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Alternate, Summary of Benefits and Coverage (SBC), and Prescription
Summary of Changes PY13-14
Changes = Bold
ALTERNATE

Eligible Benefits
 Major Medical - Pg. 6 • Breast Oncology – Evidence based mastectomy/lumpectomy and reconstructive oncology surgery of affected and
non affected breast. • Cardiac Rehabilitation – A program of clinicaly supervised exercise designed to strengthen the heart and
improve cardiovascular functioning.
• Testosterone – Prior Authorization wil be required to review two separate morning lab results defining the
testosterone level wil be required. The lab report wil indicate whether the level is low or within normal
ranges. The eligible benefit plan's hormonal low level treatment wil be injectable medication.

General Exclusions or Limitations - Pgs. 10-12
45. for treatment of developmental delays;
Note: This exclusion is deleted.
Pre-Existing Condition Limitations
 Exception to the Pre-existing Condition Limitations - Pg. 13
2. Pre-Existing condition limitations wil be prohibited for nineteen (19) years of age and older for benefit plan years
effective January 1, 2014 thereafter.

Dates of Eligibility and Coverage
 Employee - Pg. 14
• TML IEBP wil exempt the fol owing employees from the 100% participation requirement:
1. If an individual is hired to work for a political subdivision and can provide the employer with documentation
of benefits from prior employment due to retirement;
2. An employee who is accessing a parental healthcare plan to the attained age of twenty-six (26);
3. Employee chooses to be covered under the spouse's healthcare plan in place of the TML IEBP Plan;
4. Employees or employee's spouse accessing the TRICARE plan (employer provided financial incentive is
disal owed);
5. Employees that choose to be on Medicare plan with NO financial incentive;
6. Employees that access the tribal coverage offered to tribal membership;
7. An employee who is accessing another plan due to Ful Time Equivalency status with two employers (30 hours
a week, 130 hours a month or 120 seasonal days a year).
TML Intergovernmental Employee Benefits Pool (Rev 11.20.13) Alternate, SBC, and Rx Summary of Changes PY13-14  Active Duty Reservists - Pg. 14 • Under 38 USCA § 4316. an employee who is cal ed for military leave may have rights to Continuation of Coverage
for up to twenty-four (24) months and a right to reemployment once he/she is discharged from active military
service.
If the employee wil be on active duty for thirty-one (31) days or less, the employer wil keep the employee on the
plan with no change in coverage. If the employee wil be on active duty for more than thirty-one (31) days, the employer wil notify TML IEBP of the qualifying event and submit a copy of the employee's written order for cal to
duty.
If TML IEBP administers Continuation of Coverage, the employer must notify TML IEBP by sending a Qualifying Event
Notice and mark the qualifying event "Cal ed to Active Duty" and attach a copy of the employee's written order for
the cal to duty.
Section 143.072, Texas Local Government Code may require an employer to "continue to maintain" coverage on a
police officer or fire fighter while he/she is on military leave if the employer has adopted civil service
requirements and the leave has been approved by the Fire Fighters' and Police Officers' Civil Service Commission.
This section only applies if the employer meets the requirements of Chapter 143 of that Code, including having a
population of 10,000 or more and voted to adopt the applicable provisions of the law.

Definitions - Pgs. 18-28
 Active Employee
• In order for sick pool leave to be considered as sick leave under this definition, Member's sick pool policy must be (1)
in writing, (2) on file with TML IEBP prior to the start of the employer's plan year, and (3) available uniformly to al
employees. Employees that do not meet the definition of an employee in the benefit book are not eligible for medical benefits.
A Family Medical Leave Act (FMLA) certification shal extend the period of coverage for Benefit eligible
employee(s) when the FMLA documentation is provided in writing to TML IEBP within thirty (30) days of the
certification and one hundred and twenty (120) days of the beginning date of the FMLA leave.

