Medical Care and Prescription Drug Plan Summary Plan Description

Regular full-time and part-time employees scheduled to work nine or more months are eligible to participate in the plan 12 months per year; regular full-time and part-time employees scheduled to work less than nine months are eligible to participate in the plan when working. Adjunct employees are eligible to participate in semesters in which they work. If you elect coverage, it can begin on the first day of the month on or after your date of employment. You need to enroll, however, and authorize the payroll deductions to pay your share of the cost before coverage can begin. However, if your contribution is too high to be deducted from your pay, we will set you up for billing by our outside billing administrator and you will pay with after-tax dollars. You must enroll within 31 days from your date of hire; otherwise, you cannot enroll until the fall open enrollment, effective January 1 of the following year. If you are not at work on the day coverage is supposed to start, coverage will become effective on the day you return to active employment

You also may obtain coverage for your spouse or domestic partner and/or eligible children by enrolling in two person or family coverage and authorizing payroll deductions to pay your share of the cost. You may not cover your spouse/domestic partner as a dependent if your spouse is enrolled for coverage as an employee. No child can be covered as both an employee and a dependent.

Please refer to the separate summary on providing benefits for your domestic partner.

The eligibility rules for children are as follows:

• The child of the employee or the employee’s spouse who is under age 26.
• The child of the employee’s domestic partner who is under age 26 (NOTE: if the child is not claimed as a dependent on the employee’s federal income tax return, this benefit will be taxable).
• The foster child (under age 18) of the employee, defined as an individual who is placed with the employee by an authorized placement agency or by judgment decree, or other court order.
• Any other child who is under age 26, and
  • for whom the employee is the legal guardian or custodian, and
  • who resides in the employee’s home, and
  • who is claimed as a tax dependent on the employee’s federal income tax return.

Coverage for your family members usually begins when your coverage begins. However, if your spouse/partner or a child is confined in an institution or at home for medical reasons when coverage is supposed to begin, coverage will become effective on the first day the person is no longer confined.

A spouse who is divorced from you is not eligible for coverage under the Plan (except under the provisions of COBRA, as described later in this summary), even if a court orders you to provide health care coverage for your former spouse. If you have an eligible dependent who is also an RIT employee, he or she may be covered either as an employee or as a dependent, but not both.

Also eligible for coverage under this Plan are those in the following categories who meet the requirements described later in this summary:

• Pre-Medicare retirees and pre-Medicare spouse/partner/children
• Pre-Medicare LTD recipients and pre-Medicare spouse/partner/children
• Pre-Medicare surviving spouse/partner/children.

RIT has a family member verification (FMV) process to ensure that only those people who are eligible for benefits are covered and that the proper tax status is applied. It is important that RIT and employees are spending money as intended and that required taxes are paid.

The process is a simple one; copies of the eligibility verification documents only need to be provided once for an individual regardless of future benefit plan enrollments (e.g., if you cover your spouse only under dental and later add your spouse to your medical coverage, you will not need to provide another copy of the verification document).

Generally, the approved documents are a marriage certificate for a spouse and a birth certificate for a child, and an affidavit for your eligible domestic partner; refer to the benefits page of the HR website for more details on accepted documents. Copies of verification documents should be provided as follows:

New hires: a new employee must provide the eligibility verification documents before family members can be added to the various benefits coverage.

Mid-Year Changes: generally, the employee must provide the eligibility verification documents before family members can be added to the various  benefits coverage. In the case where the document is not available (e.g., birth certificate for a new baby), the family member will be added to the coverage but the employee must provide the required proof within 30 days; otherwise, coverage will be cancelled for the family member.

Open Enrollment Changes: the employee must provide eligibility verification documents by the end of the open enrollment period for any family  members added to the coverage. If the documentation is not provided, the open enrollment change will not be processed and the family member will not be added to the coverage effective January 1.

Providing Social Security Numbers for Family Members
The Affordable Care Act (ACA) requires an employer who offers employee medical coverage to submit detailed reporting regarding all the people covered by the medical plan. One of the required items that RIT must report to the government is the name and Social Security Number (SSN) of each covered family member of an employee.

Therefore, RIT collects the SSN for each covered family member on the enrollment/change form. Please be assured that this information will be safeguarded with the same level of security protection we provide for all employee confidential data.
 

Plan coverage is not automatic for a new employee; you need to complete an enrollment form for coverage to take effect. On the form you indicate your choice of medical plans and whether you want individual, two person, family coverage, or one-parent family (i.e., employee and two or more children) coverage.

It’s important for you to return the completed enrollment form within 31 days after you first become eligible for coverage. If you wait beyond 31 days to enroll, you will not have another opportunity to enroll until the Plan’s next open enrollment. If you have initially enrolled in one of the medical plans and wish to change to another plan, you may do so only at open enrollment.

Because medical coverage needs change from time to time, you have the opportunity once each year – effective as of January 1 - to make changes in your election. You can enroll in or cancel coverage, change plans, or change your coverage level (e.g., change from individual to two person). If you do not make a change during this open enrollment period, you will have to wait until the next open enrollment period to make a change unless you experience a qualified change in status, described in the next section.

In general, once you have enrolled in the Plan, you cannot change plans, change your coverage level or cancel coverage until the beginning of the next plan year. However, pursuant to federal regulations, you may be able to make mid-year election changes if you meet certain criteria, as explained in items one through six, below. Your requested election change must be consistent with the reason for the change, as defined by the Internal Revenue Service. For example, it would be consistent for an employee with two-person coverage that adopts a child during the year to change his or her election to family coverage. It would not be consistent to move from family coverage to individual coverage. Changes must be made within 31 days of the event that gives you the right to make a new election. The Plan Administrator may require you to submit certain documentation related to your reason for making a mid-year election change. New elections will become effective on the qualifying event date.

Your benefit elections may be changed within 31 days – consistent with the event - to reflect the following events:

1. Qualified Change in Status
   • The following events constitute a qualified change in status:
     • change in legal marital status: for example, a marriage or divorce
     • a change in the number of dependents: for example, the birth of a child, an adoption, a death, and so on
     • a change in a dependent’s eligibility: for example, a child reaches the maximum age under a medical plan
     • a change in your residence or that of your spouse or child: for example, a move out of a geographic area covered by a medical plan
     • you, your spouse or your child become eligible for continued health coverage under federal law (COBRA) or similar state law
     • you, your spouse or your child become entitled to or lose Medicare or Medicaid coverage
2. Change in Employment Status
   • The following events constitute a change in employment status where they affect you or your spouse or child:
     • termination of employment
     • commencement of employment
     • commencement or return from an unpaid leave of absence
     • change in employment classification that makes the person either eligible or ineligible to participate in a plan (for example, a change from full-time to part-time status, or the reverse, if such a change affects one’s eligibility to participate in a plan).
3. Changes in Employee’s Cost of Coverage
   • With respect to your pre-tax premium contributions, you are permitted to make a mid-year election change if there is a significant increase in the cost of an underlying health care plan. If there is an ordinary increase or decrease in premiums, your payroll deductions will be automatically adjusted to reflect this change. Any determination of what constitutes a “significant increase” will be made by RIT.
4. Changes in Coverage
   • You may make a change in your election regarding your pre-tax premium contributions consistent with the following changes in coverage in an underlying health care plan:
     • If the coverage provided by an underlying plan is significantly curtailed, you may revoke your prior election with regard to that plan
     • If a new health care option is added or an option you have selected is eliminated, you may make a new election.
5. Qualified Medical Child Support Orders (QMCSO)
   • If a court ordered judgment requires you to provide health care coverage for a child or foster child, or if the order requires someone else to provide coverage, which you were previously providing, you may make mid-year election changes consistent with the QMCSO.
6. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
   • Losing eligibility for coverage under a non-RIT plan may allow you to exercise special enrollment rights provided by HIPAA and make a mid-year election change.

