SilverScript & CVS/Caremark Plan Begins Jan. 1, 2016! Prescription Drug Benefits (Retirees)

This page includes only highlights of your prescription drug benefits. See the Details Tab for more information.

Your prescription drug coverage depends on whether you are in Retiree Plan 82, 80 or 70

Retiree Plan 82 and Retiree Plan 80

You must be enrolled in basic health insurance through the NYC Employee Health Benefits Program (NYC HBP)  as well as Medicare Parts A & B to be eligible for the Welfare Fund SilverScript Medicare Part D Prescription Plan. (If you are not Medicare-eligible, see the Details Tab for a description of the CVS/Caremark Prescription Plan.) Prescription drug benefits are available through SilverScript for yourself and your eligible dependents. The program covers most FDA-approved drugs that require a prescription. Over-the-counter medications are not covered. The amount you pay for a prescription depends on a number of factors:

  • whether your prescription is filled with a generic drug when one is available
  • whether your prescription is filled with a drug that is included on CVS/Caremark's formulary
How Much You Pay for
a Covered Prescription Drug 
 Retail Pharmacy
(up to a 90-day supply)
CVS Mail 
or CVS Retail
(up to a 90-day supply)
 Retail, 31 daysRetail, 90 days 
Generic 20% ($5 minimum) 20% ($15 minimum) 20% ($10 minimum)
Preferred Formulary 20% ($15 minimum) 20% ($45 minimum) 20% ($30 minimum)
Non-Preferred Formulary 20% ($30 minimum) 20% ($90 minimum) 20% ($60 minimum)

If you fill a prescription at a CVS/Caremark participating pharmacy (nearly all chains, such as Duane Reade or Walgreens, and independents are in the network) and show your ID card, you will pay only a co-pay at the time of purchase. If you use a non-participating pharmacy or do not show your SilverScript card, you may have to pay the full retail amount and submit a SilverScript claim form for reimbursement.  You must submit a CVS/Caremark mail order form to use the mail-order pharmacy. You can also arrange for mail order on the CVS/Caremark website.

If you are not eligible for Medicare, do not want to participate in the Express Scripts Prescription Drug Program and are enrolled in CIGNA, HIP Prime POS or GHI HMO under the basic health insurance program, you may choose instead to purchase prescription drug coverage from your basic health insurance carrier. If you elect this option, you will receive a stipend from the supplemental health insurance program to help cover the cost of your prescription drug coverage.

Retiree Plan 70

The Fund will reimburse up to $400 per year per family.

Create a PDF of:

Retiree Plan 82 and Retiree Plan 80

Plan participants must be enrolled in a basic health plan to be eligible for the Welfare Fund SilverScript Medicare Part D Prescription Drug Program.

Retirees who are not yet Medicare-eligible, please refer to the CVS/Caremark Prescription Plan described in the section following this one.

Participating members will receive a SilverScript prescription drug card unless they elect to purchase an optional drug rider through certain basic health programs. Those who elect a rider over the card should refer to the Stipend section below. Please note that the SilverScript Medicare Part D Prescription Drug Program restricts coordination of benefits with other drug coverage.

SilverScript Medicare Part D Prescription Plan 
for Medicare-eligible Retirees

(Plan excludes participants whose basic health insurance is HIP VIP)

Effective January 1, 2012, all Medicare-eligible retiree participants who qualify for the Welfare Fund retiree drug coverage are enrolled in a joint Welfare Fund-Medicare Part D prescription program. This includes all Medicare-eligible dependents of retiree members of the Welfare Fund. Eligible dependents under age 65 will continue to be covered by the regular (non-Medicare) CVS/Caremark plan. In order for a participant to be eligible for the drug benefit, the primary participant must be enrolled in the NYC HBP basic health insurance program. Retiree participants residing outside of the U.S. cannot participate in the Medicare program and are thus covered by the regular (non-Medicare) program.

Upon eligibility, participants will be issued a new SilverScript card and are entitled to fill prescriptions at a pharmacy or through the CVS/Caremark mail order program, subject to the terms and conditions of the benefit.