 Extenuating Circumstances
• If a Covered Person requires care from a specialist care provider, but there is not a Network specialist care
provider within a seventy-five (75) mile radius from the employee's place of business, the provider would be paid
at network benefits subject to U&R al owable amounts.
 Waiting Period • A required period of time an active employee must complete before an employee or his/her eligible dependents can be effective for coverage under this Plan. Waiting periods must not be in excess of ninety (90) days for plan years
January 1, 2014 thereafter.
TML Intergovernmental Employee Benefits Pool (Rev 11.20.13) Alternate, SBC, and Rx Summary of Changes PY13-14 SBC SUMMARY OF CHANGES

Common Medical Event
 Frequently Asked Questions - Pg. 2
• Does this coverage provide minimum essential coverage? The Affordable Care Act requires most people to have
health care coverage that qualifies as "minimum essential coverage." This plan does provide minimum essential
coverage.

• Does this coverage meet the minimum value standard? The Affordable Care Act establishes a minimum value
standard of benefits of a health plan. The minimum value standard is 60 percent (actuarial value). This health
coverage does meet the minimum value standard for the benefits it provides.
 If your child needs dental or eye screenings (attained age of 19) - Pg. 5
 Treatment Episode of the Medical y Necessary Hearing Appliance - Pg. 9
• $3,500 Maximum Benefit (per three (3) calendar years)
 Custom Molded Foot Orthotics - Pg. 9 • 1 molded orthotic per thirty-six (36) months unless documented medical y physiological changes
 Physical Therapy (PT)/Aquatic Therapy (AT) - Pg. 9
• 24 PT/OT/AT Outpatient Visits Calendar Year (CY)
 Occupational Therapy (OT) - Pg. 9
• 24 PT/OT/AT Outpatient Visits Calendar Year (CY)
 Durable Medical Equipment and Related Supplies - Pg. 10 • Notification is required for charges in excess of $1,000 per base piece of durable medical equipment prior to
purchase, lease, or rental; limited to the U&R charges of standard models as determined by Medical Intel igence
Care Management. Parity payment with major services under employer medical plan.
PRESCRIPTION SUMMARY OF CHANGES

Retail Covered Individual Copayments
Mail/Maintenance up to 84/90
day dispensement

MedVantx: (866) 744-0621
up to 34 day dispensement
Over the Counter Alternates
Retail: Covered Individual Out of Pocket (OOP)
Diplomat: (877) 977-9118
and Prescription Networks
(up to 34 days supply max unless noted otherwise)
Covered Individual OOP
Prescribed Over the Counter Alternates: Non-Sedating Antihistamines (Claritin®, Claritin-D®, Alavert®, Al egra®, Al egra-D®, Zyrtec®, Zyrtec-D®); per prescription Stomach and Ulcer (Prilosec®, Prevacid®, Zegerid®); per prescription Smoking Cessation (Nicorette Gum) Quantity Limit - 3 boxes per plan year TML Intergovernmental Employee Benefits Pool (Rev 11.20.13) Alternate, SBC, and Rx Summary of Changes PY13-14 Mail/Maintenance up to 84/90
day dispensement

