Your Prescription Drug Cost Reimbursement Benefit

What Is The Prescription Drug Benefit?   

What Kinds Of Prescription Drugs Are Covered By The Plan’s (American Health Care) Prescription Drug Cost Reimbursement Benefit Program?   

Are My Prescriptions Drugs Covered By the Plan And What Will They Cost?

 
The Mail Order Prescription Drug Program   

Non-Participating Pharmacies   

About Chemotherapy, Injectible and Asthma Drugs 


What Is The Prescription Drug Benefit?

The Fund’s prescription drug benefits are designed to help you and your eligible dependents meet the high cost of prescription drugs.  The CWA Local 1180 prescription drug benefit for active members and their eligible dependents is administered by American Health Care.  With this program, members have two ways of obtaining their medications.

All members receive a prescription drug card issued by American Health Care.  Members and dependents requiring acute medications should take their prescription and the member identification card to the pharmacy.  An “acute” medication is a medication you need to take immediately and for a short period of time.  You may also obtain information concerning participating pharmacies by accessing the American Health Care’ web site www.americanhealthcare.com. In many instances, these are antibiotics used to treat infection.  Your doctor or prescriber may order up to a 30 day supply and up to a ninety (90) day supply at mail order pharmacy.

For medications you need to take repeatedly, you should use the mail order provider (see Mail Order Program description). You can now obtain refills to medications filled at mail order by accessing Costco’s web site www.pharmacy.costco.com and clicking on the Pharmacy link at the top of the page, or by calling Costco at 1-800-607-6861 for detailed instructions.

If employment terminates or your retire, you must return the I.D. card to the Fund Office immediately
.

There is no dollar maximum on the amount of money that the SBF will pay for prescription drugs for any member or dependent of the Fund.

Preventive medications available to you at no cost!

In addition, the following items are paid for by the SBF if you have a doctor’s prescription for them without any copayment on your part:

  • Aspirin, generic only, for men who are age 45-79 and women who are age 55-79.
  • Influenza and pneumonia immunizations given outside of a doctor’s office or hospital such as at a pharmacy.
  • Vitamin D in generic form twice/day for those in an adult community (i.e., a nursing or long term care facility).
  • Folic acid in generic form, .4 to .8 mg. once/day for women who may become pregnant.
  • Fluoride in generic pill form for children up to age 5.
  • Smoking cessation products – generic only. After six (6) months of providing these products, a member will only be eligible thereafter if he/she is in a smoking cessation program.
  • FDA approved contraceptives – i) oral - generic only. ii) patch - generic only. iii) vaginal rings if not provided by your City health plan, iv) IUDs if not provided by your City health plan, v) Female condoms if not provided by your City health plan, vi) Emergency contraception – presently, only Plan B is available.
  • Iron supplements up to one year of age, generic only.
The following co-payments apply.

  • The generic copay will be $5 per prescription for up to a thirty (30) day supply at a participating retail pharmacy and $10 per prescription for up to a 90 day supply at the mail order pharmacy.
  • Brand name copay will be 20% of the cost of a prescription for up to a thirty (30) day supply at retail pharmacy and 20% per prescription for up to a ninety (90) day supply at mail order pharmacy.
  • The copay for a brand name drug with a generic equivalent will be the difference between the price of the brand name drug and the price of the generic drug for both retail and mail order.
  • The SBF will cover the generic form of proton pump inhibitor only.
  • There are no changes in the current participating pharmacy network or mail-order pharmacy except for specialty medications (see below).
You should know that Generic drugs are required by the U.S. Food and Drug Administration to be the same as (bioequivalent) the brand name drug and have the same active ingredient, strength, dosage form, and route of administration as the brand name product. Through review of bioequivalence data, FDA ensures that the generic product performs the same as its respective brand name drug.

What Kinds of Prescription Drugs Are Covered By the Plan’s (American Health Care) Prescription Drug Cost Reimbursement Benefit Program?

