PRESCRIPTION DRUGS

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AMERICAN FEDERATION OF STATE, COUNTY & MUNICIPAL EMPLOYEES / AFL-CIO

DC 37 Health & Security Plan Benefits

Prescription Drug Benefit

Innoviant Customer Service - 1-800-207-1561, is available 24-hours a day, 7 days a week, or visit Innoviant's website at www.Innoviant.com

Innoviant Member Portal

Innoviant Member Portal-Key Points (*PDF)

Getting Started (*PDF)

DC 37 H&S Plan Notice of Prescription creditable coverage (PDF)*

The Prescription Drug Benefit is available to both active and retired members and their eligible dependents. The Prescription Drug Benefit can be used in one of three ways: through the use of the prescription drug card, through the use of the direct reimbursement method, or through the mail service program. The most beneficial way of using the Prescription Drug benefit is with the Drug Identification Card issued by the Plan.

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 member co-payments are in effect as of July 1, 2006:

DRUG	30 days @ Retail Pharmacy	90 days @ Retail 90 Rx Pharmacy	90 days @ Voluntary Mail Order Pharmacy
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 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.

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.

So remember! 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 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 appropriate co-payment as opposed to a 90 day supply at a Retail 90 Rx pharmacy. You can register directly with our mail order provider through the following link https://www.innoviantrx.com/Registration.aspx

Annual Limit: The Annual limit for the prescription drug benefit is $100,000 per cardholder, per year.

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)

Rx Instep is a 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.
*The Plan's prescription drug benefit provides diabetes medication for Medicare-eligible retirees only.

Please note if you were prescribed a Step Two medication in the past and have not filled a prescription for it in four months or longer, you will not be able to re-start that medication without first trying a Step One drug.

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 included in your Innoviant Member Welcome package. You can access a copy of the Member package along with other benefit information on our website.

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 a 1st step 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.

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.

The City sponsored program for Injectable and Chemotherapy medication maintained the following changes implemented in April 2004:

A three-tier co-pay structure for generic, preferred and non-preferred medications
Mandatory use of the mail order pharmacy for maintenance medications
Generics Preferred Program
Prior Authorization required for some medications
Step Therapy for certain classes of medications
Lifetime limit on the use of Fertility medications
Specialty Care Pharmacy for certain medications
$100 annual deductible for each patient using injectable drugs

The City sponsored program is administered by Express Scripts, in conjunction with the New York City Office of Labor Relations and the Municipal Labor Committee. Questions about the Injectable and Chemotherapy program should be directed to Express Scripts at 1-800-467-2006.

DC 37 Health and Security Plan members covered by the program must use their City of New York ESI PICA prescription card for injectable and chemotherapy medication.

The co-pays for Injectable and Chemotherapy drugs (30 day supply) obtained at the pharmacy are:

$10 for generic medication
$25 for preferred brand name (formulary) medications
$45 for non-preferred brand name (non-formulary) medications**

The co-pays for Injectable and Chemotherapy drugs (90 day supply) obtained through the mail order pharmacy are:

$20 for generic medication
$50 for preferred brand name (formulary) medications
$90 for non-preferred brand name (non-formulary) medications**

**If you choose a non-preferred brand name medication that has a generic equivalent, you will be charged the difference in cost between the non-preferred brand name drug and the generic drug plus the non-preferred brand name drug co-pay.

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.

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 January 1, 2001 active employees and retirees of the Office of Court Administration and the State Rent 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).

3. Effective July 1, 2001, 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: psychotropic, injectable, chemotherapy and asthma, will be provided by the PICA Drug program.

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, sanitarium, 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 medical, custodial or skilled nursing care is provided;

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. drugs including vitamins, foods and diet supplements and any other over-the counter medication that may be legally purchased 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) for the administration

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;

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;

q. injectable medication for active members, non-Medicare eligible retirees and eligible dependents enrolled in the City of New York's Health Benefits program;

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 cost of:

a. 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;

b. FDA approved fertility medication, up to 12 treatments per lifetime;

c. 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.

d. 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

e. 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.

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