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受托人的意见
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在再保险
原告: 领取养老金者和未亡配偶
被申请人: 雇主
ROD案例编号: CA-066 - 2003年2月25日
受托人: A. 弗兰克·邓纳姆，迈克尔·H. 霍兰德，马蒂·D. 哈德逊,
艾略特一. 西格尔.
受托人审查了有关根据《皇冠搏彩中心》第9711条维持的1992年《皇冠搏彩中心网站》(《皇冠搏彩中心》)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
1月1日生效, 2002, 被访者实施了一项邮寄服务药房计划，用于维持处方药——长期用于治疗高血压等慢性疾病的药物, 糖尿病, 哮喘和高胆固醇. 一般来说，根据《皇冠搏彩中心》雇主福利计划，受益人支付5美元.每张处方的自付额最高可达50美元.每个计划年每个家庭00美元. 根据答辩人, 如果受益人通过邮购计划购买维持药物, 的5美元.00元的自付费用(如适用)可获豁免. If a beneficiary purchases a maintenance drug at a retail pharmacy, the beneficiary pays 的5美元.00美元自付(如适用)外加10美元.00附加费. 然而，10美元.00附加费 is waived if the beneficiary can document for reasons of medical necessity that the beneficiary is unable to use the mail order program. 例如，10美元.住在护养院的受益人可获豁免额外收费00元. 此外，10美元.从零售药房购买的短期处方药物(例如治疗链球菌性咽喉炎的抗生素)，不适用附加费.
的 Respondent’s program was communicated to beneficiaries by mail in August 2001 and September 2001. 除了, 为与受益人讨论该方案举行了136次会议，并设立了两个新职位，帮助受益人解决处方问题.
原告声称，10美元.00附加费 applied for purchasing maintenance drugs through a retail pharmacy is in violation of the Coal Act 雇主 好处 Plan.
争端
Is the Respondent’s mail order maintenance drug program in violation of the Coal Act 雇主 好处 Plan?
双方立场
投诉人的立场:被投诉人的邮购维持药品计划违反了《皇冠搏彩中心》雇主福利计划，要求额外支付10美元的附加费.在零售药房购买药品的维修费用.
Position of the 被申请人: 的 Respondent’s mail order maintenance drug program is not in violation of the Coal Act 雇主 好处 Plan for the following reasons: 1) 的 program has not eliminated or reduced any benefits participants are eligible to receive under the Coal Act Plan; 2) Articles III and IV of the Coal Act Plan support the implementation of cost containment rules that encourage participants to utilize mail order deliver of maintenance drugs; 3) By waiving 的5美元.00自费比例, the mail order maintenance program saves the beneficiary money; 4 ) 的 program provides an appeal process for identifying medically necessary situations that require alternatives to the mail order program; and 5) 的 $10.00元附加费是由零售行政及配发费3元扣除.75加6美元.25 which is the difference between the average cost of ingredients at retail and the average cost under the mail order plan.
相关的规定
《皇冠搏彩中心》雇主福利计划第三条导言指出:
Subject to 第四条, the benefits provided under this Plan are set forth in this Article III. 好处 payments shall not exceed reasonable and customary charges for covered services and supplies. 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. 在确定合理性和必要性的问题上, due consideration will be given to the customary practices of physicians in the community where the service is provided. 不合理和不必要的服务包括, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. 的 benefits described in this Article are subject to any requirements implemented pursuant to 第四条. 将继续提供医疗上必要的承保服务, 和相应的, 虽然福利金支付可能受到管理式护理和成本控制规则的约束, this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
第三条A. 《皇冠搏彩中心网站》第(4)(a)条规定:
药费表
(处方药)
(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。. 初始分配的数量不得超过30天的供应量. Any original prescription may be refilled for up to six months as directed by the attending physician. 的 first such refill may be for an amount up to, but no more than, a 60 day supply. 的 second such refill may be for an amount up to, but no more than, a 90 day supply. 好处s for refills beyond the initial six months require a new prescription by the attending physician.
处方药或胰岛素的合理收费也包括在内. Subject to any cost containment rules and procedures adopted pursuant to 第四条, 合理收费包括以下两者中较低者:
(1) 每份处方或续药的实际账单金额，或者
(2) 平均批发价加上25%，不低于2美元.50元以上，不超过10元.每支处方或补药的平均批发价高于100美元, or the Plan Administrator may determine average wholesale price from either the American Druggist Blue Book, 药物主题红皮书, 或《皇冠搏彩中心》.
(3) For a pharmacist participating in a Trustee-established prescription drug program, the current price paid by the Funds and available to the 雇主 in a piggybacked program.
(4) 适用的非专利替代药品的价格, 如果是AB或更高评级, approved by the 联邦食品和药物管理局; or, in the event the prescribing physician determines that use of a brand name drug is medically necessary, 该品牌药品的价格;
(5) 特定药物处方清单上所列药物的费率以及计划管理者采用并提供给计划参与者的支付费率;
(6) 的 current price paid to participating pharmacies on a Participating Provider List (PPL) adopted by the 雇主 pursuant to 第四条. 雇主将通知受益人使用PPL药房的需要. If a Beneficiary purchases a prescription drug or insulin from a pharmacy that is not on the 雇主’s PPL, the 雇主 will advise the Beneficiary by letter regarding the future consequence of using a non-PPL pharmacy. 如果受益人未能第二次使用PPL药房, the 雇主 will contact the Beneficiary in person or by telephone to counsel the Beneficiary on the consequences of using a non-PPL pharmacy. 遵循这样的咨询, 第(10)(g)3条的“保持无害”保护将不再适用于为该受益人或其合格家属从非雇主PPL上的任何药房购买的处方药和胰岛素.
