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AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 1

Avaya Inc. Health & Welfare

Benefits Plan

Active Represented Prescription Drug Plan

Summary Plan Description

Effective: January 1, 2018

Express-Scripts

You should keep a copy of this Summary Plan Description for future reference. If this Summary Plan Description has been delivered to you by electronic means, you have the right to receive a written summary and may request a copy of this summary on a written paper document at no charge by contacting the Plan Administrator (contact information is provided under the heading “Administrative Information” in this summary).

Summary Plan Description


This booklet describes the Prescription Drug Plan (also referred to herein as the “Plan”) in effect as of

January 1, 2018, and serves as the summary plan description (“SPD”) for the Plan. It describes the

prescription benefits as they apply to eligible, active represented Avaya employees who are participants

in one of the following Avaya-sponsored medical plans offered through Aetna:

Point-of-Service (“POS”)

Traditional Indemnity (“Indemnity”)

Separate SPDs describe the medical benefits available to you through the medical plan you have chosen.

For a copy of your medical plan SPD, please go to: www.avaya.com/benefitanswers.

We encourage you to read this SPD carefully and share it with your family members. If you have any questions

about your benefits, please contact the Avaya Health & Benefits Decision Center at 1-800-526-8056 (Option 1)

or contact Express-Scripts, Avaya’s prescription drug administrator, directly at 1-877-505-3213.

The Prescription Drug Plan is offered through The Avaya Inc. Medical Expense Plan (“Medical Plan”),

which is a part of the Avaya Inc. Health & Welfare Benefits Plan (the “Wrap Plan”). This Summary Plan

Description (SPD) contains a summary in English of your prescription drug benefits and your rights and

benefits under the Prescription Drug Plan. If you have difficulty understanding any part of this SPD,

please contact the Avaya Health & Benefits Decision Center at 1-800-526-8056 (Option 1).

Note that this SPD is only a summary of the pharmacy benefits. If there is any difference between the

information in this SPD and the Wrap Plan document, the Wrap Plan document will govern.

This SPD contains a summary of the provisions of the Plan as of the date of publication. The Board of

Directors of Avaya Inc. (or its delegates) reserves the right to modify, suspend or terminate these

benefits, in whole or in part, at any time. The Plan Administrator, or its designee, has sole discretionary

authority to interpret and construe the provisions of the Plan, to determine eligibility for benefits under

the Plan, and to resolve any disputes that arise under the Plan. Benefits under the Plan will be paid only

if the Plan Administrator decides, in its discretion, that the applicant is entitled to them.

No provision of the Wrap Plan, Medical Plan or Prescription Drug Plan is to be considered an offer of

employment or a guarantee of employment for any period of time at Avaya. Avaya employees are

employees at will, which means that they can terminate their employment at any time and for any

reason. Likewise, Avaya may terminate an employee’s employment at any time and for any reason.

Summary of Material Modifications

In addition to this SPD, Avaya and/or Express Scripts may notify you from time to time of changes to the

Prescription Drug Plan described here (for example, changes to covered drugs or changes to the

prescription drug formulary). These notices serve as Summaries of Material Modifications (“SMMs”). It is

important to read these notices so you understand the effect of any change on your personal situation,

as well as be familiar with the material in this SPD.


How to Use this SPD

Read the entire SPD, and share it with your family. Then keep it in a safe place for future reference.

Many of the sections of this SPD are related to other sections. You may not have all the information

you need by reading just one section.

Terms used in this SPD have special meanings. See “Section 12 - Important Terms” for definitions of

commonly-used terms.

If eligible for coverage, the words “you” and “your” refer to eligible Avaya employees, as defined in

“Section 2 - Eligibility and Participation”.

Express Scripts is also referred to as the “Claims Administrator”.

Avaya Inc. is also referred to as the “Company”.

Effective Date of this Summary Plan Description

This SPD summarizes the prescription drug benefits available to eligible represented employees under

the Medical Plan as of January 1, 2018.

Where You Can Get a Printed Copy

If you would like to have a printed copy of this SPD, please contact the Avaya Health & Benefits Decision

Center at 1-800-526-8056 (Option 1) or email us at [email protected].

How to Reach Express Scripts

Prescription Drug Plan Telephone Number Website Address

Member Services 1-877-505-3213

(TDD: 1-800-289-1089)

www.express-scripts.com

Physician Services Phone: 1-888-327-9791

Fax: 1-800-837-0959

Address for submitting claims Express Scripts

P.O. Box 2872

Clinton, IA 52733-2872

Download claim form from

www.express-scripts.com

Express Scripts Mobile App Free from Android and Apple App Stores.

Search for “Express Scripts” in your app

store.

Download the app from

www.express-

scripts.com/mobileapp

mailto:[email protected]

http://www.express-scripts.com/





Table of Contents Highlights of the Prescription Drug Plan .................................................................................................... 8

SECTION 2 – ELIGIBILITY AND PARTICIPATION .................................................................................... 10

Who Is Eligible for Prescription Coverage ............................................................................................... 10

Dependent Eligibility ......................................................................................................................... 10

Coverage for a Domestic Partner ...................................................................................................... 12

Coverage for Your Domestic Partner’s Child(ren) ............................................................................. 12

SECTION 3 – ENROLLING FOR COVERAGE ........................................................................................... 13

If You Do Not Enroll ................................................................................................................................. 14

If You Waive Medical/Prescription Drug Coverage ................................................................................. 14

Paying for Coverage ................................................................................................................................. 14

When Prescription Benefit Coverage Begins ........................................................................................... 15

Coverage Levels ....................................................................................................................................... 15

Making Changes During the Year ............................................................................................................ 15

HIPAA Special Enrollment Rights ............................................................................................................. 15

Loss of Eligibility for Other Medical Coverage .................................................................................. 15

Loss or Gain of Eligibility for a State Children’s Health Insurance Program (CHIP) or Medicaid ...... 15

When Prescription Coverage Ends .......................................................................................................... 16

Continuing Coverage When It Might Otherwise End .............................................................................. 17

SECTION 4 – PRESCRIPTION DRUG BENEFITS ...................................................................................... 18

Overview of Your Prescription Drug Benefits .......................................................................................... 18

Finding a Participating Pharmacy ............................................................................................................ 19

Retail Pharmacy ....................................................................................................................................... 19

Home Delivery Program .......................................................................................................................... 19

How the Plan Works ................................................................................................................................ 20

A Quick Look at the POS Plan: ........................................................................................................... 20

A Quick Look at the Traditional Indemnity Plan ............................................................................... 21

Your Prescription Drug Benefits at a Glance ........................................................................................... 21

Tips for Using the Home Delivery Service ......................................................................................... 22


Your ID Card ...................................................................................................................................... 23

Covered Medications ............................................................................................................................... 23

Preventive Drugs Covered at 100% ................................................................................................... 24

Drugs the Plan Covers Based on Copayments (Coinsurance at a Non-Participating Pharmacy) ...... 24

Express Scripts Specialty Pharmacy Services ........................................................................................... 25

Specialty Medications ....................................................................................................................... 25

Special Features of the Prescription Drug Plan ....................................................................................... 25

The Prescription Drug Formulary ...................................................................................................... 25

Precertification/Coverage Review Programs ........................................................................................... 26

Prior Authorization ............................................................................................................................ 26

Qualification by History ..................................................................................................................... 27

Supply Limits ..................................................................................................................................... 28

Step Therapy Requirements .............................................................................................................. 28

Additional Pharmacy Services.................................................................................................................. 29

What Is Not Covered ................................................................................................................................ 29

SECTION 5 – FILING PRESCRIPTION DRUG CLAIMS .............................................................................. 31

In-Network ............................................................................................................................................... 31

Out-of-Network ....................................................................................................................................... 31

Filing for Reimbursement from a Health Care Flexible Spending Account ............................................. 31

Filing a Claim Appeal ................................................................................................................................ 31

Claim Appeal Procedures .................................................................................................................. 31

How to Request an Initial Coverage Review ............................................................................................ 32

How a Coverage Review Is Processed ..................................................................................................... 32

Denial Process .......................................................................................................................................... 33

How to Request Appeals after Coverage Review Has Been Denied ........................................................ 33

Level 1 Appeal ................................................................................................................................... 33

Level 2 Appeal ................................................................................................................................... 34

Standard External Appeals ................................................................................................................ 34

Expedited Reviews ............................................................................................................................ 35

Appeals Filing Time Limit .................................................................................................................. 36


Judicial Review .................................................................................................................................. 36

SECTION 6 – COORDINATION OF BENEFITS ......................................................................................... 37

Coordination of Benefits If You Are Covered by More Than One Prescription Drug Plan ...................... 37

Coordination with Medicare .................................................................................................................... 37

Benefits for Individuals Who Are Entitled to Medicare .................................................................... 37

Subrogation and Right of Reimbursement .............................................................................................. 38

Specific Requirements and Plan Rights ............................................................................................. 38

Participant Duties and Actions .......................................................................................................... 39

Additional Provisions ......................................................................................................................... 40

Refund of Overpayments .................................................................................................................. 41

SECTION 7 – CONTINUATION OF COVERAGE ...................................................................................... 42

Continuation Coverage Rights Under COBRA .......................................................................................... 42

What Is COBRA Continuation Coverage ............................................................................................ 42

COBRA Qualifying Events .................................................................................................................. 43

Giving Notice that a COBRA Qualifying Event (or Second Qualifying Event) Has Occurred ............. 43

How Is COBRA Continuation Coverage Provided .............................................................................. 44

Duration of COBRA Continuation Coverage ...................................................................................... 44

Electing COBRA Continuation Coverage............................................................................................ 46

Paying for COBRA Continuation Coverage ........................................................................................ 47

When COBRA Continuation Coverage Ends ...................................................................................... 47

If You Have Questions ....................................................................................................................... 48

Keep Your Plan Informed of Address Changes .................................................................................. 48

Family Security Program .......................................................................................................................... 48

SECTION 8 – WHAT IF… ...................................................................................................................... 49

You Leave Avaya ...................................................................................................................................... 49

You Become Disabled .............................................................................................................................. 49

You Die ..................................................................................................................................................... 49

Family Security Program ................................................................................................................... 49

You Go on an Approved Leave of Absence .............................................................................................. 49


You Gain a New Dependent ..................................................................................................................... 50

A Dependent Loses Eligibility ................................................................................................................... 50

Your Physically or Mentally Handicapped Child Reaches Age 26 ............................................................ 50

You Go on Military Leave ......................................................................................................................... 50

You Go on FMLA Leave ............................................................................................................................ 51

SECTION 9 – HIPAA PRIVACY RIGHTS .................................................................................................. 53

SECTION 10 – OTHER REGULATORY AND LEGAL REQUIREMENTS ........................................................ 54

Qualified Medical Child Support Order (QMCSO) ................................................................................... 54

Plan Administration/Interpretation ......................................................................................................... 54

Plan Document ........................................................................................................................................ 55

How You May Lose Benefits .................................................................................................................... 55

Rescission ................................................................................................................................................. 55

The Company’s Right to Amend or Terminate the Plan .......................................................................... 55

Limitation on Assignment ........................................................................................................................ 56

Your Employment .................................................................................................................................... 56

Statement of ERISA Rights ....................................................................................................................... 56

Receive Information about Your Plan and Benefits .......................................................................... 56

Continue Group Health Plan Coverage ............................................................................................. 56

Prudent Actions by Plan Fiduciaries .................................................................................................. 57

Enforce Your Rights ........................................................................................................................... 57

Assistance with Your Questions ........................................................................................................ 57

SECTION 11 – ADMINISTRATIVE INFORMATION ................................................................................. 59

SECTION 12 – IMPORTANT TERMS ..................................................................................................... 61


SECTION 1 – WELCOME

What this section includes:

Overview of your prescription drug coverage

Highlights of your prescription drug benefits

Prescription drug coverage is provided under the Plan, and is administered by Express Scripts (“Claims Administrator”). When you enroll in the Point of Service (POS) or Traditional Indemnity medical plan, you automatically receive prescription drug coverage through Express Scripts, Inc. (“Claims Administrator”).

You may purchase prescriptions through a national network of participating retail pharmacies, through a non-participating retail pharmacy (at a higher cost), or through the home delivery service program. See “Section 4 - Prescription Drug Benefits” for detailed information about how the Prescription Drug Benefit works.

Highlights of the Prescription Drug Plan

Plan Feature Summary

Eligibility You are eligible for coverage if you are an active represented employee who is enrolled in

one of the following medical plans:

Point-of-Service (POS)

Traditional Indemnity

If your dependents are enrolled for medical coverage in one of these plans, they will also

be eligible for prescription drug benefits.

Enrollment You are automatically enrolled for prescription drug coverage when you enroll in one of

the medical plans listed above.

Cost of Coverage You are not required to make contributions in connection with the medical or prescription

drug plans after coverage is effective on your 90th day of net credited service. If you wish

to enroll for medical and prescription drug coverage to be effective during the 90-day

waiting period, you must pay the full cost of coverage during that time. In that case, the

cost of your prescription drug coverage is included in your medical plan contributions.

Cost of Prescriptions The cost of the prescription drugs you purchase will depend on whether you choose a

generic, a preferred brand or a non-preferred brand name drug. Your cost will also

depend on whether you use in-network or out-of-network pharmacies.