You and RIT share the cost of your medical plan, with the employee contribution being deducted from your paycheck, usually on a pre-tax basis. However, if your contribution is too high to be deducted from your pay, we will set you up for billing by our outside billing administrator and you will pay with after-tax dollars. Your share of the cost will be based on the plan you select and whether you choose individual, two person, one parent family or family coverage.

Contribution rates for medical coverage are provided annually by the Human Resources Department; the published rates include both the medical and prescription drug costs, if applicable, on a combined basis. These rates are subject to change. You will be notified in the event of any change in rates.

There are four cost sharing levels for full-time employees, based on the employee’s annual base pay; part-time employees and adjunct employees each have their own cost sharing schedule.

Effective January 1, 2024, regular full-time employees will pay for coverage based on their annual base pay as follows; these salary levels are generally adjusted on an annual basis, effective each January 1.

• Level 1:  less than $48,000
• Level 2:  $48,000-$103,999
• Level 3:  $104,000-$153,999
• Level 4:  $154,000 or more

Pre-Medicare retirees and pre-Medicare LTD recipients as of January 1, 2006 are in cost sharing Level 2. Employees who retire after January 1, 2006 or those who are approved for LTD after January 1, 2006 remain in the cost sharing level they were in prior to retirement or the LTD effective date.

Pre-Medicare retirees and surviving family members covered by the Plan are billed monthly by our outside billing administrator. LTD recipients will have their contribution amount deducted from the insurance company’s LTD benefit payment unless the deduction is higher than the payment; if that occurs, LTD recipients will be billed monthly by our outside billing administrator. All payments are made on an after-tax basis.

Refer to the separate contribution summaries for the employee contribution amounts and retiree/LTD/survivor contribution amounts. These rates are subject to change.

If any benefit is paid in error to you or a provider (e.g., hospital, physician, pharmacy), the Plan has the right to recover the amount overpaid. You, your dependent or legal representative shall, on request, provide the Plan with information, sign any documents, make repayment, and do whatever else the Plan says is necessary to recover an overpayment. Any failure to cooperate may result in the Plan’s seeking reimbursement directly from you, your dependent or your estate, through legal action.

If you have medical coverage under another group plan in addition to this one - through that of a spouse/partner, for example - the total benefits you are eligible to receive could be greater than your actual expenses. To help eliminate this duplicate spending, our Plan’s coverage is coordinated with other group plans with which you have coverage. This means that when the RIT Plan pays second, benefits will be adjusted so that the total payments from both plans won’t be more than 100% of total covered charges.

For your own claims and those of your spouse/partner, the plan that pays first is the one that covers you, your spouse or partner as an employee. If your children are covered by more than one plan, the plan of the parent whose birthday occurs earlier in the year will pay benefits first. However, if you are separated or divorced, the plan of the parent who has financial responsibility for the child’s medical care expenses will pay first. If there is no court decree for medical care coverage, then the plan of the parent who has custody of the child will pay first. Where none of these situations apply, the plan that you’re covered under the longest will pay first.

Other plans include any medical coverage available through:

•  Any group or blanket insurance contract, plan or policy, including HMO and other prepaid group coverage, except that blanket school accident coverages or such coverages offered to substantially similar groups (e.g., Boy Scouts, youth groups) shall not be considered a health insurance contract, plan or policy;
• Any self-insured or noninsured plan, or any other plan arranged through any employer, trustee, union, employer organization, or employee benefit organization;
• Any BlueCross BlueShield, or other service type group plan;
• Any coverage under governmental programs, or any coverage required or provided by any statute. However, Medicaid and any plan whose benefits are, by law, excess to those of any private insurance plan or other non-governmental plan shall not be considered health insurance policies; and
• Medical benefits coverage in group and individual mandatory automobile “no fault” and traditional “fault” type contracts.
   

Medicare, which is a federally sponsored medical insurance plan, becomes available at the beginning of the month in which you (or your spouse) turn age 65 (if the birth date is the first of the month, Medicare becomes effective the first of the prior month). There are special rules for people age 65 or over who are actively working, or who are being covered by a spouse, if the spouse is actively working. An employer must offer the same medical plans to an active employee (or spouse of an active employee) who is age 65 and over as they do to active employees who are under age 65.

Therefore, you (or your spouse) can continue to be covered under the same RIT medical plan with the same level of benefits when you turn age 65. All references below to “you” also apply to your spouse.

Under Federal law, this special rule does not apply to a domestic partner. While the domestic partner can continue to be covered under the RIT coverage, Medicare will be the primary coverage and the RIT coverage will be secondary. Refer to the additional information below.

Medicare Part A-Hospital Insurance

The Social Security Administration (SSA) recommends that you enroll in Medicare Part A beginning the first of the month in which you turn age 65. Medicare Part A is the hospital insurance and pays some of the cost of hospitalization, inpatient hospital care, and home health services. There is no premium during retirement for Medicare Part A benefits (these are funded through payroll taxes while you are working) and it will be secondary to your RIT employee coverage. Part A is not set up automatically; you will need to contact the Social Security Administration at 800-772-1213 or enroll online at https://www.ssa.gov/benefits/medicare/ to ensure that you are enrolled in Medicare Part A. If you do not enroll in Medicare Part A at age 65, Medicare provides a special enrollment period when you leave or retire from RIT.

For domestic partners, Medicare Part A will be the primary coverage; the RIT coverage will be secondary.

Medicare Part B-Medical Insurance

If you continue to work as a regular employee at RIT and have RIT medical coverage, it is not necessary for you to enroll in Medicare Part B and pay the required Part B premium; Part B covers medical care (doctor’s fees, etc.). When contacting the SSA you should let them know you do not need Part B coverage since you are still working and have RIT coverage. When you leave or retire from RIT, Medicare provides a special enrollment period to enroll in Medicare Part B benefits, with no penalty. You should begin this special
enrollment process at least three months prior to your retirement/termination date.

A domestic partner needs to enroll in Medicare Part B; there will be a premium for the Part B coverage that is payable to the Social Security Administration. Medicare Part B will be the primary coverage; the RIT coverage will be secondary. Please note that the Plan is administered as if the domestic partner has Medicare Part B, so it is critical to enroll to avoid gaps in coverage.

Medicare Part D-Prescription Drug Insurance

You do not need to enroll in any Part D prescription plan when you turn 65 as long as you are enrolled in creditable coverage from RIT. Creditable coverage is defined as coverage that is at least as good as standard Medicare prescription drug coverage. If you do not have creditable coverage, you will have a Part D late enrollment penalty from Medicare when you ultimately retire.

Creditable Coverage (RIT Rx Plan 1)

• Blue Point2 POS A
• Blue Point2 POS B
• Blue PPO

NOT Creditable Coverage

• Blue Point2 POS B No Drug (there is no prescription drug coverage)
• Blue Point2 POS D (RIT Rx Plan 2)

If you are enrolled in an RIT plan that does not have creditable coverage and you are not covered by other creditable coverage (e.g., spouse’s plan, Veteran’s coverage), you should consider enrolling in a Medicare Part D prescription drug plan.

There are no special rules for a domestic partner for prescription drug coverage; the rule is the same as explained above for employees.
 

