受托人的意见
____________________________________________________________________________

在再保险

原告:退休老人
被申请人:雇主
ROD案例编号:CA-0097 - 2011年10月7日

受托人: 迈克尔·H. 荷兰，丹尼尔·L. 莫里斯·D·法西奥. 菲布希和卡洛·塔利

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Coal Industry Retiree Benefit Act of 1992 (Coal Act) Employer Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.

背景事实

Complainant is receiving health benefits from Respondent under the terms of the Coal Industry Retiree Benefit Act of 1992 Employer Benefit Plan (the “Plan”). 申诉人试图重新开处方服用伟哥, 但被告的药房福利经理(简称“PBM”)拒绝付款. PBM随后将一份包含13个问题的预授权表格传真给投诉人的医生. Complainant’s physician filled out the pre-authorization form and faxed it to the PBM the following day. 然而, the PBM denied payment again because Complainant’s physician failed to answer all of the questions on the pre-authorization form. Another physician subsequently filled out the pre-authorization form on Complainant’s behalf and returned it to the PBM. 这个处方最终被配药了, 申诉人被批准获得一年的伟哥福利.

Complainant asserts that Respondent may not include questions in a pre-authorization form for Viagra prescriptions beyond the six guidelines set forth in ROD 98-024.

争端

May Respondent require Complainant’s physician to complete a pre-authorization form containing questions other than the six guidelines set forth in ROD 98-024 原告获得伟哥的利益?

双方立场

Position of the Complainant: Respondent may only require Complainant’s physician to address the six guidelines set forth in ROD 98-024, 以及其他与伟哥有关的类似的rod, 原告获得伟哥的利益.

Position of the Respondent: The Plan Administrator may require a pre-authorization form as a health care cost containment measure pursuant to 第四条 of the Plan.

相关的规定

《皇冠搏彩中心网站》第三条的序言指出:
第三条福利待遇
除第4条另有规定外，本计划提供的福利载于第3条. Benefit payments shall not exceed reasonable and customary charges for covered services and supplies. Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, 或计划另有规定. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan. 在确定合理性和必要性的问题上, due consideration will be given to the customary practices of physicians in the community where the service is provided. 不合理和不必要的服务包括, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. The benefits described in this Article are subject to any requirements implemented pursuant to 第四条. 将继续提供医疗上必要的承保服务, 和相应的, 虽然福利金支付可能受到管理式护理和成本控制规则的约束, this paragraph shall not be construed to detract from plan coverage or eligibility as described in this 第三条.

第三条.《皇冠搏彩中心网站》A(4)(A)的有关部分规定:

(4)处方药

(a) 提供的福利

Benefits are provided for insulin and prescription drugs (only those drugs which by Federal or State law require a prescription) dispensed by a licensed pharmacist and prescribed by a (i) physician for treatment or control of an illness or a nonoccupational accident or (ii) licensed dentist for treatment following the performance of those oral surgical services set forth in (3)(e). 初始分配的数量不得超过30天的供应量. Any original prescription may be refilled for up to six months as directed by the attending physician. 第一次这样的补充可能会达到，但不超过，60天的供应. 第二次这样的补充可能是数量最多，但不超过，90天的供应. Benefits for refills beyond the initial six months require a new prescription by the attending physician.

第三条.计划A(10)(b)项规定:

(10)总则
(b)管理
The Plan Administrator is authorized to promulgate rules and regulations to implement and administer the Plan, and such rules and regulations shall be binding upon all persons dealing with the Beneficiaries claiming benefits under this Plan. UMWA 1992年福利计划的受托人将解决任何争议, 包括过高的费用纠纷, to assure consistent application of the Plan provisions which are identical to the benefit provisions of the 1992 Benefit Plan.

第四条.《皇冠搏彩中心网站》A的有关部分指出:

用人单位也可以实行处方药处方;
实现处方药邮购程序，包括
appropriate limits on quantity and periodic physician review; and
将处方药计划置于适当使用的严格审查之下.

第四条.该计划的B项规定:

此外，雇主可实施某些其他管理式医疗和
成本控制规则，这可能适用于PPL提供的福利
供应商和非ppl来源，但其中(除共同支付)
(计划中特别规定的)不会导致减少
本计划所涵盖服务的福利或额外费用.

讨论

该计划第三条规定了由持牌药剂师配药的处方药的保险范围, 只要是医学上必要的. 第四条.B of the Plan permits Employers to implement cost containment rules that do not result in a reduction of benefits or additional costs for covered services under the Plan.

Respondent adopted the pre-authorization form in the instant case as a cost containment measure to ensure the medical necessity of Viagra prescriptions. 的资金’ Pharmacy Program Manager and Medical Director have determined that Respondent’s pre-authorization form provides a reasonable basis for determining the medical necessity of Viagra prescriptions. Inasmuch as the terms of the Plan subject prescription drug benefits to cost containment rules implemented by the Employer, 被调查者的预授权表格不会导致福利的减少. 此外, 被投诉人的预授权表格不会对投诉人产生额外费用，而且是, 因此, 《皇冠搏彩中心网站》条款下允许的成本控制规则.

受托人的意见

Respondent may require the completion of its pre-authorization form before providing benefits for a Viagra prescription.