MINIMUM ESSENTIAL COVERAGE INSURANCE PLAN ENROLLMENT GUIDE

Transcription

1 MINIMUM ESSENTIAL COVERAGE INSURANCE PLAN ENROLLMENT GUIDE

2 YOUR MINIMUM ESSENTIAL COVERAGE Having health insurance is important. To provide the best value, considering coverage, service and price, Hallmark, Inc, is pleased to offer a Minimum Essential Coverage (MEC) as a standalone benefit, or in conjunction with a group hospital indemnity insurance plan. This plan is available to you, your spouse and children. This program is made available to all part-time mass service operations and corporate stores active employees working the minimum number of hours per week required for eligibility (as determined by the Employer) and their eligible Dependents. This program is administered by AmWINS Group Benefits, Inc. (AGBI), an AmWINS Group Company. AGBI is known for its high customer service standards and excellence in administration. The MEC can be purchased on its own or with the group hospital indemnity insurance plan to offer employees coverage for both preventative care services as well as healthcare related services. By enrolling in a MEC plan, you may be able to avoid a tax penalty for not purchasing health insuranceas required by the Affordable Care Act. HOW TO ENROLL Review the information in this booklet. Review your monthly payment on the Payment Summary pages. Complete the enrollment through the informational website provided. Please note: Any premiums you owe will be deducted from the bank account you provide during enrollment. If you have any questions, please contact: AmWINS Group Benefits Contact Center Toll-free at Monday through Friday, 8:00 AM to 8:00 PM EST 1 amwins.com

3 MEC INSURANCE PLAN SUMMARY The summary of program benefits described herein is for illustrative purposes only, and does not replace the legal documents governing the Plans. In case of differences or errors, the legal documents govern. Please refer to your employer s Summary Plan Description (SPD). SCHEDULE OF BENEFITS REFERENCE TABLE The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA) have designated the services listed below as preventive benefits and available with no cost-sharing when provided by an in-network provider for members of nongrandfathered group health plans. This information is intended as a reference tool for your convenience and is not a guarantee of payment. This list of services included as Standard Preventive Care may change from time to time depending upon government guidelines. A current listing of required preventive care can be accessed at: IMPORTANT INFORMATION: Services must be billed with a primary diagnosis of preventive, screening, counseling, or wellness, if applicable, to qualify and other restrictions may apply. Services otherwise deemed Preventive received inpatient or in an emergency room or that include additional procedures or diagnostic services may not be covered. Grade A and B Recommendations of U.S. Preventive Services Task Force (USPSTF) currently effective unless otherwise noted Abdominal Aortic Aneurysm Screening (one time screening for abdominal aortic aneurysm by ultrasonography in men ages who have ever smoked) Alcohol Misuse Screening and Counseling (Screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse) Aspirin to Prevent Cardiovascular Disease in Men and Women (initiating low-dose aspirin use for the primary prevention of cardiovascular disease and colorectal cancer in adults aged 50 to 59 years who have a 10% or greater 10-year cardiovascular risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years) Bacteriuria Screening (screening for asymptomatic bacteriuria with urine culture for pregnant women at weeks' gestation or at the first prenatal visit, if later) Blood pressure Screening (in adults 18 and older. Also recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.) BRCA Risk Assessment and Genetic Counseling/testing (primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing Breast Cancer Screening [mammography] (for women aged 40 or over every 1-2 years with or without clinical breast examination) Breast Cancer Preventive Medications (Clinicians engaged in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk reducing medications such as tamoxifen and raloxifene) Frequency / Comments Over-the-Counter (OTC) Aspirin (81 mg) is available only with a prescription. Part of wellness office visit. 2 amwins.com