MedVantx: (866) 744-0621
up to 34 day dispensement
Over the Counter Alternates
Retail: Covered Individual Out of Pocket (OOP)
Diplomat: (877) 977-9118
and Prescription Networks
(up to 34 days supply max unless noted otherwise)
Covered Individual OOP
Doctor Ordered: Aspirin, Folic Acid, Fluoride
Chemoprevention Supplements, Iron Deficiency Supplements, and Vitamin D
supplementation to prevent fal s in
community-dwel ing adults age 65 years and
older who are at an increased risk for fal s;
per prescription
Women's Preventive Health Services:
Medical Plan Prescription Plan
Oral Generic/Align Network (no cost share)
IUD Device (no cost share)
Implant Device (no cost share)
Permanent Implantable Contraceptive Coil
(subject to the appropriate deductible and benefit
Insertion and/or Removal of Devices (no
cost share)
Sonogram to Detect Placement of Device
(no cost share)
Injectable Contraceptives/Align Network
(no cost share)
Injectable Administration Fee (no cost share)
Diaphragm, Hormone Vaginal Ring,
Hormone Patch, Cervical Cap, Spermicides,
Sponges (no cost share)
Diaphragm Instruction and Fitting Fee (no
cost share)
Contraceptive Management (no cost share)
** Represents no cost share under prescription plan within Align and Broad
Network.
Align Network Value Tiered up to 34 day non $0.00 (up to 34 days supply) Cost Share generic dispensement Align Network Value Tiered up to 90 day non $9.00 (35 up to 90 days supply) Cost Share generic dispensement Broad Network non Cost Share Generic Broad and Align Network non Cost Share Best $38.00 Price Brand List Broad and Align Network non Cost Share Non-Best Price Brand List Broad and Align Network Cost Share Specialty/Biotech Prescriptions $100.00 for up to 34 day supply Biosimilar Prescriptions $75.00 for up to 34 day supply
MedVantx Demographics
MedVantx Pharmacy service is the mail order al iance partner for TML IEBP membership. The MedVantx services include a
comprehensive prescription delivery program featuring world class customer service and industry leading accuracy and
delivery times. A state of the art mail dispensing facility in Sioux Fal s, SD including technological y advanced pharmacy
software and hardware. The MedVantx blend of automation and human touch ensures the quality of patient orders is the
first priority.
If you have any mail order prescription questions cal MedVantx tol free at (866) 744-0621 or log on to
TML Intergovernmental Employee Benefits Pool (Rev 11.20.13) Alternate, SBC, and Rx Summary of Changes PY13-14 Diplomat Demographics
Diplomat Specialty Pharmacy is the TML IEBP Biotech/Specialty prescription al iance partner for the TML IEBP
membership.
Diplomat Demographics
 The Diplomat Exception – staying committed to our heritage by providing true high touch service that has been in
place since 1975.
 Diplomat's unequaled drug therapy & care management programs:
» oncology
» growth hormone deficiency » hemophilia/lg
» psoriasis
» cystic fibrosis
» respiratory syncytial virus (RSV) prevention
» hereditary angioedema » arthritis
» deep venous thrombosis (DVT) prevention
» Crohn's disease
» hepatitis
» osteoporosis
» HIV/AIDS
» multiple sclerosis
» fertility
» transplant
Key Offerings
1. Comprehensive care and quality management of specialty pharmaceuticals within the pharmacy and medical
2. Ful col aboration with patient's entire health care team
3. Innovative exact dose dispensing programs for high-cost orals
4. Industry accreditations
5. Hospital and retail pharmacy support services
6. Patient Advocacy Team to help patients manage complex treatment regimens, physicians' visits and insurance
concerns
7. Pharmacist access 24/7/365
8. 340b Expertise
9. NO AUTO REFILLS - Rather a pro-active model of care that delivers clinical outcomes with optimal cost effectiveness