Scope of Benefit  

The plan covers drugs that legally require a prescription and have FDA approval for treatment of the specified condition. Restrictions and limitations are listed on the following pages. Drugs available without a prescription or classified as "over the counter" (OTC) are not covered, regardless of the existence of a physician's prescription. The Welfare Fund program, administered by SilverScript, encourages utilization of (a) generic equivalent medications and (b) selected drugs among clinical equivalents.

(a) If a generic equivalent medication is available and you or your physician chose it, you pay the standard co-payment for a generic drug. If you choose a brand name drug (either preferred or non-preferred) when a generic is available, you will pay the brand name drug's co-payment plus the difference in cost between the generic drug and the brand name drug.

(b) SilverScript has a list of preferred drugs called a formulary.This list of predominantly brand name drugs is regularly reviewed and updated by physicians, pharmacists and cost analysts. In order to encourage formulary compliance, the program assesses a higher co-payment on prescriptions filled with non-formulary drugs.

Deductible, Annual and Lifetime Limits

As of January 1, 2012, the Welfare Fund Retiree Drug benefit for Medicare-eligible participants has no annual deductible and no annual or lifetime limitation on allowable drug expenditures.

Co-payment

A co-payment is the part of the drug cost that is paid by the plan participant. Co-payments are determined by the category (generic, preferred, and non-preferred), size of order and place of purchase(retail pharmacy or mail-order pharmacy).

 

How Much You Pay for a
Covered Prescription Drug 
 Retail Pharmacy
(up to a 90-day supply)
CVS Mail 
or CVS Retail
(up to a 90-day supply)
 Retail, 31 daysRetail, 90 days 
Generic 20% ($5 minimum) 20% ($15 minimum) 20% ($10 minimum)
Preferred Formulary 20% ($15 minimum) 20% ($45 minimum) 20% ($30 minimum)
Non-Preferred formulary 20% ($30 minimum) 20% ($90 minimum) 20% ($60 minimum)

The above co-payment levels refer only to that phase in any calendar year when total drug expenditure is not yet in the "catastrophic phase" as defined by the Medicare Part D program. The "catastrophic phase" is determined by calculations on behalf of each individual, and is currently no more than $10,000 per year.Those who attain the catastrophic level in any year will be subject to a reduced co-pay of 5%for the balance of the year.

Non-Covered or Restricted Drugs

The program does not cover the following:

  • Fertility drugs
  • Growth hormones
  • Experimental and investigational drugs
  • Over the counter drugs
  • Cosmetic medications
  • Therapeutic devices or applications
  • Charges covered under Workers' Compensation
  • Weight Management drugs

The following drugs are covered with limitations:

  • Drugs for erectile dysfunction up to an annual maximum reimbursement of $500, with a maximum of 18 tablets every 90 days.
  • Smoking cessation drugs up to an 84-day supply
  • Medication taken or administered while a patient in a hospital rest home, extended care facility, convalescent hospital, nursing home or similar institution.

Reimbursement Practices

Prescriptions filled at participating pharmacies will require presentation of a valid drug card. The co-payment must be met in order to acquire medication.

Prescriptions filled at non-participating pharmacies or without presenting a drug card may require payment in full. In such cases, SilverScript will honor a Direct Reimbursement Claim for payment, but only to the extent of the amount that would have been paid to a participating pharmacy, adjusted for co-payment and deductible.

Using Mail Order

Participants may obtain a CVS/Caremark Mail Service Order Form here. Physicians may call 1-866-881-8573 for instructions on how to FAX a prescription. Temperature-sensitive items are packaged appropriately, but special measures may be necessary if there are delivery and receipt issues at an additional cost to the participant.

Special Accommodations

Travel or Vacation

If a larger than normal supply of medication is required, a participant may contact Express Scripts-at least three weeks in advance-so that appropriate arrangements can be made with the prescription drug plan.

Eligible dependent children away at school

If an eligible dependent child is away at school, a separate card may be made available for that child by contacting the Fund. The initial card is issued at no cost but a payment of $10.00 is required each time a card is re-issued.  Prescriptions filled in other manners will require the student to pay the full cost of the prescription and submit a claim for direct (partial) reimbursement.

