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High-Cost Rx Program FAQs

Q: What receipts should I save to make a claim?

A: Beginning January 1, save and make copies of ALL CVS retail pharmacy register receipts (example here), CVS mail-order receipts and CVS Specialty receipts.

Q: How can I know if I have $2,500 in eligible out-of-pocket costs?

A: By saving your CVS receipts you are keeping track of your annual accruing copay costs.

Q: Can I be reimbursed for the copay costs of diabetic medicines?

A: Diabetic medicines are not eligible for claims because they are covered by your basic health insurance plan, not CVS.

Q: I get injectable and/or chemotherapy drug coverage from the NYC PICA Express Scripts plan. Can I get reimbursed for those copays?

A: No. The plan only reimburses copay costs for prescriptions purchased through the Welfare Fund CVS Prescription Plan.

Q: What if I have a Catastrophe Major Medical (CMM) insurance plan? 

A: Welfare Fund members who are covered by the Welfare Fund CMM plan or the NYSUT CMM plan must first make reimbursement claims on those plans. If you are covered by either of the plans above, an Explanation of Benefits (EOB) from the insurer must be included in your High-Cost Rx Plan reimbursement claim.

Q: My CVS copays are very high. How soon can I get reimbursed? 

A: Reimbursement claims may be made quarterly, according to the schedule below. The Fund will look to increasing the frequency of claim submissions as we see how the first year goes.

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. 

Q: What if waiting for a quarterly reimbursement poses a severe financial hardship. What should I do?

A: Please contact the Fund and arrange for an individual counseling session. Call 212-354-5230 and ask to speak to a prescription drug coordinator.

 

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