Your Prescription Drug Cost Reimbursement Benefit

What Is The Prescription Drug Cost Reimbursement Benefit?
When Is Coverage Provided?
What Expenses Are Covered By The Prescription Drug Cost Reimbursement?
For Retirees who have the City Health Plan Optional Drug Rider
For Retirees Who Do Not Have the City Health Plan Optional Drug Rider
What Kinds of Prescription Drugs Are Covered By the Plan’s (American Health Care) Prescription Drug Cost Reimbursement Benefit Program?
Where Do I Get My Prescription Drugs Under the (American Health Care) Plan?
Mail Order Prescription Drug Program?
Non-participating Pharmacies
Getting Your Benefit
About PICA Drugs
Medicare Eligible Retirees with Three or more Eligible Dependants
Retirees, Spouse and/or dependents with MEDICARE PART D Plan


What Is The Prescription Drug Cost Reimbursement Benefit?
The Fund will provide you, your spouse and eligible children up to a maximum benefit of $1, 500 per family, per calendar year for your family’s covered prescription drug costs.

When Is Coverage Provided?
Coverage is provided when:

  • Services are received in accordance with the procedures described in this Benefit Summary Plan Description.
  • Services are obtained while you, your spouse or your children are eligible for coverage (See the section entitled “Eligibility”).
  • Services are medically necessary and covered hereunder.
  • Services are not otherwise excluded.

What Expenses Are Covered By The Prescription Drug Cost Reimbursement?

For Retirees who have the City Health Plan Optional Drug Rider:

  • If you have chosen the Optional Drug Rider with your City Health Plan, the Fund will reimburse the cost of the prescription drug portion of your City Health Plan Optional Drug Rider and any deductibles and out-of-pocket co-payment expenses you incur for covered prescription drugs, up to the annual maximum of $1,500 per calendar year
  • If the cost of your Optional Drug Rider, deductibles and out-of-pocket co-payment expenses for covered prescription drugs exceed the annual maximum of $1,500 per calendar year, your out-of-pocket expenses may be covered by the Fund’s “General Medical Reimbursement Benefit.”  (See “Your General Medical Reimbursement Benefit.”)

For Retirees Who Do Not Have the City Health Plan Optional Drug Rider:

  • If you do not have the Optional Drug Rider with your City Health Plan, you, your spouse and eligible children will be eligible for the Prescription Drug Cost Reimbursement Benefit administered by American Health Care.  Upon presentation of your prescription card, participating pharmacists will provide covered prescription drug benefits at no out-of-pocket cost up to the $1,500 per family annual maximum.
  • If you reach the $1,500 per family annual maximum, your additional covered prescription drug costs will automatically continue to be covered by the Fund’s “General Medical Reimbursement Benefit” until you have exhausted the maximum benefit allowed. (See “Your General Medical Reimbursement Benefit.”)

IMPORTANT INFORMATION

If your covered prescription drug expenses exceed the maximum reimbursement limits allowed under the Prescription Drug Cost Reimbursement and General Medical Reimbursement Benefits, you should continue to use your Prescription Drug Card at a participating pharmacy (or the Mail Order Program) to receive discounts for prescription drugs you require.

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, with the exception of vitamins or dietary supplements, even if these are legend drugs
  • State restricted drugs
  • Compound prescription, when one ingredient is a federal legend medication
  • Insulin on prescription * ( Only for Medicare eligible retirees aged 65 and over)
  • Syringes and needles on prescription
  • Federal legend oral contraceptives
  • Smoking cessation medications
  • Topical acne agents, limited to participants 23 years of age and under

* For Non-Medicare eligible retirees, 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.

Covered medications requiring a prior authorization from America Health Care: **

  • Erectile dysfunction medications
  • Gleevac
  • Topical acne agents for participants over 23 years of age.

**To obtain a prior authorization, call American Health Care at 800-872-8276. You will need to obtain a physician’s letter of medical necessity for certain of the above referenced medications. Please call American Health Care for detailed instructions.

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
  • Items lawfully obtainable without 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 on prescription *
  • Investigational or experimental drugs
  • Unauthorized refills
  • Immunization agents, biological sera, blood or plasma
  • Medication for an retiree confined to a rest home, nursing home, sanitarium, extended care 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 Program 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.

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. If you are enrolled in the Prescription Drug Benefit program which has a $1,500 annual family maximum per year, you can have more of your prescribed medications covered by the Fund’s benefit by using generic drugs instead of the more costly brand name equivalent.

* Only Medicare Eligible Retiree - Age 65 and older

Where Do I Get My Prescription Drugs Under the (American Health Care) Plan?

