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Home > Health Plan > D5 - Prescription Drug Benefit
PRESCRIPTION DRUG BENEFIT
Your eligible dependents are covered only if you elected
Family Coverage and are working enough hours to qualify for full-time coverage.
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 NMHC/Rx Customer Service at 888-354-0090. They are open
24 hours a day, 7 days a week.
Participating Pharmacy Program
The Prescription Drug Benefit is managed by NMHC/Rx, 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 NMHC/Rx Customer Service at 888-354-0090.
Annual Maximum Benefit
The maximum prescription drug benefit per person is $14,000 per year.
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 NMHC/Rx Customer Service at 888-354-0090 for information on which drugs currently require pre-approval
and how to obtain the pre-approval.
Generic Equivalents and Brand-Name Drugs
If you or your eligible dependent 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 NMHCRx Customer Service 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 NMHC/Rx Customer Service at 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 D5 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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