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Home > Health Plan > B5 - Prescription Drug Benefit
PRESCRIPTION DRUG BENEFIT
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.
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 Customer Service at the Benefits Fund Office.
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.
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.
Specialty Drugs—Require Purchase by Mail
What are Specialty Drugs. Drugs that may require special storage, handling or administration (such as injection or infusion) or are for conditions where it may be beneficial to monitor the drug therapy or an underlying medical condition are considered “specialty drugs.” Examples of such drugs are Atripla, Enoxaparin, Humira, Enbrel, Truvada.
The Fund Administrator, in consultation with the Fund’s Medical Consultant and with approval by the Trustees, periodically identifies which drugs are specialty drugs. Inquiries as to whether any drug is on the current specialty drugs list should be directed to the Benefits Fund Office.
Specialty Drugs Must be Purchased by Mail from US Specialty Care. Under the Prescription Drug Benefit, specialty drugs can be obtained only by mail through US Specialty Care. Specialty drugs are not covered if obtained at a local pharmacy.
To obtain your specialty drug:
US Specialty Care pharmacists and staff are available to answer any questions. They can give you detailed instructions and support for how and when to take your drugs. They also offer refill reminder calls.
You can reach US Specialty Care at 800-641-8475, FAX at 800-530-8589, or by mail at PO Box 4517, Englewood CO 80155-4517.
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.
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.
Covered Drugs
The Plan covers the following:
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:
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.
What's Not Covered
In addition to the Plan’s General Exclusions and Limitations, the following expenses are not covered:
Other drugs, as determined by the Trustees from time to time, may be excluded from coverage.
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.
Creditable Coverage Under Medicare
The prescription drug benefit provided by this Plan B5 classification has been determined to be "creditable coverage" under Medicare. This means that if you are eligible for Medicare, you may defer electing Medicare Pard D Prescription Drug Coverage while you remain covered under the Plan and you will not be penalized if you then elect it at a later date. For more detailed information, you may refer to the Notice of Prescription Drug Creditable Coverage Coverage under Medicare.
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