10. eNAV® proprietary patient care software
11. Best-in-class Drug Therapy Management programs target the leading chronic disease states
12. State-of-the-art facilities with top-of-the-line production automation
13. Specialty Infusion expertise with nurse support on a national basis
Steps Necessary for Biotech/SpecialtyRx Medication
Al Biotech/Specialty Rx medication require a prior authorization. Your provider wil be required to cal RxResults at
(888) 871-4002 or visitfor a prior authorization form. You can order directly from Diplomat Specialty
Pharmacy by cal ing (877) 977-9118 or by completing the enclosed Prior Authorization Form and faxing it to (800) 550-
6272.
 RxResults Phone: (888) 871-4002
 RxResults Fax: (877) 540-9036
 Diplomat Phone: (877) 977-9118
 Diplomat Fax: (800) 550-6272
TML Intergovernmental Employee Benefits Pool (Rev 11.20.13) Alternate, SBC, and Rx Summary of Changes PY13-14 Step Therapy
For clinical authorization, doctor/prescription prescribers should cal RxResults at (888) 871-4002. Your doctor/prescription
prescriber wil be asked a series of questions and RxResults wil then approve or deny the authorization request.  Sample of what wil occur at pharmacy Claim is processing for Advair® & the fol owing message wil alert the pharmacist: Step Therapy after inhaled steroid 1st or Prior Authorization cal (888) 871-4002. Required for members <40 years of age who have not demonstrated adherence to an inhaled corticosteroid (ICS) (90 days of therapy in the past 120 days). Category A  Inhaled corticosteroid (ICS) - Member must demonstrate adherence to an inhaled steroid and/or satisfy specific clinical criteria as determined by RxResults prior to obtaining a Category B medication. Category B (Only after failure with a Category A medication)  Advair®  Perforomist® Treatment Plan Adherence is required for authorization to be approved. Note: Al clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines.
Clinical Prior Authorization
The list of conditions below may change as appropriate for the plan. For prior authorization requests, please have your
doctor/prescription prescriber cal RxResults at (888) 871-4002. Your doctor/prescription prescriber wil be asked a series of questions and RxResults wil then approve or deny the authorization request. A Prior Authorization is active for one year. If the covered individual has consistently taken the medication, (no lapse in medication greater than 100 days) the prescribing provider wil be required to resubmit clinical information to maintain the ongoing Prior Authorization Approval. Antibiotics  Zyvox® General  Attention Deficit Disorder ADHD (For individuals 17 years of age or older)
These medications may be reimbursed fol owing satisfaction of clinical criteria as determined by prior authorization review.
 Narcolepsy Medications including Xyrem® (For individuals 17 years of age or older)
 Acne Medications (For individuals 26 years of age or older)
Major Biotech Prescription Categories  Blood Cel Deficiency  Crohn's Disease  Cystic Fibrosis  Growth Hormones  Osteoarthritis  Pulmonary Arterial Hypertension  Rheumatoid Arthritis  HIV/Immune Deficiency Medications  Multiple Sclerosis  Oncology Oral  Renal Disease  Hepatitis C
 Others
TML Intergovernmental Employee Benefits Pool (Rev 11.20.13) Alternate, SBC, and Rx Summary of Changes PY13-14 Testosterone - Al Products
Two separate morning lab results defining the testosterone level wil be required. The lab report wil indicate whether the level
is low or within normal ranges.
 Injectable Only
Diabetes These medications may be reimbursed fol owing satisfaction of clinical criteria as determined by prior authorization review.  Bydureon®  Byetta®  Januvia®/Janumet®, Janumet XR® (covered for diabetes only)  Jentadueto®  Kazano®  Kombiglyze®
 Nesina®
 Oseni®

