RIT
Human Resources

RIT Rx Plan Summary

Important Information

The information in this document is a summary of the major provisions of this benefit plan, and constitutes the summary plan description as governed by the Employee Retirement Income Security Act of 1974 (ERISA). Benefits under the plan are determined by the terms of the underlying plan document and contracts. In the case of any inconsistency between this document and the plan document or contract, the plan document or contract will govern your rights and benefits. \n\n RIT intends to continue the benefit plans indefinitely, but reserves the right to modify or terminate all or any portion of the employee benefits package at any time with or without notice. Such changes automatically will apply to you and your employment relationship at RIT. Participation in this plan is provided to eligible employees and does not constitute a guarantee of employment, requires continued employment and eligibility and is subject to the terms and conditions of the underlying plan document and insurance contracts.

Table of Contents

Introduction

The RIT Prescription Drug Plan (RIT Rx) is designed to pay a portion of covered prescription drug expenses for you and your eligible family members. Coverage under RIT Rx is automatic when you enroll in one of the following participating medical plans offered by RIT:

One medical plan currently offered by RIT does not include coverage for prescription drugs under RIT Rx: Blue Point2 POS Plan B No Drug.

RIT Rx is administered on RIT's behalf by a Pharmacy Benefit Manager ("PBM"). Medco is the currently designated PBM for RIT Rx.

Eligibility

Regular full-time and extended part-time employees enrolled in participating RIT-offered medical plans are eligible to participate in RIT Rx.

You may also obtain RIT Rx coverage for your spouse or domestic partner and/or dependent children by enrolling in the appropriate level of coverage for RIT-offered medical insurance under one of the participating plans. Your dependent children are those who are covered by your RIT participating medical plan, and include your natural-born children, step-children, foster children, legally adopted children, and children for whom you have been granted legal guardianship and who live with you in a child-parent relationship. An eligible unmarried dependent child is able to be covered to age 19, or to age 26 if a full-time student, or if living at home, financially dependent on you (claimed as a dependent on your tax return), with no coverage from his or her employer.

A spouse who is divorced from you is not eligible for coverage under the plan. If you have an eligible dependent who is also an RIT employee/retiree, he or she may be covered either as an employee/retiree or as a dependent, but not both. Please refer to pages XIV5-7 of the Employee Benefits Handbook for more information on covering a domestic partner.

Open Enrollment and Effective Dates

RIT Rx does not require a separate enrollment. When you enroll in one of the RIT-offered medical plans listed as participating plans in the Introduction to this summary, you are automatically enrolled in RIT Rx as of the same date your medical plan coverage is effective. You cannot enroll in RIT Rx without enrolling in one of the participating medical plans.

Your coverage level for RIT Rx will be the same as the coverage level you elect for your medical plan: individual, two-person, family or one-parent family. Coverage for your dependents usually begins when your coverage begins. However, if your spouse/partner or a dependent 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, consistent with coverage under the medical plan.

You have an opportunity once each year, during open enrollment, to make changes to your medical plan election. RIT Rx coverage is the same regardless of which participating medical plan you choose. You can choose not to be covered by RIT Rx by electing medical coverage under the one nonparticipating plan (Blue Point2 POS Plan B No Drug), or by choosing not to participate in RIT medical benefits (you would receive the Medical Opt-Out benefit).

Generally, your elections cannot be changed until the following plan year. Under certain circumstances, you may be able to make mid-year changes in your medical coverage, which may impact your RIT Rx coverage. See the description of "Election Changes During the Plan Year" in the Medical Care Plan section of your Employee Benefits Handbook for details.

Who Pays for This Protection

The cost of RIT Rx coverage is set by RIT each year and included in the coverage cost of each of the participating medical plans. As a result, a portion of any contribution that you are required to make toward the cost of your medical plan will apply toward the cost of your RIT Rx coverage. The remainder of the cost is paid by RIT from general assets under the self-insured RIT Rx Plan. Please note: Your online pay slip will reflect two separate contribution amounts: one for the medical plan and one for RIT Rx. However, you cannot elect RIT Rx without coverage under a participating RIT medical plan.

How to Use RIT Rx

Medco is the PBM which administers RIT Rx on RIT's behalf. Under the plan, covered medications can be purchased from a participating retail pharmacy or from Medco's mail-order pharmacy called Medco By Mail.

