You should already have received information about the Drug Card Program along with a Prescription Drug Card and a list of participating pharmacies and a mail service order form.
Your Prescription Drug Program consists of:
YOU MUST USE PARTICIPATING PHARMACIES
When you (or a covered dependent) have a prescription to be filled, the prescription must be filled by a pharmacy that participates in the drug card program, or at the Sav-Rx mail-order pharmacy.
Be sure to show your drug card to the pharmacist at the time the prescription is filled.
In most cases, the Plan pays no benefits for prescriptions filled by pharmacies that do not participate in the Prescription Drug Program.
Do not send a prescription drug claim to the Fund Office from a pharmacy that doesn’t participate in the Drug Card Program, unless:
You pay the following percentage co-pays for your covered prescription drug charges. The same percentages apply to retail, mail and Walgreens walk-in purchases:
|all drugs||$5 minimum/$200 maximum co-pay|
A formulary is a list of brand name drugs that have been evaluated by physicians and pharmacists, and have been determined to be the most effective treatments for most patients. These drugs have also been determined to be reasonably priced.
Lifestyle drugs are drugs that are not medically necessary to treat a specific illness or injury, and an individual’s health is not at direct risk if the drugs are not taken. Some examples are:
PPI and NSAHs are available in over-the-counter versions. The prescription versions are covered under the Plan only when, in very rare instances, it is medically necessary for the patient to use the prescription version. Med-Care Management must review the necessity for these drugs and pre-authorize them before they are purchased. If Med-Care pre-authorizes a PPI or NSAH, Plan benefits will be paid the same as any other lifestyle drug. If Med-Care does not pre-authorize the drug, it will not be covered.
The Prescription Drug Program is completely separate from the Comprehensive Benefit. Your pharmacy co-pays do not apply to your out-of-pocket limit amount under the Comprehensive Benefit.
If the amount of a covered person’s prescription drug co-pays total $3,000 during a calendar year, the Plan will pay 100% of the cost of that person’s covered prescription drugs during the remainder of that year.
Similarly, if the co-pays for your covered family members total $5,000 in a year, the Plan’s payment percentage will increase to 100% for you and your dependents during the remainder of that year.
Annual Maximum for Retirees
The maximum the Plan will pay for all the prescription drug expenses incurred by a retiree covered under the Retiree Comprehensive Plan is $4,000 per calendar year. A separate $4,000 calendar year maximum applies to the retiree’s covered spouse.
Sav-Rx Mail Service Program
If you or a covered dependent need more than two refills for a short-term prescription, or if a prescription is for a long-term or maintenance drug, you should use the mail service program.
If you need more than two refills for a short-term prescription, or if your prescription is for a long-term or maintenance drug, you should obtain the prescription through the mail service program.
If your doctor prescribes a new medication to be taken for more than 30 days, ask him to give you two prescriptions:
You can use the mail service program for prescription oral birth control medications.
Viagra and similar oral prescription drugs for male impotence are covered under the mail service program only if the drugs are determined by the Fund Office to be medically necessary. With respect to Viagra and similar drugs, “medically necessary” means that the patient’s impotence is caused by an underlying physical condition such as diabetes, a non-occupational injury, or a circulatory or neurological disorder. Pre-approval must be obtained from the Fund Office before Sav-Rx will fill the prescription. If pre-approval has been obtained, you can obtain the quantity of drugs prescribed up to a maximum of 72 tablets per calendar year.
Walk-In Program (Walgreens)
The Plan also has a special arrangement with Walgreens that allows you to purchase your long-term and maintenance medications at any local Walgreens. Your Sav-Rx prescription card must be shown to the Walgreens pharmacist at the time the prescription is filled. All the other rules applicable to the regular mail service program apply to the walk-in program.
WHEN ANOTHER PLAN IS PRIMARY
If your dependent spouse or child has primary coverage for drugs under another insurance plan, your spouse or child is not entitled to obtain prescription drugs under the drug card program.
PRESCRIPTION DRUG PROGRAM EXCLUSIONS
Except for certain diabetic drugs and supplies, only “legend” drugs may be obtained through this program. Legend drugs are those that can be obtained only with a doctor’s prescription.
In addition, the Plan excludes:
Dispensing time limits and days supply limits may also apply. For example, you cannot purchase a refill until 75% of the prior supply has been used. Other limits may be based on the manufacturer’s recommended dosage and duration of therapy, FDA recommendations, federal or state law, or clinical determinations made by Sav-Rx.
If you have any questions about your Prescription Drug Program, call Sav-Rx toll-free at 1 (800) 228-3108. You should also call Sav-Rx if you need a prescription drug card, a list of participating pharmacies or a formulary list. The list will be provided at no cost.