Prescription Drug Benefits

Prescription Drug Coverage Summary

The Board of Trustees has implemented an integrated mail/retail prescription drug and formulary program through Script Care for all persons covered for medical benefits through the Self-Funded PPO Plan. Persons who are covered through Kaiser receive prescription drug benefits only through Kaiser.

The prescription drug program is a $5/10% copayment program. For each prescription, the Participant’s copayment will be $5 or 10% of the cost of the prescription, whichever is higher, and the difference between brand and generic, if a brand is dispensed when a generic is available. To be eligible for prescription drug benefits, Participants must use either the Script Care mail order program (currently through Drug Source) or the Script Care retail network of pharmacies.

The mail order program is designed for the dispensing of maintenance prescription drugs. Participants may obtain a 90-day drug supply with a $5/10% copayment through the mail order program, versus a 30-day supply with a $5/10% copayment through the retail program. (Maintenance drugs are prescription drugs used on a long term, regular basis. The Plan considers any prescription which is in excess of a 30-day supply to be a maintenance drug, unless it is clearly established to be an acute drug. Acute drugs are prescription drugs taken for a short period of time.)

Both the mail order and retail programs will have an automatic generic substitution system. A generic drug is a drug that has the same therapeutic effect, same active ingredients and can do the same job as a brand name drug. If a Participant’s prescription has a generic equivalent, the generic equivalent will be dispensed, unless the prescribing physician believes such substitution is inappropriate and specifically states on the prescription that there be no generic substitution. This generic substitution system is not new; it is a very effective cost-control method and generics can help save the Plan up to 50% on the cost of prescription drugs.

Both the mail order and the retail programs have a Formulary program. The Formulary program is similar to the automatic generic substitution system, but is a non-generic substitution for more expensive brand name drugs that do not yet have generic equivalents. This program is a cost-control program specifically for non-generic drugs. The Formulary is a list of non-generic drugs based on effectiveness, safety and cost. Drugs are only classified as Formulary drugs if they are:

  1. As therapeutically effective as brand name drugs,
  2. As safe as brand name drugs, and
  3. More cost effective than other brand name drugs.

A nationally renowned Pharmacy and Therapeutics Committee decides on which drugs should be on the Formulary list. The Formulary program is not a new concept. Formulary programs have been around since the 1980’s, so most physicians are aware of such programs.

Formulary Program

Here is how the Formulary program works:

  1. Each member and pharmacist will be provided a condensed list of Formulary drugs. (Participants are encouraged to show this list to their physicians.) A Formulary drug list is available upon request from the Trust Fund Office.
  2. If a non-Formulary drug is prescribed to a Participant, the pharmacist will contact the prescribing physician and inform the physician of the existing Formulary program. The Physician can then choose to prescribe the more cost effective drug. If the physician is of the opinion that the Formulary drug is not appropriate, the original prescribed brand name drug will be dispensed to the Participant.

The Plan has an “Open” Formulary program. This means that Participants can receive any covered brand name drug, whether or not it is a Formulary drug.  However, please keep in mind that the Formulary program will help reduce the operating cost of the Plan and your copayment.

Members must submit their enrollment forms to the Trust Fund Office for the prescription drug benefit to apply to eligible dependents. If members do not submit their enrollment cards, Script Care will have no record of the dependents’ eligibility and may not dispense prescriptions to the dependents through the Health and Welfare Plan.

How to Use Mail Order

Prescriptions ordered through the mail order prescription drug program will be paid at 100% after the Participant pays his $5/10% copayment. Prescriptions will be delivered to a Participant’s home, postage paid, within 10-14 working days of the order. If you have questions about the cost of your prescription, you may contact Script Care at 866-807-0072.

To order prescriptions by mail:

  1. Ask your physician to prescribe needed medications for a 90-day supply plus three refills. If you are presently taking medication, ask your doctor for a new prescription and tell him you are going to be using a mail order program for your prescriptions. If you are starting a new medication, ask your doctor for 2 prescriptions, one for a 14-day supply which you can have filled at a local pharmacy and the second prescription for the 90-day supplies,which you will send to Script Care to be filled.
  2. Complete the patient profile questionnaire with your first prescription order.
  3. Send the complete profile questionnaire and your original prescription(s) to Script Care using the pre-addressed envelope.
  4. Script Care will process your order and return your medication immediately.

YOU ALSO MAY ORDER ONLINE AT www.scriptcare.com.

How to use the Retail Program

Prescriptions ordered through the Script Care retail prescription drug program will be paid at 100% after the Participant pays the $5/10% copayment.  Here is how the retail program works.

  1. Each member will receive a prescription drug card which will be coded for the status (single, married, etc.) of that member. This drug card can be used when obtaining prescriptions for any of a member’s eligible dependents. (The drug card eligibility information will be based on the enrollment card information you provide to the Trust Fund Office.)
  2. When a person takes in a prescription and the drug card to a pharmacist, the pharmacist will check for a match between the eligibility information for the member on the drug card, and the eligibility information of the person the prescription is for (as shown on the pharmacy’s records), to ensure that the prescription is for a person covered under this Plan, before dispensing under the terms of this Plan’s prescription drug benefit.

Your participating pharmacy’s eligibility records are based on information provided on a monthly basis by the Trust Fund Office, and the Trust Fund Office’s records depend on the information you provide. If you do not accurately report your eligible dependents, or you do not inform the Trust Fund Office of any changes (newborns, etc.), your dependents may be denied prescription drug benefits.

Your local pharmacy should be able to advise you whether or not it is a member of the Script Care network.  A list of participating pharmacies and a list of formulary drugs is distributed from time to time, and is available any time from the Trust Fund Office on request, free of charge to Plan Participants and beneficiaries.  If you do not use a participating pharmacy, the Plan will not pay for your prescription.

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