ID Cards

When you first enroll in RIT Rx, you will receive two prescription drug identification cards from Medco. If you need additional cards (for instance, if your child is attending college out of town), you can request them by calling Medco Member Services. In an emergency, you are able to print a temporary identification card from Medco's website. It is important to remember to use your RIT Rx ID card at the pharmacy, rather than your medical insurance ID card - the one exception to this is for individuals purchasing diabetic medications and supplies (see the detailed description in the section of this summary entitled "Important Coverage Alert: Diabetic Medications and Supplies").

Retail Pharmacies

Medco has contracted with a broad national network of retail pharmacies. This network includes more than 50,000 pharmacies throughout the United States. The network includes nearly all major retail pharmacy chains, such as CVS, Eckerd, Rite Aid (but not Walgreen's), 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 Medco network are referred to as "participating pharmacies." To locate a participating pharmacy close to your home or other location, you can call Medco Member Services or check Medco's website at www.medco.com. You can purchase up to a 30-day supply at one time at the retail pharmacy.

RIT Rx has Medco’s Retail Refill Allowance (RRA); the purpose of the RRA is to encourage plan participants to fill their prescriptions for maintenance medications (those drugs you take for an ongoing medical condition) through Medco’s home delivery pharmacy, Medco By Mail. See below for more details.

Medco By Mail

Medco also has a mail-order pharmacy service, Medco By Mail, for ordering maintenance medications (those drugs you take for an ongoing medical condition). Medco By Mail dispenses up to a 90-day supply of medications. Your copay for a 90-day supply will be lower with Medco By Mail than at a retail pharmacy. Your copays can be lower because RIT is sharing the savings that come from deeper discounts through Medco By Mail. In addition, you will have 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.medco.com and are typically delivered within seven to 10 days. An added benefit of Medco By Mail is the availability of registered pharmacists to answer questions about your medication or reactions 24 hours a day, seven days a week.

See the section “Claims and Payment of Benefits” for detailed instructions on using Medco By Mail.

As mentioned in the Retail Pharmacy section, if you do not use Medco By Mail for your maintenance medications, the Retail Refill Allowance (RRA) will apply and you will pay a higher copay. Refer to the Plan Design section for details.

On rare occasions, a particular drug will not be available through Medco By Mail. In this situation, you will need to fill your prescription at a participating retail pharmacy and pay the applicable retail pharmacy copay and the RRA would not apply.

Benefits

Covered Medications

RIT Rx provides coverage for Federal legend drugs, which are drug products bearing the legend "Caution: Federal law prohibits dispensing without a prescription." RIT Rx also covers certain prescription supplies, oral contraceptives, and some compound medications which contain at least one Federal legend drug in a therapeutic amount.

In order for RIT Rx to cover a prescription, the prescribed item must meet the following three requirements:

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:

The Various Tiers are Also Called Also Called
Tier 1 Generic N/A
Tier 2 Preferred Formulary
Tier 3 Non-preferred Non-Formulary

Generic Drugs

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 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:

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

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. Medco 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 Medco. 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 Medco'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 RIT Rx, but you pay a higher copayment than for generic or preferred brand name drugs.

Plan Design

Your cost for a prescription will be based on a 3-tier copay structure, and will differ depending on:

Copays and the Retail Refill Allowance (RRA)

The copays are summarized in the chart below. As you will see, if your take maintenance medications (those you take for an ongoing medical condition), there is a significant financial incentive to purchase them through Medco By Mail due to the RRA.

The RRA works as follows. On the 4th fill (original plus 3 refills) of a maintenance prescription filled at a retail pharmacy, 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 Medco By Mail. This will result in greatly increased copays if you continue to fill your maintenance medications at a retail pharmacy beyond the 3rd fill.

The RRA does not apply to acute care drugs such as antibiotics – your copays for such medications purchased at a retail pharmacy will not change from the current copays. Also, certain medications are not available from Medco By Mail, such as certain controlled substances; the RRA will also not apply in these situations.

RETAIL – 30-day supply up to 3 fills* RETAIL – 30-day supply 4th fill and after MEDCO BY MAIL – 90-day supply*
Tier 1: Generic Drugs $10 $25 $25
Tier 2: Brand Name Formulary Drugs $25 $62.50 $62.50
Tier 3: Brand Name Non-Formulary Drugs $40 $100 $100

*Please note that the copays for Medco By Mail 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.