When you first enroll in the RIT coverage, you will receive two identification cards from Excellus, both of which will have the employee’s name on them. If you need additional cards (for instance, if your child is attending college out of town), you can request them by contacting Excellus Customer Service. In an emergency, you are able to print a temporary identification card from the Excellus website. Your ID card is also available to be viewed on the Excellus app for your mobile device.

An out-of-pocket maximum provides protection for plan participants who have high medical and/or Rx expenses since it limits the total amount you will have to pay during the plan year.  The medical benefit and the prescription drug benefit each have a separate out-of-pocket maximum.  This means that medical expenses count only toward the medical plan out-of-pocket maximum, while prescription drug expenses count only toward the prescription drug out-of-pocket maximum.  And in both cases, only covered plan expenses count toward the out-of-pocket maximums; non-covered expenses do not count.  You will find the amounts listed in the Medical Benefits Comparison Book. Once you reach your medical out-of-pocket maximum, the medical plan will cover you in full at 100% for your eligible plan expenses for the remainder of the plan year.

As an RIT employee, you can benefit from RIT’s strategic alliance with Rochester Regional Health in several ways.  You will find information below about how to take advantage of the resources provided by RIT’s official affiliated clinical partner.  

Rochester Regional Health (RRH) Copay Option

Under the “RRH Copay Option” within our point of service (POS) medical plans, there are lower copays when you obtain the following medical services from RRH providers:

• office visit to primary care physician (PCP)
• office visit to specialists
• emergency room visits  

For POS A only, the RRH Copay Option also applies to Inpatient Hospitalization and Outpatient Services.  

Please note that the lower copays do not apply to tests, treatments or any other services not listed above (e.g., allergy shots, chiropractic services, physical therapy, x-rays, etc.).  These lower copays are outlined in each applicable section of the Medical Benefits Comparison Book.  

If you use an RRH provider and believe you are not being charged the proper copay, you can request that they verify the copay with Excellus. 

It can be challenging to find a primary care physician in the area who is accepting new patients, and this is equally true for some specialties. To help employees and pre-Medicare retirees locate a physician within the RRH network, use the Find a Doctor search tool (www.rochesterregional.org/physician-directory).

In addition, we post an updated list of participating providers on the HR website (Health Care section) that RRH provides to RIT. You can use this list to help you find RRH participating physicians and/or identify whether your provider is affiliated with the RRH network. The list includes the provider’s name, address, phone number and specialty. Since the list is quite lengthy, we recommend that you search for any of the fields (name, specialty, etc.) instead of printing the entire list. To search, simply hold down the CTRL key (the ⌘ Command key for Macs) and press the F key, then enter the text you are searching for and click Next.

Important Note: Since participating physicians can change from time to time, before scheduling an appointment with a provider from this list, you should verify that they still participate in the RRH network.

If you have any questions about searching for a provider, you can call the RRH referral help line at (585) 922-7480/V.

The Rochester Regional Health Family Medicine practice opened on the RIT campus in fall 2015. The convenient practice offers a wide range of primary care services and you can designate the practice physician, Dr. Eric Wilcox, as your primary care physician if you choose. Participants in RIT’s pre-Medicare point of service plans (POS) medical plans pay a lower copay for an office visit at the practice than at other participating providers. Good News: they have same day appointments available for RIT employees covered by this Plan, even if the RRH physician is not your primary care physician (PCP).

The plan does not provide coverage for the following:

• Any service or supply that is not specifically included as a covered service in the plan, even if it is prescribed, provided, recommended, approved or referred by a health care provider, except as deemed medically appropriate by Excellus BlueCross BlueShield.
• Any service or supply that is in excess of a limit specified in the plan.
• Any service or supply that is incurred prior to the covered person’s coverage under the plan, or after the covered person’s plan coverage terminates.
• Any claim submitted past the claim-filing deadline, generally within 12 months following the date the service was rendered.
• Any service or supply that is not prescribed, recommended and approved by a health care provider.
• Treatment that is not medically necessary, as determined by Excellus BlueCross BlueShield.
• Services or supplies that are experimental or investigational, as determined by Excellus BlueCross BlueShield.
• Any portion of a charge for a service or supply that exceeds the allowable expense for such service or supply.
• Any service or supply that is normally provided without charge, or for which a charge is made solely because the plan would cover such service or supply, or which the patient is not legally obligated to pay.
• Any service or supply available under any government program unless required by state or federal law. When a covered person is eligible for Medicare, benefits under the plan will be reduced by the amount Medicare would have paid for the services; except as required by law, this reduction is made even if the covered person fails to enroll in Medicare, does not pay the charges for Medicare or receives services at a facility that cannot bill Medicare. This exclusion does not apply if the covered person is entitled to Medicare benefits by reason of age, disability or end-stage renal disease, is in current employment status and the plan is required by law to pay its benefit before Medicare.
• Any service or supply provided by a hospital or other institution which is owned, operated or maintained by the U.S. Veteran’s Administration, federal, state or local government, unless the hospital or institution is a participating provider or the care consisted of emergency care covered under the plan.
• Any service or supply provided by a person or entity acting outside the scope of his, her or its license, or by an unlicensed provider.
• Services or supplies that a covered person’s employer is required to provide by federal state or local law, including services or supplies for which coverage is available under a Workers Compensation arrangement.
• Any expense for conditions or services that are reimbursed by a third party, including no-fault automobile insurance.
• Any expense for services or care related to any military service-connected disability or condition, if the Veterans Administration (VA) has the responsibility to provide the service or care.
• Any service or care to the extent covered under any other health benefits contract, program or plan.
• Certification examinations, including but not limited to those required for school, employment, insurance, marriage, licensing, travel, camp, sport or adoption.
• Cosmetic services that are primarily intended to improve appearance and not medically necessary, as determined by Excellus BlueCross BlueShield.
• Court-ordered services, including evaluation, testing and/or treatment, medical reports not related to treatment or prepared in connection with litigation, or that is required by a court as a condition of parole or probation.
• Custodial care primarily for the purpose of meeting personal needs, including activities of daily living such as help in transferring, bathing, dressing, eating, toileting and such other related activities; or therapy that is not expected to improve the covered person’s condition, as determined by Excellus BlueCross BlueShield.
• Dental care, except for: medical treatment that is directly related to an injury or accident involving the jaw or other bone structures adjoining the teeth, as approved by Excellus BlueCross BlueShield’s medical director; treatment of a congenital anomaly or disease that was evident at birth and caused by a medical condition that was present at birth; services determined as medically necessary by Excellus BlueCross BlueShield for treatment of cleft palate and ectodermal dysplasia; and in rare situations when more complex anesthesia than can be delivered in a dental office setting is determined to be medically appropriate under Excellus’ medical policy, coverage for ambulatory surgery unit and anesthesia.
• Any service or care related to medical supplies (such as bandages, surgical gloves and  compression stockings); disposable supplies (such as diapers, sponges, syringes, incontinence pads); wigs, hair prosthetics or hair implants; and the purchase or rental of household fixtures.
• Reversal of elective sterilization.
• Hypnosis/biofeedback.
• Nutritional therapy, unless it is determined as medically necessary by Excellus BlueCross BlueShield.
• Personal comfort services such as radio, telephone, television, or beauty/barber services.
• Prescription drugs, over-the-counter (nonprescription) drugs, or injections, except for prescription drugs and/or injections administered in the course of a covered outpatient or inpatient treatment in a facility or health care provider’s office, or through home health care benefits, or as required to be covered by medical plans under Federal law.
• Private duty nursing services, even if ordered by a health care provider.
• Prohibited referral, including coverage for any pharmacy, clinical laboratory, radiation therapy, physical therapy, x-ray or imaging services that were provided pursuant to a referral prohibited by the New York Public Health Law.
• Reproductive procedures in connection with in vitro fertilization, gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), cloning, sperm banking and donor fees associated with artificial insemination or other procedures, or other procedures excluded by law.
• Routine care of the feet, including but not limited to corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain, toenails or symptomatic complaints of the feet.
• Self-help diagnosis, training and treatment for recreational, educational vocational or employment purposes.
• Services that should have been covered under a hospice care program related to terminal illness.
• Miscellaneous charges for telephone consultations, missed appointments, new patient processing, interest, copies of provider records, completion of claim forms, late charges or extra day charges incurred upon discharge from a facility because the covered person did not leave the facility before the facility’s discharge time.
• Smoking cessation programs, except for the Quit for Life program offered through Excellus BlueCross BlueShield.
• Social counseling and family, marital, religious, sex or other therapy, except as otherwise specified as covered under the plan.
• Transsexual surgery and related services designated to alter the physical characteristics of biologically determined gender to those of another gender, unless determined as medically necessary by Excellus BlueCross BlueShield.
• Vision therapy, vision training and orthoptics.
• Weight loss programs, or services in connection with weight reduction or dietary control, including but not limited to laboratory services, gastric stapling, gastric by-pass, gastric bubble or other surgery for treatment of obesity, unless determined to be medically necessary by Excellus BlueCross BlueShield.

