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Microsoft word - smm #1 _jan 2012 spd_ - formulary exclusions.doc
SUMMARY OF MATERIAL MODIFICATIONS
STONE AND MARBLE MASONS OF METROPOLITAN WASHINGTON, D.C.
HEALTH & WELFARE FUND
March 1, 2012
SUMMARY OF MATERIAL MODIFICATION #1
Effective April 1, 2012, certain prescription drugs will cease being covered by the
Plan unless prior authorization is obtained from CVS/Caremark for use of these medications. These specific medications are listed below. Each of these medications has a therapeutic equivalent prescription drug that is covered under the Plan.
You may have received written notification or a telephone call advising you that
these prescription drugs will no longer be covered, if you have an existing prescription for these medications. You and your physician should discuss whether to use the alternate medication instead of the prescription drug on this list. If your physician believes that you should use one of the excluded drugs rather than the therapeutic equivalent, your physician will be asked to provide CVS/Caremark with certain information, so that CVS/Caremark may determine whether to provide you with prior authorization for use of this drug.
If CVS/Caremark provides prior authorization, then the drug will be covered
under the normal rules of the Plan. If CVS/Caremark does not provide prior authorization, your prescription for the excluded drug will not be covered under the Plan rules at all. If you agree to use the alternate medication, rather than the excluded drug, the alternate medication will be covered under the normal rules of the Plan.
The reason this prior authorization procedure is being implemented, and the
reason the list of excluded drugs has been adopted is that these medications are extremely expensive and alternate medications have proven to be as effective in most cases. The following drugs are excluded from coverage under the Plan, effective April 1, 2012, without prior authorization:
LIST OF EXCLUDED DRUGS:
Sincerely, The Board of Trustees SMM#1 (01/12 SPD)
During the health reform debate, President Obama stated to Americans that “if you like your
health plan, you can keep it.” The Trustees of the Stone and Marble Masons of Metropolitan Washington, D.C. Health and Welfare Fund have chosen to do so, and believe that the Stone and Marble Masons of Metropolitan Washington, D.C. Health and Welfare Fund is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (“PPACA”).
The Plan uses collectively bargained employer contributions to the Plan, and income from the
investment of Plan assets, to provide the most generous health plan that is prudently possible given the assets of the Plan. To avoid the financial and other burdens on the Plan that would be associated with full implementation of the PPACA, the Trustees have decided to operate the Plan as a “grandfathered health plan” under the PPACA.
A health plan that was in existence on March 23, 2010, the enactment date of the PPACA, is
referred to under the PPACA as a “grandfathered health plan.” As permitted by the PPACA, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that the Plan may not include certain consumer protections of the PPACA that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the PPACA, for example, coverage of dependents up to age 26.
Questions regarding which protections apply and which protections do not apply to a grandfathered
health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at: Stone and Marble Masons of Metropolitan Washington, D.C. Health and Welfare Fund, 7130 Columbia Gateway Drive, Suite A, Columbia, MD 21046, (410) 872-9500. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans. For more information, or if you have any questions, please call the Fund Office at (410) 872-9500.
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