The rest of the cost of your drugs will be paid by RIT Rx, except as described below. While the retail pharmacy copays listed above apply to each 30-day supply.

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 Medco. Your cost will be the retail copay you would have paid at a participating pharmacy, plus any additional amount charged by the nonparticipating pharmacy above the amount the drug would have cost at a participating retail pharmacy.

Under RIT Rx, there is no annual deductible to meet before the plan begins to pay benefits. There is also no out-of-pocket maximum.

Exclusions and Benefit Limitations

Exclusions

The following are not covered by RIT Rx. Some of them may be covered by your medical plan.

Prior Authorization

For certain medications, RIT Rx requires prior authorization by Medco 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 Medco's website, www.medco.com, or call Medco 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 Medco prior authorization form, which is available on Medco's website, www.medco.com or call Medco Member Services.

Quantity Limits

For certain medications, RIT Rx has 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 Medco's website, www.medco.com or call Medco Member Services.

Refill Limits

For refills from either a retail pharmacy or from Medco by Mail, 75% 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 Medco for a "vacation override."

Drug Utilization Review

Participating network pharmacies are given information by Medco 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 Medco'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 Medco By Mail pharmacists, is especially important if more than one physician is prescribing medications for an individual, or if prescriptions are filled at different pharmacies.

Important Coverage Alert for Diabetics

Diabetic Medications and Supplies

If you or a covered family member has diabetes, the following information is very important:

Under New York State law, insured medical plans are required by mandate to include coverage for diabetic medications and supplies, even if there is no insured prescription drug rider. Because of this law, most of the medical plans offered by RIT will continue to provide coverage for diabetic medications and supplies.

Claims and Payment of Benefits

Note: The general claims procedure for RIT benefit plans can be found on pages I-4 through I-5 of your Employee Benefits Handbook.

At a Participating Retail Pharmacy

Present your RIT Rx (Medco) ID card when you purchase your medication at a retail pharmacy that is part of Medco'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 RIT Rx. You do not need to file any claims.

Medco By Mail

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 Medco By Mail envelopes or ask your doctor to call 1-888-EASYRX1 (1 888 327-9791) for instructions on how to fax the prescription. If your order is faxed, your doctor must have the member number from your Medco 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 Medco By Mail, if you choose, but you have the option to fill it at a retail pharmacy if you prefer. The choice is up to you, although your cost for a 90-day supply through Medco By Mail will be lower. Note: do not submit 30-day prescriptions to Medco By Mail 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 copayment and there is a balance due of less than $100, an invoice will be included with your prescription order. If you overpaid, your account will be credited. If you owe more than $100 on your account, your prescription order will not be shipped until payment is made; you will receive a phone call from Medco 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 Medco. No more than $500 will be charged to a credit card at one time. You can join the automatic payment program by calling 1 800 948-8779 or by enrolling online at www.medco.com.

To check on the status of an order, you may call Medco Member Services or visit www.medco.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 Medco By Mail. You can order online anytime, or call 1-800-4REFILL (1 800 473-3455) 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 Medco's website, you will need to provide your member number, found on your Medco ID card, and the 12-digit 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 Medco Member Services toll-free number to use the automated telephone system. The requested materials will be mailed to you right away.

Using the Direct Reimbursement Claim 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 Direct Reimbursement Claim Form to Medco to obtain reimbursement of the amount that RIT Rx will pay. You can print the Direct Reimbursement Claim Form from RIT's Human Resources website, or can call Medco 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. Direct Reimbursement Claim Forms must be submitted within 12 months following the date you purchased the medication.

Payment of Benefits

Other than claims submitted using Direct Reimbursement Claim Forms, benefits will be paid directly to the participating pharmacy dispensing the medication. For claims submitted via Direct Reimbursement Claim Forms, benefits will be paid to you by check from Medco.

Recovery of Overpayments

If any benefit is paid in error to you or a pharmacy, RIT Rx 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 Participate in Beneflex

If you elected to contribute to a Beneflex Health Care Spending Account, your prescription drug copays and any other out-of-pocket expenses you incur for prescription drugs are eligible for reimbursement from your account.

You can use your Beneflex Flex Card to pay for your medications, whether you purchase them at the retail pharmacy or Medco By Mail. If you do not use the Flex Card for your prescription drugs, then you will need to file paper claims with the Beneflex administrator for reimbursement of your prescription drug copays and out-of-pocket expenses. See pages IV-8 through IV-9 of your Employee Benefits Handbook for the claims procedure to follow.