An out-of-pocket maximum provides good protection for plan participants who have high medical and/or Rx expenses since it limits the total amount you will have to pay during the plan year. The medical benefit and the prescription drug benefit each have a separate out-of-pocket maximum. This means that medical expenses count only toward the medical plan out-of-pocket maximum, while prescription drug expenses count only toward the prescription drug out-of-pocket maximum. And in both cases, only covered plan expenses count toward the out-of-pocket maximums; non-covered expenses do not count. You will find the amounts listed in the Medical Benefits Comparison Book. Once you reach your Rx out-of-pocket maximum, the Rx plan will cover you in full at 100% for your eligible plan expenses for the remainder of the plan year.

When you first enroll in the RIT coverage, you will receive two prescription drug identification cards from OptumRx, both of which will have the employee’s name on them. If you need additional cards (for instance, if your child is attending college out of town), you can request them by calling OptumRx Member Services. In an emergency, you are able to print a temporary identification card from the OptumRx website. Your ID card is also available to be viewed on the OptumRx app for your mobile device. It is important to remember to use your prescription drug ID card at the pharmacy, rather than your medical ID card. Your ID card is also available to be viewed on the OptumRx app for your mobile device.

OptumRx has contracted with a broad national network of retail pharmacies. This network includes thousands of pharmacies throughout the United States, including nearly all major retail pharmacy chains, such as CVS and Rite Aid, certain stores containing pharmacies such as Wegmans, Target, Tops, and Wal-Mart, and most smaller, independent pharmacies, including nearly all in the Rochester area. Retail pharmacies in the OptumRx network are referred to as “participating pharmacies.” To locate a participating pharmacy close to your home or other location, you can call OptumRx Member Services or check OptumRx website at www.optumrx.com.

Wegmans Pharmacies are designated as the “preferred pharmacy” under the plan.  Wegmans offers the convenience of a local pharmacy paired with the preferred pricing typically available only at a mail pharmacy. Wegmans also has a free home shipping option available.  

Because of this special designation, your copay is lower when you purchase your medications at Wegmans than at other retail pharmacies.  You are also able to purchase up to a 90-day supply of your medications at Wegmans, but only up to a 30-day supply at other retail pharmacies.  Your copay for a 90-day supply at Wegmans is equal to your copay at the mail pharmacy, and lower than the total of three 30-day copays that you would pay at another participating retail pharmacy.  You may choose to purchase 30-day supplies at Wegmans and your copay will not increase after 3 fills; at other retail pharmacies, your copay for a maintenance medication (those drugs you take for an ongoing medical condition) will increase significantly after 3 fills.  And RIT’s plan cost will be equivalent overall when you purchase your medications at Wegmans compared with the mail pharmacy and significantly lower than at other retail pharmacies, which will help keep the plan affordable in the future.  Refer to the Plan Design section for details.  

Please note if you are in Rx Plan 2 and have not yet met your annual deductible, you will pay RIT’s applicable contracted price at a retail pharmacy, including Wegmans.  In this situation, you may want to compare the pricing since the OptumRx contracting varies among retail pharmacies. 

When your prescription is filled at a nonparticipating retail pharmacy, your copays are as indicated in the copay charts, plus you will pay any cost difference between the nonparticipating pharmacy’s prescription price and OptumRx’s discounted network prescription price. You will be required to pay the full cost of the prescription at the time you make your purchase; you must then submit a paper claim to OptumRx to receive reimbursement from the plan. The reimbursement process is described in the section “Using a Reimbursement Form.”

For maintenance medications (those prescriptions you take on an ongoing basis), OptumRx’s mail pharmacy offers the convenience of home delivery. Your initial prescription will be delivered within 10 to 14 days of receipt. Refills can be ordered online at www.optumRx.com and are typically delivered within seven to 10 days. The mail pharmacy has registered pharmacists available to answer questions about your medication or reactions 24 hours a day, seven days a week.

See the section “Prescription Drug Claims and Payment of Benefits” for detailed instructions on using OptumRx’s mail pharmacy. On rare occasions, a particular drug will not be available through the mail pharmacy. In this situation, you will need to fill your prescription at a participating retail pharmacy and pay the applicable retail pharmacy copay.

Please be sure that your physician provides a prescription for a 90-day supply when you are ordering from the mail pharmacy. The mail copay is based upon a 90-day supply, but if your prescription is written for a lesser supply, the same mail copay will apply.

Except as specified in the section “Exclusions and Benefit Limitations,” the prescription drug plan provides coverage for Federal legend drugs, which are drug products bearing the legend “Caution: Federal law prohibits dispensing without a prescription.” The prescription drug plan also covers certain prescription supplies and some compound medications which contain at least one Federal legend drug in a therapeutic amount. Contraceptives are covered as required by Federal law, and coverage details can be found in the Medical Benefits Comparison Book.

In order for a prescription to be covered by the plan, the prescribed item must meet the following requirements:

• It must be prescribed by a licensed physician.
• It must be approved by the Federal Food and Drug Administration (FDA).
• It must be dispensed by a pharmacy.
• It must meet the plan’s special requirements for certain drugs, and
• It must not be listed under “Exclusions and Benefit Limitations” in this summary.

Prescription drugs covered by the plan are classified as either generic or brand name drugs. Generic drugs are sometimes referred to as Tier 1 drugs. Brand name drugs are also considered either preferred or non- preferred. You may sometimes see preferred brand name drugs referred to as formulary or Tier 2 drugs. Non- preferred brand name drugs may be referred to as non-formulary or Tier 3 drugs. In summary, here are the tiers and which type of drugs fall into each category:

New drugs, like many other new products, are developed under patent protection. The patent protects the investment in the drug’s development by giving the manufacturer the exclusive right to sell the brand name drug while the patent is in effect. When patents or other periods of exclusivity on brand name drugs expire, pharmaceutical manufacturers can apply to the FDA to sell generic versions.

Generic drugs must meet strict FDA requirements for safety and effectiveness. The proposed generic equivalent must have an FDA-approved brand name drug that is the “same” in terms of:

• Active ingredient(s)
• Labeled strength, and labeling information
• Dosage form, such as tablets, patches and liquids
• Administration – for example, swallowed as a pill or given as an injection
• Bioequivalence – performs in the same manner as the brand name drug
• Quality, purity and stability under extremes of heat and humidity

Generic drugs generally cost less than brand name drugs. They often have a different appearance (e.g. color, shape) and different inactive ingredients from their brand name counterparts for ease in identification, but this does not impact their therapeutic performance.