Lipid-Lowering Agents (Statins)
 Crestor® (Prior authorization required for 40mg strength only. Other strengths considered Cost Share Copay drugs.)
Note: Al clinical programs (Clinical Prior Authorization, Step Therapy, Cost Share Drugs, etc.) are subject to change without notice to accommodate new drug entries to the marketplace and adjustments in established medical and pharmacy practice guidelines.
Cost Share Copay Drugs
Note: Cost Share Notification Letters wil be submitted to covered individuals thirty (30) days prior to plan year.
TML IEBP has implemented a clinical evidence-based approach to its prescription plan for groups adopting 2013-2014 Plan
Year benefits. As such, TML IEBP wil impose a higher patient copayment for drugs for which there is no clinical evidence to show that non-preferred "Cost Share Drugs" perform any better than therapeutic doses of less costly preferred "Alternative ADHD / CNS Stimulants  Impacts utilization on: Immediate Release Amphetamine Products: Adderal ®, Dexedrine®, Dextrostat®; Immediate Release
Methylphenidate Products: Ritalin® (brand only), Focalin®; Extended Release Amphetamine Products: Adderal XR®, Amphetamine ER, Dexedrine Spansules®; Extended Release Methylphenidate Products: Concerta®, Daytrana®, Focalin XR®, Metadate CD®, methylphenidate
ER, Ritalin LA®, Intuniv®, Kapvay®, Nuvigil®, Provigil® (brand only); Alternate Drugs: Generic: methylphenidate®, amphetamine, guanfacine immediate release (for Intuniv®), clonidine (for Kapvay®), modafinil (for Provigil®, Nuvigil®); Brand: Strattera®, Vyvanse® Analgesics / Anti-Inflammatory / Pain Agents  Impacts utilization on: Lazanda®, Subsys®; Alternative Drugs: Generic: fentanyl patch, fentanyl lozenge  Impacts utilization on: Celebrex®, Naprelan®, diclofenac ER, Flector patch®, Solaraze®, Pennsaid®, Zipsor®; Alternative Drugs: Generic: naproxen, diclofenac  Impacts utilization on: Conzip®, Rybix®, Ryzolt®, tramadol ER, Ultracet®, Ultram®, Ultram ER®; Alternative Drug: Generic: tramadol Antibiotics: Anti-Infective Agents  Impacts utilization on: Adoxa®, Doryx®, Dynacin®, Monodox®, Periostat®, Solodyn®, Oraxyl®, Oracea®; Alternative Drugs: Generic: minocycline (for Dynacin®, Solodyn®), doxycycline (for Adoxa®, Doryx®, Monodox®, Periostat®, Oracea®, Oraxyl®) Anticonvulsants  Impacts utilization on: Gralise®, Lamictal XR®, Lyrica®; Alternative Drugs: Generic: gabapentin (for Gralise®, Lyrica®), lamotrigine (for
TML Intergovernmental Employee Benefits Pool (Rev 11.20.13) Alternate, SBC, and Rx Summary of Changes PY13-14 Antidepressants / Fibromyalgia
 Impacts utilization on: Vi bryd®, Cymbalta®, Savel a®; Alternate Drugs: Generic (Multiple): citalopram, escitalopram, fluoxetine,
paroxetine, sertraline, venlafaxine, buproprion Antihypertensive Agents  Impacts utilization on: Dutoprol®, Amturnide®, Atacand®/Atacand HCT®, Avapro®/Avalide®, Azor®, Benicar®/Benicar HCT®, Cozaar®/Hyzaar® (brand only), Diovan®/Diovan HCT® (brand only), Edarbi®/Edarbyclor®, Exforge®/Exforge HCT® (brand only), Micardis®/Micardis HCT®, Tekamlo®, Tekturna®/Tekturna HCT®, Teveten®/Teveten HCT®, Tribenzor®, Twynsta®, Valturna®; Alternate Drugs: Generic: metroprolol- hydrochlorothiazide (for Dutoprol®), any generic ACE Inhibitor, losartan/losartan HCTZ (for Cozaar®/Hyzaar®), irbesartan/irbesartan HCTZ (for Avapro®/Avalide®), eprosartan/eprosartan HCTZ (for Teveten®/Teveten HCT®), valsartan/valsartan HCTZ (for Diovan®/Diovan HCT®) Central Nervous System: Sedative Hypnotics  Impacts utilization on: Ambien®, Ambien CR®, Edluar®, Lunesta®, Rozerem®, Sonata®, zolpidem ER®, Intermezzo®, Silenor®, Zolpimist®; Alternate Drugs: Generic: zolpidem immediate release (generic for Ambien®), zaleplon (generic for Sonata®), doxepin (for Silenor®), zolpidem (for Intermezzo®, Zolpimist®)
Lipid-Lowering Agents (Statins)
 Impacts utilization on: Advicor®, Altoprev®, Caduet®, Crestor® (except 40mg strength), Lescol®, Lescol XL®, Lipitor®, Livalo®, Mevacor®,
Pravachol®, Simcor®, Vytorin®, Zocor®, Zetia®; Alternate Drugs: atorvastatin (generic for Lipitor®), lovastatin (generic for Mevacor®),
pravastatin (generic for Pravachol®), simvastatin (generic for Zocor®)

