PRESCRIPTION DRUG BENEFITS

The Health Plan’s nationwide prescription drug benefit is administered by Medco Health Solutions, Inc. All participants eligible for the program will be issued a Medco identification card. For participants who are not entitled to the Medco program, prescription drug coverage is provided at the non-network level under the major medical portion of the Plan.

Eligibility
You and your eligible dependents are covered under the Medco prescription drug program if this Plan is your primary plan. If Medicare is your primary plan and this Plan is your secondary plan, you and your eligible dependents are covered under the Medco prescription drug program, provided you and your spouse do not enroll in a Medicare Part D Prescription Drug Program. If you enroll in Medicare Part D, you will not be eligible for any prescription drug coverage under the Plan.

If this Plan is not your primary plan or if you owe the Plan money due to audit findings by the Contribution Compliance or Participant Eligibility Departments, your prescription drug benefits will be covered at the non-network level under the major medical portion of your coverage.

The Plan applies a special rule if your benefits are coordinated with the Equity-League Health Plan on a pro-rata basis. This means you have the same type of eligibility (i.e., Earned) and have been covered the same length of time under this Plan and the Equity Plan. In this case, you are eligible for the Medco prescription drug program under the SAG-Producers Health Plan if your birthday occurs during the first half of the year (January through June). If your birthday falls in the second half of the year (July through December), the Equity Plan is primary for prescription drug coverage and you are eligible for secondary coverage under the major medical portion of the SAG-Producers Health Plan.

Some key provisions of the prescription drug benefit are outlined below.

Deductible
The calendar year deductible for the Medco prescription drug program is outlined on the prior page. The deductible applies to both the retail pharmacy program and Medco by Mail. The family deductible is satisfied when at least two or more family members have paid $200 in covered expenses, except that the Plan will not apply more than the individual deductible to any one family member. The pharmacist will collect deductible amounts.

Any price differences you are requested to pay between brand and generic drugs do not apply toward the deductible amount.

Your Retail Pharmacy Program
Co-payment

Your retail pharmacy co-payments are outlined on the prior page and vary depending on whether the prescription is a generic or brand drug. If your prescription is for a brand-name drug that has a generic alternative, you will be responsible for the regular co-payment plus the difference in price between the generic and brand-name prescription. The price differential does not apply toward the deductible amount.

Your Pharmacy Options
You should use a participating retail pharmacy for short-term prescriptions such as antibiotics to treat infections. Show your prescription drug identification card to the pharmacist and pay your retail co-payment each time you order a new prescription. Because your prescription drug identification card does not contain your Social Security Number, please remember to share it as appropriate with your pharmacist when you obtain prescriptions.

To find a participating retail pharmacy near you:

• Visit www.medco.com and click “Find a local pharmacy”.
• Ask at your retail pharmacy whether it participates in the Medco network.

If you use a non-participating pharmacy, you must pay the entire cost of the prescription and then submit a claim form to Medco as described on page 75. You will be reimbursed the amount that would have been charged by a participating retail pharmacy less the required co-payment. The discounted cost will be used to satisfy your prescription drug deductible.

If you are eligible for a Medco drug card, your prescriptions will not be considered under the major medical benefits of the Plan.

Medco by Mail
Co-payment

Your co-payments for the Medco by Mail mailorder program are outlined on the prior page and vary depending on whether the prescription is a generic or brand drug. The maximum co-payment is $75 per prescription.

If your prescription is for a brand-name drug that has a generic alternative, you will be responsible for the regular co-payment plus the difference in price between the generic and brand name prescription. This price differential does not apply toward the deductible amount.

Ordering Prescriptions
The first time you are prescribed a medication, ask your doctor for two prescriptions: the first for up to a 30-day supply to be filled at a retail pharmacy; the second for the balance, up to a 90-day supply, to be filled through Medco by Mail. Medco by Mail will fill for a generic medication if your doctor does not write DAW (dispense as written) on the prescription.