How to Get the Most

from Your Plan

Here are a few tips:

Use generic drugs. They are therapeutically equivalent to their brand name

counterpart and less expensive.

Go in-network. Otherwise, you pay a higher cost for your medication, after you meet

a deductible.

Using ongoing medication? Home delivery is required after 3 fills at retail. It’s

convenient and much less expensive.

Understand the prescription formulary, what’s covered and any special features of

the Plan.

Use this booklet as a reference and contact Express Scripts for detailed information


Plan Feature Summary

and questions.


SECTION 2 – ELIGIBILITY AND PARTICIPATION


Who is eligible for prescription drug coverage

Who are eligible dependents

Who is not eligible for prescription drug coverage

Who Is Eligible for Prescription Coverage

You are eligible for the prescription drug coverage described in this SPD if you are a regular, full-time or

part-time, represented employee covered by a collective bargaining agreement that provides for the

benefits provided under the Plan who works for Avaya Inc. and such other affiliates that have elected to

participate in the Plan with the prior approval of Avaya Inc. (an “Avaya Participating Company”) and who

is enrolled for coverage under one of the following medical plans offered through Aetna:

Point-of-Service (POS)

Traditional Indemnity

You are not eligible for the Prescription Drug Program:

If you are enrolled in an International Assignee plan and paid from the U.S. payroll of an Avaya

Participating Company, or you are covered through Aetna Global Benefits under the International

Indemnity plan. Instead, you will receive the prescription drug benefits available through Aetna

Global Benefits. Contact Aetna Global Benefits at the number on your Medical ID card for specific

information about prescription drug benefits.

If you select a non-Aetna medical plan through Avaya, such as Kaiser or HMSA. Instead, you will

receive the prescription drug benefit available through your plan. Contact your carrier for specific

information about the coverage available.

If you are not paid from the U.S. payroll of an Avaya Participating Company, you are employed by

an independent company (such as an employment agency), or your services are rendered as part of

an agreement excluding participation in benefits.

Dependent Eligibility

Your eligible dependents can also participate in the Prescription Drug Plan if you elect coverage for them

under the POS or Traditional medical plan. You must enroll your dependents in the same medical plan in

which you are enrolled. Eligible dependents are defined by Avaya Inc.

Eligible Dependents Include:

• Your Lawful Spouse or Domestic Partner (either same-sex or opposite-sex; both parties must

complete and file a notarized Domestic Partner Affidavit or Government registration).


• Children To be eligible for coverage, a dependent child must be under 26 years of age. Each child is

eligible for coverage through December 31st of the year in which the child reaches age 26. An

eligible dependent child includes:

• Your biological and/or legally adopted child, including any child in the formal legal process of

adoption, regardless of residence;

• a stepchild living with you; and

• a child living with you for whom you or your lawful spouse or your domestic partner is the

legal guardian (this does not include "wards of the state" or "foster children")

A child, for this purpose, does not include the spouse, domestic partner, or child(ren) of a child.

An unmarried handicapped child of any age may be eligible for coverage (as certified by the

applicable medical Claims Administrator under the Medical Plan) by meeting all of the following

criteria:

• Permanently incapable of self-support,

• Physically or mentally handicapped, and

• Fully dependent on you for support.

You must complete an application form available from your applicable medical Claims

Administrator, and submit it for approval to the address listed on the form.

No coverage is available for a child over age 26 who is incapacitated for a short time due to illness

or accident.

• Class II Dependents (must receive less than $12,000 per year in income from all sources, other than

the Avaya employee’s support; must live with you or in a nearby household provided by you, and in

the case of unmarried dependent stepchildren, live with you throughout the period of coverage;

AND must either have been continuously re-enrolled during each annual enrollment since January

1, 1996 and continue to be re-enrolled each year (non-grandfathered Class II dependents), or have

been enrolled before June 1, 1986 and continuously enrolled each plan year thereafter

(grandfathered Class II dependents). Class II Dependents include:

• Your unmarried dependent child(ren) not included above;

• Your unmarried dependent stepchild(ren) not included above;

• Your unmarried grandchild(ren);

• Your unmarried brothers and sisters;

• Your parents and grandparents;

• Your lawful spouse’s parents and grandparents.

Ineligible dependents include a legally separated spouse, a divorced spouse, and a domestic partner

where the domestic partnership has terminated.


Coverage for a Domestic Partner

A domestic partner is an individual (same-gender or opposite-gender) who certifies, by affidavit, the

following as of the date of enrollment:

• He or she is your sole domestic partner and intends to remain so indefinitely.

• He or she is not married or legally separated from anyone else.

• He or she has not registered as a member of another domestic partnership.

• He or she is of the age of consent in your state of residence.

• He or she is not a blood relative to a degree of closeness that would prohibit legal marriage in the

state in which you legally reside.

• He or she resides with you in the same residence.

• He or she is engaged with you in a committed relationship of mutual caring and support, and is

jointly responsible for your common welfare and living expenses.

• He or she is not in the relationship solely for the purpose of obtaining the benefits of coverage.

• He or she has mental sufficiency to enter into a valid contract.

Coverage for Your Domestic Partner’s Child(ren)

A domestic partner’s child is defined as:

• The natural or adopted child of a domestic partner,

• A child whom the domestic partner is in the formal, legal process of adopting, or

• A child living with you for whom the domestic partner is the legal guardian.


SECTION 3 – ENROLLING FOR COVERAGE


About enrollment

What happens if you don’t enroll

When coverage begins

How long elections are in effect

Changes due to a qualified status change

Paying for coverage

When coverage ends

When you enroll in the Medical Plan you are automatically enrolled for prescription drug coverage.

The timeline for enrollment in an Avaya medical plan varies by your employment status. Here are some key

dates to keep in mind:

Employment Status Timeline to Enroll Eligibility Coverage Date

Newly-hired/rehired or newly-

eligible active full-time or part-time

employees

You have 31 days from your eligibility coverage date to enroll in or waive coverage for yourself and/or your dependents

90th day of net credited service* * Note: You can get coverage during the 90-day waiting period if you pay the full cost of coverage during the waiting period. The cost is waived if you have been continuously covered as a dependent of another Avaya employee or retiree.

Current active eligible employees Annual enrollment period January 1st of the following calendar year (after meeting your 90th day of net credited service)

Within 31 days of a qualified status change (e.g. birth, adoption, marriage, death of dependent, divorce, involuntary loss of other group health coverage, etc.)

Your coverage eligibility date depends on your qualified status change. Coverage typically begins on the date of the event or the first of the month following the event.

Your elections are in effect as follows:

The elections you make as a newly-hired/rehired employee are effective following a 90-day waiting

period for the duration of the calendar year in which you are hired/rehired and enroll.

The elections you make during annual enrollment are in effect for the next full calendar year.


If You Do Not Enroll

If you do not enroll in a medical plan as an eligible newly-hired/rehired/newly-eligible employee,

you may be assigned medical coverage (including prescription drug coverage) based on your

employment status and where you live. Your eligible dependents will not have coverage.

If you are a current eligible employee enrolled in the POS or Traditional Indemnity medical plan,

your current medical/prescription drug coverage will carry over to the next calendar year (at the

next year’s contribution rates) unless you make an active election during the annual enrollment

period or have a mid-year qualified status change.

If you are not currently enrolled in the Medical Plan and do not enroll in a medical plan during

annual enrollment, your eligible dependents will have no medical/prescription drug coverage. You

will not be able to elect medical/prescription drug coverage until the next annual enrollment

period, unless you have a mid-year qualified status change. See “Making Changes during the Year”

in Section 3 for more information.

If You Waive Medical/Prescription Drug Coverage

If you waive coverage because you have health insurance coverage elsewhere, you may not enroll

yourself and your dependents for coverage until the next annual enrollment period, unless you have a

mid-year qualified status change. See “Making Changes during the Year” in Section 3 for more

information.

Paying for Coverage

You are not required to make contributions in connection with the medical or prescription drug plans

after coverage is effective on your 90th day of net credited service. If you wish to enroll for medical and

prescription drug coverage to be effective during the 90-day waiting period, you must pay the full cost

of coverage during that time. In that case, the cost of your prescription drug coverage is included in your

medical plan contributions.

Refer to your annual enrollment materials or go to https://my.adp.com to see your plan contributions.

If you elect to cover a domestic partner (and their child(ren)) for medical/prescription drug coverage,

Avaya’s contributions toward your medical/prescription drug premiums for covering your domestic

partner and their child(ren) will be reported as income to you. This is called imputed income and is

included in your W-2 wages (except for state taxes in certain situations). This taxable income is subject

to both income tax and FICA withholding. The amount of taxable income depends on the medical plan

you elect, and on whom you elect to cover.

However, imputed income does not apply if your domestic partner and their child(ren) are your federal

tax dependents for group health plan purposes. You may want to consult a tax advisor to discuss your

individual situation before enrolling your domestic partner in an Avaya benefit plan.

https://my.adp.com/


In addition to any contributions you make for medical/prescription drug coverage, you pay your share of

prescription drug expenses when you order prescriptions from an Express Scripts retail pharmacy or

through the home delivery service. See “Section 4 - Prescription Drug Benefits” for information.

When Prescription Benefit Coverage Begins

Your coverage under the Prescription Drug Plan begins when your medical plan coverage begins. If you

enroll, medical and prescription drug coverage is effective for you and your eligible dependents on your

90th day of net credited service, or the first day of the year following an annual enrollment period, if

coverage is elected during annual enrollment.

Coverage Levels

The level of coverage you elect under your Avaya medical plan will apply to the Prescription Drug Plan as

well. In other words, if you elect medical coverage for yourself under the POS or Traditional Indemnity

medical plan, you will have coverage for yourself under this Prescription Drug Plan. If you elect to cover

yourself and your eligible dependents under the POS or Traditional Indemnity medical plan, you and

your dependents will be covered under this Prescription Drug Plan.

Making Changes During the Year

Changing your medical plan may result in a change to your prescription drug coverage. Please refer to

the Aetna Summary Plan Description for the medical plan applicable to your enrollment to see the

requirements for making changes during the year. You may make changes during the year only if you

have a change in your family status or experience a life event (referred to as a “qualified status change”)

permitting a mid-year election change.

HIPAA Special Enrollment Rights

Loss of Eligibility for Other Medical Coverage

The Prescription Drug Plan is considered a part of your group health plan under the law and, as such, the

same Health Insurance Portability and Accountability Act (HIPAA) enrollment rights that would enable

you to make enrollment changes during the year to your medical plan elections will apply. Any medical

plan changes you make also apply to your Prescription Drug Plan coverage. Please refer to the Aetna

Summary Plan Description for the medical plan applicable to your enrollment for details.

Loss or Gain of Eligibility for a State Children’s Health Insurance Program (CHIP) or Medicaid

If you are eligible for, but not enrolled in, an Avaya-sponsored Aetna medical plan (or your dependent is

eligible for, but not enrolled in, an Avaya medical plan), you (and your dependent) may enroll in a

medical plan (and automatically receive coverage under this Prescription Drug Plan) or switch medical

plans in certain situations. Please refer to the Aetna Summary Plan Description for the medical plan

applicable to your enrollment for information on special enrollment periods provided and contact

information regarding State CHIP programs.


When Prescription Coverage Ends

Your coverage under this Prescription Drug Plan will end when your Avaya-sponsored Aetna medical

plan coverage ends. Medical plan coverage ends on the last day of the month in which any of the

following events occur:

• The Prescription Drug Plan is discontinued;

• You retire or die;

• You voluntarily stop your coverage;

• You are no longer eligible for coverage;

• You do not make any required contributions;

• You become covered under another plan offered by your employer;

• You have exhausted your overall maximum lifetime benefit under your health plan, if your plan

contains such a maximum benefit; or

• Your employer notifies Express Scripts that your employment is ended.

Generally, your dependent’s coverage will end if:

• You are no longer eligible for dependents’ coverage;

• You do not make your contribution for the cost of dependents’ coverage;

• Your own coverage ends for any of the reasons listed under When Prescription Coverage Ends. (This

does not apply if you use up your overall lifetime maximum, if included);

• Your dependent is no longer eligible for coverage. Coverage ends at the end of the calendar month

when your dependent is no longer eligible for coverage or at the end of the calendar year in which

your dependent reaches the maximum age limit; or

• As permitted under applicable federal and state law, your dependent becomes eligible for like

benefits under this or any other group plan offered by your employer.

In addition, a "domestic partner" will no longer be considered to be a defined dependent on the earlier

to occur of:

• The date this plan no longer allows coverage for domestic partners.

• The date of termination of the domestic partnership.

Coverage for dependents may continue for a period after your death. Coverage for handicapped

dependents may continue after they reach any limiting age. See “Section 7 - Continuation of Coverage”

later in this SPD for more information.


Continuing Coverage When It Might Otherwise End

If you or your dependent loses your Avaya medical plan coverage, you may have the right to extend it

under the Consolidated Budget Reconciliation Act of 1985 (COBRA). If you elect to extend your medical

plan coverage through COBRA, your coverage under the Prescription Drug Plan is also extended. See

“Section 7 - Continuation of Coverage” later in this SPD for more information.

You also may be able to continue coverage if you are on military leave (see Section 8 “What If… You Go

on Military Leave” or “What If…You Go on FMLA Leave”).


