6807 - Amendment 1 Executed 1
THE STATE OF TEXAS §
§
COUNTY OF DENTON §
FIRST AMENDMENT TO CONTRACT
BY AND BETWEEN THE CITY OF DENTON, TEXAS
AND LABOR FIRST, LLC.
(CONTRACT 6807)
THIS FIRST AMENDMENT TO CONTRACT 6807 (“Amendment”) by and
between the City of Denton, Texas (“City”) and Labor First, LLC (“Contractor”);
WHEREAS, the original Agreement provided for Labor First, LLC for services
related to Post-65 Retiree Medicare and Prescription Coverage as is contained in Contract
#6807 (on file in the Purchasing Office). The initial agreement was approved on October
16, 2018 by the City Council (Ordinance 18-6807).
WHEREAS, the First Amendment modifies Exhibit F by replacing Aetna Medicare
Prescription Drug (Rx) Plan with the attached Humana 2019 Prescription Drug (Rx) Plan;
and
NOW THEREFORE,
1. Exhibit F “Contractor’s Proposal”, Pages 33 through 42 of the Agreement,
which are labeled as follows, “Retiree First Proposal Letter, dated July 18,
2018” is hereby amended by the replacement of these pages with the following:
“Retiree First Proposal Letter, dated October 15, 2018” (11 pages).
2. Exhibit F “Contractor’s Proposal”, Pages 45 through 52 of the Agreement,
which are labeled as follows, “Aetna Medicare Rx Plan” is hereby amended
by the replacement of these pages with the following:
“Humana 2019 Custom PDP Plan 037 Option TBD2 for City of Denton” (4
pages).
All other provision of the contract 6807, as heretofore amended, remain in full force and
effect.
IN WITNESS WHEREOF, the CITY and the CONTRACTOR, have each executed
this Amendment, by and through their respective duly authorized representatives and
officers on this date_______________________________________.
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
11/20/2018
2
“CITY”
CITY OF DENTON, TEXAS
A Texas Municipal Corporation
By: __________________________________
CINDY ALONZO
SENIOR BUYER
“CONTRACTOR”
LABOR FIRST, LLC
By: _________________________________
AUTHORIZED SIGNATURE, TITLE
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
PRESIDENT & CFO
October 15, 2018
•
•
•
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EXHIBIT F
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Group Retiree Medicare Advantage with Prescription Drug (MAPD) Financial Rate Summary
prepared for: City of Denton
Plan: MAPD - City of Denton- 2019
MAPD Carrier: Humana
Rate Period: 1/1/2019 - 12/31/2019
MAPD Premium - $293.17 PMPM
Medical Coverage
Medical Deductible $0
Office Copay $10
Specialist Copay $20
Emergency Room $65; Waived if admitted
Inpatient Hospital Care 100% after $150 copayment per day (days 1 - 5)
Outpatient Surgery $50
Pharmacy Coverage
Prescription Calendar Year Deductible $0
Retail 30 Day Supply
Tier 1 (Generics) $10
Tier 2 (Brands) $20
Tier 3 (NP Brands) $40
Tier 4 (Specialty) 25%
Retail 90 Day Supply
Tier 1 (Generics) $30
Tier 2 (Brands) $60
Tier 3 (NP Brands) $120
Tier 4 (Specialty) N/A
Mail-Order 90 Day Supply
Tier 1 (Generics) $0
Tier 2 (Brands) $40
Tier 3 (NP Brands) $80
Tier 4 (Specialty) N/A
Part D Coverage Specifications
Drug Formulary Most Comprehensive (Open)
Coverage Gap Full-Coverage
Lifestyle Drugs Covered No
All Non-Part D Drugs Covered Yes
Utilization Management Prior Authorizations and Quantity Limits
Catastrophic Coverage Greater of $3.40 for generic/multiple source drugs
($8.50 for all others) or 5% coinsurance
Medicare Advantage Stipulations
• National PPO Network: Plan accepted wherever Medicare is in all 50 states to include U.S. territories.
• The proposed plan premium rate includes all Medicare Part D subsidies. There is no additional
subsidy filing needed.
• The catastrophic coverage phase begins once the true out-of-pocket costs has reached $5,100 as
defined per CMS.
• Pharmacy network of over 66,000 locations including all major chains, super markets, and mom/pop
stores.
