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Prescription Drug Coverage This section describes the Prescription Drug Plan which is offered to employees and their dependents who are enrolled in a Company-sponsored self-insured medical plan administered by Anthem Blue Cross, including the Network Access Plan (NAP) and the Comprehensive Access Plan (CAP). This Plan, administered by Medco Health Solutions, Inc., provides retail and mail-order prescription drug coverage. The benefits of this Plan do not coordinate with any of the benefits administered by Anthem Blue Cross. HMO Participants
Employees and their dependents who are enrolled in a Health Maintenance Organization (HMO) Plan receive
retail and mail-order prescription drug coverage directly through their plan rather than through Medco. For more information about one of these other plans, contact that plan’s member services department directly. In This Section
Benefits Effective January 1, 2011
For eligible union-represented employees
Plan Benefits
The following chart provides a summary of outpatient drug coverage administered by Medco.
Prescription Drug Benefits for Anthem Blue Cross Plan Members (Administered by Medco) First three 30-day supplies at a participating pharmacy:  85% for generic drugs, 75% for brand-name drugs. For refills beyond 90 days and coverage at non-participating pharmacies:  80% for generics and 70% for brand-name drugs. Generic Incentive Provision applies. 90% for generic drugs and 80% for brand-name drugs. Generic Incentive Provision applies. Member is responsible for paying the difference between the price of a generic drug and a brand-name drug, plus coinsurance, if purchasing a brand-name drug when a generic version is available. Please note that any generic-brand price differential you pay is a non-covered expense and, thus, does not count towards your  $500 per person, $1,000 per family.  Out-of-pocket maximum covers both the retail drug plan and the mail-order drug plan (does not coordinate with medical plan). Non-covered expenses, such as generic-brand price differentials, are not eligible expenses and, thus, will not count toward your out-of-pocket maximum nor will these expenses be covered by the Plan after your annual out-of-pocket maximum is met.  50% for both retail and mail-order plans, unless medically  Medically necessary drugs are covered at standard  Generic Incentive Provision applies. Medco has negotiated rates with many retail pharmacies. Benefits for prescription drugs purchased at these pharmacies are paid based on these negotiated rates. The pharmacies that Medco has negotiated with are called “participating” pharmacies. To receive the greatest benefit on retail prescriptions, participating pharmacies should be used. A directory of participating pharmacies can be obtained by calling Medco Member Services at 800-718-6590 or by visiting Medco’s Web site at www.medcohealth.com. You also can use the easy “Medco by Mail” mail-order program for your maintenance drugs. Manufacturer rebates are earned upon participant purchase of certain prescription drugs. The value of these rebates is based on the contract that Pacific Gas and Electric Company, as Plan sponsor, has with Medco Health. These rebates are received from Medco Health approximately six months after the purchase of a drug and are deposited back into the trust holding the plan assets for retirees or employees on long-term disability or back to the company for active employees. The cost of the Plan is reduced by the value of the rebates. Benefits Effective January 1, 2011
For eligible union-represented employees
Generic Incentive Provision
For all prescription drug purchases, whether at a retail drug store or through mail-order, members will be
responsible for paying the difference between the price of a generic prescription drug and a brand-name prescription drug, plus coinsurance, if purchasing a brand-name drug when a generic is available. (The difference in cost between the brand-name drug and the generic drug does not apply toward your annual out-of-pocket maximum.) Here’s an example of how the “Generic Incentive Provision” works: Example of a brand-name purchase versus a generic purchase: Al purchases a 30-day supply of Mevacor, a brand-name prescription drug, at the local pharmacy. He chooses not to use the generic alternative, Lovastatin. Price difference between brand-name and generic Extra cost for member to purchase brand-name drug If Al had elected to use the generic alternative, Lovastatin, his coinsurance would have been 15% of the $24.04 price tag of the generic drug, or $3.61. However, because he chooses to purchase the brand-name drug (Mevacor) when a generic is available, his coinsurance will be 25% of the higher price for the brand-name drug, or $19.78. In addition to this coinsurance amount, he must pay the full difference in price between the brand name and generic ($79.10 - $24.04 = $55.06). In total, Al must pay $74.84 for the brand-name prescription (coinsurance amount of $19.78 plus the brand-generic price difference of $55.06). By purchasing the generic version, Al could have saved $71.23. (Please note that prices shown in this example are for purposes of illustration. Actual prices Certain brand-name drugs will not be subject to the “pay the difference” penalty. These brand-name drugs are on Medco’s Narrow Therapeutic List which changes from time to time. In addition, if no generic version exists for a brand-name drug, the penalty will not apply. Only the 25% brand coinsurance will apply to the purchase of these brand-name prescription drugs. Your participating pharmacy has Medco’s Narrow Therapeutic List and will charge Eligibility