SECTION 4 – PRESCRIPTION DRUG BENEFITS


Overview of prescription drug benefits

Home Delivery program for maintenance medications

How the Plan works

If you need Specialty Drugs

Special programs

What is covered

What is not covered

Overview of Your Prescription Drug Benefits

When you enroll in the POS or Traditional Indemnity medical plan, you are automatically enrolled in the

Prescription Drug Plan, administered by Express Scripts. You do not need to make a separate election to

receive prescription drug benefits.

Under the Prescription Drug Plan, your cost is lower for generic and preferred brand-name prescription

(formulary) drugs. Express Scripts has contracts with most chain and independent pharmacies

nationwide. You can also have medications filled at a non-participating pharmacy or through the Express

Scripts Home Delivery program.

There is a three-tier structure for prescription drug coverage. Your coinsurance/copayment is

determined by the tier of your medication:

Tier 1 (Generic) has the lowest copayment and includes generic medications.

Tier 2 (Preferred Brand) has a higher coinsurance than Tier 1, and includes preferred brand

medications.

Tier 3 (Non-Preferred Brand) has the highest coinsurance and includes non-preferred brand name

medications.

The Plan will cover drugs in the three tiers as long as they are medically necessary and plan rules are

followed. Regardless of whether you choose a local retail participating pharmacy, retail non-

participating pharmacy or Home Delivery, generic drugs are used to fill prescriptions whenever possible

unless your doctor specifies otherwise. If you are prescribed a non-preferred brand-name drug, the

pharmacist may contact your doctor to suggest that a non-preferred brand-name drug be substituted

with a comparable drug from Express Scripts’ National Preferred Formulary list. Your doctor decides

whether or not to switch to the formulary drug.

If you or your doctor requests a brand-name medication when a generic equivalent is available, you will

be responsible for your generic copayment plus the difference in price between the brand-name


medication and its generic equivalent. This will apply even if the doctor writes “dispense as written”

(DAW) on the prescription. If you order a brand-name medication that has a generic equivalent, the

difference in cost between the brand-name medication and the generic medication will not apply

toward the deductible or out-of-pocket maximum.

Finding a Participating Pharmacy

Prescriptions filled at participating retail pharmacies will cost you less than at a non-participating

pharmacy. To find an Express Scripts retail pharmacy near you, please register at www.express-

scripts.com. You can visit this site or call Express Scripts to find a network pharmacy and check your drug

coverage/costs. You can also ask your local pharmacy if it participates in the Express Scripts program.

Retail Pharmacy

You should use a local pharmacy for short-term prescriptions of up to 30 days (or a 90-day supply of

insulin). When you go to a participating pharmacy, present the pharmacist with your Express Scripts ID

card.

If you use a participating pharmacy, the pharmacist will charge you the appropriate copay for your

prescription. This is the only amount you will pay. There are no claim forms to file.

If you are in the POS medical plan and use a non-participating pharmacy, you will pay 30% of the cost of

the medication, subject to a deductible. The individual deductible for the POS medical plan is $50 and

the family deductible is $100. You must pay the full cost of the medication at the pharmacy, and then

submit a claim for reimbursement.

It’s a Fact! There are over 68,000 pharmacies in the Express Scripts Network.

Home Delivery Program

If you are taking ongoing medication to manage a chronic health condition (such as diabetes or high

blood pressure) you will need to use Express Scripts Home Delivery for maintenance prescriptions. There

is no out-of-network option for home delivery. You can purchase up to a 90-day supply of medication

through this program, which is less costly and very convenient.

Use Express Scripts Home Delivery for maintenance medications and save – with home delivery

service you receive a 90-day prescription for the price of two retail pharmacy copays.

After your third consecutive fill of medication for the same dosage at retail, you must use the home

delivery program for maintenance medication or you will pay the full cost of your prescription. If you

pay the full cost of your prescription it will not apply to the deductible and/or out-of-pocket

maximum.




How the Plan Works

The prescription drug plan works differently based on the medical plan in which you are enrolled.

If you are enrolled in the POS medical plan and visit a participating pharmacy, there is no deductible

required for prescription drugs. Expenses are paid from the first prescription presented. At a

participating pharmacy, you pay a copayment for each prescription. At a non-participating pharmacy,

you pay 30% of the cost of the drug, after you meet an annual deductible.

There is an out-of-pocket maximum to limit your expenses at participating pharmacies. Your

copayments for prescriptions filled at a retail participating pharmacy or through home delivery count

toward the POS medical out-of-pocket maximum. Once your in-network prescription drug copayments

and medical coinsurance meet the medical plan out-of-pocket maximum ($2,000 per individual or

$4,000 per family), in-network prescription drug expenses will be paid in full for the remainder of the

calendar year. Charges incurred at a non-participating pharmacy count toward the POS medical out-of-

network out-of-pocket maximum. Once your out-of-network prescription drug copayments and medical

coinsurance meet the medical plan out-of-pocket maximum ($5,000 per individual or $10,000 per

family), out-of-network prescription drug expenses will be paid in full for the remainder of the calendar

year.

A Quick Look at the POS Plan:

✓ Option to use a retail non-participating pharmacy to purchase medication (but will pay more)

✓ No deductible to pay at a participating pharmacy

✓ Prescription drug expenses DO NOT count toward your medical plan deductible

✓ Prescription drug expenses DO count toward your medical plan out-of-pocket maximum

✓ Your copay varies depending on the type of drug you purchase – generic, preferred brand or non-

preferred brand

✓ The home delivery incentive applies – you pay the full cost of your medication on your third fill of a

maintenance prescription at a retail pharmacy

✓ If you fill your prescription with a brand medication and a generic is available, you pay the difference

between the generic and the brand in addition to the brand copay (unless your doctor specifies that

the brand name drug is medically necessary)

✓ You can reimburse yourself for prescription expenses through your Health Care Flexible Spending

Account, up to the maximum contribution amount you elected for the year

If you are enrolled in the Traditional Indemnity medical plan, you pay the same copayment and

coinsurance amounts as for the POS medical plan. The difference is that the Traditional Indemnity

medical plan has an out-of-pocket maximum for prescription drugs ($1,000 per individual and $3,000

per family). This maximum is separate from the medical plan out-of-pocket maximum, which means

your prescription drug expenses do not count toward meeting the medical plan out-of-pocket

maximum.


Once your eligible prescription drug expenses meet the prescription drug out-of-pocket maximum, the

Plan will cover 100% of eligible prescription drug expenses for the remainder of the calendar year.

A Quick Look at the Traditional Indemnity Plan

✓ Prescription drug expenses DO NOT count toward your medical plan deductible and out-of-pocket

maximum

✓ Your copay varies depending on the type of drug you purchase – generic, preferred brand or non-

preferred brand

✓ The home delivery incentive applies – you pay the full cost of your medication on your third fill of a

maintenance prescription at a retail pharmacy

✓ If you fill your prescription with a brand medication and a generic is available, you pay the difference

between the generic and the brand in addition to the brand copay

✓ You can reimburse yourself for prescription expenses through your Health Care Flexible Spending

Account, up to the maximum contribution amount you elected for the year.

Your Prescription Drug Benefits at a Glance

Deductibles and out-of-pocket maximums vary by medical plan. The following chart summarizes the

prescription drug coverage provided with enrollment in the POS or Traditional Indemnity medical plan.

Point-of-Service (POS) Traditional Indemnity

In-Network Participating

Pharmacy

Out-of-Network Non-

Participating Pharmacy

Annual Deductible $0 $50 per individual

$100 per family

$0

Annual Out-of-Pocket

Maximum

$2,000 per individual

$4,000 per family

(combined with medical)


$10,000 per family

(combined with medical)


$3,000 per family

(separate from medical)


Point-of-Service (POS) Traditional Indemnity

In-Network Participating

Pharmacy

Out-of-Network Non-

Participating Pharmacy

Preventive Drugs: 100%, deductible waived

30%, after prescription

deductible 100%, deductible waived

Retail (up to a 30-day supply):

Tier 1 (generic) $15 copay/prescription 30% coinsurance, after

prescription drug

deductible

$15 copay/prescription

Tier 2 (preferred

brand)

$30 copay/prescription $30 copay/prescription

Tier 3 (non-preferred

brand)


Home Delivery (up to a 90-day supply):

Tier 1 (generic) $30 copay/prescription No coverage – Express

Scripts Home Delivery only

$30 copay/prescription

Tier 2 (preferred

brand)


Tier 3 (non-preferred

brand)


Note: You pay the difference in cost between the brand-name and generic drug copayment, if a generic equivalent

is available. The difference in cost will not apply toward your deductible, if any, or out-of-pocket maximum.

Specialty Drugs: If you need a specialty medication, you are required to fill your prescription through the

Accredo Specialty Pharmacy or pay 100% of the cost of those medications at retail.

Specialty drugs are filled initially for a 30-day supply and then, depending on the

situation, subsequent fills may be for up to a 90-day supply based on plan rules.

Your cost through the Accredo Specialty Pharmacy mirrors your retail or home delivery

costs shown above.

Tips for Using the Home Delivery Service

To fill a prescription for home delivery, simply get an order form from Express-Scripts or print a form

from Avaya’s benefit portal at https://my.adp.com (select the Forms & Plan Documents tile on the home

page), follow the instructions and return the completed form to the address indicated along with the

appropriate payment and the written prescription. Generally, your prescription will be delivered to you,

postage-paid, within 14 days from when your order is received.

Alternatively, your doctor can call (1-888-327-9791) or fax (1-800-837-0959) a new prescription directly

to Express Scripts Home Delivery.

https://my.adp.com/


Refills are even easier. You can order a refill by mail, call the phone number on your prescription label or

visit www.express-scripts.com. You can use your credit card or Health Care Flexible Spending Account

(FSA) debit card to pay.

Prescriptions can be filled in senior-friendly, child-resistant bottles. Each new prescription will include an

informative insert about the medication.

In general, you pay less for generic and certain formulary brand-name drugs and more for non-

formulary brand-name drugs.

Your ID Card

When you first enroll in the POS or Traditional Indemnity medical plan, you will receive prescription drug

identification cards from Express Scripts. If you elect coverage for your dependents, you will receive two

cards in your name. If you need additional cards (for instance, if your child is attending college out of

town), you can request them by calling Express Scripts Member Services at 1-877-505-3213. In an

emergency, you are able to print a temporary identification card from Express Scripts’ website,

www.express-scripts.com.

Your prescription drug ID card is separate from your medical plan ID card. It is important to remember

to use your Prescription Drug Plan ID card at the pharmacy rather than your medical plan insurance

card.

Covered Medications

The Prescription Drug Plan provides coverage for federal legend drugs which are drug products bearing

the legend, “Caution: Federal law prohibits dispensing without a prescription”. The Plan also covers

certain prescription supplies, oral contraceptives and some compound medications.

For the Prescription Drug Plan to cover a prescription, the prescribed item must meet the following

requirements:

It must be a prescription written by a licensed physician and not have exceeded the accepted date

range of validity. Prescriptions for all drugs other than controlled substances are valid for one year

from the date they were written. Controlled substance prescriptions are valid for six months from

the date they are written.

It must be approved by the Federal Food and Drug Administration (FDA).

It must be dispensed by a pharmacy.

It must not be listed as an exclusion under this Plan.

Prescription drugs covered by the Plan are classified as either generic or brand-name drugs. Brand-name

drugs are then considered either preferred brand-name (part of the Express Scripts formulary) or non-

preferred brand-name (non-formulary). The Plan uses the Express Scripts National Preferred Formulary.

For detailed information on the National Preferred Formulary, visit www.express-scripts.com.





Preventive Drugs Covered at 100%

To comply with the Affordable Care Act (ACA), the Prescription Drug Plan covers certain drugs at 100%

with no deductible or copay. The ACA preventive drug list is subject to change as ACA guidelines are

updated or modified but currently includes the following.

Aspirin - Benefits are available to adults (over-the-counter requires a prescription)

Iron supplements for children without symptoms of iron deficiency or children who are at increased

risk for iron deficiency anemia (over-the-counter requires a prescription)

Oral fluoride supplements for pre-school children whose primary water source is deficient in

fluoride (does not cover over-the-counter)

Folic acid supplements for women planning to become pregnant or capable of pregnancy (over-the-

counter requires a prescription)

Vitamin D supplements for adults to promote calcium absorption and bone growth in their bodies

Risk-reducing breast cancer prescription drugs, prescribed by a physician for a woman who is at

increased risk for breast cancer and is at low risk for adverse medication side effects

Contraceptive drugs and devices (generic only) with a doctor’s prescription

Coverage of preventive drugs and supplements will be subject to any sex, age, medical condition, family

history and frequency guidelines in the recommendations of the United States Preventive Services Task

Force. Coverage of any medication requires a prescription from a licensed health care provider.

Drugs the Plan Covers Based on Copayments (Coinsurance at a Non-Participating Pharmacy)

The Plan generally covers the following drugs:

Drugs provided by a pharmacist and prescribed by a physician (see “What is Not Covered” for

exceptions)

Prescription birth control medications or contraceptive devices (including oral contraceptives or

injections)

Insulin

Disposable supplies ordered by a physician for a diabetic patient including:

– Insulin needles and syringes

– Blood and urine testing supplies

Prescription (not over-the-counter) smoking deterrents (including nicotine products such as gums

and patches)

Diabetic testing equipment may be covered under the durable medical equipment benefit of the

POS or Traditional Indemnity medical plan.


