Prescription Drug Benefits

Express Scripts

Prescription drug benefits are available to all active and retired 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 program, which includes both a drug card and mail service plan, 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 mail service order forms. The program works as follows:

Express Scripts Drug Program

Prescriptions filled at a local, retail pharmacy will have the following co-payments:

Generic	$10 for a 21 day fill or refill (one re-fill limit)
Brand	$30 for a 21 day fill or refill (one re-fill limit)
Controlled Substances	$43 for a 30 day fill or refill (no limit)

 

Prescriptions filled through the Express Scripts Delivery mail order program will have a $60 co-payment for a 90 day fill or re-fill.

Both retail and mail order prescriptions must be filled generically if a generic equivalent drug is available. If you have a prescription filled with a brand name drug when a genericis 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 drug is available the difference which you must pay does not accrue towards your annual deductible.

Utilization Management Program

Certain drugs require prior approval through Medco's Utilization Management Program. You or your doctor can reach Express Scripts Utilization Management Program at 1-800-753-2851.

Covered Drugs

Prescription drugs available under both the Mail Service and the Card Program include:

• Federal Legend Drugs
• State-Restricted Drugs
• Compounded Medications [can be purchased through retail pharmacy only]
• Insulin and insulin syringes only

Exclusions

Drugs not covered by the program include:

• 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 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 in excess of the number specified by the physician, or any refill dispensed after one year from the physician's original order.