Employees and their Eligible Dependents who are enrolled in one of the self-insured medical plans administered
by Anthem Blue Cross are eligible for the Prescription Drug Plan administered by Medco Health Solutions, Inc. Employees and their Eligible Dependents who are enrolled in a Health Maintenance Organization (HMO) Plan are not eligible for the Prescription Drug Plan described in this section. HMO members receive retail and mail-order prescription drug coverage directly through their medical plan. For more information regarding your plan’s prescription drug coverage, contact the plan’s member services department directly. You are not eligible for prescription drug benefit coverage if you are a contract or agency worker, or a hiring hall employee. Intermittent employees and other temporary employees who are not expected to become regular employees are also not eligible for coverage. Benefits Effective January 1, 2011
For eligible union-represented employees
How the Plan Works
Retail Pharmacy Service
The Retail Pharmacy Service, managed by Medco, helps you pay part of the cost of retail prescription drugs —
that is, drugs that you purchase at local pharmacies. You have coverage under the Retail Pharmacy Service only if you are enrolled in a medical plan administered by Anthem Blue Cross. When you enroll in one of the self-insured plans administered by Anthem Blue Cross, you are issued a member identification card by Medco. Go to any participating pharmacy (such as CVS, Rite Aid, Walgreens, Raley’s or a number of independent pharmacies), present your card identifying you as a Medco member, and pay the appropriate coinsurance. You may also go to a non-participating pharmacy; however, you will be responsible for paying the entire cost of the prescription upfront and then filing a claim form for reimbursement. It is likely that a non-participating pharmacy will charge more than the pre-negotiated rates of a participating pharmacy. Reimbursement is based on the amount a participating pharmacy would have charged, minus the coinsurance amount. You may call 800-718-6590 or go to www.medco.com to verify pharmacy participation. Maintenance drugs (i.e., those you use on an ongoing basis) purchased at a participating retail pharmacy will be reimbursed for up to three 30-day supplies at 85% for generic drugs and 75% for brand-name drugs. However, for retail refills of maintenance drugs beyond 90 days, the reimbursement rate will be 80% for generic and 70% for brand-name drugs. For example, members will be reimbursed at 85% for an initial 30-day supply of a generic maintenance drug as well as for two 30-day generic refills at a retail pharmacy. If the member requests a fourth prescription of a maintenance drug at a retail pharmacy, the reimbursement rate will drop to 80% because the 90-day supply limit for maintenance drugs will have been exceeded. Therefore, it is suggested that members use Medco By Mail for refills of maintenance drugs beyond a 90-day supply.  Ask your physician for two separate prescriptions: one prescription for a 30-day supply (to be filled at your local retail pharmacy) and one prescription for a 90-day supply (to be filled through Medco By Mail).  Have your 30-day prescription filled immediately at your retail pharmacy. About two weeks later (after you have used up half of your 30-day supply and have decided to continue taking this particular prescription drug), submit your 90-day prescription to Medco By Mail. This will allow a 14-day turn-around for your mail-order prescription to be delivered to your home. Medco will not issue your 90-day supply if you send your order in any sooner than this because it will still be too early to fill the prescription. When Claim Forms Are Required
You will need to pay the full cost of your prescription and file a claim form for reimbursement if you:
 purchase drugs at a non-participating pharmacy;  do not present your Medco identification card when purchasing drugs at a participating pharmacy; or  have other prescription drug coverage which pays first before Medco and you want Medco to pay second on any claim remainder. This is called a Coordination of Benefits or “COB” claim; see “If You Have Other Coverage” in the Health Care Participation section. A member may obtain prescription drugs from participating pharmacies without using their membership card and then seek reimbursement from Medco by submitting a claim form. However, the member’s reimbursement in such cases will be limited to the cost for the drug negotiated by Medco and the pharmacy. Any additional amounts charged to the member by the pharmacy will be the member’s responsibility. To obtain a claim form, call Medco Member Services at 800-718-6590 or visit Medco’s Web site at www .medcohealth.com. If you are a first-time visitor to www.medcohealth.com, take a minute to register. Please remember to have your member ID number and a recent prescription number handy. Benefits Effective January 1, 2011