For specific drug coverage information, call Express-Scripts or visit them online (see “How to Reach

Express Scripts”).

Express Scripts Specialty Pharmacy Services

Specialty Medications

Specialty medications are used to treat complex, chronic conditions, such as multiple sclerosis and

rheumatoid arthritis. These medications often require special handling, preparation or refrigeration.

Accredo is Express Scripts’ specialty pharmacy home delivery order service. Accredo provides clinical

support to employees and their dependents if identified as using a specialty drug to treat complex

conditions. Prescriptions for standard specialty medications must be filled through Accredo. To access

Accredo, call the Member Services number on the back of your ID card.

Under the Prescription Drug Plan, all of your specialty medications must be filled through the Accredo

Specialty Pharmacy mail order service. The home delivery service copayment or coinsurance you have to

pay will be based on the type of drug you are requesting (generic, preferred brand-name drug, non-

preferred brand-name drug). If you do not go through the Accredo Specialty Pharmacy, you will pay the

full cost of your prescription. If you pay the full cost of your prescription, it will not apply to the

deductible and/or out-of-pocket maximum.

When you fill specialty prescriptions through Accredo, you also receive a variety of specialized services:

Accredo will schedule and quickly ship all your specialty medications, including those that require

special handling such as refrigeration. Most supplies, such as syringes, needles and sharps

containers, will be provided with your medication.

Specialty-trained pharmacists and nurses are available 24 hours a day, seven days a week to answer

your questions and help you manage your condition.

Accredo will contact you regularly to schedule your next refill and see how your therapy is

progressing. For convenience, some specialty medication refills can be ordered online, safely and

securely, through www.express-scripts.com.

As an Express Scripts pharmacy, Accredo can access your prescription information on file at all

Express Scripts pharmacies to monitor for potential drug interactions and side effects of your

medications.

It’s a Fact! Specialty drugs account for 52% of drug costs nationally.

Special Features of the Prescription Drug Plan

The Prescription Drug Formulary

A formulary is a list of FDA-approved, generic and brand-name prescription drugs that are covered by a

health plan. The Plan includes a list of preferred drugs that are either more effective at treating a

particular condition than other drugs in the same class, or as effective as and less costly than similar



medications. Non-preferred drugs may also be covered under the prescription drug program, but at a

higher cost-sharing tier. Collectively, these lists of drugs make up the Plan’s formulary. The Plan uses the

Express Scripts National Preferred Formulary. The Plan’s formulary is updated periodically and is subject

to change. To get the most up-to-date list of drugs on the formulary, visit www.express-scripts.com.

Drugs that are excluded from the Plan’s formulary are not covered under the Plan unless approved in

advance through a formulary exception process managed by Express Scripts on the basis that the drug

requested is (1) medically necessary and essential to the patient’s health and safety and/or (2) all

formulary drugs comparable to the excluded drug have been tried by the patient. If approved through

that process, the applicable formulary copay would apply for the approved drug based on the Plan’s cost

share structure. Without this approval, if you or a covered dependent selects drugs excluded from the

formulary, you will be required to pay the full cost of the drug without any reimbursement under the

Plan. If your physician believes that an excluded drug meets the requirements described above, your

physician should take the necessary steps to initiate a formulary exception review.

The formulary will continue to change from time to time. For example:

A drug may be moved to a higher or lower cost-sharing formulary tier.

Additional drugs may be excluded from the formulary.

A restriction may be added on coverage for a formulary-covered drug (e.g. prior authorization).

A formulary-covered brand name drug may be replaced with a formulary-covered generic drug.

Please be sure to check before the drug is purchased to make sure it is covered on the formulary, as you

may not have received notice that a drug has been removed from the formulary. Certain drugs, even if

covered on the formulary, will require prior authorization in advance of receiving the drug. Other

formulary-covered drugs may not be covered under the Plan unless an established protocol is followed

first; this is known as step-therapy. As with all aspects of the formulary, these requirements may also

change from time to time.

If you are taking a drug that becomes excluded from the formulary or moves from preferred to non-

preferred status, you will receive a notification from Express Scripts including a list of alternative

medications to discuss with your doctor.

Registered members can look up specific medications at www.express-scripts.com.

Precertification/Coverage Review Programs

The Plan has four programs in place to ensure the medications are taken safely, to avoid uncovered

costs and help Avaya to continue providing affordable healthcare options.

Prior Authorization

For certain medications, the Prescription Drug Plan requires a coverage review or “prior authorization”

by Express Scripts before benefits will be paid. The review will determine whether the Plan covers your

prescribed medication based on medical necessity. This review uses plan rules based on FDA-approved




prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and

effective.

Below are examples of common medications that may require pre-approval. This is not a complete list

of affected medications; all medications listed below are subject to change:

Topical Acne Medications (e.g. Retin-A, Tazorac, etc.) (Prior authorization requirement applies to

members 27 years of age and older)

Injectable Anemia Medications (e.g. Epogen, Procrit, Aranesp)

Injectable Growth Stimulating Medications (e.g. Humatrope, Tev-Tropin, Nutropin, etc.)

Hepatitis Medications (e.g. Intron-A, Peg-Intron, Pegasys, Incivek, etc.)

Multiple Sclerosis Medications (e.g. Copaxone, Avonex, Rebif, etc.)

Cancer Medications (e.g. Gleevec, Iressa, Tarceva, Sutent, etc.)

As noted above, 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. To find out whether a

medication requires a coverage review, log in to www.express-scripts.com at any time.

Prior authorizations, when approved, are typically approved for a one year period, unless otherwise

noted.

Your physician may call Express Scripts at 1-888-327-9791 to request a prior authorization approval.

Qualification by History

Qualification by history requires you to obtain pre-approval through a coverage review in cases where

your prescription profile history does not indicate medical necessity. The review will determine whether

your plan covers your prescribed medication based on medical necessity. Below are examples of

common medications that may require a coverage review. This is not a complete list of affected

medications; all medications listed below are subject to change:

Rheumatoid Arthritis & Psoriasis Medications (e.g. Enbrel, Humira, etc.) – These are medications

that are covered only if you have tried first-line therapies such as oral methotrexate (or other

related medications).

Atypical & Traditional CNS Stimulants – Coverage authorization requirement applies to members

under 5 years of age and adults.

Non-Sedating Antihistamines – Coverage of a brand non-sedating antihistamine for members under

the age of six and in cases where a member has tried a first-line therapy- OTC and/or generic

product first.

Narcotic Pain Medications – Medications such as Actiq & Fentora are covered only if you have

developed a tolerance to narcotic pain medications, as evident by long-term use of long-acting

narcotic pain medications.



Ribavirin – This medication is covered only if you are currently receiving Interferon therapy

(Injectable therapy for Hepatitis).

Supply Limits

For some medications, the Plan may cover a limited quantity within a specified period of time. A

coverage review may be necessary to have additional quantities of these medications covered by the

Plan.

The medications listed below are authorized for a limited quantity only. This is not a complete list of

affected medications; all medications listed below are subject to change:

Erectile Dysfunction Medications (limited to 8 units per month, 24 units per 3 months)

Migraine Medications (e.g. Imitrex, Maxalt, Zomig, Frova, etc.) – Coverage is limited to an amount

sufficient for up to 4 treatment days per month or 12 treatments in 90 days. Benefit coverage for

prescriptions submitted for greater quantities is determined through a coverage authorization

process.

Narcotic Pain Medications: Actiq – Coverage is limited to 120 units per month; Fentora - 100mcg

and 200mcg tablet strengths = 240 tablets per 30 days (no prior authorization available) or 300

mcg, 400 mcg, 600 mcg, and 800 mcg tablet strengths = 120 units per 30-days. Benefit coverage for

prescriptions submitted for greater quantities is determined through a coverage review process.

Smoking Deterrents: Allows for a maximum of two courses of treatment per year.

Cancer Medications (e.g. Gleevec, Iressa, Tarceva, Sutent, etc.) – Coverage is limited to an amount

sufficient for standard treatment. Benefit coverage for prescriptions submitted for greater

quantities is determined through a coverage authorization process.

This does not affect the day supply limits which are part of the Plan design and would only change if the

Plan design is changed. Currently, the days’ supply limit in place is a 30-day supply at retail and, for

maintenance drugs, a 90-day supply by mail through Express-Scripts Rx Home DeliveryTM Pharmacy. You

may obtain information on maximum dispensing limits by either visiting www.express-scripts.com or by

contacting Express Scripts at 1-877-505-3213.

Step Therapy Requirements

Step therapy is a program designed to help you save money by using the most cost effective treatments

if you have certain health conditions that require maintenance medications. It requires that you try a

first line alternative, often a generic medication, to treat your medical condition. Then, based on your

doctor’s review, if necessary, you may be able to move to a brand-name drug. However, if a brand-name

drug is dispensed and there is a generic available, you will pay the cost difference between the generic

and the brand-name drug.

For some drug categories, a coverage review may be necessary to determine if non-preferred formulary

therapies are covered. This is not a complete list of affected medications; all medications listed below

are subject to change:



Proton Pump Inhibitors (PPIs) (e.g. Aciphex, Dexilant, Zegerid) – These are covered only if you have

tried and failed on an OTC or generic PPI first.

Angiotension II Receptor Blockers (ARBs) (e.g. Atacand, Benicar, Avapro, Avalide, Teveten) – These

are second-line medications primarily used to treat high blood pressure. These medications are

only covered if you have tried and failed on first-line medications such as losartan/losartan HCTZ,

Diovan/Diovan HCT, or Micardis/Micardis HCT.

Insomnia Therapy – Medications such as Edular, Lunesta and Rozerem are covered only if you have

tried generic insomnia medications (e.g. generic Ambien, generic Restoril, etc.).

Migraine Medications – Medications such as Amerge, Frova, Zomig/ZMT, Treximet, Axert, Sumavel

are only covered if you have tried and failed on preferred medications such as sumatriptan, Relpax,

Maxalt/MLT.

For additional and up to date information on coverage of specific drugs, or medications that require

precertification or coverage review, please call Express-Scripts Customer Service at 1-888-505-3213.

Participants should confirm coverage prior to filling a prescription.

Additional Pharmacy Services

You are entitled to the following additional pharmacy services under the Prescription Drug Program:

Drug Utilization Review. Prescriptions filled through the program become part of a computerized

database that alerts the participating pharmacy or home delivery pharmacists to potential drug

interactions each time you have a prescription filled.

Toll-Free Prescription Drug Customer Service. Express-Scripts maintains a special toll-free customer

service number you can call with questions about the Prescription Drug Program, for help locating a

participating pharmacy, or to get an order form for Express-Scripts Rx Home DeliveryTM Pharmacy

or a claim form for a prescription filled at a non-participating pharmacy. To help locate a

participating pharmacy, you may also search online at www.express-scripts.com (See “How to

Reach Express Scripts”.)

Other special services available by calling Express-Scripts (see “How to Reach Express Scripts”) include:

Emergency pharmacist consultations, 24 hours a day, seven days a week

Large print or Braille labels on medications filled through Express-Scripts Rx Home Delivery, upon

request

Special telephone numbers are also available for hearing impaired employees or their covered

dependents and for those overseas. See “How to Reach Express Scripts”.

What Is Not Covered

The Prescription Drug Plan does not cover certain prescription drugs, some of which are listed below.

Please call Express Scripts to confirm whether or not your service will be covered.



Drugs and medicines provided (or that can be obtained) without a prescription from a physician

Non-federal legend drugs (non-approved prescription drugs)

Injectable medications that cannot be self-administered (unless approved by Express-Scripts)

Ostomy supplies (may be covered under the durable medical equipment benefit of your medical

plan)

Therapeutic devices (not considered to be drugs, but may be covered under your medical plan)

Drugs used solely to promote hair growth

Drugs labeled “caution – limited by federal law to investigational use” or experimental drugs even if

you are charged for those drugs

Medication for which the cost is recoverable under any Workers’ Compensation or occupational

disease law or any state or local governmental agency or any drug or medical service furnished at

no cost to the covered individual

Medication provided to a covered individual while a patient in a licensed hospital, rest home,

sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home,

home health care agency or similar institution that has a facility for dispensing pharmaceuticals on

its premises

Prescriptions filled in excess of the refill number specified by the physician or any refill dispensed

one year after the original prescription

Charges for the administration or injection of any drug

Any drug or medicine the doctor or Express-Scripts does not certify as medically necessary to treat

the condition

Prescriptions filled at a pharmacy that exceed the 30-day limit (90-day limit for insulin) or through

Express-Scripts Rx Home Delivery that exceed the 90-day limit

Prescriptions filled for maintenance drugs after three consecutive fills for the same dosage through

a retail pharmacy or mail order drug program other than Express-Scripts Rx Home Delivery

Prescription drugs that require precertification/coverage review through the Prescription Drug

Program. Requirements will have to be met before the drugs will be covered

Drugs used for experimental or investigational treatments or procedures

Mifeprex (may be available through your medical plan as supplied by your physician)


SECTION 5 – FILING PRESCRIPTION DRUG CLAIMS


How in-network and out-of-network claims work

What to do if your claim is denied, in whole or in part

In-Network

If you go to a pharmacy that is in the Express Scripts network, you simply show your Prescription ID Card

and pay your share of the cost when you buy the drug. You will need your receipt if you are filing a claim

for reimbursement from your Health Care Flexible Spending Account (or “FSA”).