• By Fax from Your Doctor – Give your Social Security Number to your doctor and have your doctor call 1-888-EASYRX1 (1-888-327-9791) to obtain fax instructions.
• On the Internet – Visit www.medco.com and follow the instructions to register for Medco by Mail. Once you have registered, click“Order center” and follow the instructions. Medco will contact your doctor to transfer your current prescriptions to Medco by Mail.
• By Mail – Request an order form and reply envelope from the Plan Office. Mail your prescription and required co-payment along with the order form in the envelope.
  
  Medco
  P.O. Box 34093
  Tampa, FL 33630-3493

Delivery of Your Medication
Prescription orders are processed promptly and are usually delivered to you within eight days. If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering. If you don’t have enough, ask your doctor to give you a second prescription for a 14-day supply and fill it at a participating retail pharmacy while your mail-order prescription is being processed.

Paying for Your Medication
You may pay by check, money order, VISA, MasterCard, Discover/NOVUS, American Express or Diners Club.

Please note: The pharmacist’s judgment and dispensing restrictions, such as quantities allowable, govern certain controlled substances and other prescribed drugs. Federal law prohibits the return of dispensed controlled substances.

Other Plan Features
Medco Special Care Pharmacy

Some conditions, such as anemia, hepatitis C, multiple sclerosis, asthma and rheumatoid arthritis, are treated with specialty medications. The Medco Special Care Pharmacy includes access to nurses who are trained in specialty medications, pharmacist availability 24 hours a day, seven days a week and coordination of home care and other health care services. For more information, call the Medco Special Care Pharmacy at 1-800-903-4728.

Prior Authorization
Most of your prescriptions can be filled without prior authorization at a retail pharmacy. However, some drugs are only covered for certain uses or in certain quantities. Lamisil and Wellbutrin SR are examples of medications that require prior authorization before they can be covered. If you present a prescription requiring prior authorization, your doctor may need to provide additional information before the prescription is covered.

When you take a prescription that needs prior authorization to the retail pharmacy, the system will automatically review your file (age, sex and prior drug therapy history) to determine if the medication can be dispensed on the criteria available. The pharmacy will advise you if additional information is required. Either you or the pharmacy can ask your doctor to call 1-800-753-2851 to initiate the prior authorization process. This call will start a review that typically takes two to five business days unless additional information is required, in which case, the review may take longer. Both you and your doctor will be notified in writing of the decision. If the prescription is approved, the letter will tell you the length of your coverage approval. If the prescription is denied, the letter will include the reason for coverage denial and instructions on how to submit an appeal if you choose.

If you want the prescription immediately without waiting for the prior authorization, you will have to pay the full retail price at the pharmacy. If the prescription is approved, your claim should be sent to Medco for reimbursement at 100% minus the prescription drug co-payment and deductible.

Compound Medications
A compound medication is custom-made by a pharmacy based on a doctor’s prescription, often including more than one ingredient. At a participating retail pharmacy, you will pay your retail co-payment for compound medications if the pharmacist submits a claim electronically. In other cases, you must submit a claim for reimbursement to Medco, which must be accompanied by an itemized list of the ingredients for the claim to be processed. Please note: Coverage limits apply to compound medications. The Health Plan will only reimburse the cost of the active main ingredient, minus the copayment.

Male Erectile Dysfunction Drugs
Prescriptions for male erectile dysfunction drugs, including but not limited to, Cialis, Levitra and Viagra, are limited to six pills of any combination of these drugs in a 30-day period.

Fill your first prescription at a participating pharmacy with your Medco prescription drug card and pay 100% of the discounted price for the prescription. Send your original pharmacy receipt and a completed medical claim form to the Plan Office. Include a letter from your doctor confirming your underlying medical condition warranting treatment, and your medical records for review. If the prescription is determined to be medically necessary, the claim will be reimbursed at 100% minus the prescription drug co-payment, subject to the prescription drug deductible.

If you use a non-participating pharmacy, your first claim should be filed with the Plan Office as outlined above. If the prescription is determined to be medically necessary, you will be reimbursed the amount that would have been paid if you had used a participating pharmacy. You are responsible for the remainder of the bill.

After medical necessity is determined, subsequent prescriptions may be filled in the usual way by paying the prescription drug co-payment at participating pharmacies. For non-participating pharmacies, claims should be submitted to Medco as described on page 75.