Brand name drugs are medications and supplies requiring a prescription which are distributed under a trademarked name by the pharmaceutical manufacturer whose new drug application was approved by the FDA.

Preferred and Non-Preferred Brand Name Drugs

For the treatment of many conditions, there are several drugs available, both brand name and generic. OptumRx has a list of preferred drugs, called a “formulary.” Medications on the formulary are evaluated for safety and effectiveness by an independent Pharmacy and Therapeutics Committee consisting of practicing physicians and clinical pharmacists who are not employed by OptumRx. Formulary medications are selected based on their safety and effectiveness, along with the opportunity for cost savings.

The formulary is updated quarterly. New drugs are added, and sometimes a drug can change categories, for example, from preferred to non-preferred. A current list of preferred drugs is available on OptumRx’s website or by calling their Member Services telephone number.

Brand name drugs that are not on the formulary are considered non-preferred. Unless specifically excluded by the plan (see “Exclusions” section of this summary), these drugs are covered by the prescription drug plan, but you pay a higher copayment than for generic or preferred brand name drugs.

If you are prescribed a specialty medication, you generally must fill it with OptumRx Specialty Pharmacy in order to have coverage. There are a few limited situations in which an exception may be granted in advance by OptumRx and the medication may be purchased at a participating retail pharmacy. Please call OptumRx Customer Service at the dedicated Rochester Institute of Technology toll-free member phone number 1-855-209-1300 (TTY: 711) or visit www.optumrx.com for more information.

A specialty medication is an injectable, oral or inhaled medication, typically used to care for certain rare and complex conditions, which:

• May require ongoing clinical oversight and additional education for best management;
• Has unique storage or shipping requirements;
• May not be available at retail pharmacies.

Examples of conditions that may require specialty medications are multiple sclerosis, rheumatoid arthritis, cancer, transplants and hepatitis.

Specialty medications are typically high priced, costing more than $1,000 for a 30-day supply. They are complex, meaning that the drug imitates compounds found in the body and is part of a specialty drug class. And they are high-touch because they have special shipping or handling requirements, such as refrigeration,
and need a physician or pharmacist to measure how well it works for you.

OptumRx Specialty Pharmacy offers support to help you manage your condition. Take advantage of personalized patient support from knowledgeable pharmacists and nurses who specialize in your condition at no additional cost to you. In addition, you will receive:

• 24/7 access to pharmacists
• Support through clinical and adherence programs
• Any medication-related supplies at no additional cost
• Proactive refill reminders
• Timely delivery and shipping in confidential packaging
• Free video consultations with an OptumRx clinician
• Free videos designed to help provide patients with tips along the way in regard to select specialty conditions.

Your cost for a prescription will be based on a tiered copay structure, and will differ depending on:

• The drug’s tier – generic, preferred (formulary), or non-preferred (non-formulary);
• Whether you choose (or your doctor prescribes) a brand name drug when a generic is available;
• Whether you purchase your drug at Wegmans Pharmacy (the plan’s preferred pharmacy), a different participating retail pharmacy or through the PBM’s mail pharmacy;
• Whether you purchase your drug from a participating or non-participating retail pharmacy; and
• Whether your prescription is subject to any special limitations or procedures.

Your copay will never exceed the full price of the medication.

If you take maintenance medications (those you take for an ongoing medical condition), there is a significant financial incentive to purchase them at Wegmans, our preferred retail pharmacy, or through OptumRx’s mail pharmacy.

On the 4th fill (original plus 3 refills) of a maintenance prescription filled at a retail pharmacy (other than Wegmans), your copay for a 30-day supply will be equal to the copay for a 90-day supply of the medication if you ordered it from OptumRx’s mail pharmacy or purchased it at Wegmans. This will result in greatly increased copays if you continue to fill your maintenance medications at a retail pharmacy other than Wegmans beyond the 3rd fill.

This higher copay does not apply to acute care drugs such as antibiotics – your copays for such medications purchased at a retail pharmacy will not change. Also, certain medications are not available from OptumRx’s mail pharmacy, such as certain controlled substances; the higher copay will also not apply in these situations. The rest of the cost of your drugs will be paid by the prescription drug plan, except as described below.

In cases of selected brand name drugs where an FDA-approved generic is available, your benefit will be based on the generic drug’s cost. If you or your doctor chooses the brand name drug, regardless of the reason, you will be required to pay the difference in cost between the brand-name drug and the generic, in addition to the applicable copay.

If you purchase your medication at a nonparticipating pharmacy, you will be required to pay the full cost at the pharmacy. You can then file a claim for reimbursement (described in the section “Claims and Payment of Benefits”) with OptumRx. Your cost will be the retail copay you would have paid at a participating pharmacy (other than Wegmans), plus any additional amount charged by the nonparticipating pharmacy above the amount the drug would have cost at a participating retail pharmacy.

Copay Information Rx Plan 1 (included with medical plans POS A, POS B, Blue PPO)

Under Rx Plan 1, you have “first dollar coverage,” meaning there is no annual deductible to meet before the plan begins to pay benefits.

Copay Information Rx Plan 2 (included with medical plan POS D)

Under Rx Plan 2, there is a $1,250 annual per person annual deductible. This means that, until you meet your deductible, you will pay the full cost of the medication; once you meet your deductible, you will pay copays for your medications for the remainder of the plan year. You should show your card when you purchase prescriptions so you receive any negotiated discounts and so OptumRx can track the $1,250 deductible.

Important Notes for Rx Plan 1 and Rx Plan 2

1. if you fill your prescription at a non-participating pharmacy, you will be required to pay the pharmacy’s full charge for your medication at the time you purchase it; you can submit a claim for reimbursement, but may be responsible for more than the copays listed above.
2. applies to maintenance medications only
3. the copays shown for OptumRx’s Mail pharmacy apply even if your prescription is written for less than a 90-day supply. To get the best advantage of this program, be sure your physician writes the prescription for a 90-day supply

Exclusions and Benefit Limitations

The following are not covered by the prescription drug plan. Some of them may be covered by your medical plan.

• Medications and supplies which are specifically excluded from coverage by the plan’s Pharmacy Benefit Manager.
• Drugs subject to preferred drug step therapy where the requirements have not been satisfied.
• For drugs subject to quantity limits, any amount that exceeds the stated quantity limit.
• For any drug, a quantity in excess of a 90-day supply.
• A quantity greater than a 30-day supply when filled at a retail pharmacy other than Wegmans.
• Specialty medications which are not filled at the plan’s designated specialty pharmacy.
• Medications and supplies which are covered by your medical plan.
• Excess charges by a non-participating pharmacy beyond the allowed amount that would have been paid to a participating pharmacy.
• Medications ordered or purchased prior to the covered person’s coverage under the plan, or after the covered person’s coverage terminates.
• Non-Federal Legend and Over the Counter Medications (including drugs for which a prescription was formerly required, except if required to be covered under Federal law).
• Injectable drugs that are not self-administered.
• Biologicals (immunization agents and vaccines).
• Allergy serums.
• Blood or blood plasma products.
• Mifeprex.
• RU-486.
• Dental fluoride products.
• Ostomy supplies.
• Therapeutic devices or appliances.
• Drugs to promote or stimulate hair growth or for cosmetic purposes.
• Drugs labeled "Caution-limited by Federal law to investigational use", or experimental drugs, even though a charge is made to the individual.
• Medication for which the cost is recoverable under any Workers' Compensation or Occupational Disease Law or any State or Governmental Agency, or medication furnished by any other Drug or Medical Service for which no charge is made to the member.
• 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, skilled nursing 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.
• Implantable time-released medications.
• Nutritional supplements, except for those included on OptumRx’s list of approved nutritional products intended for treatment of specific metabolic conditions, and which are purchased through a pharmacy.
• Unit doses of medication.
• 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.
• Drugs requiring prior authorization for which a prior authorization was not obtained.
• Drugs which are new to market for which a coverage determination has not yet been made.
• Items not specifically described as covered by the Plan.
• Claims submitted past the 12-month claim filing deadline.