Out-of-Network

If you purchase a prescription at a Non-Participating Pharmacy, you must pay the full cost of the

prescription, and then file a claim for reimbursement.

Filing for Reimbursement from a Health Care Flexible Spending Account

You can be reimbursed for prescription drug expenses from your Health Care Flexible Spending Account.

Claim forms for the Health Care Flexible Spending Account are available at https://my.adp.com (select

the Forms & Plan Documents tile on the home page).

Filing a Claim Appeal

Claim Appeal Procedures

To appeal a decision for a denied claim for medication purchased at a Non-Participating Pharmacy, or a

denied Precertification or Coverage Review claims under the Prescription Drug Program, contact

Express-Scripts (See “How to Reach Express Scripts”). Your concern will be investigated and you will be

contacted. If you are not satisfied, you can appeal the decision, as described in this section.

You must use and exhaust this Plan’s administrative claims and appeals procedure before bringing a suit

in either state or federal court. Similarly, failure to follow the Plan’s prescribed procedures in a timely

manner will also cause you to lose your right to sue regarding an adverse benefit determination.

You have the right to request an initial review for a medication that is not covered at point of sale at

either retail or home delivery pharmacies to be covered or to be covered at a higher benefit (e.g., lower

copay, higher quantity, etc.). The first request for coverage is called the initial coverage review. Express

Scripts reviews both clinical and administrative coverage review requests:

Clinical coverage review requests: A request for coverage of a medication that is based on clinical

conditions of coverage that are set by the Plan. For example, medications that require a prior

authorization.

https://my.adp.com/


Administrative coverage review request: A request for coverage of a medication that is based on

the Plan’s benefit design.

How to Request an Initial Coverage Review

The preferred method to request an initial clinical coverage review is for the prescriber to submit the

prior authorization request electronically. Alternatively, the prescriber or dispensing pharmacist may call

the Express Scripts Coverage Review Department at 1-800-753-2851 or the prescriber may submit a

completed coverage review form by faxing it to the number provided on the form. Forms may be

obtained online at www.express-scripts.com/services/physicians. Home delivery coverage review

requests are automatically initiated by the Express Scripts Home Delivery pharmacy as part of filing the

prescription.

To request an initial administrative coverage review, you, your doctor or your dispensing pharmacist

must submit specific information in writing to:

Express Scripts

Attn: Benefit Coverage Review Department

P.O. Box 66587

St. Louis, MO 63166-6587

If the patient’s situation meets the definition of urgent under the law, an urgent review may be

requested and will be conducted as soon as possible, but no later than 72 hours from receipt of request.

In general, an urgent situation is one which, in the opinion of the patient’s provider, the patient’s health

may be in serious jeopardy or the patient may experience severe pain that cannot be adequately

managed without the medication while the patient waits for a decision on the review. If the patient or

provider believes the patient’s situation is urgent, the expedited review must be requested by the

provider by phone at 1-800-753-2851.

How a Coverage Review Is Processed

In order to make an initial determination for a clinical coverage review request, the prescriber must

submit specific information to Express Scripts for review. For an administrative coverage review request,

the member must submit information to Express Scripts to support his or her request. The initial

determination and notification to patient and prescriber will be made within the specified timeframes as

follows:




Type of Claim Decision Timeframe Notification of Decision

Approval Denial

Standard Pre-Service* 15 days (retail)

5 days (home delivery)

Patient:

Automated call (letter if

call not successful)

Prescriber: Fax (letter if fax

not successful)

Patient:

Letter

Prescriber: Fax (letter if

fax not successful)

Standard Post-Service 30 days

Urgent 72 hours** Patient:

Automated call and letter

Prescriber: Fax (letter if fax

not successful)

Patient:

Live call and letter

Prescriber: Fax (letter if

fax not successful)

* If the necessary information needed to make a determination is not received from the prescriber within the decision timeframe, a letter will

be sent to the patient and prescriber informing them that the information must be received within 45 days or the claim will be denied.

** Assumes all information necessary is provided. If necessary information is not provided within 24 hours of receipt, a 48 hour extension will

be granted.

Denial Process

An initial coverage/administration review will be denied if the necessary information needed to make a

determination is not received from the prescriber within 45 days of the decision timeframe or the

information received does not meet the approval standards. An appeal request for further review can be

initiated at that point.

How to Request Appeals after Coverage Review Has Been Denied

Level 1 Appeal

Upon receipt of a denial notice, a covered member or authorized representative can request a level 1

appeal with Express Scripts within 180 days from receipt of a denial notice. To initiate an appeal, the

following information must be submitted by mail or fax to the appropriate department for clinical or

administrative review requests:

Name of patient

Member ID

Phone number

The drug name for which benefit coverage has been denied

Description of why the claimant disagrees with the denial


For clinical coverage appeal requests, call/fax/mail to:

Express Scripts

Attn: Clinical Appeals Department

Express Scripts

P.O. Box 631850

Irving, TX 75063-0030

Attn: Clinical Appeals

Phone: 1-800-753-2851

Fax: 1-877-852-4070

For administrative coverage appeal requests, call/fax/mail to:

Express Scripts

Attn: Administrative Appeals Department

Express Scripts

P.O. Box 631850

Irving, TX 75063-0030

Attn: Admin Appeals

Phone: 1-800-753-2851

Fax: 1-877-328-9660

Notice of approval or denial will be sent out to you and to your prescriber through mail or fax.

Level 2 Appeal

If a level 1 appeal is denied, a request for a level 2 appeal may be submitted by the member or authorized representative to Express Scripts within 90 days from receipt of notice of the level 1 appeal denial notice. You should submit required information to the appropriate address (same as the level 1 appeal shown in the section above).

Standard External Appeals

If you receive an adverse benefit determination or a final adverse benefit determination, you may file a

request for an external review within four months (or by the first day of the fifth month if there is no

corresponding date) after the date of the denial. Within five days of receipt of your request, the Plan

must conduct a preliminary review to determine whether you are eligible for an external review,

including consideration of the following:

If you were covered under the Plan at the time the service was provided,

If the determination related to your eligibility for coverage under the Plan,

If you had exhausted all internal review processes, if required, and

Whether you had provided all the information and forms necessary to process the claim.


The Plan will notify you of your eligibility for an external appeal within one business day of completing

the preliminary review. If you are not eligible, the Plan will explain the reasons why and provide contact

information for the U.S. Department of Labor’s Employee Benefits Security Administration (toll-free

number 1-866-444-3272). If the request is not complete, the Plan must notify you what is needed and

allow you to respond with the additional information within the initial filing period or within the 48 hour

period following notification, whichever is later.

If eligible for an external review, the Plan will assign your case to an accredited independent review

organization (“IRO”) to conduct a full independent review of your claim. The Plan will be bound by the

decision of the IRO. The IRO will notify you in writing that you are eligible for the external review and

allow you to submit any additional documentation about your claim within 10 days. The IRO must

provide written notice of the final decision on your claim within 45 calendar days. The notice will

include:

A general description of the reason for the request for external review, including the date or dates

of service, the health care provider and the claim amount (if applicable)

The date the IRO received the assignment to conduct the external review and the date of the IRO

decision

References to the evidence or documentation, including the specific coverage provisions and

evidence-based standards, considered in reaching the decision

A discussion of the principal reason or reasons for its decision, including the rationale for its

decision and any evidence-based standards that were relied on in making its decision, and

A statement that the determination is binding except to the extent that other remedies may be

available under state or federal law to either you or the Plan, such as judicial review, and including

current contact information for any applicable office of health insurance consumer assistance or

ombudsman established under the Public Health Service Act Section 2793.

In the case of an expedited external review (as described below), the IRO will provide notice of the final

external review decision as expeditiously as the circumstances allow, but in no event more than 72

hours after the IRO receives the request for an expedited review.

Upon receipt of a notice of a final external review decision to reverse the adverse benefit determination,

the Plan immediately must provide coverage or payment (including immediately authorizing or paying

benefits) for the claim.

Expedited Reviews

Any level of appeal can be expedited if:

The service at issue has not been performed,

The service at issue has been denied as experimental/investigative or as not medically necessary,

and


Your physician believes that the standard appeal timeframes could seriously jeopardize your life or

health or could subject you to severe pain that cannot be adequately managed.

The Claims Administrator, by applying a prudent layperson standard, may also determine that an appeal may be expedited.

Appeals Filing Time Limit

You are encouraged to file Level 1 appeals on a timely basis. The Claims Administrator will not review a

Level 1 appeal if it is later than 180 calendar days after you are notified of the denial or rescission.

External appeals must be filed within four months of notice of an adverse benefit determination.

Judicial Review

You must file a Level 1 appeal before bringing a civil action under 29 U.S.C. 1132 §502(a). You will be

notified of your right to file for review if the response to your current appeal level (that is, Level 1) is

adverse. Upon completion of the Plan’s internal and external review procedures, any action brought on

your behalf for Plan benefits must be filed no later than 12 months after completion of the Plan’s claims

and appeals process. Except as may be otherwise required by law, the final decisions made under the

Plan’s claims and appeals process will be final and binding on all parties.


SECTION 6 – COORDINATION OF BENEFITS


How your prescription drug coordinate if you are covered under more than one plan

How coverage is affected if you become eligible for Medicare

Procedures in the event the Plan overpays benefits

Coordination of Benefits If You Are Covered by More Than One Prescription

Drug Plan

In situations where you have other primary coverage, the Coordination of Benefits provision ensures

that payments from all of your group prescription drug plans do not exceed the amount the primary

plan would have paid if it were your only coverage.

The Prescription Drug Plan does not coordinate benefits. Express Scripts will always pay prescription

drug claims as the primary plan if a claim is processed by Express Scripts for an eligible employee or

family member.

Note: For medical/prescription drug expenses covered under the Medical Plan, the Coordination of

Benefits procedures will be the same as for the Medical Plan. See your medical plan SPD for information.

Coordination with Medicare

Benefits for Individuals Who Are Entitled to Medicare

If you are actively employed and Medicare-eligible (or if you are the Medicare-eligible dependent of an

active employee), the Prescription Drug Plan will generally pay benefits first.

Avaya is the primary payer in other words, your claims go to Avaya first if any of the following

apply:

You have current employment status with Avaya or are enrolled as a legal spouse or domestic partner

of an active employee, and you (or your covered spouse/domestic partner) first become entitled to

Medicare benefits because of age;

You have current employment status with Avaya or are enrolled as a family member of an active

employee and you (or your covered family member) first become entitled to Medicare benefits

because of disability; or

You (or your covered family member) first become entitled to Medicare benefits because you (or

your covered family member) have end-stage renal disease. In this case, the Avaya

medical/prescription drug plan is the primary payer for the first 30 months of Medicare entitlement

due to end-stage renal disease. At the end of the 30-month period, Medicare will become the


primary payer. This rule applies regardless of whether or not you have current employment status

with Avaya.

The Prescription Drug Plan will pay secondary if you elect to enroll in Medicare Part D. For more

information about Coordination of Benefits, see your medical plan SPD.

Subrogation and Right of Reimbursement

The purpose of this Plan is to provide prescription drug coverage for qualified prescription drug

expenses that are not covered by a third party. Therefore, you or a covered dependent shall reimburse

the Plan for related plan benefits received out of any funds or monies you or your covered dependent

recovers from any third party as a result of receiving Plan benefits related to prescription drug expenses

(1) that are also payable under workers’ compensation, any statute, any uninsured or underinsured

motorist program, any no fault or school insurance program, any other insurance policy or any other

plan of benefits, or (2) arising through an act or omission of another person and paid by a third party

whether through legal action, settlement or for any other reason.

Specific Requirements and Plan Rights

Because the Plan is entitled to reimbursement, the Plan shall be fully subrogated to any and all rights,

recovery or causes of actions or claims that you or your covered dependent may have against any third

party. Subrogation is the substitution of one person or entity in the place of another with reference to a

lawful claim, demand or right.

The Plan is granted a specific and first right of reimbursement from any payment, amount or recovery

from a third party. This right to reimbursement is regardless of the manner in which the recovery is

structured or worded, whether in the form of a settlement (either before or after any determination of

liability) or judgment, and even if you or your covered dependent has not been paid or fully reimbursed

for all of his or her damages or expenses. The proceeds available for reimbursement will include, but not

be limited to, any and all amounts earmarked as non-economic damage settlement or judgment. You or

your covered dependent may not reduce the amount you owe the Plan to account for the payment of

attorney’s fees or other obligations.

The Plan’s share of the recovery will not be reduced because the full damages or expenses claimed have

not been reimbursed unless the Plan agrees in writing to such reduction. Further, the Plan’s right to

subrogation or reimbursement will not be affected or reduced by the “make whole” doctrine, the “fund”

doctrine, the “common fund” doctrine, comparative/contributory negligence, “collateral source” rule,

“attorney’s fund” doctrine, regulatory diligence or any other equitable defenses that may affect the

Plan’s right to subrogation or reimbursement.

The Plan may enforce its subrogation or reimbursement rights by requiring you or your covered

dependent to assert a claim to any of the benefits to which you or your covered dependent may be

entitled. The Plan will not pay attorney’s fees or costs associated with the claim or lawsuit without

express written authorization from Avaya.