4 Breast Feeding Counseling (interventions during pregnancy and after birth to promote and support breastfeeding) Cervical Cancer Screening(in women ages 21 to 65 yrs with cytology (pap smear) every 3 yrs or, for women ages yrs who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 yrs) Chlamydial Infection Screening Women (for all sexually active non-pregnant and pregnant young women ages 24 and younger and for older, non-pregnant and pregnant women who are at increased risk) Cholesterol Abnormalities Screening *men 35 and older (for lipid disorders) *men younger than 35 (for ages for lipid disorders if they are at increased risk for coronary heart disease) *women 20 and older (for lipid disorders if they are at increased risk for coronary heart disease) Colorectal cancer screening (screening for colorectal cancer starting at age 50 years and continuing until age 75 years) Depression Screening *adults, including pregnant and postpartum women (screening for depression with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up) *adolescents (screening yr olds for major depressive disorder when systems are in place to ensure accurate diagnosis, effective treatment and appropriate follow-up) Diabetes Screening (screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Referral for patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.) Fall Prevention (exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 yrs and older who are at increased risk for falls.) Fluoride Application (application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption in primary care practices. oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient.) Folic Acid Supplementation (for all women planning or capable of pregnancy to take a daily supplement containing mg [ mcg] of folic acid) Gonorrhea screening: women (screening for gonorrhea in sexually active women age 24 years or younger and in older women who are at increased risk for infection.) Gonorrhea prophylactic medication: *newborns (ocular topical medication for all newborns against gonococcal ophthalmia neonatorum) Healthy Diet and Physical Counseling to Prevent Cardiovascular Disease: adults with risk factors (intensive behavioral dietary counseling interventions to promote a healthful diet and physical activity for adults who are overweight or obese and have additional cardiovascular disease risk factors) Hearing loss Screening: Newborns Hemoglobinopathies Screening (for sickle cell disease in newborns) Hepatitis B Screening *Nonpregnant adolescents and adults (screening for those at high risk for *Pregnant women (screening at first prenatal visit) Hepatitis C Screening infection.) OTC only with script Over-the-Counter (OTC) folic acid supplements are available only with a prescription. This medication is generally administered to newborn at birth facility. Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth. Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth. 3 amwins.com

5 (Screen for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends one time screening for HCV infection in adults born between 1945 and 1965) HIV Screening *Nonpregnant adolescents and adults (screening for on all adolescents ages 15 to 65 years, younger adolescents and older adults who are at increased risk, and all pregnant women including those who present in labor who are untested and whose HIV status is unknown) *Pregnant women (screening for pregnant women at their first prenatal visit) Hypothyroidism Screening (in newborns) Intimate Partner Violence Screening (screening women of childbearing age for intimate partner violence, such as domestic violence, and providing or referring women who screen positive to intervention services.) Iron Deficiency Anemia Screening (in symptomatic pregnant women) Iron Supplementation in Children (routine iron supplementation for asymptomatic children 6-12 mo. of age who are at increased risk for iron deficiency anemia) Lung Cancer Screening (annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.) Obesity Screening and Counseling: *adults (screening for adults; clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m 2 or higher to intensive, multi-component behavioral interventions.) *children (screening for children aged 6 yrs and older for obesity and offer/refer to comprehensive, intensive behavioral interventions to promote improvement in weight status) Osteoporosis (bone density) Screening (screening for women aged 65 and older for osteoporosis and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors) Phenylketonuria (PKU) Screening (in newborns) Rh Incompatibility Screening: *first pregnancy visit (recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care) *24.28 weeks gestation (recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at weeks gestation unless the biological father is known to be Rh (D)-negative) Sexually Transmitted Infections Counseling (recommends high-intensity behavioral counseling to prevent STIs for all active adolescents and for adults at increased risk for STIs) Skin Cancer Behavioral Counseling (counseling children, adolescents, and young adults aged 10 to 24 yrs who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer Statin preventive medication (adults ages years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater) Syphilis Screening *non pregnant persons (screen persons at increased risk for syphilis infection) *pregnant women (screen all for syphilis infection) Tobacco Use Counseling and Interventions: Adults *nonpregnant adults (ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA) approved pharmacotherapy for cessation to adults who use tobacco.) *pregnant women (ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco.) Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth. Over-the-Counter (OTC) iron supplements are available only with a prescription. Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth. Initial testing is part of the obstetric panel. Considered part of wellness visit. 4 amwins.com