Prior Authorization

For certain medications, the prescription drug plan requires prior authorization by OptumRx before benefits will be paid. The list of medications that require prior authorization will change from time to time, and drugs that do not require prior authorization may require it in the future. In order to determine whether a specific medication has a prior authorization requirement, you can search by the name of the drug on OptumRx’s website, www.optumRx.com, or call OptumRx Member Services. Prior authorizations are typically approved for a one- year period, unless otherwise noted.

To obtain a prior authorization, your physician must complete a OptumRx prior authorization form, which is available on OptumRx’s website, www.optumRx.com or call OptumRx Member Services.

Preferred Drug Step Therapy

One of the features of the Plan is called “preferred drug step therapy (PDST).” The purpose of PDST is to ensure that a person has tried a particular preferred drug or drugs in a specific therapeutic category before the Plan will cover a more expensive drug in that category. It is often common for physicians to prescribe brand name drugs with which they are familiar, but that may not always be the most effective and cost effective choice of therapy. Only selected categories that have clinically accepted substitutes, determined by OptumRx clinicians, are part of the PDST program.

When your physician prescribes a brand name drug that is part of the PDST program, the Plan will only cover it if you have tried the clinically accepted alternative drug(s) and either:

• they have not worked for you, or
• there is a medical reason why you are unable to take the drug, such as an allergy to one of the ingredients.

If this information is in OptumRx’s records, the brand name drug will be approved without any intervention needed by your physician. If this information is not in OptumRx’s records (for instance, if you tried the other medication before you were covered by the Plan), the drug will not be covered without a coverage review and approval by OptumRx.

If your physician believes that you should use a medication that is not preferred, you or your physician can request a review for coverage. Your physician can call OptumRx toll-free at 800-626-0072, 8:00 a.m. to 10:00 p.m., Eastern Time.

If you obtain approval before filling your prescription, you will pay your applicable copay. If you obtain approval after filling your prescription, you will pay for the full cost of the medication at the pharmacy but will be able to be reimbursed for the covered cost of the medication minus the copay. In this case, you will need to file a manual claim in order to be reimbursed.

Please note that new categories may be added to the PDST program over time, and preferred drugs may change from time to time as new drugs become available, and as brand name drugs lose their patent protection and are available as generics.

Quantity Limits

For certain medications, there are limits on the quantity that will be covered. The list of medications that have quantity limits will change from time to time, and drugs that do not have quantity limits may require them in the future. In order to determine whether a specific medication has a quantity limit, you can search by the name of the drug on OptumRx’s website, www.optumRx.com or call OptumRx Member Services.

Refill Limits

For refills from a retail pharmacy or specialty pharmacy 75% of the prior order of the medication must have been used before the prescription can be refilled; for the OptumRx mail pharmacy, 60% of the prior order of the medication must have been used before the prescription can be refilled. If you will be traveling and need to refill your prescription early, let the pharmacist know and request that he or she call OptumRx for a “vacation override.”

Drug Utilization Review

Participating network pharmacies are given information by OptumRx that helps protect patients from interactions between current medications and a new drug being prescribed or other adverse reactions such as previously identified allergies. The pharmacist is alerted to a potential reaction at the time the new drug is entered into OptumRx’s system at the point of purchase. The pharmacist can then discuss the situation with patient, and/or the patient’s physician. This safety feature, which is also available to OptumRx mail pharmacy pharmacists, is especially important if more than one physician is prescribing medications for an individual, or if prescriptions are filled at different pharmacies.

Excluded Medications and Supplies

The Pharmacy Benefit Manager, OptumRx, has the authority to exclude specific medications and supplies from coverage. If an item is on this list of exclusions, the plan will not pay anything toward the cost, and you will be required to pay the full cost at the pharmacy. Any item on the excluded list has available substitutes which you can request your physician to prescribe. If your physician believes there is a medical necessity for you to continue with the medication that has become excluded from coverage, your physician should initiate a coverage review by contacting the coverage review team at OptumRx.

At a Participating Retail Pharmacy

Present your prescription drug (OptumRx) ID card when you purchase your medication at a retail pharmacy that is part of OptumRx’s retail pharmacy network. You will be charged the applicable copay and any other applicable charges. The remainder of the cost will be paid to the retail pharmacy by the prescription drug plan. You do not need to file any claims. Remember you are limited to a 30-day supply except at a Wegmans Pharmacy, where you can fill up to a 90-day supply at one time.

Using the OptumRx Mail Pharmacy

Let your doctor know that you have a mail-order prescription drug benefit and that you would like to have the maximum supply of medication (usually 90 days) plus refills for up to one year. You may mail your prescription(s) in OptumRx mail pharmacy envelopes or ask your doctor to call 1-855-209-1300/V for instructions on how to fax the prescription. If your order is faxed, your doctor must have the member number from your OptumRx ID card.

When your doctor prescribes a new medication, it is recommended that you have your doctor write two prescriptions: one for a 30-day supply and one for a 90-day supply with refills. You should first fill the 30-day supply prescription at a retail pharmacy and try the new drug to ensure you will not experience any adverse reaction and that the drug will be effective for you. Once you determine that the new drug will work for you, you can fill the 90-day prescription through OptumRx mail pharmacy, if you choose, but you have the option to fill it at a Wegmans pharmacy if you prefer for the same copay. Note: do not submit 30-day prescriptions to OptumRx mail pharmacy because you will be automatically charged the copay applicable to a 90-day supply.

You can pay your copays by check or credit card. If you send in the wrong copay and there is a balance due of less than $150, an invoice will be included with your prescription order. If you overpaid, your account will be credited. If you owe more than $150 on your account, your prescription order will not be shipped until payment is made; you will receive a phone call from OptumRx to let you know that this is the case. A way to avoid this situation is to have a credit card number on file with OptumRx. No more than $500 will be charged to a credit card at one time without your approval. If you have a Beneflex account, you can use the flex card as your credit card for prescription drug orders as long as you have a sufficient balance available. You can join the automatic payment program by calling 1-855-209-1300 or by enrolling online at www.optumrx.com.

To check on the status of an order, you may call OptumRx Member Services or visit www.optumrx.com. You can find out the date your prescription was received, the status of your order, the date your prescription was mailed to you, and other billing and timing data.

If you would like to order online, you can do this through OptumRx mail pharmacy. You can order online anytime, or call 1-855-209-1300 and use the automated telephone system. Or you can mail in your refill orders by using the mail-order envelope. If you order by phone or via OptumRx’s website, you will need to provide your member number, found on your OptumRx ID card, and the prescription number found on the medication container and the refill slip.

If you need to order mail-order envelopes or retail claim forms, you can do this online also. Or if you prefer, you can call OptumRx Member Services toll-free number to use the automated telephone system. The requested materials will be mailed to you right away.