If the Plan should become aware that you or your covered dependent has failed to comply with these

provisions, the Plan, in its sole discretion, may (1) suspend all further benefits payments related to you

or any of your dependents until the reimbursable portion is returned to the Plan or offset against

amounts that would otherwise be paid to or on behalf of you or your covered dependents, (2) terminate

health benefits, or (3) institute legal action against you (or your covered dependents, if applicable).

Participant Duties and Actions

By participating in the Plan, you and your covered dependents consent and agree that a constructive

trust, lien or an equitable lien by agreement in favor of the Plan exists with regard to any settlement or

recovery from a third person or party.

Thus, you and your covered dependents agree that if you or your covered dependents receive any

payment from any potentially responsible party as a result of an injury or illness, whether by settlement

(either before or after any determination of liability) or judgment, you or your covered dependents will

serve as a constructive trustee over the funds. This means that you or your covered dependents, or an

authorized agent (such as your attorney), must hold any funds received from any potentially responsible

party that are due and owed to the Plan, as stated herein, separately and alone.

Further, in accordance with that constructive trust, lien or equitable lien by agreement, you and your

covered dependents also agree to cooperate with the Plan in a timely manner in protecting Avaya’s legal

and equitable rights to subrogation and reimbursement.

Once you or your covered dependents have any reason to believe that you or they may be entitled to

recovery from any third party, you or your covered dependents must notify the Plan. In addition, at that

time, you and your covered dependents (and your attorney or their attorney, if applicable) may be

required to sign a subrogation/reimbursement agreement in a form provided by the Plan or its agents

that confirms the prior acceptance of the Plan’s subrogation rights and the Plan’s right to be reimbursed

for expenses arising from circumstances that entitle you or your covered dependents to any payment,

amount or recovery from a third party.

You and your covered dependents consent and agree to assign to the Plan all rights of recovery against

third parties, to the extent of the reasonable value of services and benefits the Plan provided, plus

reasonable costs of collection. The Plan will be entitled to recover reasonable attorney’s fees from you

incurred in collecting any funds held by you that you recovered from any third party.

You and your covered dependents also consent and agree that you or they will not assign your rights or

their rights to settlement or recovery against a third person or party to any other party, including their

attorney, without the Plan’s consent. As such, the Plan’s reimbursement will not be reduced by

attorney’s fees and expenses.

You and your covered dependents’ duty to cooperate with the Plan in enforcing its rights also include

the following:

Providing any relevant information requested by the Plan,


Signing and/or delivering such documents as the Plan or its agents reasonably request to secure the

subrogation and reimbursement claim,

Responding to requests for information about any accident or injuries,

Appearing at depositions and in court, and

Obtaining the consent of the Plan or its agents before releasing any party from liability or payment

of prescription drug expenses.

If you or your covered dependents are asked by the Plan to sign a subrogation/reimbursement

agreement and you fail or refuse to do so, the Plan may deny payment of any benefits to you and any of

your covered dependents until the agreement is signed. Or, if you or your covered dependents fail or

refuse to execute a subrogation/reimbursement agreement upon the Plan’s request and the Plan

nevertheless pays benefits to or on behalf of you or your covered dependents, you or your covered

dependents’ acceptance of such benefits shall constitute agreement to the Plan’s right to subrogation or

reimbursement.

You and your covered dependents consent and agree not to (1) negotiate any agreements with a third

party that would undermine the subrogation rights of the Plan, (2) accept any settlement that does not

fully compensate or reimburse the Plan without the Plan’s written approval, or (3) do anything to

prejudice the Plan’s rights under this section.

Additional Provisions

The Plan may, at its option, take necessary and appropriate action to preserve its rights under these

subrogation provisions including filing suit in your name or your covered dependent’s name

which does not obligate the Plan in any way to pay you part of any recovery the Plan might obtain.

The Plan will not be obligated in any way to pursue this right independently or on your behalf.

Benefits paid by the Plan may also be considered benefits advanced. The Plan may set off from any

future benefits otherwise allowed by the Plan the value of benefits paid or advanced under this

section to the extent not recovered by the Plan.

The Plan’s rights will not be reduced due to your own negligence.

If the injury or condition giving rise to subrogation or reimbursement involves a minor child, this

section applies to the parents or guardian of the minor child.

If the injury or condition giving rise to subrogation or reimbursement involves the wrongful death

of a plan beneficiary, this section applies to the personal representative of the deceased plan

beneficiary.

The Plan has the sole authority and discretion to resolve all disputes regarding the interpretation of the

language in this SPD.


Refund of Overpayments

If Avaya pays benefits for expenses incurred on your behalf, you or any other person or organization

that was paid must make a refund to us if either of the following applies:

All or some of the expenses were not paid by you or did not legally have to be paid by you

All or some of the payment Avaya made exceeded the benefits under the Plan.

The refund equals the amount Avaya paid in excess of the amount Avaya should have paid under the

Plan. If the refund is due from another person or organization, you agree to help us get the refund when

requested.

If you, or any other person or organization that was paid, do not promptly refund the full amount, Avaya

may reduce the amount of any future benefits that are payable under the Plan. The reductions will equal

the amount of the required refund. Avaya may also sue to recover such amounts or use any other lawful

remedy to recoup any such amounts.


SECTION 7 – CONTINUATION OF COVERAGE


Information about COBRA coverage and when it is available

Eligibility for COBRA coverage

Election period, duration of coverage and cost of COBRA coverage

Circumstances under which your prescription drug coverage can be extended by the Plan and/or

under COBRA

If you lose health care coverage, you may be able to continue coverage under COBRA under certain

conditions. To be eligible to continue prescription drug coverage under COBRA, you must have been

enrolled in the POS or Traditional Indemnity medical plan immediately before the loss of coverage. You

can only enroll for COBRA coverage in the medical plan in which you were enrolled at the time of your

qualifying event.

Continuation Coverage Rights Under COBRA

This section contains important information about your right to COBRA continuation coverage, which is

a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation

coverage, when it may become available to you and your covered spouse/domestic partner and

dependent children, and what you need to do to protect the right to receive it.

The right to COBRA continuation coverage was created by a federal law. COBRA continuation coverage

can become available to you when you would otherwise lose coverage under the Plan. It can also

become available to your spouse/domestic partner and dependent children who are covered under the

Plan when they would otherwise lose such coverage.

You may have other options available to you when you lose group health coverage. For example, you

may be eligible to buy an individual plan through the public health insurance marketplace. By enrolling

in coverage through the marketplace, you may qualify for lower costs on your monthly premiums and

lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for

another group health plan for which you are eligible (such as a spouse’s plan).

What Is COBRA Continuation Coverage

COBRA continuation coverage is a continuation of plan coverage when you would otherwise lose such

coverage because of a life event known as a “qualifying event”. Specific qualifying events are listed

below. After a qualifying event, COBRA continuation coverage must be offered to each person who is a

“qualified beneficiary”. You, your spouse/domestic partner, and your dependent children could become

qualified beneficiaries if covered under the Plan at the time of a qualifying event, and such coverage is

lost because of the qualifying event. Additionally, a child who is born to or adopted or placed for

adoption with you (the covered employee) during the COBRA continuation coverage period is also


considered a qualified beneficiary, provided that you elected COBRA continuation coverage for yourself.

Under the Plan, qualified beneficiaries must pay for the COBRA continuation coverage they elect, as

described in the “Paying for COBRA Continuation Coverage” section.

COBRA Qualifying Events

If you are an employee, you will become a qualified beneficiary if you lose coverage under the Plan

because either of the following qualifying events occur:

Your hours of employment are reduced, or

Your employment ends for any reason other than your gross misconduct.

If you are the spouse/domestic partner of an eligible employee, you will become a qualified beneficiary

if you lose coverage under the Plan because any of the following qualifying events occur:

Your spouse/domestic partner dies

Your spouse/domestic partner’s hours of employment are reduced

Your spouse/domestic partner’s employment ends for any reason other than his or her gross

misconduct

Entitlement to Medicare benefits, or

You become divorced or legally separated from the employee, or there is a dissolution of your

domestic partnership with the employee.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan

because any of the following qualifying events occur:

The parent-employee dies

The parent-employee’s hours of employment are reduced

The parent-employee’s employment ends for any reason other than his or her gross misconduct

Entitlement to Medicare benefits

The parents become divorced (or legally separated), or there is a dissolution of their parent’s

domestic partnership, or

The child stops being eligible for coverage under the Plan as a “dependent child”.

For this purpose, “lose coverage” means to cease to be covered under the same terms and conditions as

in effect immediately before the qualifying event.

Giving Notice that a COBRA Qualifying Event (or Second Qualifying Event) Has Occurred

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan

Administrator has been timely notified that a qualifying event has occurred. When the qualifying event

is the employee’s termination of employment (other than for gross misconduct) or reduction of work

hours, the employer must notify the Plan Administrator of the qualifying event.


Important Note: For other qualifying events (e.g. divorce or legal separation of the employee,

dissolution of a domestic partnership, death of the employee, Medicare-entitlement, and/or the

spouse/domestic partner or a dependent child’s loss of eligible coverage), you or another qualified

beneficiary must notify the Plan Administrator in writing within 60 days after the later of: 1) the date of

qualifying event (or second qualifying event), or 2) the date the qualified beneficiary loses (or would

lose) coverage under the Plan as a result of the qualifying event (or second qualifying event). This notice

must be provided in writing to the Avaya Health & Benefits Decision Center by first calling them at 1-

800-526-8056 (Option 1).

How Is COBRA Continuation Coverage Provided

Once the Plan Administrator receives timely notice that a qualifying event has occurred, COBRA

continuation coverage will be offered (through a “COBRA Continuation Coverage Election Notice”) to

each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect

COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of

their spouse/domestic partner, and parents may elect COBRA continuation coverage on behalf of their

children.

If coverage under the Plan is changed for active employees, the same changes will apply to individuals

receiving COBRA continuation coverage. Qualified beneficiaries also may change their coverage

elections during the annual enrollment period, or at other times under the Plan to the same extent that

an active employee may make changes.

Duration of COBRA Continuation Coverage

COBRA continuation coverage is a temporary continuation of health coverage. When the qualifying

event is the employee’s termination of employment (other than for gross misconduct) or reduction of

work hours, COBRA continuation coverage for the employee and the employee’s covered

spouse/domestic partner and dependent children generally lasts for up to a total of 18 months from the

date of the qualifying event.

When the qualifying event is the death of the employee, your divorce or legal separation, the dissolution

of your domestic partnership, or the employee’s Medicare entitlement, COBRA continuation coverage

for the employee’s spouse/domestic partner and/or dependent children (but not the employee) lasts for

up to a total of 36 months from the date of the qualifying event. Also, the employee’s dependent

children are entitled to COBRA continuation coverage for up to 36 months after losing eligibility as a

dependent child under the terms of the Plan.

There are three ways in which the 18-month period of COBRA continuation coverage due to the

employee’s termination of employment or reduction of work hours can be extended.

1. Employee’s Medicare Entitlement Occurs Before a Qualifying Event That Is Employee’s

Termination of Employment or Reduction of Work Hours: When the qualifying event is the

employee’s termination of employment (other than for gross misconduct) or reduction of work

hours, and the employee became entitled to (that is, enrolled in) Medicare benefits less than 18


months before the qualifying event (even if Medicare entitlement was not a qualifying event for

the employee’s spouse/domestic partner or dependent children because their coverage was not

lost), COBRA continuation coverage for qualified beneficiaries other than the employee lasts for

up to 36 months after the date of the employee’s Medicare entitlement. For example, if the

employee become entitled to Medicare eight months before the date his or her employment

terminates, COBRA continuation coverage for the employee’s covered spouse/domestic partner

and dependent children can last up to 36 months after the date of Medicare entitlement, which

is equal to 28 months after the date of the qualifying event (36 months minus 8 months).

2. Disability Extension: If you, your spouse/domestic partner, or any of your dependent children

covered under the Plan are determined to be disabled by the Social Security Administration

(SSA) on the date of the employee’s termination of employment or reduction of work hours, or

at any time during the first 60 days of COBRA continuation coverage due to such qualifying

event, each qualified beneficiary (whether or not disabled) may be entitled to receive up to an

additional 11 months of COBRA continuation coverage, for a total maximum of 29 months from

the date of the qualifying event. The disability would had to have started at some time before

the 60th day of COBRA continuation coverage and must last at least until the end of the 18-

month period of continuation coverage. To qualify for this disability extension, you must notify

the Plan Administrator in writing of the person’s disability status BOTH: (1) within 60 days after

the latest of:(i) the date of the disability determination by the SSA, (ii) the date on which the

qualifying event occurs, iii) the date on which you lose (or would lose) coverage under the Plan,

or iv) the date on which you are informed of both the responsibility to provide this notice and

the Plan’s procedures for providing such notice to the Plan Administrator, AND (2) before the

original 18-month COBRA continuation coverage period ends. Also, if Social Security determines

that the qualified beneficiary is no longer disabled, you are required to notify the Plan

Administrator in writing within 30 days after this determination. If these procedures are not

followed or if the notice is not provided in writing to the Plan Administrator within the

required period, you will not receive a disability extension of COBRA continuation coverage.