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Part D Financial Rate Summary Prepared for: City of Denton
Plan: EGWP - City of Denton - 2019 Option 1
Part D Carrier: Aetna
Rate Period: 1/1/2019- 12/31/2019
Part D Pharmacy Premium - $130.15 PMPM
Plan Design & Coverage Level
Calendar Year Deductible $0
Retail 30 Day Supply
Tier 1 (Generics) $5
Tier 1A (Preferred Generics) $10
Tier 2 (Pref. Brands) $25
Tier 3 (NP Brands) $60
Tier 4 (Specialty) ⃰ 29%
Retail 90 Day Supply
Tier 1 (Generics) $15
Tier 1A (Preferred Generics) $30
Tier 2 (Pref. Brands) $75
Tier 3 (NP Brands) $180
Tier 4 (Specialty) Limited to one-month supply
Mail-Order 90 Day Supply
Tier 1 (Generics) $12.50
Tier 1A (Preferred Generics) $25
Tier 2 (Pref. Brands) $62.50
Tier 3 (NP Brands) $150
Tier 4 (Specialty) Limited to one-month supply
Part D Coverage Specifications
Drug Formulary B2 Plus Formulary
Coverage Gap Full-Coverage
Lifestyle Drugs Covered No
All Non-Part D Drugs Covered Yes
Utilization Management Prior Authorizations and Quantity Limits
Catastrophic Coverage
Your share of the cost for a covered drug will be 5% but not
greater than the cost share amounts listed in the Initial
Coverage Stage section above.Catastrophic Coverage
benefits start once $5,100 in true out-of-pocket costs is
incurred.
Additional Part D Plan Considerations
*Most specialty drugs can only be dispensed up to a 31-day supply at retail
Part D Stipulations
- The plan premium rate includes all Medicare Part D subsidies with no additional subsidy filing needed.
- The catastrophic coverage phase begins once the true out-of-pocket costs has reached $5,100 as defined per
CMS.
- Network of over 60,000+ locations including all major chains, super markets, and mom/pop stores.
- All Part D drug plans are creditable coverage; therefore, Creditable Coverage Notices are not required.
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Plan: EGWP - City of Denton - 2019 Option 2
Part D Carrier: Aetna
Rate Period: 1/1/2019- 12/31/2019
Part D Pharmacy Premium - $148.73 PMPM
Plan Design & Coverage Level
Calendar Year Deductible $0
Retail 30 Day Supply
Tier 1 (Generics) $5
Tier 1A (Preferred Generics) $10
Tier 2 (Pref. Brands) $25
Tier 3 (NP Brands) $60
Tier 4 (Specialty) ⃰ $75
Retail 90 Day Supply
Tier 1 (Generics) $15
Tier 1A (Preferred Generics) $30
Tier 2 (Pref. Brands) $75
Tier 3 (NP Brands) $180
Tier 4 (Specialty) Limited to one-month supply
Mail-Order 90 Day Supply
Tier 1 (Generics) $12.50
Tier 1A (Preferred Generics) $25
Tier 2 (Pref. Brands) $62.50
Tier 3 (NP Brands) $150
Tier 4 (Specialty) Limited to one-month supply
Part D Coverage Specifications
Drug Formulary B2 Plus formulary
Coverage Gap Full-Coverage
Lifestyle Drugs Covered No
All Non-Part D Drugs Covered Yes
Utilization Management Prior Authorizations and Quantity Limits
Catastrophic Coverage
Your share of the cost for a covered drug will be 5% but not
greater than the cost share amounts listed in the Initial
Coverage Stage section above. Catastrophic Coverage
benefits start once $5,100 in true out-of-pocket costs is
incurred.
Additional Part D Plan Considerations
*Most specialty drugs can only be dispensed up to a 31-day supply at retail
Part D Stipulations
- The plan premium rate includes all Medicare Part D subsidies with no additional subsidy filing needed.
- The catastrophic coverage phase begins once the true out-of-pocket costs has reached $5,100 as defined per
CMS.
- Network of over 60,000+ locations including all major chains, super markets, and mom/pop stores.
- All Part D drug plans are creditable coverage; therefore, Creditable Coverage Notices are not required.
