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
How Does The Prescription Drug Benefit Program
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
||$30 for a 21 day fill or re-fill (one re-fill
||$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 $60 co-payment for a 90 day 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 Medco for processing.
What Prescription Drugs Are Covered In This
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
- 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
- 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
- Charges for the administration or injection of any
- 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
- 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
Medco, 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
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.
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
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®)
hormones (Humatrope®, Nutropin®,
Serostim®, Saizen®, Norditropin®,
Genotropin®, Tev-Tropin®, Zorbtive™,
weight loss (Meridia®, Xenical®, Didrex®,
diethylporpion, Tenuate®, phentermine,
Miscellaneous pulmonary agents (Xolair®)
Hepatitis medications: interferons (Infergon®,
Roferon®, Intron-®A, Alferon®,
PEG-Intron®, Pegasys®); ribavirin
Antinarcoleptic agents (Provigil®)
Antineoplastic agents (Iressa®)
Contraceptive agents (various)
(Epogen®, Procrit®, Aranesp®)
Miscellaneous dermatologicals (Retin-A®, Tazorac®
Mutliple sclerosis therapy (Avonex®,
Rebif®, Betaseron®, Copaxone®)
Myeloid stimulants (Neupogen®, Leukine®,
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
(Enbrel®, Arava®, Kineret®,
Humira®, Orencia®, Remicade®)
Pain (Oxycontin®, Actiq®)
Dermatologicals (Protopic®, Elidel®)
Allergy (Singulair®, Accolate®,
Cancer Therapy (Tarceva®)
COX 2 inhibitors (Celebrex®)
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
Sleep therapy (Lunesta®,
Ambien®, Sonata®, Prosom®,
Doral®, Restoril®, Dalmane®,
Halcion®, temazepam, flurazepam, triazolam)
Erectile dysfunction agents (Cialis®, Levitra®,
Viagra®, Caverject®, Edex®,
Migraine therapy (Imitrex®,
Zomig®, Axert®, Amerge®,
Frova®, Relpax®, Maxalt®,
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.
dysfunction agents (Cialis®, Levitra®,
Viagra®, Caverject®, Edex®,