of this section.
12 SECTION 3 – OUTPATIENT PRESCRIPTION DRUGS
Prescription Drug List (PDL) The Prescription Drug List (PDL) is a tool that helps guide you and your Physician in choosing the medications that allow the most effective and affordable use of your Prescription Drug Benefit.
Limitation on Selection of Pharmacies
If OptumRx determines that you may be using Prescription Drug Products in a harmful or abusive manner, or with harmful frequency, your selection of In-Network Pharmacies may be limited. If this happens, OptumRx may require you to select a single In-Network Pharmacy that will provide and coordinate all future pharmacy services. Benefits will be paid only if you use the designated single In-Network Pharmacy. If you don't make a selection within 31 days of the date the Plan Administrator notifies you, OptumRx will select a single In-Network Pharmacy for you.
Supply Limits
Benefits for Prescription Drug Products are subject to supply limits that are stated in the table under the heading Prescription Drug Product Coverage Highlights. For a single Copayment and deductible, you may receive a Prescription Drug Product up to the stated supply limit. Whether or not a Prescription Drug Product has a supply limit is subject to OptumRx's periodic review and modification.
Note: Some products are subject to additional supply limits based on criteria that the Plan
Administrator and OptumRx have developed, subject to periodic review and modification. The limit may restrict the amount dispensed per Prescription Order or Refill and/or the amount dispensed per month's supply or may require that a minimum amount be dispensed. You may determine whether a Prescription Drug Product has been assigned a supply limit for dispensing, at www.myuhc.com or by calling the telephone number on your ID card.
Special Programs
Columbia University and OptumRx may have certain programs in which you may receive an enhanced or reduced Benefit based on your actions such as adherence/compliance to medication or treatment regimens and/or participation in health management programs. You may access information on these programs at www.myuhc.com or by calling the number on the back of your ID card.
Prescription Drug Products Prescribed by a Specialist Physician
You may receive an enhanced or reduced Benefit, or no Benefit, based on whether the Prescription Drug Product was prescribed by a Specialist Physician. You may access information on which Prescription Drug Products are subject to Benefit enhancement, reduction or no Benefit by calling the telephone number on your ID card.
14 SECTION 4 – PLAN HIGHLIGHTS - OUTPATIENT PRESCRIPTION DRUGS
SECTION 4 – PLAN HIGHLIGHTS - OUTPATIENT PRESCRIPTION DRUGS
The table below provides an overview of the Plan's Prescription Drug Product coverage. It includes Copay amounts that apply when you have a prescription filled at a Retail or Mail Order Pharmacy.
Schedule of Benefits - Outpatient Prescription Drugs
Benefit Information for Prescription Drug Products at either an In-Network
Pharmacy or an Out-of-Network Pharmacy
Covered Health Services1,^2 , 3 Percentage of Prescription Drug Charge Payable by the Plan (Per Prescription Order or Refill): Percentage of Predominant Reimbursement Rate Payable by the Plan (Per Prescription Order or Refill): In-Network Out-of-Network Retail and Specialty - up to a 30 - day supply^1. 100% after you pay a: ■ Generic $10 Copay^ Not Covered ■ Single-source brand $25 Copay^ Not^ Covered ■ Multi-source brand $45 Copay^ Not Covered Mail Order In-Network Pharmacy - up to a 90-day supply 100% after you pay a: Not Covered ■ Generic $15 Copay^ Not Covered ■ Single-source brand $50 Copay^ Not Covered ■ Multi-source brand $90 Copay^ Not^ Covered (^1) The Plan pays Benefits for Specialty Prescription Drug Products as described in this table. (^2) For all Plans including the High Deductible Health Plan you are only responsible for paying a Copayment for Preventive Care Medications. (^3) Enrollment in the High Deductible Health Plan: Non-Preventative care drugs: If a non- preventative drug is filled, you will be required to meet the medical plan deductible first then the copayment will apply. Note: there is a $30,000 lifetime maximum for infertility Outpatient Prescription Drugs applicable to all members enrolled in the Columbia University Group Benefits Plan for active employees and the Pre-65 Retiree Plan. Members enrolled in the Post 65 Retiree Plan or the Indemnity Plan have a $5,000 lifetime maximum for infertility Outpatient Prescription Drugs.
If a Brand-name Drug Becomes Available as a Generic
If a Brand-name Prescription Drug Product becomes available as a Generic drug, the tier placement of the Brand-name Prescription Drug Product may change. As a result, your Copay may change. You will pay the Copay applicable for the tier to which the Prescription Drug Product is assigned.
15 SECTION 5 - EXCLUSIONS AND LIMITATIONS
SECTION 5 - EXCLUSIONS AND LIMITATIONS: WHAT THE PLAN WILL NOT
COVER
The Plan does not pay Benefits for the following services, treatments or supplies even if they are recommended or prescribed by a provider or are the only available treatment for your condition. In addition to the exclusions below, please review all benefit and supply limits carefully, as the Plan will not pay Benefits for any of Prescription Drug Products that exceed those limits. Please note that in listing services or examples, when the SPD says "this includes," or "including but not limited to", it is not OptumRx's intent to limit the description to that specific list. When the Plan does intend to limit a list of services or examples, the SPD specifically states that the list "is limited to."
Drugs
When an exclusion applies to only certain Prescription Drug Products, you can access www.myuhc.com or call the number on your ID card for information on which Prescription Drug Products are excluded.
- For any condition, Injury, Sickness or Mental Illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received.
- Any Prescription Drug Product for which payment or benefits are provided or available from the local, state or federal government (for example Medicare) whether or not payment or benefits are received, except as otherwise provided by law.
- Any prescription medication that must be compounded into its final form by the dispensing pharmacist, Physician, or other health care provider.
- Prescription Drug Products dispensed outside of the United States, except in an Emergency.
- Durable Medical Equipment, including insulin pumps and related supplies for the management and treatment of diabetes, for which Benefits are provided in your SPD. Prescribed and non-prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered.
- For growth hormone therapy.
- The amount dispensed (days' supply or quantity limit) which exceeds the supply limit.
- The amount dispensed (days' supply or quantity limit) which is less than the minimum supply limit.