3. Second Qualifying Event Extension: If the employee’s spouse/domestic partner and/or

dependent children experience a second qualifying event while receiving the initial 18 months of

COBRA continuation coverage, the employee’s spouse/domestic partner and dependent

children (but not the employee) can get up to 18 additional months of COBRA continuation

coverage, for a maximum of 36 months from the initial qualifying event, if timely written notice

of the second qualifying event is given to the Plan. This extension may be available to the

employee’s spouse/domestic partner and any dependent children receiving COBRA continuation

coverage if the employee or former employee dies, becomes entitled to Medicare, or gets

divorced [or legally separated], or if the dependent child stops being eligible under the Plan as a

dependent child, but only if the event would have caused the spouse/domestic partner or

dependent child to lose coverage under the Plan had the first qualifying event not occurred. If a

second qualifying occurs at any time during the 29-month disability continuation period (as

described above), then each qualified beneficiary who is the employee’s spouse/domestic

partner or dependent child (whether or not disabled) may further extend COBRA continuation


coverage for seven more months, for a total of up to 36 months from the date of the initial

qualifying event. (See the “Giving Notice That a COBRA Qualifying Event (or Second Qualifying

Event) Has Occurred” section for important details on the proper procedures and timeframes

for giving this notice to the Plan Administrator.) If these procedures are not followed or if the

notice is not provided in writing to the Plan Administrator within the required 60-day period,

you will not receive an extension of COBRA continuation coverage due to a second qualifying

event.

The table below provides a summary of the COBRA provisions outlined in this section.

Maximum Continuation Period

Qualifying Events That Result in Loss of Coverage Employee

Spouse/Domestic

Partner Child

Employee’s reduction of work hours (for example, full-time

to part-time)

18 months 18 months 18 months

Employee’s termination of employment for any reason

(other than gross misconduct)


Employee or employee’s covered spouse/domestic partner

or dependent child is disabled (as determined by the Social

Security Administration) at the time of the qualifying

event, or becomes disabled within the first 60 days of

COBRA continuation coverage that begins as a result of

termination of employment or reduction of work hours


Employee dies N/A 36 months 36 months

Eligible employee and spouse/domestic partner divorce,

legally separate, or there is a dissolution of a domestic

partnership

N/A 36 months 36 months

Employee becomes entitled to Medicare within 18 months

before termination of employment or reduction in work

hours (even if such Medicare entitlement was not a

qualifying event for the covered spouse/domestic partner

or dependent child because their coverage was not lost)

N/A 36 months1 36 months1

Child no longer qualifies as a dependent child under the

terms of the plan

N/A N/A 36 months

1 36-month period is counted from the date the employee becomes entitled to Medicare.

Electing COBRA Continuation Coverage

You and/or your covered spouse/domestic partner and dependent children must choose to continue

coverage within 60 days after the later of the following dates:


The date you and/or your covered spouse/domestic partner and dependent children would lose

coverage under the Plan as a result of the qualifying event, or

The date Avaya notifies you and/or your covered spouse/domestic partner and dependent children

(through a “COBRA Continuation Coverage Election Notice”) of your right to choose to continue

coverage as a result of the qualifying event.

Paying for COBRA Continuation Coverage

Cost: Generally, each qualified beneficiary is required to pay the entire cost of COBRA continuation

coverage. The cost of COBRA continuation coverage is 102% of the cost to the Plan (including both

employer and employee contributions) for coverage of a similarly situated Plan participant or

beneficiary who is not receiving COBRA continuation coverage. With regard to the 11-month disability

extension of COBRA continuation coverage, the cost of coverage for the 19th through 29th months of

coverage is: 1) 150% of the cost of the Plan’s coverage for all family members participating in the same

coverage option as the disabled individual’s, and 2) 102% of the cost of the Plan’s coverage for any

family members participating in a different coverage option from the disabled individual’s, except as

provided in the next sentence. If a second qualifying event occurs during the first 18 months of

coverage, the 102% rate applies to the full 36 months even if the qualified beneficiary is disabled.

Premium Due Dates: If you elect COBRA continuation coverage, you must make your initial payment for

continuation coverage (including all premiums due but not paid) no later than 45 days after the date of

your election. (This is the date the COBRA Election Notice is post-marked, if mailed.) If you do not make

your initial payment for COBRA continuation coverage within 45 days after the date of your election,

you will lose all COBRA continuation coverage rights under the Plan. Payment is considered made on

the date it is sent to the Plan.

After you make your initial payment for COBRA continuation coverage, you will be required to make

periodic payments for each subsequent coverage period. The premium due date and exact amount due

each coverage period for each qualified beneficiary will be shown in the COBRA Election Notice you

receive. Although periodic payments are due on the dates shown in the COBRA Election Notice, you will

be given a grace period of 30 days after the first day of the coverage period to make each periodic

payment. Your COBRA continuation coverage will be provided for each coverage period as long as

payment for that coverage period is made before the end of the grace period for that payment.

If you elect COBRA continuation coverage but then fail to make an initial or periodic payment before the

end of the 45- or 30-day grace period respectively for that coverage period, you will lose all rights

to COBRA continuation coverage under the Plan, and such coverage will be terminated retroactively to

the last day for which timely payment was made (if any).

When COBRA Continuation Coverage Ends

COBRA continuation coverage for any person will end when the first of the following occurs:

The applicable 18-, 29- or 36-month COBRA continuation coverage period ends

Any required premium is not paid on time


After the date COBRA continuation coverage is elected, a qualified beneficiary first becomes

covered (as an employee or otherwise) under another group health plan (not offered by Avaya)

After the date COBRA continuation coverage is elected, a qualified beneficiary first becomes

entitled to (that is, enrolled in) Medicare benefits (under Part A, Part B, or both). This does not

apply to other qualified beneficiaries who are not entitled to Medicare

In the case of extended COBRA continuation coverage due to a disability, there has been a final

determination, under the Social Security Act, that the qualified beneficiary is no longer disabled. In

such a case, the COBRA continuation coverage ceases on the first day of the month that begins

more than 30 days after the final determination is issued, unless a second qualifying event has

occurred during the first 18 months of COBRA continuation coverage

For newborns and children adopted by or placed for adoption with you (the employee) during your

COBRA continuation coverage, the date your COBRA continuation coverage period ends unless a

second qualifying event has occurred

Avaya ceases to provide any group health plan for its employees.

COBRA continuation coverage may also be terminated for any reason the Plan would terminate

coverage of a participant or beneficiary not receiving COBRA continuation coverage (such as fraud).

If You Have Questions

Questions concerning your plan or your COBRA continuation coverage rights should be addressed to the

Avaya Health & Benefits Decision Center. You may reach a representative by phone Monday through

Friday at 1-800-526-8056 (Option 1). For more information about your rights under the Employee

Retirement Income Security Act of 1974 (ERISA), including COBRA, HIPAA and other laws affecting group

health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee

Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa.

(Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s

website.)

Keep Your Plan Informed of Address Changes

In order to protect your rights as well as the rights of your spouse/domestic partner and dependent

children, you should keep the Plan Administrator informed of any address changes for your

spouse/domestic partner and/or dependent children. You should also keep a copy for your records of

any notices you send to the Plan Administrator.

Family Security Program

The surviving spouse of an eligible employee who has exhausted COBRA continuation coverage or who is

ineligible for COBRA due to Medicare eligibility has the option to join the Family Security Program. See

“What If…You Die” for information on the Family Security Program.

http://www.dol.gov/ebsa


SECTION 8 – WHAT IF…

You Leave Avaya

Your prescription drug coverage will terminate on the last day of the month in which you terminate

employment with Avaya. You may be able to continue your coverage under COBRA.

You Become Disabled

Your length of service and the duration of your disability determine what happens to your coverage

during a disability. Refer to your medical plan SPD for information about Accident and Sickness disability

benefits and Long-Term Disability benefits.

You Die

When you die, your eligible dependents who are covered under the Prescription Drug Plan may continue

coverage under COBRA for a total of 36 months. Class II dependents are not eligible to continue

coverage under COBRA.

Family Security Program

At the end of the COBRA continuation period, your surviving lawful spouse or domestic partner may

choose to continue coverage under the Traditional Indemnity medical plan and the Prescription Drug

Plan if he or she pays the full cost for this coverage under the Family Security Program. Your lawful

spouse or domestic partner may also cover any Class 1 dependent children who were enrolled

immediately before your death, as long as they still qualify as Class 1 dependents.

As long as your lawful spouse or domestic partner makes the required contributions under the

Traditional Indemnity medical plan, medical/prescription drug coverage under the Family Security

Program may continue as follows:

Coverage for your spouse/domestic partner may continue indefinitely, and

Dependent child coverage may continue until the earlier of the date

- The spouse’s/domestic partner’s coverage ends, or

- The dependent child ceases to be an eligible dependent under the Medical Plan.

You Go on an Approved Leave of Absence

If you take an approved leave of absence, (excluding military leave or leave covered under the Family

Medical Leave Act (FMLA)), you may continue your medical/prescription drug coverage for up to 18-29

months under COBRA continuation benefits, depending on the circumstances surrounding your

eligibility for COBRA. You pay the full cost of COBRA continuation benefits. You must remit premium

payments timely to maintain uninterrupted coverage while on leave. If you choose not to continue your


medical coverage while on leave by not remitting payments for your contributions, your coverage will be

reinstated when you return to work, subject to Plan provisions.

You Gain a New Dependent

If you gain a new dependent (through marriage, birth or adoption), you may enroll your new dependent

if you do so within 31 days of the date he or she became your dependent by notifying the Avaya Health

& Benefits Decision Center at 1-800-526-8056 (Option 1). See “Making Changes during the Year” in

Section 3 for more information.

A Dependent Loses Eligibility

Call the Avaya Health & Benefits Decision Center at 1-800-526-8056 (Option 1) within 31 days of the

date your covered dependent is no longer eligible. You must provide notification within 31 days when

your dependent no longer qualifies as an eligible dependent, to make any corresponding changes to

your coverage level (individual, two-person, family) and ensure that your dependent is sent timely

information regarding COBRA continuation coverage. If you do not provide notification within 31 days of

when the dependent loses eligibility, your level and rates will not be retroactively adjusted, and the

dependent will be ineligible to claim benefits. If you do not provide notification within 60 days, your

dependent will lose all rights to COBRA continuation coverage.

Your Physically or Mentally Handicapped Child Reaches Age 26

If your physically or mentally handicapped child is incapable of self-support for more than a short period

of time at the point he or she reaches age 26, medical/prescription drug coverage may be continued

beyond that age if the child is fully dependent on you for support. You must apply for this coverage. It is

not automatic. To apply for coverage, contact your medical plan administrator at the telephone number

printed on your medical ID card prior to the child’s 26th birthday.

You Go on Military Leave

The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) guarantees

certain rights to eligible employees who enter military service. The terms “Uniformed Services” or

“Military Service” mean the Armed Forces (that is, Army, Navy, Air Force, Marine Corps, Coast Guard),

the reserve components of the Armed Services, the Army National Guard and the Air National Guard

when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the

commissioned corps of the Public Health Service, and any other category of persons designated by the

President in time of war or national emergency.

Upon returning from military leave, you are eligible to receive the service credits, rights and benefits

associated with the position held at the start of your leave, plus any additional service credits, rights and

benefits that you would have attained if employment had not been interrupted.


If your military leave is for less than 31 days, you may continue your coverage by paying the active

employee rate. If your leave is for more than 31 days, you may continue coverage under COBRA for up

to 18 months, and you will be charged up to the full cost of coverage plus a 2% administrative fee.

If you choose not to continue your medical/prescription drug coverage while on military leave, your

coverage will be reinstated with no waiting periods or exclusions (however, an exception applies to

service-related disabilities) when you return from leave.

In general, to be eligible for the rights guaranteed by USERRA, you must:

Return to work on the first full, regularly scheduled workday following your leave, safe transport

home, and an eight-hour rest period, if you are on a military leave of less than 31 days

Return to or reapply for employment within 14 days of completion of such period of duty, if your

absence from employment is from 31 to 180 days

Return to or reapply for employment within 90 days of completion of your period of duty, if your

military service lasts more than 180 days.

You Go on FMLA Leave

Under the federal Family and Medical Leave Act (FMLA), if you meet eligible service requirements, you

may take up to 12 weeks of unpaid leave for certain family and medical situations. During FMLA leave,

you will continue to have medical/prescription drug coverage: (a) if you had such coverage before taking

the leave, and (b) your coverage will be under the same terms as if you had continued to work. You will

need to pay your share of the group health plan contributions while on leave.

If you are eligible, you may take up to 12 weeks of unpaid leave in a 12-month period for the following

reasons:

For the birth and care of your newborn child or a child that is placed with you for adoption or foster

care

For the care of a spouse, child, or parent who has a serious health condition

For your own serious health condition

For “any qualifying exigency” (a qualifying urgent situation or pressing need) arising out of the fact

that the spouse, son, daughter or parent of the employee is on active duty or called to active duty

status as a member of the National Guard or Reserves in support of a contingency operation

In addition, an eligible employee who is the spouse, son, daughter, parent or next of kin (that is, nearest

blood relative) of a covered military service member who is recovering from a serious illness or injury

sustained in the line of duty on active duty is entitled to up to 26 weeks of leave in a single 12-month

period to care for the service member. An eligible employee can also take leave to care for certain

veterans with a serious illness or injury incurred or aggravated in the line of duty while on active duty

and that manifested itself before or after the veteran left active duty. Military caregiver leave is also

allowed for an eligible employee to care for current service members with serious injuries or illnesses

that existed before service and that were aggravated by service in the line of duty while on active duty.