If you are a Retiree who does not have the Optional Drug Rider to your City Health Plan, the Fund will enroll you in the Prescription Drug Benefit Program. After you have been enrolled, American Health Care will mail you a Prescription Drug I.D. card which will be honored by:

  • Participating Pharmacies

Any pharmacy that is a participant in the American Health Care Prescription Drug Program will honor your doctor’s prescription for covered prescription drugs upon presentation of your card.

  • Mail Order Prescription Drug Program

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.

Mail Order Prescription Drug Program?
This program, which is administered by the 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 no co-payment on mail-order prescriptions.

  • 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 with your $1,500 annual Prescription Drug Cost Reimbursement Benefit.
  • 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 1-800-361-4542 or Costco Mail Order at 1-800-607-6861. 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 between the rate the Fund would have paid for the drug at the participating pharmacy and the non-participating pharmacy’s charge, if greater. The reimbursed amount will be charged against your $1,500 annual family maximum benefit.

Getting Your Benefit

 If you have the City Health Plan Optional Drug Rider:

  • Submit photocopies of your pension check stubs showing the deductions made for the Optional Drug Rider, and any deductibles and out-of-pocket co-pay expenses you incurred to the Fund Office.  If your pension check is deposited directly into your bank account, submit copies of your EFT (Electronic Funds Transfer) statement that you receive from your City pension plan.
  • You may make two submissions each calendar year.
  • You will be reimbursed up to a maximum of $1,500 per family, per calendar year for the prescription drug portion of the premium you paid for the Optional Drug Rider and any deductibles and out-of-pocket co-pay expenses you incurred for covered prescription drugs.
  • Your claim must be received by the Fund Office no later than June 30th following the end of the prior calendar year.

Claims submitted after that date will be denied.

If you DO NOT have the City Health Plan Optional Drug Rider

  • Once you are enrolled in the Prescription Drug Benefit program, take your doctor’s prescription and your card to a participating pharmacy or use the Mail Order Program. Your family’s prescription drug costs will be covered up to the $1500 per family annual maximum benefit.

If you use a non-participating pharmacy:

  • Obtain a Prescription Drug Benefit Reimbursement Form from the Fund Office or from American Health Care’ 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 write or call to the following:

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

About PICA Drugs
Effective July 1, 2010, there will no longer be an annual deductible for psychotropic medication prescriptions, and the co-payments will be subject to the same co-payment schedule as the general prescription drug benefit already in place.

Asthma Medication

Eligible Employees and Retirees receive these medications through the CWA Local 1180 Prescription Drug Program. There is an annual deductible of $100 per person.

Co-payments are as follows:

         Retail Pharmacy                                     Mail Order

         (up to 34 day supply)                                (up to 90 day supply)

         $10 Generic                                               $20 Generic

         $25 Brand Name                                       $50 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. These medications are subject to the same schedule of co-pays and deductibles (described above) which affect all PICA drugs.

NB: If you have an optional rider for prescription drugs with your health plan all PICA prescriptions will be included in the optional rider. Follow the procedures of your health plan’s prescription drug program.

Medicare Eligible Retirees with Three or more Eligible Dependants
As of October 24, 2005, the benefit plan was amended to provide that in every family where the member is Medicare-eligible or has a Medicare-eligible beneficiary (or where both are Medicare eligible) and the family consists of three or more individuals eligible for benefits from the Fund, the following annual prescription drug caps shall apply:

  • If the Medicare-eligible individual is the member, the participant shall have a $2,700 annual cap and the remaining beneficiaries shall have their own combined cap of $2,700 annually;
  • If the Medicare-eligible individual is the spouse of the member, the spouse shall have a $2,700 annual cap and the remaining members of the family, including the participant, shall have their own combined cap of $2,700 annually;
  • If both the member and spouse are Medicare-eligible and they have one or more dependent children, the member and spouse shall have a combined $2,700 annual cap and their dependent children shall have their own combined cap of $2,700 annually.

Retirees, Spouse and/or dependents with MEDICARE PART D Plan

  • If you have elected to receive your prescription coverage under Medicare Part D, the CWA Local 1180 Retirees Benefits Fund will, on application consider reimbursement of out of pocket expenses that you incur for premiums, co-payments and deductibles under your Medicare Part D prescription coverage up to the family limit of $2700 per year ($1500 Prescription Drug Benefit plus $1200 General Medical Benefit). However, you may only claim your dependent(s) out-of-pocket expenses as they pertain to co-payments and, deductibles (not premiums) and only under your shared $1200 General Medical Benefit.
  • If your spouse and/or your eligible dependent(s) elects to receive their prescription coverage under Medicare Part D, you may claim your dependent(s) out-of-pocket expenses as they pertain to co-payments and, deductibles (not premiums) under your shared $1200 General Medical Benefit.
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