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
63
Embed
Avaya Inc. Health & Welfare Benefits Plan · AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 1 Avaya Inc. Health & Welfare Benefits
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 2
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 3
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 4
Table of Contents Highlights of the Prescription Drug Plan .................................................................................................... 8
SECTION 2 – ELIGIBILITY AND PARTICIPATION .................................................................................... 10
Who Is Eligible for Prescription Coverage ............................................................................................... 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
What Is Not Covered ................................................................................................................................ 29
SECTION 5 – FILING PRESCRIPTION DRUG CLAIMS .............................................................................. 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
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 7
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
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 8
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 9
Plan Feature Summary
and questions.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 10
SECTION 2 – ELIGIBILITY AND PARTICIPATION
What this section includes:
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).
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 11
• 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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 12
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 13
SECTION 3 – ENROLLING FOR COVERAGE
What this section includes:
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 14
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 33
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 34
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 35
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 36
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 37
SECTION 6 – COORDINATION OF BENEFITS
What this section includes:
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 38
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 39
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,
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 40
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 41
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 42
SECTION 7 – CONTINUATION OF COVERAGE
What this section includes:
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 43
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.
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 44
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 45
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 46
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)
18 months 18 months 18 months
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
29 months 29 months 29 months
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:
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 47
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
AVAYA INC. | ACTIVE REPRESENTED PRESCRIPTION DRUG PLAN SUMMARY PLAN DESCRIPTION | OCTOBER 2018 48
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.