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Plan: EGWP - City of Denton - 2019 Option 3
Part D Carrier: Humana
Rate Period: 1/1/2019- 12/31/2019
Part D Pharmacy Premium - $116.65 PMPM
Plan Design & Coverage Level
Calendar Year Deductible $0
Retail 30 Day Supply
Tier 1 (Generics) $10
Tier 1A (Preferred Generics) $10
Tier 2 (Pref. Brands) $20
Tier 3 (NP Brands) $40
Tier 4 (Specialty) ⃰ 25%
Retail 90 Day Supply
Tier 1 (Generics) $0
Tier 1A (Preferred Generics) $0
Tier 2 (Pref. Brands) $40
Tier 3 (NP Brands) $80
Tier 4 (Specialty) N/A
Mail-Order 90 Day Supply
Tier 1 (Generics) $30
Tier 1A (Preferred Generics) $30
Tier 2 (Pref. Brands) $60
Tier 3 (NP Brands) $120
Tier 4 (Specialty) N/A
Part D Coverage Specifications
Drug Formulary Most Comprehensive (Open)
Coverage Gap Full-Coverage
Lifestyle Drugs Covered No
All Non-Part D Drugs Covered Yes
Utilization Management Prior Authorizations, Quantity Limits and Step Therapy
Catastrophic Coverage Greater of $3.40 for generic/multiple source drugs ($8.50
for all others) or 5% coinsurance
Additional Part D Plan Considerations
*Most specialty drugs can only be dispensed up to a 31-day supply at retail
Part D Stipulations
- The plan premium rate includes all Medicare Part D subsidies with no additional subsidy filing needed.
- The catastrophic coverage phase begins once the true out-of-pocket costs has reached $5,100 as defined per
CMS.
- Network of over 60,000+ locations including all major chains, super markets, and mom/pop stores.
- Plan quoted contains broadest drug formulary including coverage for all medications eligible under Medicare
Part D and covers Non-Part D drugs except for Part B drugs (covered by Medicare Part B).
- All Part D drug plans are creditable coverage; therefore, Creditable Coverage Notices are not required.
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Plan: EGWP - City of Denton - 2019 Option 4
Part D Carrier: Humana
Rate Period: 1/1/2019- 12/31/2019
Part D Pharmacy Premium - $148.73 PMPM
Plan Design & Coverage Level
Calendar Year Deductible $0
Retail 30 Day Supply
Tier 1 (Generics) $5
Tier 1A (Preferred Generics) $5
Tier 2 (Pref. Brands) $25
Tier 3 (NP Brands) $60
Tier 4 (Specialty) ⃰ $75
Retail 90 Day Supply
Tier 1 (Generics) $15
Tier 1A (Preferred Generics) $15
Tier 2 (Pref. Brands) $75
Tier 3 (NP Brands) $180
Tier 4 (Specialty) N/A
Mail-Order 90 Day Supply
Tier 1 (Generics) $12.50
Tier 1A (Preferred Generics) $12.50
Tier 2 (Pref. Brands) $62.50
Tier 3 (NP Brands) $150
Tier 4 (Specialty) N/A
Part D Coverage Specifications
Drug Formulary Most Comprehensive (Open)
Coverage Gap Full-Coverage
Lifestyle Drugs Covered No
All Non-Part D Drugs Covered Yes
Utilization Management Prior Authorizations, Quantity Limits and Step Therapy
Catastrophic Coverage
Greater of $3.40 for generic drugs ($8.50 for all others) or
5% coinsurance ($5 Maximum out-of-pocket per
prescription)
Additional Part D Plan Considerations
*Most specialty drugs can only be dispensed up to a 31-day supply at retail
Part D Stipulations
- The plan premium rate includes all Medicare Part D subsidies with no additional subsidy filing needed.
- The catastrophic coverage phase begins once the true out-of-pocket costs has reached $5,100 as defined per
CMS.
- Network of over 60,000+ locations including all major chains, super markets, and mom/pop stores.
- Plan quoted contains broadest drug formulary including coverage for all medications eligible under Medicare
Part D and covers Non-Part D drugs except for Part B drugs (covered by Medicare Part B).
- All Part D drug plans are creditable coverage; therefore, Creditable Coverage Notices are not required.