Lipid-Lowering Agents (Fibric Acid Derivatives)
 Impacts utilization on: Antara®, fenofibric acid, Fenoglide®, Fibricor®, Lipofen®, Lofibra®, Lopid®, Tricor®, Triglide®, Trilipix®; Alternate
Drugs: fenofibrate (generic for Tricor® and various other brands), gemfibrozil (generic for Lopid®)
Migraine Headaches  Impacts utilization on: Amerge®, Axert®, Frova®, Imitrex® (brand), Maxalt®, Relpax®, Treximet®, Zomig®, Zomig ZMT®; Alternate Drugs:
Generic: sumatriptan (for Imitrex®), naratriptan (for Amerge®), rizatriptan (for Maxalt®)
 Impacts utilization on: Beconase AQ®, Dymista®, Flonase® (brand), Nasacort AQ®, Nasalide® (brand), Nasarel®, Nasonex®, Omnaris®,
Rhinocort AQ®, Veramyst®, QNASL®, triamcinolone, Zetonna®; Alternate Drugs: Generic: fluticasone (for Flonase®), flunisolide
Osteoporosis Drugs  Impacts utilization on: Actonel®, Actonel® w/Calcium, Atelvia®, Binosto®, Boniva®, Fosamax®, Fosamax-D®, ibandronate (generic for
Boniva®); Alternate Drug: Generic: alendronate (for Fosamax®)
 Impacts utilization on: Auralgan®; Alternate Drug: Generic: benzocaine-antipyrine Overactive Bladder Drugs  Impacts utilization on: Detrol®, Detrol LA®, Ditropan® (brand), Ditropan XL®, Gelnique®, Myrbetriq®, Enablex®, oxybutynin ER®, Oxytrol®
patches, Sanctura®, tolterodine, Toviaz®, Vesicare®; Alternate Drug: Generic: oxybutynin immediate release
Respiratory/Al ergy/Asthma: Antihistamines  Impacts utilization on: fexofenadine®, Clarinex®, Xyzal®; Alternate Drugs: Generic: loratidine or cetirizine; OTC: Alavert®, Al egra®, Zyrtec®, TML Intergovernmental Employee Benefits Pool (Rev 11.20.13) Alternate, SBC, and Rx Summary of Changes PY13-14 Respiratory/Al ergy/Asthma: Antihistamines – Decongestant  Impacts utilization on: fexofenadine-D®, Clarinex-D®; Alternate Drugs: Generic: loratidine-D or cetirizine-D; OTC: Al egra-D®, Zyrtec-D®, Skeletal Muscle Relaxants  Impacts utilization on: Amrix®, Fexmid®, Flexeril®, Lioresal® (brand only), Lorzone®, metaxalone (generic for Skelaxin®), Norflex®,
orphenadrine (generic for Norflex®), orphenadrine compound (generic for Norgesic®), Parafon Forte®, Robaxin®, Skelaxin®, Soma®,
Soma® Compound, Soma® Compound w/Codeine, Zanaflex®; Alternate Drug: Generic: carisoprodol, chlorzoxazone, cyclobenzaprine,
methocarbamol, tizanidine
Stomach Ulcer/Reflux Drugs/Gastrointestinal/Stomach: Proton Pump Inhibitors  Impacts utilization on: Aciphex®, Dexilant®, Duexis®, lansoprazole, Nexium®, Prevacid® (prescription strength), Prilosec® (prescription
strength), Protonix®, Vimovo®, Zegerid capsules (prescription strength – brand and generic); Alternate Drugs: Generic: omeprazole,
pantoprazole, ibuprofen and famotidine separately (for Duexis®); OTC: Prevacid®, Prilosec®, Zegerid® Topical Antifungal Agents  Impacts utilization on: Pedipirox-4®; Alternate Drug: Generic: ciclopirox Cost Share Copays  Broad Network Retail Copay – up to 34 day supply - $120 or cost of drug (whichever is less)  Effective September 1, 2012: Please order mail service prescriptions from new vendor, MedVantx: (866) 744-0621.  Mail Order** Copay – 35 up to 90 days supply - $300 or cost of drug (whichever is less)  Alternative Drug Copays: $0 copay - Align Network* Retail Over the Counter $0 copay - Align Network non cost share Generic retail up to 34 day supply $9 copay - Align Network non cost share Generic retail 35 up to 90 day supply $10 copay - Broad Network non cost share Generic retail up to 34 day supply $25 copay - **Mail Order non cost share Generic copay: 35 up to 90 day supply TML Intergovernmental Employee Benefits Pool (Rev 11.20.13)

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