Using a Reimbursement Form

If you fill your prescription at a non-participating pharmacy, or forget to bring your ID card to a participating retail pharmacy, you will be required to pay the pharmacy’s full charge for your medication at the time you purchase it. You may then submit a reimbursement form to OptumRx to obtain reimbursement of the amount that the prescription drug plan will pay. You can print the reimbursement form from OptumRx’s website, or can call Member Services to request a claim form be mailed to you. The receipt you received at the pharmacy must be attached to the claim form. Reimbursement forms must be submitted within 12 months following the date you purchased the medication.

Payments of Benefits

Other than claims submitted using reimbursement forms, benefits will be paid directly to the participating pharmacy dispensing the medication.  For claims submitted via reimbursement form, benefits will be paid to you by check from OptumRx. 

Coverage continuation for your eligible survivors is based on multiple factors and is described below.

Upon Your Death if You are Retired or an Employee or LTD Recipient Who is Eligible to Retire

If you are retired at the time of your death, RIT continues coverage for your pre-Medicare spouse/partner (who was your spouse or partner at the time of your retirement from RIT) and any eligible pre-Medicare child (who was your eligible child at the time of your retirement from RIT) at the appropriate level of coverage with the cost sharing rules in effect for retirees in your category. Coverage for your surviving spouse/partner will end if he/she becomes married/partnered. Coverage for your surviving child will end when he/she no longer meets the Plan’s eligibility requirements. When your spouse/partner and/or child becomes eligible for Medicare, coverage, they are no longer eligible to be covered by this Plan. They will need to enroll in medical and prescription drug coverage through a private Medicare Exchange, Via Benefits. Contact information for Via Benefits will be provided to you by RIT Human Resources, or is available on our website. But first, they will need to enroll in Medicare.

If you die while employed at RIT and are retirement-eligible at the time of your death, RIT continues coverage for your pre-Medicare spouse/partner (who was your spouse or partner at the time of your death) and any eligible pre-Medicare child (who was your eligible child at the time of your death) at the appropriate level of coverage with the cost sharing rules in effect for retirees in your category. Coverage for your surviving spouse/partner will end if he/she becomes married/partnered. Coverage for your surviving child will end when he/she no longer meets the Plan’s eligibility requirements. When your spouse/partner and/or child becomes eligible for Medicare, coverage, they are no longer eligible to be covered by this Plan. They will need to enroll in medical and prescription drug coverage through a private Medicare Exchange, Via Benefits. Contact information for Via Benefits will be provided to you by RIT Human Resources, or is available on our website. But first, they will need to enroll in Medicare.

If you die while on RIT long-term disability (LTD) and you were retirement-eligible at the time your LTD was effective, RIT continues coverage for your pre-Medicare spouse/partner (who was your spouse or partner at the time of your death) and any eligible pre-Medicare child (who was your eligible child at the time of your death) at the appropriate level of coverage with the cost sharing rules in effect for retirees in your category. Coverage for your surviving spouse/partner will end if he/she becomes married/partnered. Coverage for your surviving child
will end when he/she no longer meets the Plan’s eligibility requirements. When your spouse/partner and/or child becomes eligible for Medicare, coverage, they are no longer eligible to be covered by this Plan. They will need to enroll in medical and prescription drug coverage through a private Medicare Exchange, Via Benefits. Contact information for Via Benefits will be provided to you by RIT Human Resources, or is available on our website. But first, they will need to enroll in Medicare.

Upon Your Death On or After January 1, 2019 if You are Not Eligible to Retire

The following rules are in effect for the death of an individual who was not retirement eligible that occurs on or after January 1, 2019:

If you die while employed at RIT and are not retirement eligible at the time of your death, your eligible pre- Medicare family members will be offered continuation of coverage under COBRA. If COBRA is elected, RIT will subsidize the COBRA premium for the first six months so the survivor is paying the same amount the employee would have paid for the same level of coverage.

If you die while on RIT long-term disability (LTD) and were not retirement-eligible at the time your LTD was effective, your eligible pre-Medicare family members will be offered continuation of coverage under COBRA. If COBRA is elected, RIT will subsidize the COBRA premium for the first six months so the survivor is paying the
same amount the employee would have paid for the same level of coverage.

Refer to the section in this summary titled “When You are Eligible for COBRA.”

The following rules are in effect for the death of an individual who was not retirement eligible that occurred before January 1, 2019:

Upon the death of an employee or RIT long-term disability recipient who was not retirement eligible and would have been in cost sharing Group 2 at the time of death, RIT continues coverage for the pre-Medicare spouse/partner (who was the spouse or partner at the time of death) and any eligible pre-Medicare child (who was an eligible child at the time of death) at the appropriate level of coverage with the Group 2 cost sharing for retirees. Coverage for the surviving spouse/partner will end if he/she becomes married/partnered. Coverage for a surviving child will end when they no longer meet the Plan’s eligibility requirements. When the spouse/partner and/or child becomes eligible for Medicare, coverage, they are no longer eligible to be covered by this Plan. They will need to enroll in medical and prescription drug coverage through a private Medicare Exchange, Via Benefits. Contact information for Via Benefits will be provided to you by RIT Human Resources, or is available on our website. But first, they will need to enroll in Medicare.

Upon the death of an employee or RIT long-term disability recipient who was not retirement eligible and would have been in cost sharing Group 3 at the time of death, RIT continues coverage for the pre-Medicare spouse/partner (who was the spouse or partner at the time of your death) and any eligible pre-Medicare child (who was an eligible child at the time of death) at the appropriate level of coverage for up to three years following the death at the regular employee contribution amount. After three years, they can continue to participate by paying the full premium. Coverage for the surviving spouse/partner will end if he/she becomes married/partnered. Coverage for the surviving child will end when he/she no longer meets the Plan’s eligibility requirements. When the spouse/partner and/or child becomes eligible for Medicare, coverage, they are no longer eligible to be covered by this Plan. They will need to enroll in medical and prescription drug coverage through a private Medicare Exchange, Via Benefits. Contact information for Via Benefits will be provided to you by RIT Human Resources, or is available on our website. But first, they will need to enroll in Medicare.

RIT’s outside administrator, Lifetime Benefit Solutions (LBS), bills employees who are on an unpaid leave of absence or whose pay is too small to take payroll deductions, LTD recipients whose LTD payment is too small to take the deduction, and pre-Medicare retirees/spouses/partners/survivors, for the applicable contributions.

There is a grace period before coverage is cancelled for non-payment. If LBS does not receive the full premium amount by the last day of the second month, coverage will be cancelled as of the last day of the second month. For example:

The first time coverage is cancelled for non-payment, there is a three-month waiting period before you can re-enroll in coverage; coverage will not be retroactive. Before you can re-enroll, you must pay the outstanding balance owed as well as the premium for the first month’s coverage. Payment must be with a cashier’s or bank check, electronic funds transfer (EFT) from your bank account, money order, or credit card.

If coverage is cancelled again for non-payment, there is a six-month waiting period before you can re-enroll in coverage; coverage will not be retroactive. Before you can re-enroll, you must pay the outstanding balance owed as well as the premium for the first month’s coverage. Payment must be with a cashier’s or bank check, electronic funds transfer (EFT) from your bank account, money order, or credit card.
 