For eligible union-represented employees
Medco By Mail
Medco By Mail is available to employees and their Eligible Dependents who are enrolled in any of the PG&E-
sponsored medical plans administered by Anthem Blue Cross. This program enables you to purchase your maintenance medications, often at a savings, while having them delivered directly to your home via U.S. mail. “Maintenance” medications are those drugs that you take on a long- term or an on-going basis — in other words, those drugs that you know you’ll need and can order in advance. Some examples of conditions for which maintenance medications are prescribed are high blood pressure, high cholesterol, heart disorders, diabetes, arthritis and stomach ulcers. How Medco By Mail Works
With Medco By Mail, you may obtain up to a 90-day supply of medication for each prescription. You pay 10% of
the cost for each prescription filled with generic drugs, and 20% for those filled with brand-name drugs. If you elect to use a brand-name drug when a generic drug is available, you will be responsible for paying the difference between the price of the generic drug and the brand-name drug, plus coinsurance, as described under Generic Patient Profile When you order from Medco By Mail for the first time, you will need to complete the last portion of the initial order form, which is a Health Assessment Questionnaire. Complete this form and mail it, along with your original prescription, in an envelope addressed to: The Medco by Mail order form, which includes the Health Assessment Questionnaire, and mail-order envelopes are available by calling Medco Member Services at 800-718-6590. You may also download the form by accessing Medco’s Web site at www.medcohealth.com. The purpose of the Health Assessment Questionnaire is to alert the pharmacists who are filling your prescriptions of any allergies or medical conditions that might be affected by the prescriptions you are ordering, in an effort to prevent any potentially harmful drug reactions. All information in the Health Assessment Questionnaire is Paying Your Coinsurance You can request that Medco bill you for your coinsurance, up to $100, or you can instruct Medco to bill your credit card or debit card (e.g., VISA, MasterCard, etc.). Alternatively, you can submit payment in advance. To do so, you will need to call Medco to find out the amount of your coinsurance. Then send your personal check or money order, along with your original prescription, when you send in your order. Obtaining Your Medications Medco will mail your medications directly to your home. You will receive your medication within 14 days from the date on which Medco receives your order. If you need your prescription sooner, just let Medco know and, for an extra charge, your prescription will be sent via UPS or Federal Express. Whenever possible, your prescription will be filled with a generic drug that meets the same standards as the brand name, unless your physician specifies otherwise. Medco’s specialty pharmacy, Accredo Health Group, handles complex conditions such as anemia, hepatitis C, multiple sclerosis, asthma, growth hormone deficiency, and rheumatoid arthritis, which are treated with specialty medications. Specialty medications are typically injectable medications administered either by yourself or by a health care professional, and often require special handling. In addition, Medco partners with Liberty Medical to fulfill prescription requests for certain drugs and supplies covered by Medicare Part B. For more information about Accredo or Liberty Medical, please call Medco Member Services at 800-718-6590. Benefits Effective January 1, 2011
For eligible union-represented employees
Ordering Your Refills You can order your refills by mail or by calling Medco directly at 800-718-6590, 24 hours a day, seven days a week, except Thanksgiving and Christmas. For refills by mail, send the refill slip provided with your last mail-order prescription, along with your copayment, to Medco Health Solutions, Inc., P.O. Box 747000, Cincinnati, Ohio 45274-7000. You may also order your refills online using Medco’s Web site at www.medcohealth.com. You can also check on the status of your refill online. When Your Current Prescription Expires Prescriptions expire one year from the date of issue, regardless of whether you have any refills left. You may mail your new prescription to Medco Health Solutions, Inc., P.O. Box 747000, Cincinnati, Ohio 45274-7000. You may also have your physician fax your new prescription to Medco. Ask your doctor to call 888-327-9791 for What the Plan Covers
Covered expenses under the Prescription Drug Plan consist of drugs and
