![j0297105[1]](prescription_files/image009.gif)
Benefits
DC
37 Health & Security Plan Benefits
|
What's new |
|
|
·
Innoviant
Customer Service |
|
Prescription Drug Benefit
|
ATTENTION |
||
|
|
Access your benefit
information including co-payments, programs and view or print your claims
history. o
Innoviant Member Portal-Key
Points (*PDF)
o Getting
Started (*PDF) |
|
The Prescription Drug
Benefit pays most of the cost of prescription drugs. A covered prescription
drug is a drug approved by the Food and Drug Administration ("FDA"),
used for the purpose and time period approved by the FDA and which cannot be
purchased without a Physician's or Dentist's prescription (except prescription
medications that have over the counter counterparts); or drugs, which require
compounding, except that such term shall include prescribed insulin or drugs
that have not been specifically excluded. While allergens are not prescription
drugs, they are covered under the Plan if the medication is purchased from an
allergy testing lab or a Participating Pharmacy and is prescribed by your
doctor.
Generic Based Prescription Drug Benefit
The Plan has a generic based
Prescription Drug Program. This means that the Plan will only be responsible
for paying covered prescription medication at the generic rate, except when
there is no generic available and the brand name drug is the only drug available
(sole source).
The Prescription drug
benefit is available to the covered member and eligible dependents. The
prescription drug benefit consists of a three tier co-payment program. The
following co-payments are in effect as of July 1, 2006:
|
DRUG |
30 days @ Retail Pharmacy |
90 days |
90 days |
|
Generic |
$5 |
$15 |
$10 |
|
Preferred
Brand |
$15 |
$45 |
$30 |
|
Non-Preferred
Brand |
$35 |
$105 |
$70 |
If you choose to obtain a brand name drug
that has a generic equivalent, then you will be responsible for paying the
difference in cost between the brand name drug and the generic drug in addition
to the appropriate co-payment. In no case will you be charged more than the
cost of the medication. If a generic equivalent is not available, instruct your
physician to prescribe a preferred brand name medication.
It is important to note
that the Food and Drug Administration requires that generic drugs must meet the
same standards for purity, strength and safety as the brand name drug.
Effective January 2010,
members and retirees with prescriptions for cholesterol lowering drugs known as
statins won't be charged co-pays for the generic
versions of their medication. For a flyer with details, click here. (PDF format*)
PICA
The Psychotropic, Injectable, Chemotherapy & Asthma (PICA) Program
As a result of a benefit
bargaining agreement reached between the City of New York Office of Labor
Relations and the Municipal Labor Committee of which DC 37 is a member, a
program, known as PICA was effective July 1, 2001. This program made these four
classes of drugs available to all employees, non-Medicare eligible retirees and
their eligible dependents in a City sponsored health plan.
Medications in these four
categories were provided through the PICA program only, except where otherwise
covered under a City sponsored basic health plan.
Effective July 1, 2005, the City sponsored program continued to cover two
classes of medication, Injectables and Chemotherapy.
Psychotropic and Asthma medication coverage reverted to the Plan's
responsibility and are subject to Plan rules and co-payments.
DC 37 Health and Security Plan members covered by the program must use their
City of New York PICA prescription card for injectable
and chemotherapy medication. Questions about the PICA program should be
directed to the telephone number on the back of the NYC PICA prescription card.
The Preferred Products List
Because
of the escalating cost of the Prescription Drug Benefit,
the Plan has instituted a Preferred Products List. The list identifies
prescription drugs that can be used for virtually all illnesses and conditions
and will meet the needs of all types of patients. The List was developed by a
select group of physicians and pharmacists to ensure that all the drugs are
therapeutically sound.
When there is no generic drug
available, use a prescription that appears on the Preferred Products List. It
will save money for you and the Plan.
The Mail Order Program
The mail order program is a voluntary program
designed for persons who have a long-term illness that requires maintenance
type medication. You will save money because you get a 90 day supply of
medication for the cost of two co-payments as opposed to a 90 day supply at a
Retail 90 Rx pharmacy for three co-payments. Please allow 14 days for delivery
from the date you mail in the original prescription. Be sure to enclose a check
or money order which reflects the cost and/or the co-payments associated with
the prescriptions you send to the Mail Service Program. For additional
information about the mail order program you can access the DC 37 website at
www.dc37.net or contact the Plan's Inquiry Unit at 212-815-1234.
Annual Limit
The
Annual limit for the prescription drug benefit is $100,000 per cardholder, per
calendar year. The cardholder includes the total prescription utilization of
the member and all eligible dependents. The Plan's annual limit consists of
Plan approved medications and is subject to all Plan rules and guidelines.