Your employee medical and prescription drug coverage under this plan ends the last day of the month in which

• Your employment ends*;
• You are an adjunct employee and you are not working for RIT;
• You are a less than 9-month employee and you are not working for RIT;
• Your employment ends under the RIT Severance Plan (coverage does not continue during the severance period, unless you elect coverage under COBRA);
• You retire from RIT and you (or your spouse/partner/child) are eligible for Medicare retiree coverage, the pre-Medicare coverage ends on the last day of the month in which you retire for the Medicare-eligible individual(s). Enrollment would then be under the private Medicare Exchange, Via Benefits (see information in this summary for Medicare-eligible individuals);
• Your long-term disability benefits end and you are not eligible to retire from RIT;
• You no longer meet the Plan’s eligibility requirements; this includes transfer to an employment category that is not eligible for coverage under the Plan;
• You stop making required contributions;
• You die; or
• RIT discontinues the Plan.

* Special Note for 9-month faculty:

• Coverage will end on June 30 for a faculty member on a 9-month contract, provided that the faculty member works until the end of the contract period, and the contract is not being renewed for the following academic year;
• Coverage for a faculty member on a 9-month contract will continue during the summer between the two academic years, provided that the contract is being renewed for the following academic year.

If you are retired, your medical and prescription drug coverage under this plan ends the last day of the month

• before Medicare coverage is effective. Medicare is generally effective the first day of the month in which you reach age 65, but if your birthday is on the first of the month, it will be the first of the prior month. When you become eligible for Medicare, you would be eligible for coverage under the private Medicare Exchange, Via Benefits (see information in this summary for Medicare-eligible individuals);
• you stop making required contributions;
• you die; or
• RIT discontinues the Plan.

If you are a long-term disability recipient under RIT’s LTD plan and your LTD effective date was before January 1, 2019, your medical and prescription drug coverage under this plan ends the earliest of

• the last day of the month before Medicare coverage is effective;
• the last day of the month in which your LTD benefits end and you are not retirement eligible;
• you stop making required contributions;
• you die; or
• RIT discontinues the Plan.

If you are a long-term disability recipient under RIT’s LTD plan and your LTD effective date was on or after
January 1, 2019, your medical and prescription drug coverage under this plan ends the earliest of

• the last day of the month that is two years from the date your LTD became effective;
• the last day of the month in which your LTD benefits end and you are not retirement eligible;
• last day of the month before your Medicare coverage is effective;
• you stop making required contributions;
• you die;
• RIT discontinues the Plan.

Generally, your dependent’s coverage ends when your coverage ends, except when you are retired or receiving LTD benefits and you or your spouse/partner/child becomes eligible for Medicare. The coverage rules for your Medicare-eligible spouse/partner/child are the same as for you as outlined above. However, a child’s coverage would also end on the last day of the month in which he or she no longer meets the Plan’s eligibility.

If you are a surviving spouse/partner/child, your medical and prescription drug coverage under this plan ends the earliest of

• the last day of the month before Medicare coverage is effective;
• you stop making required contributions;
• you remarry/re-partner (for the spouse/partner);
• you reach the age limit of the plan (for a child);
• you die;
• RIT discontinues the Plan.

If it is determined that you or an eligible family member has submitted a fraudulent claim or fraudulent proof of eligibility, or has intentionally misrepresented any facts under a medical, prescription drug, vision or dental plan, you and all your dependents will be permanently ineligible for coverage under the RIT Medical and Prescription Drug Plan, the RIT Retiree-Only Health Reimbursement Arrangement Plan, the RIT Vision Care Plan, and the RIT Dental Care Plan.

Coverage May Be Continued

In certain circumstances, your coverage and that of your dependents may be continued beyond the date it normally would end. Coverage may continue as shown below, provided you make any required premium contributions.

• For a Disabled Child - Coverage for an unmarried child who is physically or mentally incapable of self- support and who reached age 26 prior to 2019 may be continued beyond the age limit of the plan provided the disability occurred before that age and family coverage under this plan was in effect before the disability occurred. For a child reaching age 26 in 2019 or after, benefits will end the last day of the month in which the child reaches age 26.
• For a Personal Leave of Absence – Coverage may continue while on a personal leave of absence of up to four months. For personal leaves of absence beyond four months, coverage is not continued.
• For a Professional Leave of Absence - Coverage is continued for up to two years while on an approved professional leave of absence, including a sabbatical. For professional leaves of absence beyond two years, coverage is not continued.
   

Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), you have a right to apply for medical coverage with Rochester Institute of Technology (RIT). You should read this information even if you waive coverage.

If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in the RIT medical coverage if you or your dependents lose eligibility for the other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must contact RIT Human Resources and request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents in the RIT medical coverage. However, you must contact RIT Human Resources and request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

If you decline enrollment in RIT medical coverage for yourself or for an eligible dependent (including your spouse) while Medicaid coverage or coverage under a state children's health insurance program is in effect, you may be able to enroll yourself and your dependents in an RIT medical plan if you or your dependents lose eligibility for that other coverage. However, you must contact RIT Human Resources and request enrollment within 60 days after your or your dependents' coverage ends under Medicaid or a state children's health insurance program.

If you or your dependents (including your spouse) become eligible for a state premium assistance subsidy from Medicaid or through a state children's health insurance program with respect to coverage, you may be able to enroll yourself and your dependents in that plan. However, you must request enrollment within 60 days after your or your dependents' determination of eligibility for such assistance.

To request a special enrollment or obtain more information, feel free to contact the Human Resources Department.

Claims concerning eligibility, participation, contributions, or other aspects of the operation of the Plan should be in writing and directed to the Plan Administrator; this section does not apply to claims for benefits or services under the Plan because all claim decisions are made by the Plan’s third party administrator, Excellus BlueCross BlueShield, to whom RIT has delegated this responsibility. The Plan Administrator will generally notify you of its decision within 90 days after it receives your claim.

However, if the Plan Administrator determines that special circumstances require an extension of time to decide your claim, the Plan Administrator may obtain an additional 90 days to decide the claim. Before obtaining this extension, the Plan Administrator will notify you, in writing and before the end of the initial 90-day period, of the special circumstances requiring the extension and the date by which the Plan Administrator expects to render a decision.

If your claim is denied in whole or in part, the Plan Administrator will provide you with a written or electronic notice that explains the reason or reasons for the decision, including specific references to Plan provisions upon which the decision is based, a description of any additional material or information that might be helpful to decide the claim (including an explanation of why that information may be necessary), a description of the appeals procedures and applicable filing deadlines and your right to bring an action under Section 502(a) of ERISA.

If you disagree with the decision reached by the Plan Administrator, you may submit a written appeal to the Plan Administrator requesting a review of the decision. Your written appeal must be submitted within 60 days of receiving the Plan Administrator’s decision and should clearly state why you disagree with the Plan Administrator’s decision. You may submit written comments, documents, records and other information relating to the claim even if such information was not submitted in connection with the initial claim for benefits. Additionally, upon request and free of charge, you may have reasonable access to and copies of all documents, records and other information relevant to the claim.

The Plan Administrator will generally decide your appeal within 60 days after it is received. However, if the Plan Administrator determines that special circumstances require an extension of time to decide the claim, it may obtain an additional 60 days to decide the claim. Before obtaining this extension, the Plan Administrator will notify you, in writing and before the end of the initial 60-day period, of the special circumstances requiring
the extension and the date by which it expects to render a decision.

The Plan Administrator will provide you with written or electronic notice of its decision. In the case of an adverse decision, the notice will explain the reason or reasons for the decision, include specific references to Plan provisions upon which the decision is based, and indicate that you are entitled to, upon request and free of charge, reasonable access to and copies of documents, records, and other information relevant to the claim. Additionally, the notice will include a statement regarding your right to bring an action under Section 502(a) of ERISA. Generally, you must exhaust your internal administrative appeal rights before you can bring a legal action against the Plan. The Plan Administrator has full discretionary power to construe and interpret the Plan and its decisions are final and binding on all parties.