When to Contact SilverScript

Call SilverScript customer service, 866-881-8573, or visit the SilverScript website, for information on:

  • Location of Pharmacies
  • Direct Reimbursement
  • Eligibility issues
  • Mail Order Forms
  • Interactive Pharmacy Locator
  • Claims Form Download
  • Mail-order tracking
  • Formulary Drug Listing
  • Replacing Lost Express Scripts Cards

CVS/Caremark Prescription Drug Program
for Retirees Not Enrolled in Medicare 

Scope of Benefit  

The plan covers most drugs that legally require a prescription and have FDA approval for treatment of the specified condition. Drugs available without a prescription, classified as "over the counter" (OTC), are not covered regardless of the existence of a physician's prescription.The Welfare Fund program through CVS/Caremark encourages utilization of (a) generic equivalent medications, (b) selected drugs among clinical equivalents.

  • If a generic equivalent medication is available and you or your physician chose it, you pay the standard co-payment for a generic drug. If you choose a brand name drug (either preferred or non-preferred) when a generic is available, you will pay the brand name drug's co-paymentplusthe difference in cost between the generic drug and the brand name drug.
  • CVS/Caremark has determined a list of drugs that treat medical conditions in the most cost-efficient manner. This list, or formulary, is regularly reviewed and updated by physicians, pharmacists and cost analysts. In order to encourage formulary compliance, the program assesses a higher co-payment on prescriptions filled with non-formulary drugs.
  • Home delivery (mail-order) or use of a CVS pharmacy is encouraged as a less costly way to fill prescriptions for long-term (maintenance) drugs. After an initial fill and a two re-fills of any prescription at a local pharmacy, higher levels of co-payment are assessed for continued use of the retail pharmacy.

Co-payment

A co-payment is the part of the drug cost that is paid by the plan participant. Co-payments are based on the category (generic, formulary and non-formulary) and place of purchase(retail pharmacy or mail-order pharmacy).

How Much You Pay for a 
Covered Prescription Drug* 
 Retail Pharmacy
(up to a 30-day supply)
CVS Mail 
or CVS Retail
(up to a 90-day supply)
 First Three FillsEach Subsequent Refill 
Generic 20% ($5 minimum) 35% ($5 minimum) 20% ($10 minimum)
Preferred Formulary 20% ($15 minimum) 35% ($15 minimum) 20% ($30 minimum)
Non-Preferred Formulary 20% ($30 minimum) 35% ($30 minimum) 20% ($60 minimum)

* On July 1, 2014, the maximum benefit limit was lifted in compliance with the Affordable Care Act. Under the new benefit, the member will continue to pay a 20% co-pay until the cost to the Fund reaches $10,000. If the annual plan expenses are between $10,000 and $15,000, the member's co-pay will be 50%.

For Annual Plan Expenditures 
Between $10K and $15K
 Retail Pharmacy
(up to a 30-day supply)

CVS Mail 
or CVS Retail
(up to a 90-day supply)

 First Three FillsEach Subsequent Refill 
Generic 50% ($5 minimum) 60% ($5 minimum) 50% ($10 minimum)
Preferred Formulary 50% ($15 minimum) 60% ($15 minimum) 50% ($30 minimum)
Non-Preferred Formulary 50% ($30 minimum) 60% ($30 minimum) 50% ($60 minimum)

If the annual plan expenses exceed $15,000, the member's co-pay will become 80%.

For Annual Plan Expenditures Over $15K
 Retail Pharmacy
(up to a 30-day supply)
CVS Mail 
or CVS Retail
(up to a 90-day supply)
 First Three FillsEach Subsequent Refill 
Generic 80% ($5 minimum) 90% ($5 minimum) 80% ($10 minimum)
Preferred Formulary 80% ($15 minimum) 90% ($15 minimum) 80% ($30 minimum)
Non-Preferred Formulary 80% ($30 minimum) 90% ($30 minimum) 80% ($60 minimum)

Non-Covered or Restricted Drugs

The program does not cover the following:

