Benefits
DC 37 Health
& Security Plan Benefits
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Prescription Drug Benefit
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ATTENTION |
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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.
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
DC 37 Health and Security Plan members covered by the program must use their
City of
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
Attention: Prescription Drug Unit
IMPORTANT NOTE
1. Effective
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
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
q.
injectable
medication for active members, non-Medicare eligible retirees and eligible
dependents enrolled in the City of
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.
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