6 Tobacco Use Counseling Adolescents (Provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents) Tuberculosis Screening: Adults (screening for latent tuberculosis infection in individuals at increased risk for infection.) Visual Acuity Screening Children (vision impairment screening for all children at least once between the ages of 3 and 5 years to detect the presence of amblyopia or its risk factors) Preventative Testing for Children Sensory Screening - Vision Sensory Screening Hearing (beyond newborn screening) Developmental Screening Autism Screening Developmental Surveillance Psychosocial/Behavioral Assessment Alcohol and Drug Use Assessment Hematocrit or Hemoglobin Lead Screening (up to 7 yrs.) Tuberculin Test Dyslipidemia Screening (Cholesterol) Cervical Dysplasia Screening Oral Health Anticipatory Guidance Frequency/Comments May be part of well-child visits. May be part of well-child visits. May be part of well-child visits. May be part of well-child visits. May be part of well-child visits. May be part of well-child visits. Women's Preventive Services Well Woman Visits (Well-woman preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care specified as preventive by the USPSTF and noted under the USPSTF section above. This well-woman visit should, where appropriate, include other preventive services listed in this set of guidelines. Gestational Diabetes Screening Human Papillomavirus (HPV) testing (High-risk human papillomavirus DNA testing in women with normal cytology results.) Sexually Transmitted Infections (STIs) Counseling For All Sexually Active Women Counseling and screening for human immune-deficiency virus (HIV) for all sexually active women Contraception Education and counseling related to contraceptives and sterilization for women with reproductive capacity Surgical sterilization (hysterectomies are excluded; hysterectomies are not performed solely for sterilization) The following contraceptive methods (devices and associated procedures, such as device removal, and pharmaceutical contraceptives) for women with reproductive capacity. o OTC contraceptives Female condoms, all products Sponges, all products Spermicides, all products Emergency contraception (i.e. morning after pill, Plan B) o Cervical Caps o Diaphragms Frequency / Comments Annual, although HHS recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on a woman s health status, health needs, and other risk factors. In pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes. Screening should begin at 30 years of age and should occur no more frequently than every 3 years Annual Annual o o Only the Sterilization procedure itself will pay at 100%.This coverage applies to all places of service, with the exception of the Emergency Room. Any additional services billed separately from the surgical sterilization procedure itself, such as anesthesia or supplies, are not covered under preventive services. Diaphragms, vaginal rings, contraceptive patches, female condoms, sponges, spermicides, and emergency contraception available only with a prescription. o Diaphragms are available only through the pharmacy and IUDs are available only through a professional provider. 5 amwins.com

7 o Injections. Only covered as preventive for Medroxyprogesterone Acetate 150 mg. which is the only drug and dosage used for contraception. o Implantable Rods o IUDs o Generic oral contraceptives All generic contraceptives will be covered as preventive Brand oral contraceptives will continue to require member cost sharing (e.g. deductible, copay, and/or coinsurance) o Trans-dermal contraceptives (i.e. contraceptive patches, ORTHO EVRA ) o Vaginal rings (i.e. NuvaRing ) Breastfeeding support, supplies, and counseling (Comprehensive lactation (breastfeeding) support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for breastfeeding equipment) Certain Breast Pumps for Post-Partum Women: One manual or electric breast pump purchase per delivery is covered. Benefit available after member has delivered the baby. Breast Pumps come with certain supplies, such as tubing, shields, and bottles. All other supplies are excluded (i.e. creams, nursing bras, replacement tubing for breast pump). Breast pumps must be purchased from participating DME vendors. o Not all participating DME vendors carry all items; please check with your local participating vendor of choice to see if they carry breast pumps. o Hospital grade breast pumps are excluded and not covered. Screening and counseling for interpersonal and domestic violence Counseling covered at 100% through network providers (i.e., OB/GYNs, midwives, facilities) Annual Vaccination Information Vaccinations Adults Hepatitis A Hepatitis B Herpes Zoster Human Papillomavirus Influenza Measles, Mumps, Rubella Meningococcal Pneumococcal Tetanus Vaccinations Children Diphtheria, Tetanus, Pertussis Haemophilus influenzae type b Hepatitis A Hepatitis B Human Papillomavirus Inactivated Poliovirus Influenza Measles, Mumps, Rubella Meningococcal Pneumococcal Rotavirus Varicella Frequency / Comments Doses, recommended ages and recommended populations vary: Doses, recommended ages and recommended populations vary Doses, recommended ages and recommended populations vary 6 amwins.com

