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  Home > Health Plan > B5 - Prescription Drug Benefit

PRESCRIPTION DRUG BENEFIT

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The Prescription Drug Benefit provides coverage for most drugs that require a doctor’s prescription, for certain over-the-counter medications when prescribed by a doctor and for some diabetic supplies.

Prescription Drug ID Card

You will receive an ID card when you become eligible for benefits. When you use your ID card at a participating pharmacy to fill prescriptions, all you need to do is pay any applicable co-payment. You do not have to complete any claim forms.

If you need a replacement card or an additional card, contact informedRx at 888-354-0090. They are open 24 hours a day, 7 days a week.

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Participating Pharmacy Program

The Prescription Drug Benefit is managed by informedRx, a prescription benefit manager with a large network of pharmacies, called "participating pharmacies." You receive the highest level of benefits when you fill your prescription at a participating pharmacy.

Most pharmacies are participating pharmacies. However, should you have any problem locating a participating pharmacy, please contact informedRx at 888-354-0090.

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Annual Maximum Benefit

The maximum prescription drug benefit per person is $1,500 per year.

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Drug that Require Pre-Approval

Some drugs require pre-approval before your prescription can be filled under the Prescription Drug Benefit. For example, drugs which may require pre-approval include narcotics, amphetamines, anabolic steroids and protein pump inhibitors (stomach drugs) when more than one tablet per day is taken.

The Fund Administrator, in consultation with the Fund’s Medical Consultant and with the approval by the Trustees, periodically makes changes regarding which drugs require pre-approval.

Contact informedRx at 888-354-0090 for information on which drugs currently require pre-approval and how to obtain the pre-approval.

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Generic Equivalents and Brand-Name Drugs

If you request a brand-name drug when a generic equivalent is available (and medically appropriate), you will be responsible for paying the difference in cost between the generic and the brand-name drug, in addition to the brand-name co-payment amount.

In general, using generic drugs usually helps to control the cost of health care while providing quality drugs—and can be a significant source of savings for you and the Fund. Your doctor or pharmacist can assist you in substituting generic drugs when appropriate.

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Preferred and Non-Preferred Drugs

For the purpose of controlling costs (both yours and the Fund's), certain drugs are designated as either preferred or non-preferred. Preferred drugs have no co-payment—you pay nothing. Non-preferred drugs have a $25 co-payment.

Contact informedRx at 888-354-0090 for updated information on which drugs are preferred drugs.

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Covered Drugs

The Plan covers the following:

  • Most drugs that require the written or oral prescription of a licensed doctor or dentist under federal or state law, up to a 30-day supply maximum per prescription or refill.
  • Exceptions to the 30-day supply maximum are maintenance drugs that are used on a long-term or on-going basis to treat chronic conditions. You can receive up to a 90-day supply of these drugs. Contact informedRx at 888-354-0090 for specific information on maintenance drugs or to place a refill order.
  • Certain over-the counter (OTC) drugs when prescribed by a doctor. These drugs are OTC Prilosec and OTC Loratadine (Claritin).
  • Insulin, blood glucose testing strips, needles and syringes, up to a maximum of 150-unit supplies each 30 days.
  • Needles and syringes up to a 30-day supply.

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Co-Payments

Co-payments are based on tiers established by the Trustees to encourage cost-effective use of the Prescription Drug Benefit.

You'll pay the following:

30-Day Supply Co-Payment
Tier Zero
  Lovastatin $0
  OTC Prilosec $0
  OTC Loratadine (Claritin) $0
  other preferred drugs $0
Tier One
  most generic drugs $7
Tier Two
  most brand-name drugs $15
  high-cost generic drugs $15
Tier Three
  Januvia $25
  Zocor and the generic equivalent $25
  prescription allergy drug
  (such as Allegra and Zyrtec)
$25
  prescription ulcer and acid-reflux
  drug (such as Nexium and Prevacid)
$25
  sleep medication, anti-dementia
  drug, influenza drug, erectile
  dysfunction drug, Mobic, Accutane
$25
  other non-preferred drugs $25
Maintenance Drug (90-Day Supply) Co-Payment
Tier Zero
  Lovastatin $0
  OTC Prilosec $0
  OTC Loratadine (Claritin) $0
  other preferred drugs $0
Tier One
  most generic drugs $14
Tier Two
  most brand-name drugs $30
  high-cost generic drugs $30
Tier Three
  Januvia $50
  Zocor and the generic equivalent $50
  prescription allergy drug
  (such as Allegra and Zyrtec)
$50
  prescription ulcer and acid-reflux
  drug (such as Nexium and Prevacid)
$50
  sleep medication, anti-dementia
  drug, influenza drug, erectile
  dysfunction drug, Mobic, Accutane
$50
  other non-preferred drugs $50

You will also be responsible for paying the difference in cost between the generic and the brand-name drug if you request a brand-name drug when a generic drug is available and medically appropriate.

Contact informedRx 888-354-0090 for updated information on which drugs are preferred drugs.

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What's Not Covered

In addition to the Plan’s General Exclusions and Limitations, the following expenses are not covered:

  • drugs or medications that are payable under any other benefit provided by the Plan
  • drugs or medications that require pre-approval when you did not obtain approval before they were dispensed to you
  • medicines that do not require a prescription (over-the-counter), except as otherwise specifically noted
  • the difference in cost if you request a brand-name drug when a generic drug is available and medically appropriate
  • drugs dispensed for use while medically confined
  • drugs (except Lupron) consumed at the time and place of prescription
  • drugs that are considered experimental or not approved by the US Food and Drug Administration for the condition, dose, rate or frequency prescribed
  • appliances and devices
  • blood and blood plasma, immunization agents and biological sera
  • oral contraceptives or implanted drugs or devices, regardless of intended use
  • fertility drugs
  • erectile dysfunction drugs in excess of six tablets per 30 days
  • drugs used for cosmetic purposes
  • drugs to promote hair growth
  • drugs used as an aid to weight loss
  • lancets
  • lifestyle drugs
  • non-drug items including nutritional supplements, regardless of intended use
  • smoking deterrents, including Nicorette and nicotine transdermal patches
  • vitamins, except for prescription pre-natal vitamins
  • Aciphex
  • Ambien CR
  • Axid and its generic, Nizatidine
  • Cipro CR
  • Clarinex
  • Daytrana
  • Exubera
  • Fluoxetine tablets
  • Ketek
  • Lamisil
  • Omeprazole
  • Paxil CR
  • prescription Prilosec
  • Ranitidine capsules
  • Serafam
  • Singulair, unless used solely for the treatment of asthma
  • Wellbutrin XL
  • Xanax XR
  • Zegerid
  • Zmax

Other drugs, as determined by the Trustees from time to time, may be excluded from coverage.

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Direct Reimbursement

You receive the highest level of benefits when you fill your prescription using your ID card at a participating pharmacy. If for some reason you cannot use a participating pharmacy or your ID card, you may submit a “Direct Reimbursement” claim form to request reimbursement.

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Not Creditable Coverage Under Medicare

The prescription drug benefit provided by this Plan B5 classification has been determined NOT to be "creditable coverage" under Medicare. For more detailed information, you may refer to the Notice of Prescription Drug Coverage (Plan Classification D5–Tier B) that is Not Creditable Coverage under Medicare.

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Plan Pays Limited Benefits

This Plan B5 pays limited benefits for prescription drugs.The annual maximum is $1,500. You are encouraged to work with your doctor to ensure that the most cost-effective drugs are prescribed.

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