This statement describes the privacy standards and practices of the EnvisionRx Plus Program supported by Envision Insurance Company (hereafter, "EnvisionRx").

Please read and review this notice carefully and thoroughly. It describes how medical information about you MAY BE USED or DISCLOSED. This notice also will inform you on how to obtain this information.

EnvisionRx Plus requirements and responsibilities regarding your personal health information (PHI).

EnvisionRx Plus must comply with all HIPAA privacy provisions that protect beneficiaries’ personal health information (PHI). Be aware that a beneficiary’s PHI may be used for the purposes of health care related operations and the marketing of other products and services that are directly related to the Medicare endorsements. This regulation provides other restrictions that exceed the HIPAA privacy requirements that prevent a sponsor from seeking authorization from a beneficiary to utilize PHI for any other activity outside the immediate scope of the Medicare approved endorsement.

While EnvisionRx Plus retains certain rights to alter, include, or eliminate parts of the use of information; we will notify beneficiaries of any such changes. Please note EnvisionRx Plus is not permitted to use or release any personal health information (PHI) collected while operating the program for beneficiaries.

EnvisionRx Plus is dedicated to the protection of your PHI. We wish to make you aware of the use your PHI and to inform you of your rights and our obligations by law. We are required to do the following:

• Ensure all personal health information (PHI) remains private.
• Forward to you this notification explaining how EnvisionRx Plus may use and release your PHI.
• Notify you of your rights regarding your PHI.

We will not use or disclose any of your PHI to others without your written permission, except as described below.

EnvisionRx Plus may utilize and release your PHI in the following ways:

• To pharmacists for treatment reasons, such as managing or coordinating your care through their knowledge of knowing what your prescriptions are to avoid dangerous drug interactions.
• For reimbursement or payment purposes to your pharmacy for dispensing your prescriptions to you or to collect payment from you or the government for the drugs you receive. Also, a review of your enrollment form may be necessary to determine if you qualify for governmental assistance or discounts offered.
• For our health care organization to improve the quality and service of the EnvisionRx Plus program. This may include educational and wellness programs about medications you may be taking, customer care related matters to improve performance, medicine refill reminders, and to evaluate and improve the performance of our providers.
• For health plans or providers who are reimbursed for their services, including pharmacies that bills another payer or a health plan for your treatment and or improvement requirements.
• For certain contractors who assist us with the operation of the EnvisionRx Plus Card Program regarding enrollment, outreach materials, educational programs, or accounting agencies for auditing purposes.

We will require all contractors to agree in writing that they must protect your PHI they receive to perform their required services.

We may use or release your PHI to contract you about certain products or services offered as part of the EnvisionRx Plus program, which may include prescription refill reminders, alternative treatment options that may be beneficial to you and other health and wellness programs that may be of benefit or of interest to you.

Under no circumstances will your PHI be used to contact you about any product or service not offered by EnvisionRx.

There are other circumstances where use of your PHI be disclosed if certain circumstances apply. This includes:

• A friend or family member who is actively involved in your care or to an individual who helps or assists you in payment of care and must be informed since you may be unable to, do not object to, or in a disaster relief matter that requires notification as to your medical status, condition, and or location.
• As required by local, state, or federal law.
• To governmental agencies for oversight committees, compliance, civil rights issues, fraud and abuse investigations, abuse, neglect, and domestic violence.
• Complying with law enforcement officials relating to criminal or civil matters, worker’s compensation matters, coroner, medical examiners, and funeral directors, to public health authorities to prevent, avoid, or control diseases of a communicable nature.
• Organizations engaged in organ procurement transplants or to assist in facilitating donations or transplantations. To avoid a major threat to your general health and safety in addition to others around you, to appropriate military personnel in select circumstances should you be in armed forces or a military member, federal officials for intelligence and protection of our legislative, executive, and judicial branches of government, and correctional institutions and law enforcement officials if you are imprisoned. All of the above are under special and certain circumstances.

Your Personal Health Information (PHI) Rights

You have certain rights related to your PHI as described below. To exercise any of these rights, you must send a request in writing with any additional information you feel is necessary, including your card identification to:

Envision Insurance Company
Attention: Privacy Officer
2181 E. Aurora Road
Twinsburg, OH 44087

Right to Inspect and Copy Personal Health Information (PHI) About You

You have every right to inspect and copy PHI that is maintained about you. You may request a copy of the PHI and you may be charged to cover the cost of copying and mailing. Please note we may deny such a request, but you do have the right to request a review of the denial.

Amending your PHI

If it is your belief that your PHI is incomplete, inaccurate, or incorrect, you have the right to request it be amended. In such a request, you must also include the version(s) that support the amendment. If EnvisionRx Plus did not create the PHI, it is requested you explain why you believe the individual who created it is no longer available to amend the change. Your request may be denied, but you have the right to submit a record disagreeing with the denial and it will be linked to the relevant information in question.

Right to Account for PHI Disclosures

You may request a list of certain non-routine disclosures about your PHI. You must identify the time frame requested, you will be charged to cover costs of producing this information after the first 12 month period.

Your Right to Restrict PHI About You

You have the right to request a restriction on how EnvisionRx Plus uses or releases PHI about you regarding payment, treatment, or other health related operations. Furthermore, you have the right to request a restriction on information to be disclosed about you to the person or family member involved in your care. Such a request must specify what information should be restricted and in what way. Please note we are not required to comply with the request.

Permission to Copy this Notice in Paper

You may make a paper copy of this notice at any time. As a reminder, EnvisionRx Plus will not disclose your PHI for any other reason than those described in this notice without your written permission or authorization.

Right to File Complaints

Should you believe your privacy rights have been violated, you have the right to file a grievance or complaint to EnvisionRx Plus or to the Secretary of the Office of Civil Rights. See www.hhs.gov/ocr/hipaa/. If you wish to file a grievance or complaint with us, please do so by writing to the address below or contact Customer Service toll free: 1-800-361-4542, (TTY users 1-866-763-9630).

Changes in This PHI Notification

EnvisionRx Plus reserves the right to modify, update, or change this notification as it related to PHI at any time in the future EnvisionRx Plus will have a copy of the most up to date notice on website at www.envisionrxplus.com. For past copies of the notification, please send your written request to:

Envision Insurance Company
Attention: Privacy Officer
2181 E. Aurora Road
Twinsburg, OH 44087

Effective Date

This notice is effective October, 2006.