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受托人的意见
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在再保险

原告: 养老金领取者
被申请人: 雇主
ROD案例编号: 98-014 ——2006年6月21日

受托人: 迈克尔W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. 荷兰,
艾略特一. 西格尔.

受托人审查了有关根据雇主福利计划条款提供福利的争议的事实和情况.

背景事实

The Respondent notified all Employees and 养老金领取者s by letter dated March 20, 2000, that
配合被申请人的处方药计划, the Respondent was implementing a formulary prescription drug program called RX Selections Formulary effective April 1, 2000.
Subsequently, the Respondent notified beneficiaries that the program would begin May 1, 2000.

根据被告提交的文献资料, 供应不超过30天, a beneficiary will pay the following per prescription: 1) Generic drug–$4.50; 2) Brand-name drug when a generic is available–$4.50 co-payment plus the difference between the brand-name price and the generic price. If medical necessity for a brand-name drug is established, the charge is $4.50. This portion of the Respondent’s prescription drug program is identical to the provision of benefits under 第三条A. (8)雇主福利计划.

除了上面提供的好处之外, 文献还表明，对于30天或更短的供应, a beneficiary will pay the following per prescription: 1) Brand-name formulary drug when no generic is available–$4.50; 2) Brand-name non-formulary drug when no generic is available–$4.50美元的自付加上15美元.00附加费. 在处方计划下, a beneficiary’s physician may request a review to have a non-formulary drug designated as medically necessary. If medical necessity is established, the beneficiary does not pay the $15.00附加费.

在一般情况下, “处方集”是处方药的清单, 按治疗组别分组, that a health plan prefers and in some cases may require 医生tors to prescribe. 治疗类根据药物治疗的疾病或药物对身体的影响将药物分组.

投诉人的代表表示，Rx选择处方计划与雇主福利计划的条款不一致，因为它将投诉人的自付额从4美元增加.50 to $19.50.

争端

Is the formulary drug program implemented by the Respondent consistent with the terms of the 雇主 Benefit Plan?

双方立场

投诉人的立场:被投诉人的处方药物计划违反了雇主福利计划的条款，因为它增加了处方药允许的共付额.

被申请人的立场:被申请人的处方药物计划没有违反雇主福利计划的条款，原因如下:
1) The formulary program does not reduce benefits because non-formulary drugs are not medically necessary. Formulary drugs provide equivalent therapeutic benefits to those provided by non-formulary drugs. 然而, a beneficiary still may choose to purchase a non-formulary drug as a more costly alternative.
2) When the beneficiary utilizes the prescription drug designated in the formulary program, 该计划不会导致成本增加.
3) The appeal process allows the beneficiary to establish medical necessity and thus be exempt from the $15.00附加费. 在两个月期间，68%的上诉获得批准.
4)工资协议和雇主福利计划下的成本控制条款授权实施药物处方集.
5) The surcharge does not arbitrarily hinder or deny a beneficiary reasonable and timely access to required medications.
6)受托人在ROD 93-079中的决定支持处方药物计划，即雇主是否可以审查医疗需要，以确定是否为品牌处方药提供保险.

相关的规定

Article XX (12) of the 1998 Wage Agreement states in pertinent part:

(12)卫生保健费用控制

The Union and the 雇主s recognize that rapidly escalating health care costs, including the costs of medically unnecessary services and inappropriate treatment, 对健康福利计划有不利影响吗. The Union and the 雇主s agree that a solution to this mutual problem requires the cooperation of both parties, 在各个层面, to control costs and to work with the health care community to provide quality health care at reasonable costs. 工会和雇主是, 因此, committed to fully support appropriate programs designed to accomplish this objective. 这一目的声明绝不意味着减少矿工所提供服务的福利或增加费用, 领取养老金的人和他们的家人.

The Introduction to Article III of the 1998 雇主 Benefit Plan states in pertinent part:

. . . 承保的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供, 或计划另有规定. 医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不意味着它在本计划范围内. . . .

第三条A. 1998年雇主福利计划第(4)(a)条规定:

(4) 处方药

(a)提供的福利

胰岛素和处方药(仅限于联邦或州法律要求处方的药物)由持牌药剂师配药，并由(i)医生开具处方，用于治疗或控制疾病或非职业事故，或(ii)持牌牙医在执行(3)(e)中所述的口腔外科服务后进行治疗。.