Military caregiver leave is available during “a single 12-month period” during which an eligible employee

is entitled to a combined total of 26 weeks for all types of FMLA leave. For details on Military FMLA, visit

the U.S. Department of Labor/Employment Standards Administration website

(https://www.dol.gov/whd/fmla/2013rule/FMLA_Military_Guide_ENGLISH.pdf).

https://www.dol.gov/whd/fmla/2013rule/FMLA_Military_Guide_ENGLISH.pdf


SECTION 9 – HIPAA PRIVACY RIGHTS


How to obtain HIPAA documentation

Avaya’s Health Insurance Portability and Accountability Act (HIPAA) policies and practices are

documented in the Avaya Privacy Notice (“HIPAA Privacy Notice”). You can obtain a copy of the HIPAA

Privacy Notice by contacting Avaya Health & Benefits Decision Center at 1-800-526-8056 (Option 1).

Alternatively, you can obtain a copy of this Notice free of charge upon your written request to the Plan

Privacy Officer at the following address:

Avaya, Inc.

Health Plan Administrator

4655 Great America Parkway

Santa Clara, CA 95054

E-mail: [email protected]



SECTION 10 – OTHER REGULATORY AND LEGAL REQUIREMENTS


Court-ordered Benefits for Dependent children

Interpretation of Benefits

How to access the official Plan documents

Circumstances that may result in denial, loss, forfeiture or rescission of benefits

The future of the Plan

Your rights under ERISA

Qualified Medical Child Support Order (QMCSO)

A qualified medical child support order (QMCSO) is a judgment, decree or order issued by a court or

appropriate state agency that requires a child to be covered for medical benefits. Generally, a QMCSO is

issued as part of a paternity, divorce, or other child support settlement.

If the Plan receives a medical child support order for your child that instructs the Plan to cover the child,

you will be notified of the receipt of the order within 15 days of the date it was received. The notice will

also describe the procedures the Plan will use to determine whether the child support order or the

administrative notice is a “Qualified Medical Child Support Order” as defined in section 609 of ERISA.

The Plan Administrator will review and determine if the order is a “Qualified Medical Child Support

Order” within 60 days of receipt of the notice. If a delay is required, you will be notified of the delay in

writing. If it determines that it does, your child will be enrolled in the Plan as your Dependent, and the

Plan will be required to pay Benefits as directed by the order.

You may obtain, without charge, a copy of the procedures governing QMCSOs from the Plan

Administrator.

Note: A National Medical Support Notice will be recognized as a QMCSO if it meets the requirements of

a QMCSO.

Plan Administration/Interpretation

The administration of the Plan will be under the supervision of the Plan Administrator and Claims

Administrator. To the fullest extent permitted by law, the Plan Administrator and Claims Administrator

will have the exclusive discretionary authority to determine all matters relating to the Plan, including

eligibility, coverage and benefits.


The Plan Administrator and Claims Administrator will also have the exclusive discretionary authority to

determine all matters relating to interpretation and operation of the Plan. The Plan Administrator may

delegate any of its duties and responsibilities to one or more persons or entities. Such delegation of

authority must be in writing and must identify the delegate and the scope of the delegated

responsibilities. Decisions by the Plan Administrator, or any authorized delegate, will be conclusive and

legally binding on all parties.

Plan Document

This SPD is intended to help you understand the main features of the Plan. It should not be considered a

substitute for the official plan document, which governs the operation of the Plan. That document sets

forth all of the details and provisions concerning the Plan and is subject to amendment. If any questions

arise that are not covered in this SPD or if this SPD appears to conflict with the official plan document,

the text of that official plan document will determine how questions will be resolved. To request a copy

of the official plan document, contact the Human Resources Department.

How You May Lose Benefits

Under certain circumstances, plan benefits may be denied or reduced from those described in this SPD.

Cancellation or discontinuance of coverage is permitted if it has only a prospective effect on coverage,

or is effective retroactively due to failure to pay required premiums or contributions. Benefits may be

reduced or denied, for instance, if:

You purchase prescription drugs at an out-of-network pharmacy

You purchase a drug without getting prior authorization when required

You fail to provide notice of a qualified status change to the Plan within the required timeframe

You waive coverage or do not enroll within the required timeframes when initially eligible

Rescission

Rescission of coverage is cancellation or discontinuance of coverage retroactively for reasons other than

failure to pay required premiums or contributions. For example, rescission of coverage may be

permitted in limited circumstances such as fraud or the intentional misrepresentation of a material fact

by providing false information or making a misrepresentation in connection with a claim for benefits, or

permitting a non-eligible person to use a membership or other identification card for the purpose of

wrongfully obtaining benefits. If coverage is subject to rescission, all affected participants must be

provided with a written notice at least 30 days before the date of rescission.

The Company’s Right to Amend or Terminate the Plan

It is Avaya’s intent that the Prescription Drug Plan will continue indefinitely. However, Avaya has the

right to amend, modify, suspend or terminate the Plan, in whole or in part, by action of the Board of

Directors of Avaya Inc., subject to the terms of any collective bargaining agreement between Avaya and

your union.


Any such action would be taken in writing and maintained with the records of the Plan. Plan

amendment, modification, suspension or termination may be made for any reason, and at any time, and

may, in certain circumstances, result in the reduction of or elimination of benefits or other features of

the Plan to the extent permitted by law.

If the Prescription Drug Plan described in this SPD is terminated, you will not have any further rights

other than payment of expenses or other claims incurred before the Plan was terminated.

Limitation on Assignment

Your rights and benefits under the Plan cannot be assigned, sold, transferred, or pledged by you or

reached by your creditors or anyone else.

Your Employment

This SPD provides detailed information about The Prescription Drug Plan and how it works. This SPD

does not constitute an implied or express contract or guarantee of employment. Similarly, your eligibility

or your right to benefits under the Plan should not be interpreted as an implied or express contact or

guarantee of employment. Avaya’s employment decisions are made without regard to benefits to which

you are entitled upon employment.

Statement of ERISA Rights

As a participant in the Prescription Drug Plan described in this handbook, you are entitled to certain

rights and protections under ERISA. ERISA provides that all benefit 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 and union halls, all documents governing the Plan, including insurance contracts and

collective bargaining agreements, 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 EBSA

Obtain, upon written request to the Plan Administrator, copies of documents governing the

operation of the Plan, including insurance contracts and collective bargaining agreements, copies of

the latest annual report (Form 5500 series) and updated summary plan description. The Plan

Administrator may request a reasonable charge for the copies, and

Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law

to furnish each participant with a copy of this summary annual report.

Continue Group Health Plan Coverage

Continue healthcare coverage for yourself, your spouse/domestic partner, or dependent if there is a loss

of coverage under a health plan as a result of a qualifying event. You or your dependents may have to

pay for such coverage. Review this SPD and the documents governing the Plan for the rules governing

your COBRA continuation coverage rights.


Prudent Actions by Plan Fiduciaries

In addition to creating rights for plan participants, ERISA imposes duties on the people who are

responsible for the operation of employee benefit plans. The people who operate the 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 the Company or your union 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 health and 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 it within 30 days, you may file suit in 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 Plan

Administrator

If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a

state or federal court, but you have exhausted the Plan’s claims and appeals procedures as

described under Claim Denials and Appeals in “Section 5 - Filing Prescription Drug Claims”. In

addition, if you disagree with the Plan’s decision or lack thereof concerning the qualified status of a

QMCSO, you may file suit in federal court, and

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 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 (if, for example, it finds your claim is frivolous).

Assistance with Your Questions

If you have any questions about any of the healthcare benefit plans offered by the Company, 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 EBSA, U.S. Department of Labor, listed in your telephone directory.

Or you can contact the Department of Labor’s Division of Technical Assistance and Inquiries by writing

to:


Employee Benefits Security Administration

U.S. Department of Labor

200 Constitution Avenue N.W.

Washington, D.C. 20210

You also may obtain certain publications about your rights and responsibilities under ERISA by calling the

publications hotline of the Employee Benefits Security Administration at 1-866-444-EBSA (3272). You

also may visit EBSA’s website at www.dol.gov/agencies/ebsa.

http://www.dol.gov/agencies/ebsa


SECTION 11 – ADMINISTRATIVE INFORMATION


Plan administrative information

This section includes information on the administration of the Prescription Drug Plan. While you may

not need this information for your day-to-day participation, it is information you may find important.

This information about the administration of the Prescription Drug Plan is provided in compliance with

the Employee Retirement Income Security Act (ERISA) of 1974, as amended. While you should not need

these details on a regular basis, the information may be useful if you have specific questions about your

plan.

Details About Plan Administration

Plan Sponsor/Plan Administrator Avaya Inc.



1-866-472-8292

Employer Identification Number / Plan No. 22-3713430 / 551

Official Plan Name The Avaya Inc. Medical Expense Plan, which is a part of the

Avaya Inc. Health & Welfare Benefits Plan

Plan Year January 1 – December 31

Type of Plan Health and Welfare Plan that includes prescription drug

benefits

Agent for Service of Legal Process Any legal actions regarding a claim should be sent to the Claims

Administrator

All other legal actions should be sent to the Plan Administrator

E-mail: [email protected]

Claims Administrator Express Scripts

Attn: Commercial Claims

P.O. Box 2872

Clinton, IA 52733-2872

1-877-505-3213

Plan Funding The prescription drug coverage component of the Medical Plan

is self-funded. Benefits from this Plan are paid from employee

contributions, as applicable, and from the general assets of

Avaya Inc., as needed. Avaya Inc. has contracted with Express

Scripts, a third party administrator, to administer this Plan.



SECTION 12 – IMPORTANT TERMS


Definitions of terms used to describe prescription drug benefits

The following terms will help you understand the features and benefits of the Prescription Drug Benefit.

For more information, contact the Avaya Health & Benefits Decision Center at 1-800-526-8056 (Option

1) or Express Scripts at 1-877-505-3213.

Annual deductible. The annual amount you must pay out-of-pocket for prescription drug expenses

under the POS medical plan before the Plan begins paying prescription drug benefits when you use a

non-participation pharmacy.

Annual medical out-of-pocket maximum. The most you will pay out-of-pocket for covered medical and

prescription drugs each year. The amount includes your retail pharmacy and home delivery copays. The

annual out-of-pocket maximum does not include your regular contributions and any amounts that

represent the difference in cost between a brand drug and a generic, when a generic is available, or

charges for not preauthorizing medication when required. After you reach the out-of-pocket maximum,

the Plan pays 100% of any remaining eligible medical and prescription drug charges for that year.

Annual prescription drug out-of-pocket maximum. The most you will pay out-of-pocket for covered

prescription drugs each year. The amount includes your retail pharmacy and home delivery copays. The

annual out-of-pocket maximum does not include your regular contributions and any amounts that

represent the difference in cost between a brand drug and a generic, when a generic is available, or

charges for not preauthorizing medication when required. After you reach the out-of-pocket maximum,

the Plan pays 100% of any remaining eligible medical and prescription drug charges for that year.

Avaya Participating Company. Avaya Inc. and such other affiliates that have elected to participate in the

Medical Plan, with the prior approval of Avaya Inc.

Brand Name drug. A drug that has been patented and is produced by only one manufacturer.

Claims Administrator. The third party administrator responsible for administering the Plan and paying

claims. The Claims Administrator does not insure the prescription drug benefits, but pays claims with

funds provided by Avaya Inc.

Coinsurance. The percentage you and the Plan pay if enrolled in the POS medical plan toward the

covered prescriptions you purchase at a non-participating pharmacy.

Copayment (or “copay”). The flat dollar amount that you must pay for prescription drugs under the

POS and Traditional Indemnity medical plans as your share of the cost when you use a participating

retail pharmacy or home delivery. Copayment amounts vary by drug tier.


“Covered Drug” means a drug that is covered under the Express Scripts formulary used by the Plan for

Prescription drug services and satisfies all of the rules to be considered for payment under the Plan.

Experimental or investigative treatment, drug or device. Medical, surgical and psychiatric procedures,

treatments, devices, drugs and drug treatments not approved by governmental agencies such as the

Food and Drug Administration (FDA) and not accepted as standard, tested and accepted effective

practice by the medical community at large at the time the service, treatment or drug is provided, as

determined by the health care company.

Formulary. A formulary is a clinically based drug list (the “Express Scripts National Preferred Formulary”)

that contains the generic, brand name and specialty medications covered by the Plan. It is created and

maintained by Express Scripts, as amended from time to time. The Medical Plan has a three-tier

structure, known as an open formulary, for prescription drug coverage. Your coinsurance/copayment is

determined by the tier of your medication.

Generic drug. A drug that does not bear the trademark of the original manufacturer. It must have the

same active ingredients as its brand name drug counterpart. Generic drugs usually cost less than brand

name drugs.

In-Network Participating Pharmacy. A retail pharmacy that participates in the Express Scripts Network

subject to an agreement between the pharmacy and Express Scripts.

Out-of-Network Non-Participating Pharmacy. A pharmacy that does not participate in the Express

Scripts retail network.

Specialty drug. A medication used to treat complex, chronic conditions, such as multiple sclerosis and

rheumatoid arthritis. Specialty medications often require special handling, preparation or refrigeration.

Avaya Inc. Health & Welfare Benefits Plan

Active Represented Prescription Drug Plan Summary Plan Description

Avaya Inc.



Effective: January 1, 2018