8 MONTHLY PREMIUM RATES MINIMAL ESSENTIAL COVERAGE Enrollment Tier Monthly Rates Employee Only: $44.24 Employee & Spouse $73.94 Employee & Children $64.04 Employee & Family $93.73 MINIMUM ESSENTIAL COVERAGE INSURANCE PLAN EXCLUSIONS Note: All exclusions related to Prescription Drugs are shown in the Prescription Drug Plan. As stated above, all claims for services and supplies that are not Preventive Care benefits as defined above are not a "Covered Charge" under this Plan. This Plan does not pay for services such as: Abortion. Services, supplies, care or treatment in connection with an abortion unless the life of the mother is endangered by the continued Pregnancy or the Pregnancy is the result of rape or incest. Acupuncture. Biofeedback. Educational or vocational testing. Services for educational or vocational testing or training. Excess charges. The part of an expense for care and treatment of an Injury or Sickness that is in excess of the Usual and Reasonable Charge. Exercise programs. Exercise programs for treatment of any condition, except for Physician-supervised cardiac rehabilitation, occupational or physical therapy if covered by this Plan. Experimental or not Medically Necessary. Care and treatment that is either Experimental/Investigational or not Medically Necessary. Eye care. Radial keratotomy or other eye surgery to correct refractive disorders. Also, routine eye examinations, including refractions, lenses for the eyes and exams for their fitting. This exclusion does not apply to coverage under the preventive medical benefits sections of this Plan. Foot care. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions (except open cutting operations), and treatment of corns, calluses or toenails (unless needed in treatment of a metabolic or peripheral-vascular disease). Foreign travel. Care, treatment or supplies out of the U.S. if travel is for the sole purpose of obtaining medical services. Government coverage. Care, treatment or supplies furnished by a program or agency funded by any government. This exclusion does not apply to Medicaid or when otherwise prohibited by applicable law. Hearing aids and exams. Charges for services or supplies in connection with hearing aids or exams for their fitting, except as may be covered under the preventive medical benefits sections of this Plan. Home Health Care. Charges in connection with Home Health Care. 7 amwins.com

9 No charge. Care and treatment for which there would not have been a charge if no coverage had been in force. Non-compliance. All charges in connection with treatments or medications where the patient either is in non-compliance with or is discharged from a Hospital or Skilled Nursing Facility against medical advice. No obligation to pay. Charges incurred for which the Plan has no legal obligation to pay. No Physician recommendation. Care, treatment, services or supplies not recommended and approved by a Physician; or treatment, services or supplies when the Covered Person is not under the regular care of a Physician. Regular care means ongoing medical supervision or treatment which is appropriate care for the Injury or Sickness. Not specified as covered. Non-traditional medical services, treatments and supplies which are not specified as covered under this Plan. Occupational therapy. Charges in connection with occupational therapy. Orthotics. Charges in connection with orthotics. Out Of Network Providers: Preventive Care Services rendered by an Out-of-Network Provider. Personal comfort items. Personal comfort items or other equipment, such as, but not limited to, air conditioners, air-purification units, humidifiers, electric heating units, orthopedic mattresses, blood pressure instruments, scales, elastic bandages or stockings, nonprescription drugs and medicines, and first-aid supplies and nonhospital adjustable beds. Physical therapy. Charges in connection with physical therapy. Plan design excludes. Charges excluded by the Plan design as mentioned in this document. Relative giving services. Professional services performed by a person who ordinarily resides in the Covered Person's home or is related to the Covered Person as a Spouse, parent, child, brother or sister, whether the relationship is by blood or exists in law. Services before or after coverage. Care, treatment or supplies for which a charge was incurred before a person was covered under this Plan or after coverage ceased under this Plan. Sex changes. Care, services or treatment for non-congenital transsexualism, gender dysphoria or sexual reassignment or change. This exclusion includes medications, implants, hormone therapy, surgery, medical or psychiatric treatment. Skilled Nursing Facility. Charges for care, treatment, services or supplies in a Skilled Nursing Facility. Sleep disorders. Care and treatment for sleep disorders unless deemed Medically Necessary. Speech therapy. Charges in connection with speech therapy. Spinal Manipulation. Any spinal manipulation care, services or treatment. Substance abuse. Care and treatment of Substance Abuse except as covered under the covered preventive medical benefits section of this Plan. Temporomandibular Joint Syndrome. All diagnostic and treatment services related to the treatment of jaw joint problems including temporomandibular joint (TMJ) syndrome. Travel or accommodations. Charges for travel or accommodations, whether or not recommended by a Physician, except for ambulance charges as defined as a Covered Charge. Voluntary Surgical sterilization for male insureds. Care and treatment for surgical sterilizations or their reversal War. Any loss that is due to a declared or undeclared act of war. If you are ever in doubt about your coverage please contact AmWINS at amwins.com