Drug Reimbursement Claims
If a member does not have
the drug card with him/her, or does not go to a participating pharmacy, then
the direct reimbursement method must be used. Drug re-imbursement claim forms
(PDF format*) are posted on the Innoviant website. The
member will be reimbursed based on the amount listed in the Plan's drug
schedule in accordance with the generic based program, minus the appropriate
co-payment, regardless of the actual amount spent for the drugs.
Rx Instep (Step Therapy Program)
The Plan has instituted
the mandatory Rx Instep program especially for people who take prescription
drugs to treat certain ongoing medical conditions with safety, cost and most
importantly your health in mind.
It allows you and your family to receive the affordable treatment you need and
helps the Plan contain the rising cost of prescription drug coverage.
- The program starts with
generic drugs in the "first step". The generics covered by the
Plan have been proven to be effective in treating many medical conditions.
You will have the lowest co-payment for a first step generic drug.
- More costly brand name drugs
are usually covered in the second step, even though generics have been
proven to be effective in treating many medical conditions. These brand
name drugs will have higher co-payments.
The drug categories in the
Rx Instep program include high blood pressure, dermatitis and eczema, attention
deficit hyperactivity disorder, asthma and allergy, depression, rheumatoid
arthritis, diabetes*, pain and arthritis medication and ulcer and
gastro-esophageal reflux disease medication.
*Please refer to Important Notes regarding diabetes coverage.
If your doctor is prescribing a medication for an Rx Instep therapy condition
for the first time, ask your doctor to prescribe a Step One medication. The Rx
Instep program's medication list is available at the Plan's website,
www.dc37.net or from the Plan office.
If the initial treatment with a Step One drug does not work well, the patient
can be given a more costly Step Two drug. You will not need an approval to fill
the new prescription at the pharmacy because we will have a record of the use
of the Step One drug.
If you are being prescribed medication for an Rx Instep therapy condition for
the first time, and your doctor did not prescribe a Step One drug, your
pharmacist will receive a message indicating that our Plan has a Step Therapy
program. The pharmacist will generally contact the physician to request a new
prescription for a step one drug. If a physician is unavailable, the member or
patient will be responsible for obtaining the new prescription. If you choose
to get your written prescription filled as is, you will pay the full cost for
it, and the medication will not be covered by the Plan.
Please
note: If you
were prescribed a Step Two medication in the past and have not filled a
prescription for it in 120 days or longer, you will not be able to re-start
that medication without first trying a Step One drug.
How To Use The Prescription Drug Card
The most effective way of using
your Prescription Drug benefit for short-term medication is with the
prescription drug card issued by the Plan. You take the card and your
prescription, which must be written on your Physician's prescription pad, to a
Participating Pharmacy. When getting medication from your neighborhood
participating pharmacy, you can obtain a 30 day supply or 90 day supply based
on your written prescription for the appropriate Plan co-payment. In the event
that you did not receive a valid prescription drug card, or if your card has
been stolen, lost or destroyed, you must notify the Plan office by calling the
Inquiry Unit at 212-815-1234.
How To Use The Reimbursement
Method
In case you do not have your
prescription drug card with you, or if you do not go to a Participating
pharmacy, you must then utilize the Direct Reimbursement Method to obtain your
prescription drugs. You must complete the Prescription Drug Benefit
Reimbursement form available at the Plan office. You must send the form along
with the prescription receipt to the Plan's Prescription Drug Benefit
Administrator in order to be reimbursed. Your reimbursement amount is based on
the participating pharmacy's contracted rate minus your co-payment and will be
subject to Plan rules and restrictions. If
you obtained a brand name drug that had a generic equivalent, then you will be
responsible for paying the difference in cost between the brand name drug and
the generic drug in addition to the appropriate co-payment. Reimbursement
is based on a specific fee schedule, minus the appropriate co payment,
regardless of what the pharmacist's charges are. The same fee schedule is used
to reimburse a participating pharmacy when a member uses his/her prescription
drug card.
Medicare Eligible Actively Working Members and the DC 37
Prescription Benefit
Actuaries for the Plan, using guidelines established by the Centers for
Medicare and Medicaid Services, have determined that your prescription drug
coverage with the Plan is, for all plan participants, expected to pay out as
much as or more than the standard Medicare prescription drug coverage.
Because your existing coverage is at least as good as or better than standard
Medicare prescription drug coverage, you can keep this coverage and choose not
to enroll in Medicare Part D coverage.
Should you no longer be eligible for the Plan's prescription drug coverage and
choose to elect a Medicare Drug Plan you may not be subject to late enrollment
penalties because your current Health & Security Plan benefit is considered
creditable coverage. A copy of the Notice of Creditable Coverage is available
on the Plan's website or by calling the Inquiry Unit at 212-815-1234.