Coordination of Benefits

If you have other prescription drug coverage in addition to RIT Rx, the benefits paid by RIT Rx will be subject to coordination of benefits (COB) rules. While you and/or a dependent may be covered under two plans, your total benefit cannot exceed the amount that would have been paid under RIT Rx if you had only had one plan, and also cannot exceed the total cost of the drug.

If RIT Rx is secondary to the other plan's coverage (under the rules described later in this section), you or your dependent must use the other plan's ID card at the pharmacy. You can then submit a claim as described in the section above entitled "Using the Direct Reimbursement Claim Form." When RIT Rx is secondary, RIT Rx pays the difference, if there is any, between the RIT Rx benefit (after your required copay) and the amount paid by the primary plan, as follows:

Total prescription price
Minus the amount paid by the primary plan
Minus your applicable RIT Rx copay (and any other applicable out-of-pocket expense under RIT Rx)
Equals the amount RIT Rx will pay as the secondary plan

The following rules determine which plan is primary (pays first) and which is secondary (pays second). For your own claims and those of your spouse or partner, the plan that is primary 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 earliest 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.

Here are some examples to illustrate how coordination of benefits works.

Example 1: Dave, the spouse of an RIT employee, is covered by the XYZ Co. Medical Plan, sponsored by his employer, which includes prescription drug coverage. The XYZ plan is his primary coverage because it is the plan of his employer. Under XYZ's plan, prescription drugs are covered at 50%. Dave fills his prescription for a 30-day supply at a local pharmacy, and the 50% coinsurance he must pay is $60, since the total cost of the medication is $120. He submits a claim to RIT Rx for COB. Under RIT Rx, his medication is a brand name drug on the formulary. If RIT Rx had been primary, Dave's copay would have been $25, and RIT Rx would have paid the difference of $95. Because XYZ's plan has paid $60, his reimbursement from RIT Rx will be $60.

Example 2: Pat, an RIT retiree, works for ABC University, and has coverage under their medical plan for prescription drugs. ABC's plan has 3-tier copays: $5/$20/$35. Pat pays $20 at the pharmacy for her medication, and submits a claim to RIT Rx. The total cost of her medication is $30. If RIT Rx had been primary, Pat's copay would have been $25 and RIT Rx would have paid the difference of $5. RIT Rx will reimburse Pat $5.

When Coverage Ends

Since participation in RIT Rx depends upon your enrollment in a participating medical plan, the termination of coverage rules described on pages II-8 through II-9 of your Employee Benefits Handbook will apply to RIT Rx as well as to your medical coverage. If you are covered by RIT Rx and later elect coverage under a non-participating medical plan, then your coverage under RIT Rx will end as of the date your coverage in the participating medical plan ends.

COBRA Continuation of Coverage

See pages 1-4 of the July 2004 Updates to 2003 Employee Benefits Handbook for a detailed description of your right to elect to continue coverage under your medical plan and RIT Rx under certain circumstances. Please note that RIT Rx coverage can only be continued under COBRA if you elect to continue coverage in a participating medical plan under COBRA. COBRA continuation coverage under RIT Rx cannot be elected separately.

No Conversion

Unlike medical plan coverage, there is no option to convert RIT Rx coverage to individual coverage. If you convert your medical plan to an individual policy with your carrier, you should check with your carrier to see if a prescription drug rider is available for purchase.

Important Phone Numbers

Medco Member Services: 1-800-230-0508/v 1-800-759-1089/TTY
Medco By Mail Automated Refill Line: 1-800-4REFILL (1-800-473-3455)
Medco Physician Line: 1-888-EASYRX1 (1-888-327-9791)
Medco Pharmacy Support (for pharmacists): 1-800-922-1557

Your Rights under ERISA

[The U.S. Department of Labor requires that the following notice be included in all Summary Plan Descriptions.]

As a participant in Rochester Institute of Technology benefit plans, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:

Receive Information About Your Plan and Benefits

Examine, without charge, at the plan administrator's office and at other specified locations, such as worksites, all documents governing the plan, including insurance contracts, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration.

Obtain, upon written request to the plan administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may make a reasonable charge for the copies.

Receive a summary of the Plan's annual report. The Plan Administrator is required by law to furnish each Participant with a copy of this summary financial report.

Continue Group Health Care Coverage

Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights.

Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. [NOTE: None of the health insurance options presently offered by RIT include a pre-existing condition exclusion.]

Prudent Actions by Plan Fiduciaries

In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "Fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.

Enforce Your Rights

If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with Your Questions

If you have any questions about your plan, you should contact the plan administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the plan administrator, you should contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Pension and Welfare Benefits Administration.

Your Rights under the Newborns' and Mothers' Health Protection Act

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Qualified Medical Child Support Orders ("QMCSOS")

A medical child support order shall be filed with the plan administrator as soon as reasonably possible after it has been filed promptly upon the receipt of such order, the plan administrator shall notify the participant and each person eligible to receive benefits under the terms of the order ("alternate recipients") of its receipt and of the procedures set forth in this section 14.04.

The Participant and the alternate recipients may provide comments to the Plan Administrator with respect to the order during the 30 day period commencing as of the date the Plan Administrator sends them notice of receipt of the order. The Plan Administrator shall, within the 60 day period commencing as of the expiration of the 30 day comment period specified in the preceding sentence, determine whether the order is qualified and shall so notify the participant and the alternate recipients in writing of its decision. The parties may waive the 30 day comment period. If they do so, the 60 day period shall commence as of the date all parties have waived their rights to submit comments. The Plan Administrator's determination on the qualified status of an order is final. As soon as reasonably practicable following its notification that an order is "qualified," the Plan Administrator shall take such steps it deems appropriate to implement the order.

The Plan Administrator encourages parties to submit draft orders for "pre-approval" of their qualified status prior to their being submitted to a court for signature as such pre-approval will expedite approval procedures.

An alternate recipient may designate a representative for receipt of copies of notices that are sent to an alternate recipient with respect to a medical child support order.

Claim Procedures

  1. Claims for Benefits - An Employee wishing to present a claim for benefits for himself or his Dependents should obtain a claim form or forms from his Employer or Plan Administrator. The applicable section of such form or forms should be completed by (1) Employee, (2) Employer or Plan Administrator, and (3) attending Physician or Hospital. Claims will only be processed if received within a reasonable time following the date the expense to which the claim relates arises.

    Following completion, the claim form or forms should be submitted to the Plan's representative as indicated on the reverse side of the Employee's Benefit Plan Identification Card. The organization that is authorized by the Plan to process and pay claims (the Plan's Claims Administrator) will compute benefits due, and cause proper claims to be paid. Unless the Employee assigns benefits to a doctor or to a Hospital, draft(s) will be made payable to the Employee.

    A decision will be made by the Claims Administrator no more than ninety (90) days after receipt of due proof of loss, except in special circumstances (such as the need to obtain further information), but in no case more than one hundred eighty (180) days after the due proof of loss is received. The written decision will include specific reasons for the decisions and specific references to the Plan provisions on which the decision is based.

  2. Appealing Denial of Claims - If a claim for benefits is wholly or partially denied, notice of the decision shall be furnished to the Employee. This written decision will:
    1. Give the specific reason or reasons for denial;
    2. Make specific reference to the Plan provisions on which the denial is based;
    3. Provide a description of any additional information necessary to perfect the claim, if possible, and an explanation of why it is necessary; and
    4. Provide an explanation of the review procedure.
    On any denied claim an Employee or his representative may appeal to the Plan Administrator for a full and fair review. The claimant may:
    1. Request a review upon written application within sixty (60) days of receipt of claim denial;
    2. Review pertinent documents; and
    3. Submit issues and comments in writing.

A decision will be made by the Plan Administrator no more than sixty (60) days after receipt of the request for review, except in special circumstances (such as the need to hold a hearing), but in no case more than one hundred twenty (120) days after the request for review is received. The written decision will include specific reasons for the decision and specific references to the Plan provisions on which the decision is based.

Additional information about claims submitted and review procedures may be obtained by contacting the Plan Administrator.

If you have any questions about your Plan, you should contact the Human Resources Department. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest Area Office of the U.S. Labor Management Services Administration, Department of Labor.

Additional Information

Employer
Rochester Institute of Technology

Employer Identification Number
16-0743140

Plan Sponsor
Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604

Plan Administrator
Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604

Business Telephone Number
(585) 475-2424 (voice)
(585) 475-2420 (TTY)

Agent for Service of Legal Process
Associate Director of Human Resources for Compensation and Benefits
Rochester Institute of Technology
8 Lomb Memorial Drive
Rochester, NY 14623-5604