Prescription Drug Expense Benefits

The Prescription Drug Expense Benefits portion of the Plan is a separate coverage from the Medical Expense Benefits. However, in addition to the exclusions indicated below, all provisions and limitations of the Plan shall apply to this coverage. The Plan shall not exclude coverage of any drug approved by the FDA for the treatment of certain types of cancer on the basis that such drug has been prescribed for the treatment of a type of cancer for which the drug has not been approved by the food and drug administration. Provided, however, that such drug must be recognized for treatment of the specific type of cancer for which the drug has been prescribed in one of the following established reference compendia:

(i) the American Medical Association Drug Evaluations;

(ii) the American Hospital Formulary Service Drug Information; or

(iii) the United States Pharmacopeia Drug Information; or recommended by review article or editorial comment in a major peer reviewed professional journal.

Coverage shall not be provided for any experimental or investigational drugs or any drug which the food and drug administration has determined to be contraindicated for treatment of the specific type of cancer for which the drug has been prescribed unless directed to pursuant to an external appeal. Covered expenses paid under this portion of the Plan shall not be a benefit under any other portion or coverage of the Plan.

CO-PAYMENT
The co-payment amount shall be the amount per prescription specified in the Schedule of Benefits which shall not be considered a covered expense. Payment of the co-payment amount per prescription shall be the responsibility of the Covered Person.
Note: Once your aggregate maximum co-payment per family (please refer to the Schedule of Benefits) is met, further co-payments will be waived.

COVERED DRUGS
Covered Drugs include only the following:

1. Legend drugs,

2. Insulin on prescription.

3. Tretinoin, all dosage forms (e.g., Retin-A). For individuals over age 25, documentation verifying medical necessity must be submitted to Aetna before reimbursement will be made.

4. Compounded medication of which at least one ingredient is a prescription legend drug.

5. Any other drug which under the applicable state law may only be dispensed upon the written prescription of a Physician or other lawful prescriber.

6. Nutritional supplements (formulas) as medically necessary for the therapeutic treatment of phenyl Ketonuria, branched-chain Ketonuria, galactosemia and momocystinuria as administered under the direction of a physician.

7. Syringes and needles for diabetic use.

8. Enteral formulas for home use for which a physician or other licensed health care provider legally authorized to prescribe under title eight of the education law has issued a written order. Such written order shall state that the enteral formula is clearly medically necessary and has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated cause chronic disability, mental retardation or death. Specific diseases for which enteral formulas have proven effective shall include, but are not limited to, inherited diseases of amino-acid or organic acid metabolism; Crohns's Disease, gastroesophageal reflux with failure to thrive; disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction; and multiple, severe food allergies which if left untreated will cause malnourishment, chronic physical disability,
mental retardation or death.

9. Prescription drugs approved by the federal Food and Drug Administration for use in the diagnosis and treatment of infertility, except that coverage shall not include prescription drugs in connection with in vitro fertilization, gamete intrafallopian tube transfers or zygote intrafallopian tube transfers, the reversal of sterilization, sex change procedures, cloning or procedures or services that are experimental. Coverage is limited to individuals whose ages range from twenty-one (21) through forty-four (44) years.

10. Drugs or devices for bone density as approved by the federal Food and Drug Administration (FDA).

11. Coverage for certain inherited diseases of amino acid and organic acid metabolism shall include modified solid food products that are low protein, or which contain modified protein which are medically necessary, and such coverage for such modified solid food products shall not exceed $2,500 per person per calendar year.

12. Drugs or devices for the treatment of erectile disfunction; subject to a maximum of 6 pills per month.

Please refer to the section titled List of Prescription Drugs Requiring Precertification for additional information.

EXCLUSIONS APPLICABLE TO PRESCRIPTION DRUG EXPENSE BENEFITS
In addition to the General Limitations of the Plan, no benefits shall be payable under the Prescription Drug Expense Benefits portion of the Plan for the following:

1. Non-legend drugs;

2. Charges for the administration or injection of any drug.

3. Therapeutic devices or appliances, support garments, and other non-medicinal substances, regardless of intended use, unless otherwise covered under this Plan or required by law.