medicines approved by the Food and Drug Administration for general use by the public that require a written prescription by a physician and If you are not sure if a particular drug is that are dispensed by a licensed pharmacist, physician, or hospital for take-home purposes. Eligible drugs and medicines include: 800-718-6590. There are some prescriptions that require prior  Drugs that require a prescription, except those specifically excluded  Compound drugs that contain at least one prescription drug;  Insulin, including hypodermic needles and syringes when insulin is also purchased;  Over-the-counter diabetic supplies, including items used for daily blood and urine sample testing (except  Retin-A for patients through age 25 (over age 25 when medically necessary);  Vitamins that require a prescription;  Attention Deficit Disorder drugs (e.g., Methylphenidate, Dextroamphetamine, Methamphetamine,  Smoking deterrents that require a prescription (e.g., Habitrol, Nicoderm, and Prostep anti-smoking patches);  Anorexiants with prior authorization; and  50% coverage for fertility, oral contraceptive, sexual dysfunction, and memory enhancement drugs, unless these drugs are specifically authorized by your physician as medically necessary. Medically necessary drugs are covered at standard reimbursement rates. Medically Necessary
The Prescription Drug Plan only covers services and supplies that are Medically Necessary. For the purpose of this
Plan, Medically Necessary services and supplies are those provided by a hospital, physician or other provider that: (i) have been established as safe and effective; (ii) are furnished in accordance with generally accepted professional standards to treat illness or injury, and are in accordance with the accepted standards of medical practice in the geographic area where the services are provided; (iii) are consistent with the symptoms and diagnosis or treatment of the illness, injury or condition; (iv) are furnished at the most appropriate level that can be provided safely and effectively to the patient; and (v) are not furnished primarily for the convenience of the patient, the attending physician or other provider. Medically Necessary prescriptions will be paid at the standard How New Prescription Drugs Are Added
The Prescription Drug Plan covers all prescription drugs approved by the Food and Drug Administration (FDA), as
long as they are used in the FDA-approved manner and are used in accordance with manufacturers’ usage guidelines. Coverage for new prescription drugs will begin upon FDA approval. Benefits Effective January 1, 2011
For eligible union-represented employees
What the Plan Does Not Cover
No benefit will be provided for any expense incurred for the following drugs, medicines, substances or supplies
rendered, unless specifically listed as a benefit under What the Plan Covers. Ineligible drugs, medicines,  Drugs, medicines, substances or supplies that are not Medically Necessary (see “Medically Necessary” in “What the Plan Covers” on page 328);  Experimental and investigational drugs;  Experimental or investigational drugs are not covered under the Prescription Drug Plan. These drugs are typically new products that are still being tested by the FDA and have not been approved for general distribution under the standard prescription process. Further, drugs that are limited by federal law to investigational use and that are labeled as such are not covered. A drug may also be considered experimental if prescribed for an indication or at a dosage that is not an accepted use based on published reports in standard drug publications such as the American Hospital Formulary Service Drug Information and the United States Pharmacopeia Dispensing Information.  Drugs or supplies that may be dispensed without a prescription;  Medications not used in accordance with the FDA’s approval specifications;  Inpatient medications (i.e., drugs dispensed or used while you are a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent home, nursing home, or similar  Retin-A (unless prescribed for medical treatment other than anti-aging or for individuals under age 26);  Smoking deterrents other than those listed under What the Plan Covers;  Drugs prescribed solely for cosmetic purposes (e.g., Renova) or to promote or stimulate hair growth (e.g.,  Biologicals, blood, or blood plasma;  Charges for the administration or injection of a drug;  Any prescription refill in excess of the number specified by the physician, or any refill after one year from the date of the physician’s original order;  Medications to which you are entitled under any Workers’ Compensation or occupational disease law;  Medication furnished by any other drug or medical service for which no charge is made to the participant; and  Any drug for which benefits are paid under another Company-sponsored health plan or benefit program. For further details, see “Reductions/Exclusions for Duplicate Coverage” under “If You Have Other Coverage” in the Health Care Participation section. Coordination of Benefits
If you are covered by another plan that has prescription drug coverage that is primary to this Plan (see “If You
Have Other Coverage” in the Health Care Participation section), you will need to fill out a Medco Coordination of Benefits/Direct Claim Form in order to receive any benefit, if eligible, from Medco. The form is available by calling Benefits Effective January 1, 2011
For eligible union-represented employees