第三条A. 《皇冠搏彩中心网站》的相关部分规定:
(8) 共同支付和免赔额
Certain benefits provided in this Plan shall be subject to the co-payments set forth ，此类共同付款应由受益人负责. 的 计划管理人应执行被认为适当的程序 实现这些共同支付的目的. 受益人和提供者应提供 计划管理人有效管理所需的信息 这些共同付款，或此类受益人或提供者不应符合资格 本计划项下的福利或付款. 任何支付给供应商的多付款项 超额收取本计划的费用，而不是向保险公司收取相应的共同付款 参与人或受益人应由该等人偿还给计划管理人 提供者.
承保健康福利的共同支付额确定如下:
好处
是否值得
(a)门诊医生服务
如第A(2)条所述及
与…有关的医生访问
第A(3)条规定的福利;
(c)段，但只适用于
post-natal visits if the physician charges separately for such visits in addition to
运费及段数
(g)至(m)段，(n)段除外
住院手术，第(o)段及
第A(7)条第(f)段.
每次5元，上限为100元
每个家庭每12个月.
(b)规定的处方药和胰岛素
第A(4)条所述
并在医院坐月子后将药品带回家
第(A)(1)(A)条 每份处方5美元
或者加满50美元
每12个月最高限额
每户周期.
注:仅供参考
这种共同支付
规定,一个
处方或补充
应被视为
每30天(或
部分供应.
12个月的期限从每年的3月27日开始.
Additional Rule Regarding Brand Name 处方药 where a generic equivalent is 可用:
除了定期的共同支付外，受益人还负责 品牌药的额外成本高于非专利替代品的成本. A generic drug will not be considered “available” unless it has been approved by the 联邦食品和药物管理局. 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 by the
使用品牌药品的受益人. 注:“保持无害” 第(10)(g)3条的保护不适用于品牌处方药 哪里有通用的等效物.
第三条A. 《皇冠搏彩中心》雇主福利计划第(10)(b)条规定:
(10) 一般规定
(b)管理
的 Plan Administrator is authorized to promulgate rules and regulations to implement and administer the Plan, and such rules and regulations shall be binding upon all persons dealing with the Beneficiaries claiming benefits under this Plan. UMWA的受托人，1992年 福利计划将解决任何争议, 包括过高的费用纠纷, to assure consistent application of the Plan provisions which are identical to the benefit provisions of the 1992 好处 Plan.
第三条A. (10) (g) 1. 和2. 提供以下内容:
(g) 利益解释(EOB)，成本控制和保持无害
1. Each Beneficiary shall receive an explanation of billing and payment rendered on behalf of such Beneficiary. 是否应因计划管理人认定收费超过合理和惯例收费而拒绝支付服务的全额费用, 上述EOB的副本应送交世界环境保护联盟(国际总部), 注意事项:福利部).
2. (i) 关于保健费用的控制，受托人 根据《皇冠搏彩中心》第9712(c)节的规定，1992年UMWA福利计划有权制定管理式护理和成本控制规则和程序. 在其他项目中, 受托人有权采取措施控制处方药费用, 包括但不限于, 只支付当前的平均批发价, encouraging the use of generic drugs instead of brand name drugs where medically appropriate, 在有利的情况下鼓励使用邮购药物计划.
(ii) 的 Trustees shall make available to the Plan Administrator any special cost containment arrangements that they make with outside vendors and/or 提供者s. 进一步, the Plan Administrator may “piggyback” the cost containment programs adopted by the Trustees, and may utilize the managed care and cost containment rules and programs adopted by the Trustees.
(3) 争议应按照第10条第b款解决。.
(iv) 双方明确理解，本节中的任何内容均不得减少或改变雇主目前在管理本计划方面所拥有的任何权利.
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第四条A. 和B. 《皇冠搏彩中心网站》中规定:
第四条. 管理式医疗，成本控制
A. 雇主可以采用医生的参与提供者名单(PPL), 医院, 药店和其他供应商, 前提是任何此类PPL已根据1993年全国烟煤工资协议(“1993年NBCWA”)第XX(c)(3)(i)条维护的雇主福利计划批准采用。. 雇主可以 also implement a formulary for prescription drugs; implement a mail-order procedure for prescription drugs, including appropriate limits on quantity and periodic physician review; and subject the prescription drug program to a rigorous review of appropriate use.
B. 除了, 雇主可实施某些其他管理式医疗和成本控制规则, 哪些福利既适用于PPL提供者，也适用于非PPL来源, 但(除本计划中特别规定的共同付款外)不会导致本计划下提供的承保服务的福利减少或额外费用.
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受托人的意见
受托人在这件事上陷入僵局. 受托人Holland和Hudson为原告找到的. 受托人邓纳姆和西格尔支持被告. 根据1992年UMWA福利计划受托人批准的ROD程序, 此事已提交给中立的利益仲裁者, 罗伯特E. Nagle，代表决心. 的 arbitrator was directed to choose one of the two draft opinions proposed by the Trustees. 仲裁员的选择如下所示，作为受托人的意见.
仲裁员的决定
雇主维持处方药的邮寄服务药房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, and therefore is not within the 雇主’s authority to implement under the Coal Act and Article III. A. 《皇冠搏彩中心网站》(10)(b).