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Medical Supplement Financial Rate Summary Prepared for: City of Denton
Plan: Med Supp - City of Denton - Medical Supplement
Carrier: United American
Rate Period: 1/1/2019 - 12/31/2019
Medical Supplement Premium - $173.00 PMPM
Plan Design & Coverage Level
Medicare Part A Services
Part A Deductible
$0
Part A Coinsurance
$0
Skilled Nursing Facility Care (Days 1-20)
Medicare pays all costs
Skilled Nursing Facility Care (Days 21-100)
Medicare pays all costs
Medicare Part B Services
Part B Deductible
$0
Part B Coinsurance
$0
Clinical Laboratory Services Plan pays for 100% of the Medicare approved
amount
Part B Excess Covered
Yes
Foreign Travel Coverage
Plan pays 80% of the billed charges for
emergency care when traveling outside the U.S.
after you meet a $250 deductible for the calendar
year.
Medical Supplement Stipulations
- Network open to any medical facility that accepts Medicare in all 50 states to include U.S.
territories.
- The proposed plan premium rate includes all insurance fees and administrative costs.
- The rates provided are quoted on a full replacement basis.
- A benefit period begins on the first day you receive service as an inpatient in a hospital and ends
after you have been out of the hospital and have not received skilled care in any other facility for
60 days in a row.
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
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DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Tier 1*Tier 2 Tier 3 Tier 4
037/TBD2 PDP TBD $5 $25 $60 $75
Greater of $3.40 for
generic/multiple source drugs
($8.50 for all others) or 5%
coinsurance ($5 Maximum
out-of-pocket per
perscription)
$5,100
Tier 1*Tier 2 Tier 3 Tier 4
037/TBD2 PDP TBD $5 $25 $60 $75
Greater of $3.40 for
generic/multiple source drugs
($8.50 for all others) or 5%
coinsurance ($5 Maximum
out-of-pocket per
perscription)
$5,100
*Tier 1: Generic or Preferred Generic - Generic or brand drugs that are available at the lowest cost share for this plan.
Tier 2: Preferred Brand - Generic or brand drugs that Humana offers at a lower cost than Tier 3 Non-Preferred Drug.
Tier 3: Non-Preferred Drug - Generic or brand drugs that Humana offered at a higher cost than Tier 2 Preferred Brand drugs.
Tier 4: Specialty Tier - Some injectables and other higher-cost drugs.
Footnotes
1 Catastrophic: When a member's True Out-of-Pocket (TrOOP) cost reaches $5,100.
Out of Network: Emergency Situations
When a member purchases a drug at an out-of-network pharmacy in an emergency situation:
a. the member will pay the same coinsurance as would have applied at a network pharmacy, but at the out-of-network pharmacy price, and/or,
b. the member will pay the same copayment as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy price and the network pharmacy price, not to include maximums.
Plan/Option
30 Day Standard Retail
Cost Sharing from
Catastrophic to Unlimited
PDP Option
Number
30 Day Standard Retail from $0 to
Catastrophic (1)
Out-of-Pocket that
triggers
Catastrophic
PDP Option
Number
30 Day Standard Mail Order
Cost Sharing from
Catastrophic to Unlimited
30 Day Standard Mail Order from $0
to Catastrophic Plan/Option
Out-of-Pocket that
triggers
Catastrophic
With Package(s): 1 (Cosmetics), 2 (Cough & Cold), 3 (Fertility Agents), 4 (Vitamins) & 5 (Weight Loss Agents)
2019 Custom PDP Plan 037 Option TBD2 for City of Denton
Group Plus Formulary
Effective Date: 01/01/2019 - 12/31/2019
Subject to CMS Approval
30 Day Supplies
Not for Member Use; Employer Use Only 09/17/2018
EXHIBIT F
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Tier 1*Tier 2 Tier 3 Tier 4
037/TBD2 PDP TBD $15 $75 $180 N/A
Greater of $3.40 for
generic/multiple source drugs
($8.50 for all others) or 5%
coinsurance ($15 Maximum
out-of-pocket per
perscription)
$5,100
Tier 1*Tier 2 Tier 3 Tier 4
037/TBD2 PDP TBD $12.50 $62.50 $150 N/A
Greater of $3.40 for
generic/multiple source drugs
($8.50 for all others) or 5%
coinsurance ($12.50
Maximum out-of-pocket per
perscription)
$5,100
*Tier 1: Generic or Preferred Generic - Generic or brand drugs that are available at the lowest cost share for this plan.
Tier 2: Preferred Brand - Generic or brand drugs that Humana offers at a lower cost than Tier 3 Non-Preferred Drug.
Tier 3: Non-Preferred Drug - Generic or brand drugs that Humana offered at a higher cost than Tier 2 Preferred Brand drugs.