Medicare Eligible Retirees and the DC 37 Prescription Benefit
Actuaries for the Plan, using
guidelines established by the Centers for Medicare and Medicaid Services, have
determined that your prescription drug coverage with the Plan is, for all plan
participants, expected to pay out as
much as or more than the standard Medicare prescription drug coverage.
Because your existing coverage is at
least as good as or better than standard Medicare prescription drug coverage,
you can keep this coverage and choose not to enroll in Medicare Part D
coverage.
Your DC 37 Health & Security Plan's prescription drug benefit will be directly impacted if you
choose to enroll in an independent Medicare prescription drug benefit plan or
receive a Medicare prescription drug benefit through your enrollment in a
Medicare Advantage health insurance plan.
As a retiree, Medicare coverage is primary. This means that if you are eligible
to receive a prescription drug benefit through a Medicare Drug or Medicare
Advantage plan, that prescription drug benefit will be primary. You will be
covered first by that Medicare Drug or Medicare Advantage plan and subject to
coverage rules including premiums, deductibles and co-payments and these costs
are not reimbursable by the Health & Security Plan. Your DC 37 Health &
Security Plan's prescription drug benefit will be a secondary coverage and will
"wrap around" your primary plan.
If you are enrolled in a Medicare drug plan or Medicare Advantage health
insurance plan that provides a "creditable" drug plan, your DC 37
drug benefit will be unavailable until you have used and exhausted your
Medicare Drug benefit annual limit or reached your coverage gap.
A copy of the Notice of Creditable Coverage is available on this website along
with Important Information for Retirees about Medicare Drug Plans.
Questions relating to specific prescription drug availability or benefit usage
should be directed to the Plan's prescription benefit administrator, Innoviant at 1-800-207-1561. Questions or problems relating
to eligibility should be directed to the Inquiry Unit at 212-815-1234.
COVERAGE FOR CERTAIN PRESCRIPTION DRUGS
The Prescription Drug Benefit normally provides coverage for prescription
medication when used only for purposes approved by the FDA. However, effective
January 1, 1991, the Board of Trustees extended coverage of prescription drugs
for unlabelled cancer therapy under the following conditions:
Before cancer drug claims can be
considered for payment, all three conditions must be met:
1. Medical records must be provided to the Plan by the treating physician;
2. Submission of proof that your basic health insurance carrier (i.e. GHI, HIP,
Blue Cross, etc.) rejected the prescription drug claims for payment;
3. The patient's treating physician must demonstrate to the Plan that the
medication being prescribed has been recognized by experts in the field as
being effective. Recognition is shown by the presentation or reference to
articles that have appeared in certain established medical publications.
It must be noted that, for cancer drug claims, the Prescription Drug Benefit
will pay 50% of the Plan's allowance of the drug up to a lifetime maximum of
$5,000, using the direct reimbursement method only. Please send your treating
physician's records; basic health insurance carrier rejection; and medical
authority documentation to the:
DC 37 Health & Security Plan
125 Barclay Street
New York, NY 10007
Attention: Prescription Drug Unit
IMPORTANT NOTE
1. Effective January 1,
1995, for all active members, non-Medicare eligible retirees, and dependents
enrolled in the City of New York's Health Benefits Program, diabetes medication
will be provided by the various health plans as part of the basic benefit
package.
2. Effective July 1, 2005,
for all active members, non-Medicare eligible retirees, and dependents enrolled
in the City of New York's Health Benefits Program, coverage for the following
categories of medication: injectables and
chemotherapy will be provided by the PICA program.
3, All active and retired
members of the Triborough Bridge and Tunnel Authority
will receive coverage for diabetes medication, injectables
and chemotherapy through the DC37 Health & Security Plan.,
4. Effective January 1,
2001, active employees and retirees of the Office of Court Administration and
the State Rend Regulations Services Unit will no longer be covered for
prescription drug benefits through the DC 37 Health & Security Plan.
Prescription drug coverage will be provided through the New York State Health
Insurance Program (NYSHIP).