Covered medications include:
  • Federal legend drugs, preventative medications with the exception of vitamins or dietary supplements, even if these are legend drugs
  • State restricted drugs
  • Compound prescriptions, when one ingredient is a federal legend medication
  • Federal legend oral contraceptives
  • Smoking cessation medications, genetic only. After six (6) months, a member will only be eligible thereafter if he/she is in smoking cessation program.
  • Topical acne agents, limited to participants 23 years of age and under
Covered medications requiring a prior authorization from American Health Care: *
  • Smoking cessation medications
  • Erectile dysfunction medications
  • Enbrel
  • Chemotherapy drugs
  • Topical acne agents for participants over 23 years of age.
Excluded medications:
  • Retin-A, Renova, Avita and any generic equivalent of Retin-A, Renova or Avita (regardless of the Participant’s age).
  • Fertility drugs
  • Drugs used for baldness
  • Vitamins and dietary supplements
  • Drugs for cosmetic purposes
  • Insulin on prescription **
  • Syringes and needles on prescription
  • Federal legend vitamins and dietary supplements?
  • Items lawfully obtainable without a prescription
  • Devices and appliances
  • Prescriptions covered without charge under federal, state, or local programs, including Workers’ Compensation
  • Any charge for the administration of a drug or insulin
  • Investigational or experimental drugs
  • Unathorized refills
  • Immunization agents, biological sera, blood or plasma
  • Medication for an eligible member confined to a rest home, nursing home, sanitarium, extended care are facility, hospital, or similar entity
  • No coverage is provided for O.T.C (over the counter) drugs, vitamins, diet supplements, etc., which, even though prescribed by a physician, can be legally purchased without a prescription (exceptions may be made from time to time; contact the Fund Office for a list of covered, prescribed, O.T.C. drugs)
  • Drugs covered by this Plan must be prescribed by a duly licensed medical practitioner
  • All prescriptions must be dispensed in registered pharmacies
  • Coverage does not include drugs administered to in-patients of any hospital, nursing home, or in-patient facility
* To obtain a prior authorization, call American Health Care. For certain of the above referenced medications, you will need to obtain a physician’s letter of medical necessity. Please call American Health Care for detailed instructions.

** For Non-Medicare eligible member, insulin prescriptions and diabetic supplies are covered under your basic NYC Health Insurance Plan. Please call American Health Care at 1-800-872-8276 for detailed instructions.

Generic Drugs vs. Brand Name Medications
Generic drugs are the same as brand name drugs. The major difference is cost. Because brand name drugs are heavily advertised, they cost considerably more than generic drugs.

By law, generic drugs must contain the same active ingredients in the same quantities and be the same strength as the corresponding brand name drug.  Furthermore, they must meet the same FDA standards for safety and effectiveness.
When your doctor prescribes a generic drug, both your costs and the Fund’s costs are reduced
Step Therapy

Step Therapy Program
Step therapy is an approach to prescription drug therapies intended to control the costs and risks posed by prescription drugs. The practice begins medication for a medical condition with the most cost-effective and safest drug therapy and progresses to other more costly or risky therapies only if necessary for:
  •  angiotensin receptor blockers,
  • insomnia agents (a/k/a, sleeping pills),
  • osteoporosis medications,
  • statins,
  •  fibric acid derivatives,
  • gout medications,
  • cox II inhibitors,
  • selective serotonin reuptake inhibitors (SSRIs), and
  • serotonin and norepinephrine reuptake inhibitors (SNRIs).
If you or your dependent is taking a brand name drug in the step therapy program class of drugs, the SBF will pay only for the generic form of the drug.
You or your dependent will be required to follow the regular step therapy program and the SBF will only pay for the generic form of the drug, even if not an exact replica, unless you or your dependent provide a letter of medical necessity clearing you for a step 2 drug.

How Does The Prescription Drug I.D. Program Card Work?
A plastic CWA Local 1180 Security Benefits Fund Prescription Drug Program ID Card is issued to each covered member provided the Fund Office has on file both your Enrollment Card and your Designation of Beneficiary Card.  Your I.D. card is valid only while you are employed by an employer who contributes to the Fund on your behalf.  If you lose your card, notify the Fund Office immediately.

If employment terminates or you retire, you must return the I.D. card to the Fund Office immediately.

When you or one of your eligible dependents need prescribed medicine:
  • Have your doctor write the prescription on his or her prescription form.
  • Take the prescription form and your I.D. card to your pharmacist. You will receive your prescription by paying the appropriate co-payment. Your pharmacist will be reimbursed by the Fund.
How Do You Get Refills?
If the original prescription written by your doctor specifies that it may be refilled, and if you require a refill, you can obtain a refill at the same pharmacy where the prescription was first filled by showing your I.D. card.

