Employee Prescription Policy

EMPLOYEE PRESCRIPTION POLICY

Purpose: This Employee Prescription Policy sets forth the employer’s administrative standards and employee obligations regarding prescription medication coverage, reimbursement, confidentiality of prescription-related information, and the process for submitting claims under any company-sponsored prescription assistance or reimbursement program.

Policy Effective Date

Effective Date:

Personal Information

Position Information

Reporting Manager:

Start Date:

Employment History (Most Recent First)

From: To:

From: To:

Education

Graduation Date:

References

Prescription Policy: Scope and Coverage

Scope: This policy applies to all eligible employees participating in the employer’s prescription assistance or reimbursement program. Coverage described herein is subject to program limits, coordination with any group health plan, and applicable law.

Definitions

Covered Prescription means a medication prescribed by a licensed practitioner that is eligible under the company program. Reimbursement means repayment of out-of-pocket costs consistent with program limits.

Eligibility and Enrollment

Eligibility: Employees must be actively employed and enrolled in the company benefit program, if required, to participate. To enroll in the prescription assistance program, indicate below and provide required information.

Enroll in Prescription Assistance: Yes

Covered Expenses and Limits

Covered expenses may include prescription medication co-payments, coinsurance, and certain over-the-counter medications when prescribed. Reimbursement limits, formularies, and prior authorization requirements are enforced; the company reserves the right to set maximum reimbursement amounts per calendar year.

Exclusions

Exclusions: Experimental medications, cosmetic medications, medication not prescribed by a licensed provider, and expenses reimbursed under another benefit are excluded. Misrepresentation or fraudulent claims will result in denial of reimbursement and disciplinary action up to termination.

Claim Submission Procedure

To request reimbursement, submit the required documentation within 90 days of purchase. Required documentation typically includes itemized pharmacy receipts, original prescription, and provider statement when requested.

Attach receipts and documentation: I have attached itemized receipts and prescriptions as required.

Confidentiality and Records

Medical and prescription information submitted for reimbursement is maintained as confidential personnel medical information and will be used only for administration of the prescription program and as permitted by law. The employer will limit access to such information to authorized personnel.

Coordination with Other Benefits

Reimbursements under this policy will be coordinated with any primary health coverage. Claims already reimbursed or payable by another plan must be reported; the company may require documentation of denial or coordination of benefits.

Amendment and Termination of Policy

The employer reserves the right to amend, suspend, or terminate the prescription program at any time, subject to contractual obligations and applicable law. Changes will be communicated to employees in writing.

Legal Disclosures

At-Will Employment: Nothing in this policy alters the employment-at-will relationship between the employee and the employer. Either the employee or employer may terminate employment at any time, with or without cause, subject to applicable law.

Equal Opportunity: The employer provides equal employment opportunities and administers benefits without discrimination on the basis of protected characteristics.

Authorization & Applicant Certification

Authorization to Contact Former Employers and Conduct Background Checks: By signing below, I authorize the employer to contact previous employers and references to verify employment and other relevant information, and to obtain background checks as permitted by law for purposes of benefit eligibility verification.

Certification: I certify that all information provided in connection with this policy and any claim is true, complete, and accurate to the best of my knowledge. I understand that falsification or omission of material facts may result in denial of benefits and disciplinary action up to and including termination.

Authorization to Release Information: I authorize any health care provider or pharmacy to release information necessary to process claims and to verify eligibility for benefits. I understand that such information will be treated as confidential and used solely for program administration and compliance.

I acknowledge the above statements and provide authorization: I agree

Additional Employee Information

Employee Signature Acknowledgement

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