Coordination of Prescription Drug Benefits with a $0 coinsurance amount at the pharmacy is ONLY available when all family members are covered by two active University employees (not including University Health Hospitals and Clinics employees), in the Advantage Plan. Coordination of Prescription Drug Benefits is not available when an employee has elected the University’s Consumer Directed Health Plan option. If some family members are only covered by one employee, you may be required to pay a coinsurance amount at the pharmacy and submit a paper claim for reimbursement.

We each hereby certify the following:

• I am an active University employee and enrolled in the Advantage Plan, and have enrolled my spouse and the listed dependent children as dependents on my coverage.
• I acknowledge that I, my spouse, and any listed dependent children are only eligible for coordination of prescription drug benefits for as long as my spouse and I each maintain coverage through the University (not including UUHC) and cover the other and any listed dependent children.
• In the event I terminate my coverage, I will contact the University Human Resource Management and notify them of the cancellation.
• In the event I utilize coordination of prescription drug benefits while I am not eligible, I will refund any amounts overpaid by the health plan.

All the information entered on this form is true and correct. I acknowledge that using this benefit improperly or knowingly providing a statement that contains any false, incomplete or misleading information may result in both adverse employment action, up to and including termination of employment, and adverse tax consequences, including penalties and interest.