What Happens If You Use A Non-Participating Pharmacy?
You will be eligible for reimbursement from the Fund if for any reason you have a covered prescription filled at a pharmacy which is not a participant in the CWA Local 1180 Prescription Drug Program.  In order to obtain this benefit, you must follow these procedures:

Obtain a Prescription Drug Benefit Reimbursement Form from the Fund Office or from American Health Care’s web site www.americanhealthcare.com

  • Pay the pharmacist the full cost of the prescription.
  • Sign and complete the form, be sure to attach pharmacy receipt where indicated and return it to the address shown on the reverse side of the reimbursement form.
  • The Fund will reimburse you the cost of the prescription at the same rate that would be payable for that drug at a participating pharmacy, less that appropriate co-payment.
Claims for prescription drugs filled by a non-participating pharmacy must be received by the Fund Office within 90 calendar days following the date the prescription or refill was filled.  Claims submitted after the 90-calendar day limit will be denied.

NOTE:  If your pharmacist has any question regarding the Fund’s Prescription Drug Benefit Program ask him or her to call or write to the following:

American Health Care
3850 Atherton Road
Rocklin, CA 95765
1-800-872-8276
 
                                  

The Mail Order Prescription Drug Program
This program, which is administered by American Health Care through Costco Mail Order Pharmacy, offers you the convenience of ordering from your home and of having your prescriptions refilled less often.

There is a $10.00 co-payment on mail-order prescriptions for up to a 90 day supply, unless you order a brand name drug where a generic equivalent is available the co-payment will be the difference between the price of the brand name drug and the price of the generic drug for both retail and mail order.

  • If you, your spouse or eligible children require covered medications on an on-going basis, you can order a 90-day supply through the mail.
  • Using the Mail Order Program offers the convenience of ordering from your home and having your prescriptions filled less often.  The Mail Order Program can also reduce the costs of your prescription drugs, allowing you to purchase more of your maintenance medications.
  • Your doctor can prescribe up to a 90-day supply.  When you place your first order, you will be asked to complete a Mail Order Patient Profile which you will receive from American Health Care.  Enclose the doctor’s prescription(s) in the pre-addressed, postage paid business reply envelope. You can obtain a Mail Order enrollment brochure by calling American Health Care at 1-800-872-8276 or Costco Mail Order at 1-800-633-0334. Do not send your CWA Local 1180 Prescription Drug I.D. card with your claim.

If you are enrolled in the CWA local 1180 Prescription Drug Benefit program, you or your pharmacist may call or write American Health Care with any questions regarding the program as follow:

American Health Care
3850 Atherton Road
Rocklin, CA 95765
1-800-872-8276
www.americanhealthcare.com

Non-participating Pharmacies
If for any reason you have a covered prescription filled at a pharmacy that is not a participant in the CWA Local 1180 Prescription Drug Benefit Program, you are eligible for a reimbursement from the Fund for the cost of the prescription drug at the same rate that would be payable for that drug at a participating pharmacy.  You are responsible for the difference.

About PICA Drugs
Psychotropic Drugs:

 
Psychotropic medication prescriptions, and co-payments will be subject to the same co-payment schedule as required for the general prescription drug benefit.

Asthma Medication: 

If you are enrolled in the CWA local 1180 Prescription Drug Benefit program, you or your pharmacist may call or write American Health Care with any questions regarding the program as follow:

American Health Care
3850 Atherton Road
Rocklin, CA 95765
1-800-872-8276
www.americanhealthcare.com

There is an annual deductible of $100 per person.

Co-payments are as follows:
 
Retail Pharmacy                                  Mail Order
(up to 30 day supply)                              (up to 90 day supply)
$10 Generic                                             $20 Generic
20% of the cost of Brand Name                20% per Brand Name

Chemotherapy and Injectable Medication:
Non-Medicare Eligible Members, employed or retired from the City of New York, receive these medications through the City Health Insurance Program (NPA/Express Scripts Card).

CHEMOTHERAPY AND INJECTABLE medications are covered under CWA Local 1180 Prescription Drug Plan ONLY for Medicare Eligible Members, New York City Transit and Javits Convention Center members. These medications are subject to the same schedule of co-pays and deductibles (described above) which affect all Chemotherapy, Injectable and Asthma drugs.

NOTE: If you have an optional rider for prescription drugs with your health plan all Chemotherapy, Injectable and Asthma prescriptions will be included in the optional rider. Follow the procedures of your health plan’s prescription drug program.
Co-payments and deductibles for all Chemotherapy, Injectable and Asthma category drugs are not reimbursable under the Funds’ benefits.
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