Tier 4: Specialty Tier - Some injectables and other higher-cost drugs.
Footnotes
1 Catastrophic: When a member's True Out-of-Pocket (TrOOP) cost reaches $5,100.
2 Retail and Mail Order: The benefit for a 90-day supply is limited to Rx formulary Tiers 1-2 and most drugs on Tier 3. Regardless of tier placement, Specialty drugs are limited to a 30-day supply.
Out of Network: Emergency Situations
When a member purchases a drug at an out-of-network pharmacy in an emergency situation:
a. the member will pay the same coinsurance as would have applied at a network pharmacy, but at the out-of-network pharmacy price, and/or,
b. the member will pay the same copayment as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy price and the network pharmacy price, not to include maximums.
90 Day Supplies
2019 Custom PDP Plan 037 Option TBD2 for City of Denton
Group Plus Formulary
Effective Date: 01/01/2019 - 12/31/2019
Subject to CMS Approval
90 Day Standard Retail
Cost Sharing from
Catastrophic to Unlimited
Out-of-Pocket that
triggers
Catastrophic
90 Day Standard Retail (2) from $0 to
Catastrophic (1)
With Package(s): 1 (Cosmetics), 2 (Cough & Cold), 3 (Fertility Agents), 4 (Vitamins) & 5 (Weight Loss Agents)
PDP Option
NumberPlan/Option
Plan/Option PDP Option
Number
90 Day Standard Mail Order (2) from
$0 to Catastrophic
Out-of-Pocket that
triggers
Catastrophic
90 Day Standard Mail Order
Cost Sharing from
Catastrophic to Unlimited
Not for Member Use; Employer Use Only 09/17/2018
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Weight Management Discount (Jenny Craig®): Members pay $10/month for unlimited weekly Jenny Craig one-on-one consultations with free enrollment. A 10% discount is available on Jenny Craig products, including
food. Go to JennyCraig.com/HumanaMedicare or call 1-877-Jenny70 to find out more or to find a location near you.
Weight Management Discount (Nutrisystem®): A 40% discount on all 4-week auto-delivery programs including Basic, Core, and Uniquely Yours plans, plus you'll also get free tracking tools and support from the online
Nutrisystem community. For members outside of Florida, visit Nutrisystem at www.nutrisystem.com/humana. For Humana members in Florida, visit Nutrisystem at www.nutrisystem.com/humanafl. There are special auto-
delivery shipping charges that will be incurred for shipments in Alaska, Hawaii, Puerto Rico, Canada and other US territories.
Dental Discount (HumanaDental): Discount for dental services received from participating HumanaDental providers. To find a participating provider visit Humana.com. To receive the discount show your Humana ID card
and your dental discount card. The service is not available in Puerto Rico or Florida.
Hearing Discount (TruHearing): A discount is available on hearing aids at any TruHearing hearing center. Member must schedule an appointment with TruHearing before seeing a provider. Save an average of $980 per
hearing aid compared to average retail pricing. Pricing on all TruHearing products can be found at www.truhearing.com. Not available in Florida.
EyeMed Vision Discount: Discounts from participating Eyemed Vision Care Select network providers on routine vision services such as: Exam with dilation (if necessary) – $5 off routine exam; $5 off contact lens fitting and
follow-up. Frames – 40% off retail price of a complete pair of frames and 20% off retail price of a partial pair of frames. Lenses – fixed prices for lenses and lens options. Contact lenses – 15% off retail price of non-disposable
contact lenses. Laser vision correction (Lasik or PRK)* – 15% off retail price or 5% off promotional price. This is a discount only through EyeMed Medicare discount plan ID 9243247. Discounts are taken at point of sale. To
locate an EyeMed Select network provider, go to Humana.com > Find a doctor > from the Search Type drop down, select Vision > click onto EyeMed Vision Care. Discount and funded benefits cannot be utilized within same
transaction.
Lifeline® Medical Alert Systems: Philips Lifeline may help members live independently with a peace of mind. Personal emergency response services connect members to caregivers & emergency services when an incident
occurs. The basic lifeline service is $29.95 monthly. Lifeline with Auto Alert is $44.95 monthly. Auto Alert will detect a fall & automatically place a call for the member. Wireless or landline options available. GoSafe Mobile
Lifeline functions in and out of the home. GoSafe uses two way voice communication & five location seeking technologies used to send help quickly to wherever the member is located. GoSafe starts at $54.95 monthly, uses
two way voice communication & five location seeking technologies to send help to the location. Also, a Medication Dispensing Service is available at the rate of $59.95 per month. Equipment shipping and handling is $19.95.