Infertility Drugs Prescribed for Non-Infertility Conditions
Certain medications commonly used to treat infertility, may also be prescribed for conditions that are not related to infertility. In these cases, you should follow the procedures outlined above under “Male Erectile Dysfunction Drugs”.

Growth Hormones

Growth hormones are considered specialty medications and are handled through the Medco Special Care Pharmacy. They also require pre-authorization from the Plan before filling your first prescription. Contact the Plan Office for a list of the information necessary to complete the pre-authorization.

Generic Drugs
Ask your doctor to prescribe generic drugs whenever possible. This will help us provide the highest quality medications and program benefits while keeping costs down. We will remind your doctor when a generic equivalent is available for brand name drugs.

Preferred Prescriptions® Formulary
This is a voluntary program to help control the cost of care by asking your doctor to prescribe from a list of medications preferred for their clinical effectiveness and opportunities to help contain the Plan’s costs. The list of preferred medications is available online at www.medco.com.

Prescription Drug Benefits through Your Major Medical Coverage
If this Plan is not your primary plan and your prescription drug benefits are payable under the major medical portion of the Plan, you should submit your drug bills to your primary plan first, then forward a copy of your primary plan’s Explanation of Benefits (EOB) form, together with a copy of the drug bill, to the Plan Office. Prescriptions and supplies that are processed under the major medical benefit will be paid under the non-network level of benefits, subject to the non-network major medical deductible, and considered at a level not to exceed A.W.P. (average wholesale price) plus 50%.

Initial claims for male erectile dysfunction drugs, for infertility drugs used to treat noninfertility conditions, and for growth hormones should also be submitted to the Plan Office for review.

The drug bill must include the prescription number, name of the patient, name of the doctor, quantity filled and strength of medication. Credit card vouchers, cash receipts or canceled checks will not be accepted as bills for processing drug claims. The Plan reserves the right to request original drug receipts should it become necessary to do so.

Offset of Future Benefit Reimbursements Due to Audits
If you owe the Plan money due to any audit findings by the Contribution Compliance or Participant Eligibility Department, you or your dependents are not eligible to use the Medco retail or mail order programs until the balance due is paid in full. You will need to submit prescription charges as outlined previously under “Prescription Drug Benefits through Your Major Medical Coverage”. As soon as the Plan has recovered the entire amount that you owe, irrespective of the source of recovery, you will be notified and may resume using the Medco retail and mail order programs.

Questions
If you need help or have any questions about your prescription drug program, you can call the Plan Office or contact Medco:

On the Internet – www.medco.com

By Telephone – 1-800-903-4728

Exclusions and Limitations
The prescription drug program is designed to cover those prescriptions and medicines that, under state or federal law, require a doctor’s prescription. However, the Plan reserves the right to restrict prescription drug coverage to one retail network pharmacy or to deny coverage for individual drugs. If a restriction is imposed, Medco by Mail is not available. Listed below are certain items which are not covered, including but not limited to the following:

• Amphetamines.
• Anorexiants.
• Antabuse.
• Any prescription refilled in excess of the number of refills specified by the physician or any refill dispensed after one year from the physician’s original order.
• Charges for the administration or injection of any drug.
• Contraceptive jellies, creams, foams, implants or injections.
• Dehydroepiandrosterone (DHEA).
• Diet pills or any medication which is for the purpose of weight loss or weight control.
• Drugs whose sole purpose is to promote or stimulate hair growth (i.e., Rogaine, Propecia) or drugs for cosmetic purposes (i.e., Renova).
• Drugs not approved by the Food and Drug Administration for the treatment rendered.
• Fluoride products.
• Growth hormones, except when approved by the Health Plan.
• Homeopathic medications, both over-the-counter and Federal Legend.
• Infertility drugs, except when approved by the Health Plan for the treatment of noninfertility conditions.
• Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals.
• Non-Federal Legend drugs.
• Remicade (Infliximab).
• Smoking deterrents.
• Therapeutic devices or appliances.
• Yohimbine.
• Federal Legend Vitamins. (If you or your dependent are not able to assimilate medication ordinarily prescribed for treatment of an illness, the Plan may consider covering the vitamins, subject to medical review.)