Policy AM-204-24 Prescription Drug Plan

<strong>This policy applies to eligible permanent full-time and eligible part-time employees who elect to enroll in a pharmacy program offered by the City of Baltimore.</strong>

<strong>All employees eligible for the prescription drug plan must enroll for coverage within 60 days of employment or change in status. To enroll employees will need to log on to the online enrollment website, </strong> <a href="http://www.baltimorecity.essbenefits.com/">www.baltimorecity.essbenefits.com</a> <strong>. Employees may access this website by using their Social Security number and PIN (4 digit Personal Identification Number).</strong>

<strong>Coverage for new hires will become effective on the first day of the calendar month following 30 days of service.</strong>

<strong>Coverage for employees will end on the last day of the calendar month in which termination occurs.</strong>

<strong>Employees may enroll in any one of the following levels of coverage within a health care program:</strong> <ul> <li> <strong>Individual – Employee only.</strong> </li> <li> <strong>Employee and Spouse (or Domestic Partner).</strong> </li> <li> <strong>Parent and Child –two people (Employee and one Child).</strong> </li> <li> <strong>Family – indicates three or more people.</strong> </li> </ul> DEPENDENTS ELIGIBILITY <strong>An eligible dependent is defined as:</strong> <ul> <li> <strong>A spouse. The City requires a marriage certificate to verify eligibility.</strong> </li> <li> <strong>Domestic Partner. The City requires an Affidavit of Domestic Partnership to verify eligibility.</strong> </li> <li> <strong>An unmarried child by natural birth or legal adoption until the year in which the child reaches the age of ineligibility as defined by the provisions of the health care coverage selected (outlined below). The City may require birth certificate or court documentation to verify dependency.</strong> </li> <li> <strong>An unmarried child for whom a City employee has been designated guardian or economic sole support until the end of the calendar year in which the child reaches the age of ineligibility as defined by the provisions of the health care coverage selected. The City may require court or other official documentation to verify dependency.</strong> </li> <li> <strong>An unmarried child above eligibility age who is incapable of self-support because of disability that commenced prior to the date on which the child reached the age of ineligibility as defined by the provision of the health care coverage selected.</strong> </li> </ul>

<strong>The employee pays a copay for each allowed prescription under the Prescription Drug Plan, either at a retail pharmacy or through the mail order pharmacy. The Prescription Drug Plan requires that the participating pharmacy, including mail order pharmacy, use generic drugs, unless there is a medical reason that supports the use of a brand name medication.</strong>

<strong>Employees (and their eligible dependents) have the option to have maintenance medications filled through a mail order pharmacy. Using a mail order pharmacy to fill maintenance medications allows employees (and their eligible dependents) to fill a 90-day supply instead of a 30-day supply at a local retail pharmacy.</strong> <strong>Maintenance medications are medications that will be taken on a long-term basis. Examples of maintenance medications include drugs prescribed to treat illnesses, such as high blood pressure, high cholesterol, arthritis, thyroid or diabetes.</strong> Non-Participating Providers <strong>If a non-participating provider is used to fill a prescription, the employee must pay for the cost of the prescription in full.</strong> <ul> <li> <strong>Claims with a fill date of 1 to 60 days from the participant’s effective date, reimbursement is at the submitted cost less the copay amount.</strong> </li> <li> <strong>Claims with a fill date of more than 60 days from the participant’s effective date, reimbursement is at the client’s contracted rate minus the copay amount.</strong> </li> </ul> <strong>To request reimbursement, the employee must complete a Prescription Reimbursement form, which is available from Express Scripts.</strong>

<strong>Employees traveling outside of the United States must contact the Employee Benefits Division at least two weeks before departure if any medications are required before the refill date or if an extended supply of medication is needed.</strong> QUALIFYING EVENTS FOR DEPENDENT ENROLLMENT <strong>There are certain situations, called Qualifying Events, which permit employees to enroll dependents in the Prescription Drug Program outside of the annual Open Enrollment. Employees must enroll eligible dependents within 60 days of a Qualifying Event. Employees who need to make changes to their benefits, due to a Qualifying Event, will need to access the City’s enrollment website, </strong> <a href="http://www.baltimorecity.essbenefits.com/">www.baltimorecity.essbenefits.com</a> <strong> <u>.</u> </strong> <strong> Employees must provide the required documentation for dependents, which are listed in the following paragraphs.</strong> <u>Domestic Partner</u> <strong>To add a domestic partner to the employee’s prescription plan, the employee must access the enrollment website and add the Domestic Partner. Then the employee and the domestic partner must provide an Affidavit for Employee Domestic Partnership to the Employee Benefits Division.</strong> <u>Newborn</u> <strong>To add a newborn to the employees existing prescription plan employees must access the enrollment website within 60 days of the newborn’s date of birth. The coverage effective date for a newborn will be the child’s date of birth. The employee will also need to submit a birth certificate within 60 days of the child’s date of birth.</strong> <u>Dependent Child (For New Enrollees only)</u> <strong>Employees must provide a copy of the child’s birth certificate within 60 days of the Change in Status or Date of Hire.</strong> <u>Step-Children</u> <strong>To add a stepchild the employee must access the enrollment website and add a stepchild to his/her benefits. The employee must provide a marriage and birth certificate to Employee Benefits within 60 days.</strong> <u>Children of Domestic Partners</u> <strong>The earliest a child of a domestic partner can be added is the first of the month following the date of Domestic Partnership Certification. Eligible dependents must be added by accessing the enrollment website within 60 days of the certification (or qualifying event). The employee must provide the Affidavit of Domestic Partnership and a birth certificate to Employee Benefits within 60 days.</strong> <u>Adopted Children</u> <strong>An adopted child will be effective on the date of the adoption. To enroll an adopted child the employee must enroll the child by accessing the enrollment website within 60 days of the adoption. The employee must then submit a Birth Certificate and a document of placement to Employee Benefits within 60 days.</strong> <u>Legal Guardianship</u> <strong>An eligible dependent, for whom an employee has legal guardianship, can be added to the employee’s policy on the first of the month following the event as long as the employee has enrolled the child within 60 days of legal guardianship.</strong> <u>Economic Sole Support</u> <strong>To add an eligible dependent for whom an employee provides economic sole support, the dependent must be enrolled within 60 days of the economic sole support determination. Employees must submit the following documentation of proof of the relationship: a birth certificate for a child and a grandchild and the Certification of Economic Sole Support for Grandchildren form.</strong> <u>Full-time Students</u> <strong>To add dependent children over the age of 19, the employee must enroll the child by using the enrollment website and certifying that the child is a full-time student. The employee will need to submit a Student Verification form to Employee Benefits within 60 days of this event.</strong> SEPARATION FROM CITY SERVICE <strong>Employees who separate from City service will receive information regarding Consolidated Omnibus Budget Reconciliation Act, COBRA, (<cite data-path="§AM-204-28">AM-204-28</cite>) at the time of their exit interview or through a subsequent communication from the Employee Benefits Division. If an employee is eligible for and selects enrollment in the Prescription Drug Plan through COBRA, that employee (and his/her eligible dependents) will receive a new prescription drug card.</strong>

<strong>If the employee is out of pay status for more than 30 consecutive days for reasons other than an approved Family Medical Leave (FMLA), the employee is responsible for the monthly premium to continue this benefit. However, if the employee is on an approved FMLA then the employee is entitled to continue this benefit for the length of the FMLA. For more information, contact Employee Benefits Division at 410-396-5830.</strong>