You must submit a separate claim form for each pharmacy used and for each patient. You will need to attach documentation to the completed form. The documentation required depends on what plan is primary, as follows:  If the primary plan is another health plan, you must attach the claim statement, or Explanation of Benefits, which you received from the primary plan to the completed Medco form.  If the primary plan is an HMO or another plan in which a co-payment or coinsurance is paid at the pharmacy, you will need to attach receipts that clearly show the amounts you paid at the pharmacy.  If the primary plan is another Medco By Mail plan, you will need to attach either the prescription receipt or the statement of benefits you received from Medco’s mail-order pharmacy. Complete instructions are included on the Medco Coordination of Benefits/Direct Claim Form. Claims and Appeals
For information about claims and appeals regarding your eligibility to participate in The Pacific Gas and Electric
Company Health Care Plan for Active Employees or to make election changes to your coverage under the Plan, see the Health Care Participation section. Claims and Inquiries
Medco is the Claims Administrator for the Prescription Drug Plan. Under this Plan, a network of retail pharmacies
is available as well as mail-order prescription drug coverage. When you go to a participating retail pharmacy, simply present your identification card and pay the appropriate coinsurance. If you use a non-participating pharmacy, you will be responsible for paying the full cost of the prescription to the pharmacist, and then filing a claim for reimbursement. Claim forms are available by calling Medco at 800-718-6590 or at Medco’s Web site at www.medcohealth.com. In accordance with federal law, all claims for prescription drugs, except controlled substances, must be made within twelve months of the date on which the prescription was written by the physician. If you do not file a claim within this timeframe, your claim will be denied. Federal law also requires that all claims for controlled substances must be made within six months of the date on which the prescription was written by the physician. If you have an issue or complaint regarding your prescription drug benefits, you should first address your concerns with Medco within 60 days after the issue or complaint arises. Many problems, complaints, and potential claim issues can be resolved informally. You can address these informal complaints by phoning Medco at 800-718-6590. Medco may ask you to provide additional information or ask your physician to do so, or may try to clarify any information already provided. Medco will research your issue and respond to you on its findings either in writing or by telephone within 15 days for prescriptions that have not been filled, and within 30 days for prescriptions that have already been filled and paid for. Appeals
Pre-Service Denials-Non-Urgent
If a pharmacist will not fill your prescription and your situation is not urgent, it is recommended that you first try
to resolve the situation informally as previously described. However, if you are not satisfied with the initial resolution or you believe that you have received some type of adverse benefit determination that is preventing you from filling a prescription, you or your authorized representative (such as your physician) can appeal the benefit denial/determination in writing within 180 days of receipt of the denial or adverse determination. Your appeal must be in writing and must include the following information: your name, member ID, phone number, the prescription drug for which benefit coverage has been denied, and any additional information that may be relevant to your appeal. The appeal should be sent to: Benefits Effective January 1, 2011
For eligible union-represented employees
A decision notice will be mailed to you within 15 days of receipt of your appeal. The notice will include the specific reason(s) for the decision and the Plan provision(s) on which the decision was based. You have the right to receive, upon request only and at no charge, the information used to review your appeal. If you are not satisfied with Medco’s decision, you have 90 days from the date of your receipt of the decision notice to request a second-level of appeal. To initiate a second-level of appeal, you must submit the appeal in writing to Medco’s address. A decision will be made regarding your request and will be sent to you within 15 days of Medco’s receipt of the request. A qualified individual who was not involved in the review of your original appeal will review your appeal. If, at this point, your appeal is denied, you can initiate PG&E’s Voluntary Review Process or you can bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 Pre-Service Appeal — Urgent
If a pharmacist will not fill your prescription as desired and your situation is urgent, you may request an expedited