10 PRESCRIPTION DRUG BENEFITS Pharmacy Drug Charge Participating pharmacies have contracted with the Plan to charge Covered Persons reduced fees for covered Prescription Drugs. AmWINS Rx is the administrator of the pharmacy drug plan. Prescription Drugs purchased from a non-participating pharmacy or a participating pharmacy when the Covered Person's ID card is not used are not covered. Covered Prescription Drugs Only prescription drugs that are prescribed in connection with the receipt of Preventive Care benefits by a Covered Person are Covered Charges under this Plan. Prescription Drugs that may be covered consist only of drugs prescribed by a Physician that require a prescription either by federal or state law. This includes oral contraceptives. Limits To This Benefit This benefit applies only when a Covered Person incurs a covered Prescription Drug charge. The covered drug charge for any one prescription will be limited to: (1) Refills only up to the number of times specified by a Physician. (2) Refills up to one year from the date of order by a Physician. Expenses Not Covered This benefit will not cover a charge for any of the following (1) Administration. Any charge for the administration of a covered Prescription Drug. (2) Appetite suppressants. A charge for appetite suppressants, dietary supplements or vitamin supplements, except for prenatal vitamins requiring a prescription or prescription vitamin supplements containing fluoride. (3) Consumed on premises. Any drug or medicine that is consumed or administered at the place where it is dispensed. (4) Devices. Devices of any type, even though such devices may require a prescription. These include (but are not limited to) therapeutic devices, artificial appliances, braces, support garments, or any similar device. (5) Experimental. Experimental drugs and medicines, even though a charge is made to the Covered Person. (6) FDA. Any drug not approved by the Food and Drug Administration. (7) Immunization. Immunization agents or biological sera. (8) Impotence. A charge for impotence medication. (9) Infertility. A charge for infertility medication. (10) Inpatient medication. A drug or medicine that is to be taken by the Covered Person, in whole or in part, while Hospital confined. This includes being confined in any institution that has a facility for the dispensing of drugs and medicines on its premises. (11) Investigational. A drug or medicine labeled: "Caution - limited by federal law to investigational use". 9 amwins.com

11 (12) Medical exclusions. A charge excluded under Medical Plan Exclusions. (13) No charge. A charge for Prescription Drugs which may be properly received without charge under local, state or federal programs. (14) No prescription. A drug or medicine that can legally be bought without a written prescription. (15) Refills. Any refill that is requested more than one year after the prescription was written or any refill that is more than the number of refills ordered by the Physician. 10 amwins.com

12 AFFORDABLE CARE ACT AND HEALTH CARE REFORM PREVENTIVE COVERAGE The Affordable Care Act (ACA) requires that health plans cover various preventive services at no cost to you. The goal of preventive services is to both help you stay healthy and prevent you from developing future medical problems. AmWINS Rx offers a variety of preventive medications at no cost to you. It is important to know that your healthcare provider must write you prescriptions for these medications in order for the zero copay to apply. This includes those medications that are available overthe-counter. The following is a full list of the preventive medications, along with any associated limitations, that AmWINS Rx provides to you at no cost: DRUG CATEGORY & DESCRIPTION ASPIRIN Aspirin to prevent cardiovascular disease (CVD): Men The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. AMWINS RX COVERAGE Quantity limit: 1/day Generic Only No age restrictions apply OTC (requires a prescription) Aspirin Tab 81mg - 325mg Aspirin Chew 81mg mg Aspirin Delayed Release 81mg - 325mg Aspirin Dispersible Tab 81mg Aspirin to prevent cardiovascular disease (CVD): Women The USPSTF recommends the use of aspirin for women age 55 to 79 when the potential benefit of a reduction in ischemic strokes outweighs the potential harm or an increase in gastrointestinal hemorrhage. Quantity limit: 1/day Generic Only No age restrictions apply OTC (requires a prescription) Aspirin 81mg - 325mg Aspirin Chew 81mg - 325mg Aspirin Delayed Release 81mg - 325mg Aspirin Dispersible Tab 81mg 11 amwins.com

