Prescription Drug Benefits
Who Administers The Prescription Drug Benefits?
Prescription drug benefits are available to all participants and their qualifying dependents who meet the Welfare Fund eligibility requirements. Your prescription drug benefits are administered by Express Scripts which covers almost all drugs prescribed by a licensed medical doctor, osteopath, dentist or podiatrist for their generally accepted medical use.
This benefit includes both a Card Program and a Home Delivery/Mail Service Program. This benefit program was instituted in an effort to increase benefits, alleviate the claim filing burden and reduce costs when you or your dependents require prescription drugs. At the time your coverage becomes effective you will receive a plastic identification drug card and home delivery/mail service order forms.
How Does The Prescription Drug Benefit Program Work?
Express Scripts Drug Program
Prescriptions filled at a local, retail pharmacy will have the following co-payments:
|$10 for a 21 day fill or re-fill (one re-fill limit)
$30 for a 21 day fill or re-fill (one re-fill limit)
$43 for a 30 day fill or re-fill (no limit)
Prescriptions filled through the Express Scripts Home Delivery mail order program will have a $40 co-payment for a 90 day fill or re-fill.
Both retail and mail order prescriptions must be filed generically if a generic equivalent drug is available. If you have a prescription filled with a brand name drug when a generic is available FOR ANY REASON you will pay the brand name co-payment plus the difference between the cost to the Welfare Fund for the generic and the brand. Using a brand name drug when a generic is available will cost you a great deal of out-of-pocket expense.
Please keep in mind that if you have a prescription filled with a brand name drug when a generic is available the difference which you must pay does not accrue towards your annual deductible.
- Direct Reimbursement Program
Should there arise an occasion that the retail or home delivery/mail service program is not used, a direct reimbursement claim process has been established between the Welfare Fund and Express Scripts. Your reimbursement under this program may be significantly less than your purchase price of the prescription. Participants are permitted to use the direct reimbursement claim procedure only once during their lifetime coverage.
Contact the Fund Office [(212) 465-8888 extension 244] to obtain a Direct Reimbursement Claim form. The claim form must be filled out by the patient as well as the pharmacist. Along with the complete claim form, you must submit a letter explaining why you were unable to use the card or the home delivery/mail service program to the Fund Office. Upon the approval of the Fund, your claim will be submitted to Express Scripts for processing.
What Prescription Drugs Are Covered In This Program?
Prescription drugs available under both the Card and the Home Delivery/Mail Service Programs include:
- Federal Legend Drugs
- State-Restricted Drugs
- Compounded Medications
- Insulin and insulin syringes only
- Narcotic painkillers (considered controlled substances)
- A.D.D. drugs (considered controlled substances)
Each state establishes its own legal list of controlled substances. Typically, under state laws, a controlled substance cannot have more than a 30 day fill.
Are There Any Exclusions in This Program?
The following are the excluded items to the prescription plan:
- Contraceptives, oral or other, whether medication or devices, regardless of intended use.
- Non-Federal Legend Drugs including all "over the counter" items, regardless of whether they are prescribed.
- Charges for the administration or injection of any drug.
- Needles and syringes, support garments, and other non-medical substances (such items may be covered under your medical benefits coverage).
- Prescriptions which you are entitled to receive without charge under any Workers' Compensation Laws or any municipal, state or federal program.
- Medication taken by, or administered to, a person while an inpatient in a licensed hospital, hospice, rest home, sanitarium, extended care facility, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceutical products.
- Drugs labeled "Caution - limited by federal use to investigational use" or experimental drugs.
- Blood, blood plasma or biological sera.
- Vitamins; except those, which by law, require a prescription.
- Any prescription filled, except controlled substances, in excess of the number specified by the physician, or any refill dispensed after one year from the physician's original order.
What Programs Have Been Instituted to Insure Proper Drug Use?
The Welfare Fund is committed to providing quality prescription drug benefits. With this goal in mind, we use a set of Utilization Management Programs, administered by Express Scripts, to determine how you prescription drug plan will cover certain medications. The goal of these programs is to alleviate inappropriate and potentially harmful use of prescription drugs while simultaneously assuring the proper utilization of benefit dollars. Member health, safety, and satisfaction remain the primary objectives of the prescription drug coverage.