Member may elect to self-install or choose an in-home services installation for $99 (optional). Learn more at: www.offer.lifelinesys.com/humana/.
Pharmacy Discount: Show your Humana member ID card at participating pharmacies when you buy non-covered prescription medicines to receive any available discounts. Depending on the medicine purchased, quantity
limits may apply.
Healthy Hearing Discount (HearUSA): The HearUSA discount hearing program offered by HearUSA includes special pricing on hearing aids, two years of free batteries when you buy hearing aids (up to 96 cells per hearing
aid), all styles and technology levels including invisible, Bluetooth and Smartphone compatible. A 10 percent discount on accessories and hearing assistance products is also available. Just visit www.hearingshop.com .
Please use checkout code "EARHUMANA" to receive savings. A 60-day money-back guarantee and interest-free financing available with approved credit. To get your discount, show your Humana ID card at the time of your
visit. Available in Florida only.
Dental Discount (Careington Dental): Up to 60 percent discount for dental services received from participating Careington general dentistry providers. Services include routine oral exams, cleanings, and major work such
as dentures, root canals and crowns. Available in Florida only. Find a Careington dentist by calling 1-866-636-9248 (TTY: 711) or at careington.com/humana.
Complementary and Alternative Medicine: Discounts for complementary and alternative medicine services including chiropractic, acupuncture and massage therapy. Services must be received from participating Tivity
Health's WholeHealth Living™ providers. Puerto Rico is excluded. To find a participating provider, go to humana.wholehealthmd.com or call 1-866-430-8647, Monday - Friday, 8:30 a.m. -8 p.m. Eastern Time. TTY users call
711.
The benefit and discount information presented here are current as of the date of this document. If a change should occur prior to implementation, Humana will clarify any change and notify the group
sponsor. The products and services described below are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any
disputes regarding these products and services should be addressed with Customer Care by calling the number on the back of your Humana membership card.
CMS does not permit discussing the below services with potential enrollees prior to enrollment.
Extra Services
Not for Member Use; Employer Use Only 09/17/2018
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE
Your benefits do not include the following, except as otherwise noted:
Any drug not defined by CMS as a Part D drug.
Any drug prescribed for a non-covered illness or injury.
Any drug you receive before your effective date of coverage or after the date your coverage has ended.
Any costs related to the mailing, sending or delivery of prescription drugs; unless you are utilizing our mail-order pharmacy which includes first class delivery service.
Any fraudulent misuse of this benefit, including prescriptions purchased for consumption by someone other than the member.
Any drug determined by Humana to require prior authorization and prior authorization is not obtained.
Prescriptions or refills for drugs that are lost, stolen, spilled, spoiled or damaged.
Any drug prescribed for intended use other than for indications approved by the FDA or recognized off-label indications through peer-reviewed medical literature.
May exclude drugs such as Viagra, Cialis, Levitra, and Caverject when used for the treatment of sexual or erectile dysfunction.
General Exclusions
More than one prescription for the same drug until at least 75% (up to a 30 day supply) or 83% for anything 31 days or over of the prescription has been used by the member based on the dosage schedule prescribed by the
network provider. If received through the mail-order pharmacy program at least 66% of the previous prescription has been used. The exception to this is ophthalmic solutions where the threshold is 70% through a retail
pharmacy or 66% through mail-order.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or member cost-share may change each year.
The formulary and pharmacy network may change at any time. You will receive notice when necessary. Please refer to the Evidence of Coverage for additional information regarding covered services and limitations or any
other contractual conditions. For a complete description of benefits, exclusions and limitations please refer to the actual Evidence of Coverage. If a discrepancy arises between this information and the actual Evidence of
Coverage, the Evidence of Coverage will prevail in all instances.
Humana is a Medicare Employer Prescription Drug plan with a Medicare contract. Enrollment in this Humana plan depends on contract renewal.
Any refunds or credits for prescription copayments or coinsurance after a prescription has been filled, regardless of whether the request is because of an adverse reaction or a change in the dosage or prescription.
Not for Member Use; Employer Use Only 09/17/2018
DocuSign Envelope ID: 457F40AA-1E5D-4731-A80C-F54640F59DFE