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Reasonable charges for prescription drugs or insulin are covered benefits. 合理收费包括以下两者中较低者:

(1)每份处方或补药实际开出的金额;

(二)适用的仿制替代药品价格, 如果是AB或更高评级, approved by the federal 美国食品药品监督管理局; or, in the event the prescribing physician determines that the use of a brand name drug is medically necessary, the price of such brand name drug; or

(3) The current price paid to participating pharmacies in any prescription drug program established by the 雇主.

然而, 在任何情况下，受益人均无责任为单一处方支付超过本计划中规定的适当共付额, plus any difference between the price of the generic and the brand name drug, 在适用情况下.

第三条A. (8)《皇冠搏彩中心》相关部分规定:

(8)共同支付和免赔额

Effective January 1, 1997, the benefits provided in this plan shall be subject to the 如下所列的共同支付额和免赔额，以及这些共同支付额和 免赔额由受益人负责. . . .

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处方药(自付额不包括自付额):

PPL: $4.每份处方50元*

Non-PPL: $9.每张处方00元*

邮寄: 没有费用

品牌名称(如有通用等效名称):

除了 to the co-payment, the Beneficiary is responsible for the additional 品牌药品的成本高于非专利替代品的成本. 一个通用的 drug will not be considered “available” unless it has been approved by the federal 美国食品药品监督管理局. 此外，如果开处方的医生 determines that use of a brand name drug is medically necessary, the generic drug will not be considered “available,” and there will be no additional payment 受益人使用品牌药品.

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第三条A. 1998年雇主福利计划(雇主 Benefit Plan)第(10)(b)条的相关部分规定:

(10) 一般规定

(b)管理

The Plan Administrator is authorized to promulgate rules and regulations to implement and administer the Plan, 该等规章制度对与根据本计划领取福利的受益人打交道的所有人员均具有约束力. . . .

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第四条. A. (2) 1998年雇主福利计划的相关部分:

第四条. 管理式医疗，成本控制

A. (2) 除了, the 雇主 may implement certain other managed care and cost containment rules, which may apply to benefits provided both by PPL providers and by non-PPL sources, 但(除本计划中特别规定的免赔额和共同支付额外)不会导致本计划项下提供的承保服务的福利减少或额外费用.

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讨论

根据1998年工资协议第XX(12)条, 协议各方承诺全力支持旨在控制成本并以合理成本提供优质医疗保健的适当方案. 第四条. A. 《皇冠搏彩中心》第(2)条规定:“雇主可实施某些其他管理式医疗和成本控制规则. . . . 哪些(除计划中特别规定的免赔额和共付额外)不会导致计划下提供的承保服务的福利减少或额外费用.”

第三条A. (4) of the 雇主 Benefit Plan provides benefits coverage for prescription drugs. 第三条A. (8)雇主福利计划 addresses the co-payments applied to prescription drugs. 根据后一项规定，受益人支付4美元.50 co-payment for a generic drug if the prescription is filled at a PPL (Participating Provider List) retail pharmacy. If a beneficiary purchases a brand name drug when a generic is available, the beneficiary pays a $4.50 co-payment at a PPL pharmacy plus the difference between the generic and the brand name drug. 然而，受益人只需支付4美元.50 if the beneficiary establishes that the brand-name drug is medically necessary (See ROD 93-079).
被告的计划建立了一个计划，征收15美元.00附加费 when a beneficiary purchases a non-formulary brand name drug when no generic is available. 第三条A. (8)雇主福利计划 allows beneficiaries to obtain prescription drugs for a specified co-payment amount. 被告的计划要求受益人支付指定的共付额，如果受益人在没有仿制药的情况下购买非处方品牌药，则支付附加费.

The Respondent argues that ROD 93-079 supports its position in this case. 在ROD 93-079, 受托人发现，雇主的仿制药计划要求医疗文件证明使用品牌药而非仿制药是符合雇主福利计划的规定的. 受托人进一步指出，雇主不应“强行制定规则，任意阻碍或拒绝受益人合理及时地获得所需药物。.“然而, 本案的问题不在于能否获得药物，而在于该计划是否给该计划增加了额外费用.

在ROD 98-013, 仲裁员决定了雇主是否有权在受益人购买非处方品牌药而无仿制药可用时实施收取附加费的计划的问题. 仲裁员认定“雇主实施强制性处方药物计划与雇主福利计划的处方药覆盖范围和成本控制条款不一致。, 因此不属于雇主执行《皇冠搏彩中心网站》和《皇冠搏彩中心》的权力范围.”

受托人的意见

雇主实施的强制性处方药物计划与雇主福利计划的处方药覆盖范围和成本控制条款不一致, 因此不属于雇主执行《皇冠搏彩中心网站》和《皇冠搏彩中心》的权力范围.