These programs are Coverage Review, Step Therapy, Quantity Duration and Retrospective Drug Utilization Review (RDUR) health and safety program.
For some medications, you must obtain approval through a review process in order to obtain coverage. When you use Express Scripts By Mail, we will call your doctor to start the coverage review. If you submit a prescription to a participating retail pharmacy for a medication that requires coverage review, you, your doctor, or your pharmacist can initiate the review by calling (800) 753-2851.
If coverage is not approved, either at a retail or mail-order basis, you will be responsible for the full cost of the medication. You have the right to appeal the decision. Information on how to request the appeal will be included in the letter that you receive.
The following medications are subject to a Coverage Review:
Androgens and anabolic steriods (androgens: methyltestosterone tablets and capsules, fluoxymesterone tablets, testosterone gel, testosterone patches, testosterone lozenges, injectable testosterone, and injectable methyltestosterone; anabolic steroids: Anadrol-50®, Winstrol®, Oxandrin®, Deca-Durabolin®, and Kabolin®)
Growth hormones (Humatrope®, Nutropin®, Serostim®, Saizen®, Norditropin®, Genotropin®, Tev-Tropin®, Zorbtive™, Protropin®, Increlex™)
Appetite and weight loss (Meridia®, Xenical®, Didrex®, diethylporpion, Tenuate®, phentermine, Ionamin®)
Miscellaneous pulmonary agents (Xolair®)
Hepatitis medications: interferons (Infergon®, Roferon®, Intron-®A, Alferon®, PEG-Intron®, Pegasys®); ribavirin (Rebetol®, Copegus®)
Antinarcoleptic agents (Provigil®)
Antineoplastic agents (Iressa®)
Contraceptive agents (various)
Erythroid stimulant (Epogen®, Procrit®, Aranesp®)
Miscellaneous dermatologicals (Retin-A®, Tazorac® cream)
Mutliple sclerosis therapy (Avonex®, Rebif®, Betaseron®, Copaxone®)
Myeloid stimulants (Neupogen®, Leukine®, Neumega®, Neulasta®)
Step Therapy looks at a patient's prescription history and determines whether he or she is eligible for a given medication without a coverage review. If there is not enough information in the history, a coverage review may be necessary. The following medications are subject to a Step Therapy Review:
Miscellaneous rheumatologicals (Enbrel®, Arava®, Kineret®, Humira®, Orencia®, Remicade®)
Pain (Oxycontin®, Actiq®)
Dermatologicals (Protopic®, Elidel®)
Allergy (Singulair®, Accolate®, Zyflo®)
Cancer Therapy (Tarceva®)
COX 2 inhibitors (Celebrex®)
Ribavirin therapy (Rebetol®, Copegus®)
Your prescription drug plan provides coverage for a quantity of medication and duration of treatment sufficient to meet the needs of most patients. If a greater quantity or longer course of treatment is needed, a coverage review process is required.
The following medications are subject to a Quantity Duration Review:
Sleep therapy (Lunesta®, Ambien®, Sonata®, Prosom®, Doral®, Restoril®, Dalmane®, Halcion®, temazepam, flurazepam, triazolam)
Erectile dysfunction agents (Cialis®, Levitra®, Viagra®, Caverject®, Edex®, and Muse®)
Migraine therapy (Imitrex®, Zomig®, Axert®, Amerge®, Frova®, Relpax®, Maxalt®, Migranal®)
Anti-influenza (Relenza®, Tamiflu®)
Quantity Duration - no review
Your plan will cover the following 8 pills of the medications listed below within a 21-day period. Prescriptions that exceed that amount will not be covered by the plan. Your retail pharmacist or your mail-order pharmacy may reduce the quantity of medication dispensed to an amount covered by your plan. If you choose to obtain additional quantities, you will be responsible for the full cost of the medication at your retail pharmacy.
Erectile dysfunction agents (Cialis®, Levitra®, Viagra®, Caverject®, Edex®, and Muse®)