4. Prescriptions if benefits are provided under any state or federal workers’ compensation, employers’ liability or occupational disease law;

5. Drugs labeled "Caution - limited by federal law to investigational use," or experimental drugs, even though a charge is made to the individual unless directed pursuant to an External Appeal;

6. Immunization agents, biological sera, blood or blood plasma;

7. 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;

8. Any prescription refilled in excess of the number specified by the Physician or allowed by the Plan, or any refill dispensed after one year from the Physician's original order;

9. Drugs that are available without a prescription, unless otherwise specifically included;

10. Contraceptives, oral or other, whether medication or device, regardless of intended use. (Please refer to Rider 2003-1).

Please refer to the section titled List of Prescription Drugs Requiring Precertification for additional information.

DISPENSING LIMITATIONS
The amount normally prescribed by Physician, but not to exceed a 30-day supply, except when a maintenance drug is ordered from the Plan's mail order pharmacy vendor. Maintenance medications dispensed through the mail order vendor are limited to a maximum of a 90-day supply.

NON-PARTICIPATING (PHARMACY) PROVIDERS
If you obtain covered prescription drugs from a pharmacy which does not participate in the Plan's Prescription Drug Expense Benefits program through AETNA, the Plan's payment for such covered prescription drugs shall be limited to the amount the Plan would have paid had such prescription drugs been purchased from a participating pharmacy.

You may obtain a special prescription drug claim form from your District Benefit Representative to file a claim for prescriptions purchased from pharmacies that do not accept the AETNA card.

MAIL ORDER PHARMACY
The Consortium utilizes Aetna Rx to administer a Home Delivery Prescription Drug Program for maintenance or long term use drugs. The mail order program is completely optional. Aetna Rx Home Delivery mail order kits can be obtained from your School District business or personnel office.

PRESCRIPTION DRUG COORDINATION OF BENEFITS

1. If the Consortium's Plan is the primary payer, then the member may use the AETNA ID card to purchase prescriptions at a local pharmacy.

2. If the Consortium’s Plan is not the primary payer, the member will not be allowed to use the AETNA ID card to purchase prescriptions. The member must first submit the claim to the primary insurer before submitting the claim for secondary benefits. Secondary benefits will be subject to the same co-payments as if the card had been used.

In order for a claim to be considered for secondary reimbursement, the following information must be included:

a. Employee's full name and Social Security number or ID number;

b. Evidence of primary payees claim adjudication; and

c. Copy of pharmacy receipt including:

• 10-digit National Drug Product Code or Drug Name/dose/quantity;

• Name/address of Pharmacy;

• Pharmacy prescription number;

• Date prescription filled; and

• Patient’s full name.

Secondary prescription drug claims should be submitted to:

Attn: Commercial Claims Processing
Aetna Pharmacy Management
P. O. Box 14024
Lexington, KY 40512

Claim forms are available from your District Benefits Representative.

CERTIFICATION FOR CERTAIN PRESCRIPTION DRUGS
Certification of the necessity of certain prescription drugs is required before the drug is dispensed by a pharmacy.

When one of the prescription drugs shown below is dispensed, expenses incurred will be payable as follows:

• If certification has been requested and the drug is necessary:

Benefits will be payable at the applicable payment percentage.

• If certification has not been requested and the drug is necessary:

A penalty equal to 50% of the benefits otherwise payable shall be imposed.

• If the drug is not necessary:

No benefits will be payable whether or not certification has been requested.

CERTIFICATION PROCEDURES
It is your responsibility to arrange for the prescriber of the drug to call Aetna at 1-800- 414-2386 or fax Aetna at 1-800- 408-2386 to request certification. This call/ fax must be made as soon as reasonably possible before the drug is to be dispensed. Copies of laboratory and/or medical records may be requested. If such information is requested, it must be provided in order to certify the necessity of the drug.

Aetna will notify you and your heathcare provider of the decision, by telephone and in writing, within three business days of receipt of the necessary information. This notice will show:

• the approved period of certification, during which time any authorized refills of the drug may be dispensed; or

• when certification is denied, the procedure to follow if you choose to appeal the decision.

If the drug is to be dispensed after the certification period ends, certification must again be requested, as described above.

LIST OF PRESCRIPTION DRUGS REQUIRING CERTIFICATION
The following prescription drugs require certification before the drug is dispensed:

• Appetite Suppressants

(covered only for morbid obesity and attention deficit disorder)

• Growth Hormones

• Retin-A (over age 25)

• Injectable medications