13 FOLIC ACID The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. Women Quantity limit: 1/day Generics and Brands with no generics available Prescription or OTC (requires a prescription) Multivitamin with folic acid ALL FDA-APPROVED CONTRACEPTIVE METHODS The HRSA recommends that all Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity. Abortifacients are not covered. Women Rx Only and OTC products Generics and Brands with no generics available Oral Contraceptives, Patch and Vaginal Contraceptives, Emergency Contraceptives, Injectable, Diaphragms, Spermicides, Sponges, Cervical Caps, Female Condoms, Progestin IUD*, Progestin Implants* *IUD and Implants may be covered under the pharmacy or medical benefit. FLUORIDE The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. Age limit 0 months 5 years Prescription products only Generics and Brands with no generic available Sodium fluoride products only, not in combination Sodium fluoride tab 0.5mg Sodium fluoride chew tab 0.25mg 0.5mg Sodium fluoride solution 12 amwins.com

14 IMMUNIZATIONS Prescription Only Generics and Brands with no generics available Plans who only cover under medical benefit can continue to do so. Plans must cover under their medical or pharmacy benefit The ACIP recommends immunizations for routine use in children and adults. Children: Drug Description Age Limit Quantity Limit Haemophilus influenza type b doses up to age 18 Hepatitis A doses up to age 18 Hepatitis B doses up to age 18 Human Papillomavirus doses up to age 18 Inactivated Poliovirus doses up to age 17 Influenza doses per year Measles, Mumps, Rubella doses up to age 18 Meningococcal B doses up to age 18 Meningococcal doses up to age 18 Pneumococcal doses up to age 18 Rotavirus 0 to 9 months 3 doses up to 9 months of age Tetanus, Diphtheria, Pertussis doses up to age 7 (DTAP) Tetanus, Diphtheria, Pertussis doses up to age 18 (DTAP) Varicella doses up to age 18 Adult: Drug Description Age Limit Quantity Limit Haemophilus influenza type b per lifetime Hepatitis A per lifetime Hepatitis B per lifetime Human Papillomavirus per lifetime Influenza per year Measles, Mumps, Rubella per lifetime Meningococcal B per lifetime Meningococcal dose per 5 years 4-valent conjugate Pneumococcal 23-valent per lifetime Pneumococcal per lifetime 13-valent conjugate Tetanus, Diphtheria, Pertussis per 10 years Varicella per lifetime Zoster (Herpes Zoster) per lifetime 13 amwins.com

15 SMOKING CESSATION MEDICATION The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Prescription or OTC (requires a prescription) Generics and Brands with no generics available Prescription products require coverage of branded products Zyban /Bupropion SR 12 HR 150 mg Nicotine TD patch 24 HR kit Nicotine polacrilex gum 2/ 4 mg Nicotine polacrilex lozenge 2/ 4 mg Nicotrol Nasal Spray Nicotrol Inhale VITAMIN D The USPSTF recommends vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls. Age limit: 65+ Quantity limit: 2/day Generic Only and OTC (requires a prescription) Patient Residence Code: Home Vitamin D only (400IU) SCREENING FOR COLORECTAL CANCER The USPSTF recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. Although prescription drugs are not mentioned as part of this screening, bowel preparation may be considered an integral part of a colonoscopy or a sigmoidoscopy. Therefore, Envision s recommendation is that prescriptions for bowel preparation should be covered as part of this preventive service. OTC (requires a prescription), Generics and Brands with no generics available Ages: Bowel Evacuant Combinations 14 amwins.com

16 BREAST CANCER PREVENTION MEDICATIONS The USPSTF recommends that clinicians engage in shared, informed decision-making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene. Asymptomatic women aged 35 years without a prior diagnosis of breast cancer who are at increased risk for the disease. Generics and Brands with no generics available Tamoxifen Raloxifene (Evista ) CHOLESTEROL LOWERING MEDICATIONS (STATINS) In accordance with the new Recommendation B of the United States Preventive Services Task Force (USPSTF), effective 12/1/2017, AmWINS Rx will offer low-to-moderate dose generic statin coverage at zero copay for all members who are 40 to 75 years of age. Prescription Atorvastatin 10mg & 20mg Fluvastatin 20mg & 40mg Fluvastatin Extended Release 80mg Lovastatin 10mg, 20mg & 40mg Pravastatin 10mg, 20mg, 40mg, & 80mg Rosuvastatin 5mg and 10mg Simvastatin 5mg, 10mg, 20mg & 40mg 15 amwins.com