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High-Cost Rx Program (Adjuncts)
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This new program goes into effect Jan.1, 2020. The High-Cost Rx Program is designed to include an additional $25,000 of coverage for out-of-pocket prescription drug costs when certain conditions are met. The plan is designed to assist Active (Full-time and Adjunct) members and Retirees under 65 who are enrolled in the PSC-CUNY Welfare Fund Prescription Plan, and who are experiencing significant out-of-pocket drug expenses.
How does the High-Cost Rx Program work?
Fund members will be able to apply for reimbursement when their Welfare Fund prescription drug expense exceeds $10,000 and their eligible out-of-pocket costs exceed $2,500 on an annual basis. The Fund will reimburse up to $25,000 per person per plan year. The first $2,500 of out-of-pocket is treated as a deductible and not eligible for reimbursement.
PSC-CUNY Welfare Catastrophe Major Medical (CMM) policy holders are required to file claims to Mercer Consumer/AIG before submitting to the Welfare Fund and must include a claim rejection from Mercer/AIG as part of claim to the Fund reimbursement plan.
How do I make a claim?
Members must submit the following to ASO:
- High-Cost Rx Program Claim Form
- Cashier’s receipt AND
- Rx package receipt that shows:
- Patient’s full name
- Name of Drug
- Date of Service
- Amount paid
- Any Coupons
Examples of eligible receipts are here. CVS/Caremark member portal claims printouts are NOT accepted as receipts.
What claims are eligible for reimbursement?
- All in-network pharmacy claims may be eligible for reimbursement if they are for drugs on the PSC-CUNY Welfare Fund’s CVS formulary or drugs with a valid Prior Authorization
- Specialty Drug claims are eligible ONLYthrough the CVS Specialty program
What costs are NOT eligible and DO NOT COUNT towards Deductible and/or Accumulators?
The following are not eligible:
- Dispensing penalties
- Copay costs:
- Already paid by Manufacturer’s Copay Assistance of Pharma Co.
- Related to Ineligible Drug Claims
- Related to other non-CVS specialty program drug expenses
What drug costs are not eligible for reimbursement?
The following drugs are not eligible for reimbursement:
- PICA drugs (covered by NYC Health Benefits Program)
- Diabetes drugs (covered by basic health insurance)
- Drugs not included in the Welfare Fund CVS formulary or plan
- Erectile Dysfunction (ED) drug coverage maximum (up to $500)
- ACA preventive list drugs (list available on psccunywf.org)
- Drugs covered by any provider other than PSC-CUNY Welfare Fund Prescription Plan
- Specialty Drug claims not purchased through the CVS Specialty program
When can a claim be submitted?
Claims must be submitted on a quarterly basis according to the following dates:
Q1 (Jan. 1 – Mar. 31) on or after April 15th
Q2 (Jan. 1 – June 30) on or after July 15th
Q3 (Jan. 1 – Sept. 30) on or after Oct. 15th
Q4 (Jan. 1 – Dec. 31) on or after Jan. 15th
Claims will not be accepted until the 15th day following the end of the quarter. Claims will be accepted up to March 31st of the following year for claims with date of service in the prior plan year. Only one (1) claims submission per quarter will be accepted.
IMPORTANT: When your eligible out-of-pocket copay costs exceed $2,500 you should make a claim for reimbursement at the earliest quarterly date, even if it is only for a small amount. That will insure timely processing for full copay reimbursement in the next quarter.
Please be aware fraudulent claims are grounds for permanent disenrollment from the Fund Plan.
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