Prescription Drug Benefits

Medcohealth

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 Medco Health Solutions, Inc. 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:

Mail Service Program

• If you or any of your dependents need medication on an on-going basis (maintenance drugs), you must fill those prescriptions through Medco Health Home Delivery Pharmacy Service filled through the Mail Service Program are subject to a $30 co-payment. The drugs are delivered to your home, postage paid. Your physician can prescribe up to a 90-day supply of the medication you need. You will then submit your prescription and claim form to the mail service pharmacy for dispensing. If you require a refill, just notify the mail service pharmacy by mail, telephone (1-800-445-9707), or through the internet (www.medcohealth.com).

Card Program

•  Whenever you need to fill a prescription at a local pharmacy, all you will have to do is present your Medco Health identification card and make a small co-payment. The co-payments for each prescription will be $5.00 for generic drugs and $15.00 for brand name drugs. You can receive up to a 21 day supply of your medication and one refill for the same number of days. Beyond that, you must use the Mail Service Program. If you plan to apply to the Security Benefit Fund for reimbursement of the co-payment you made, be sure to ask the pharmacy for a receipt of your transaction.
   
• Controlled Substances are those drugs that fall under the The Controlled Substance Act of the federal Comprehensive Drug Abuse Prevention and Control Act of 1970 or are so specified by individual states. Controlled substance can be filled for up to 30 days. There is no limit as to the number of fills you can obtain at the retail level. The co-payment is $22 for each controlled substance prescription regardless of the number of days the prescription calls for. 

Utilization Management Program

Certain drugs require prior approval through Medco's Utilization Management Program. You or your doctor can reach Medco's 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.