review by calling Medco at 800-753-2851. In cases of an appeal for coverage involving urgent care, you will be notified of the benefit determination within 72 hours of Medco’s receipt of the appeal. An urgent appeal is any claim for treatment with respect to which the application of the time periods for a non-urgent care determination could seriously jeopardize the life or health of the claimant or the claimant’s ability to regain maximum function or, in the opinion of a physician with knowledge of the claimant’s medical condition, could subject the claimant to severe pain that cannot be adequately managed. You or your physician may submit an urgent appeal by phone or in writing. If the appeal does not contain sufficient information to determine whether benefits are covered, you will be notified of the missing information within 24 hours of Medco’s receipt of your appeal. You will then have 48 hours to provide the missing information to Medco and will be notified by phone or in writing of Medco’s decision within 48 hours of receipt of the information. All written appeals must be sent to: If, at this point, your appeal is denied, you can initiate PG&E’s Voluntary Review Process or you have the right to bring a civil action under Section 502(a) of ERISA. Post-Service Appeals
If you paid for your prescription and believe that your level of coverage was incorrect, you can try to resolve this
issue informally, as described previously under Claims and Inquiries. If this approach is unsatisfactory, you or an authorized representative, such as your physician, may appeal the decision in writing within 180 days of your receipt of the claim processing determination (e.g., pharmacy receipt). Your appeal must be in writing and must include the following information: your name, member ID, phone number, the prescription drug for which the level of coverage appears incorrect, and any additional information that may be relevant to your appeal. The A decision notice will be mailed to you within 30 days of Medco’s receipt of your appeal. The notice will include the specific reason(s) for the decision and a reference to the Plan provision(s) on which the decision was based. You also have the right to receive, only upon request and at no charge, the information that Medco used to review your appeal. If you are not satisfied with the decision, you have 90 days from the date of your receipt of the notice to request a second-level of appeal. To initiate a second-level of appeal, you must submit the appeal in writing to Medco’s address. A qualified individual who was not involved in the review of your original appeal will review your second appeal. A decision will be made regarding your request and will be sent to you within 30 days of Medco’s receipt of your appeal. Medco’s decisions are based only on whether or not a benefit is covered by the Plan. If at this point your appeal is denied, you can initiate PG&E’s Voluntary Review Process or you can bring a civil Benefits Effective January 1, 2011
For eligible union-represented employees
PG&E’s Voluntary Review Process
If you are not satisfied with the claims and appeals process completed with Medco, you may elect to use either
PG&E’s Voluntary Review Process or elect to bring a civil action. You have 90 days from the date of receipt of the final decision from Medco to elect this voluntary review. Initiation of the Voluntary Review Process does not restrict your ability to bring a civil action against the Plan. Step 1
The first step of the Voluntary Review Process is to write to the Benefits Department, requesting a review of your
appeal. Your appeal should include all pertinent documentation. To expedite processing, you should also include a HIPAA AUTHORIZATION FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION form. You can access a copy online from the Human Resources Forms section of the PG&E@Work intranet or by calling the HR Service Center at Company extension 8-223-4357, externally at 415-973-HELP (415-973-4357) or toll-free at The Benefits Department will review your appeal and make a decision within 60 days of the date on which the appeal is received (non-receipt of the HIPAA Authorization form may delay your appeal). There may be special circumstances where an extension of up to 90 days may be required. You will be notified if such an issue occurs. If the Benefits Department denies your claim, you will receive a written response that will include:  a reference to the Plan provision(s) that apply to the denial; and  an explanation of additional appeals procedures. Step 2
If your appeal is denied, you may then request a second-level review by the Employee Benefit Appeals Committee
(EBAC). To do so, you must submit a new appeal in writing within 60 days of the date on which you received the Step One denial. Your appeal should state the reason(s) for your appeal and should include all relevant documentation and information that supports your appeal. Unless there are special circumstances where an extension of up to an additional 90 days may be required, you shall receive EBAC’s decision within 90 days of If EBAC denies your appeal, you will receive a written response which will include:  the specific reason(s) for the denial;  a reference to the specific Plan provision(s) on which the denial is based;  a statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to your claim for benefits; and  a statement of your right to bring a civil action under section 502(a) of ERISA. Benefits Effective January 1, 2011
For eligible union-represented employees

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