EXCLUSIONS/LIMITATIONS:
The Prescription Drug
Benefit will not cover the cost of:
A.
drugs prescribed for a patient confined to
a rest home, nursing home, extended care facility, hospital or similar
in-patient care facility or drugs prescribed for a member or eligible dependent
residing in an assisted living facility where such drugs are covered in whole
or in part by a federal, state, or local program or other insurance. Where only
a portion of the cost of such drug is covered by another plan or insurer, the
remaining cost of such uncovered drug will be covered to the extent permitted
under the Plan's prescription drug benefit. The covered employee and eligible
dependent will be responsible for all applicable co-pays and special shipping
costs;
B.
drugs prescribed for any condition covered
by Workers' Compensation, No Fault Automobile Insurance, or in any situation
where third party medical insurance is available;
C.
chemotherapy obtained by a non-Medicare
eligible member and/or eligible dependent; administered on an out-patient basis
in a hospital; or administered in a doctor's office;
D.
vitamins, foods and diet supplements that
may be purchased with or without a prescription;
E.
drugs supplied by a treating physician;
F.
investigational or experimental drugs;
G.
over-the counter drugs (drugs purchased
without a prescription);
H.
prescription medications that have over
the counter counterparts.
I.
appliances and all companion implements
(devices), including syringes and needles, for the administration of
prescription drugs;
J.
drugs prescribed for cosmetic purposes;
K.
prescription drugs used for Intravenous
Drug Therapy, which is infused in the home; and any charge for the
administration of home infusion of the drug;
L.
immunization agents and biological sera;
M.
refills of medication covered by the
benefit described in this section in excess of five (5) 30-day refills in any
six (6) month period.
N.
refills of maintenance drugs covered by
the benefit described in this section in excess of three (3) 90 day supplies in
any twelve (12) month period filled at the Plan's mail order program or a
Retail 90 Pharmacy;
O.
diabetes medication for active members and
non-Medicare eligible retirees and eligible dependents except as noted;
P.
chemotherapy and related medication for
active members, non-Medicare eligible retirees and eligible dependents enrolled
in the City of New York's Health Benefits program except as noted;
Q.
injectable
medication for active members, non-Medicare eligible retirees and eligible
dependents enrolled in the City of New York's Health Benefits program except as
noted;
R.
any medication for active employees and
retirees of the Office of Court Administration and the State Rent Regulations
Services Unit enrolled in the New York State Health Insurance Program.
The Prescription Drug Benefit will limit the coverage and cost of:
S.
drugs used in amounts or quantities which
exceed FDA, approved guidelines, e.g., pergonal
(fertility) no more than two (2) vials per day for twelve (12) days per cycle;
and Proton Pump Inhibitors (PPI's) for longer than three (3) months;
T.
FDA approved fertility medication, up to 12
treatments per lifetime;
U.
coverage for the class of prescription
drugs used to treat male sexual dysfunction will require pre-approval by the
Plan, must be dispensed through our mail service program and will have a 50%
co-payment and an annual cap of $500.00.
V.
coverage for the class of prescription
drugs used to treat obesity will require pre-approval by the Plan and will have
a 50% co-payment and an annual cap of $500.00
W.
prescription drugs if a health insurance
carrier provides for prescription drug coverage, then that carrier is Primary
for prescription drugs. Should there by an out-of-pocket expense after the
basic health insurance carrier processes drug related claims, the Plan will
consider Coordinating Benefits.Members are reminded
that when the spouse has separate prescription drug coverage (whether through
the spouses' employment or other sources such as Veterans Administration
Benefits, Workers' Compensation, Medicaid, No Fault Insurance, etc.), the Plan
deems this coverage to be the primary coverage for the spouse and the spouse
must use his/her own coverage.
X.
prescription drugs covered through
enrollment in a Medicare Part D Drug Plan. The Medicare Part D Drug Plan will
be considered Primary and the Plan will provide benefits after meeting the Med
D Plan annual limit or coverage gap.
Members are reminded that
when the spouse has separate prescription drug coverage (whether through the
spouses' employment or other sources such as Veterans Administration Benefits,
Workers' Compensation, Medicaid, Medicare, No Fault Insurance, etc.), the Plan
deems this coverage to be the primary coverage for the spouse and the spouse
must use his/her own coverage.
The Plan
has increased costs due to improper use and/or abuse of the Prescription Drug
Card. Members who, through carelessness or negligence, allow their Drug Card to
fall into the hands of unauthorized persons whether known to them or not will
be held responsible for the misuse of the card that was entrusted to the member
for his/her use and/ or for the use of his/her eligible dependents. Such
unauthorized or improper use can also result in the suspension of all your DC
37 Health & Security Plan benefits.
|
Starting Gate | Contact | Site
map | Awards | City-Wide
Contract | 2021 Constitution | 2021
Officers | 2021
E-mail Alerts |
| News
from 2021 | 2021 Meetings | City-Wide
Health Plans | DC 37 Officers | DC
37 Dental Plan |
| DC 37
Prescription Plan | DC 37 Vision Plan | DC 37
Legal Service | Printable Forms |
| All
Other Benefits | Website Links |