  • Fertility drugs
  • Growth hormones
  • Needles and syringes
  • Experimental and investigational drugs
  • PICA drugs
  • Over the counter drugs (i.e., not requiring a prescription)
  • Diabetic medications (refer to your NYC Health Benefits Plan carrier, ie., GHI, HIP, etc.)
  • Cosmetic medications
  • Therapeutic devices or applications
  • Charges covered under Workers' Compensation
  • Medication taken or administered while a patient in a hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution.
  • Shingles vaccine
  • Weight Management drugs

The following drugs are covered with limitations:

  • Drugs for erectile dysfunction up to an annual maximum reimbursement of $500, with a maximum of 18 tablets every 90 days.
  • Smoking cessation drugs up to an 84-day supply

Reimbursement Practices

Prescriptions filled at participating pharmacies will require presentation of a valid drug card. The co-payment must be met in order to acquire medication.

Prescriptions filled at non-participating pharmacies or without presenting a drug card may require payment in full. In such cases, CVS/Caremark will honor a Direct Reimbursement Claim for payment, but only to the extent of the amount that would have been paid to a participating pharmacy, adjusted for co-payment and deductible.

Using Mail Order

To use mail order, participants may register on the CVS/Caremark website. Physicians may call 1-866-209-6177 for instructions on how to FAX a prescription.

Standard shipping and handling is free; express delivery is available for an added charge.Temperature-sensitive items are packaged appropriately, but special measures may be necessary if there are delivery and receipt issues at an additional cost to the member.

Special Accommodations

Travel or Vacation

If a larger-than-normal supply of medication is required, a participant may contact the Welfare Fund at least three weeks in advance so that appropriate arrangements can be made with the prescription drug plan.

Eligible dependent children away at school

If an eligible dependent child is away at school, a separate card may be made available for that child by contacting the Fund. The initial card is issued at no cost but a payment of $10.00 is required each time a card is re-issued. Prescriptions filled in other manners will require the student to pay the full cost of the prescription and submit a claim for direct (partial) reimbursement.

How to Contact CVS/Caremark

Call Customer Service at 1-866-209-6177 for

  • Location of Pharmacies
  • Direct Reimbursement
  • Eligibility issues
  • Mail Order Forms

Visit the CVS/Caremark website for:

  • Interactive Pharmacy Locator
  • Claim Form Download 
  • Mail-order tracking
  • Formulary Drug Listing

 Non-Welfare Fund Drug Coverage

PICA for Non-Medicare Medco members

There are some drugs for which participants do not use the PSC-CUNY Welfare Fund Express Scripts card, but instead use another card, not issued by the Welfare Fund. For non-Medicare-eligible retirees, injectable and chemotherapy (IC) medications are available under the PICA program. The N.Y. City Retiree Benefits Health Program (212-306-7200) should be consulted for further detail and updates. Eligible individuals will be issued a drug card for PICA coverage. For retirees with Medicare, the IC drugs are treated as any other medications which are covered by the Fund.

Stipend for Non-Medicare members, in lieu of Medco

Non-Medicare eligible-retirees who wish to opt out of the Welfare Fund Drug plan may purchase a drug rider through their basic health carrier if their carrier is CIGNA, HIP Prime POS, or GHI HMO. This may be elected at the time of retirement or during any open enrollment period through the city of New York The plan participant will receive a stipend to offset cost. The current stipend is:

  • Individual: $300 per year
  • Family: $700 per year

Payment is made within 45 days of the end of a calendar year. If rider coverage was only in effect part of the year reimbursement will be pro-rated. The Fund office will provide claim forms on request.

Members who participate in a drug rider plan through a basic health carrier will automatically be dropped from the Medco plan.

HIP VIP in lieu of Welfare Fund Express Scripts Drug Coverage

Retired members over the age of 65 and enrolled for basic health insurance in the HIP VIP Medicare Advantage Programs have drug coverage through that program. This drug option is paid for by the PSC-CUNY Welfare Fund. Members who change coverage from one program to another must notify the Fund in order to maintain accurate payment records.

Retiree Plan 70

The Fund will reimburse up to $400 per year per family. Claim forms are available from the Fund Office.

Medicare Part D in lieu of Express Scripts Medicare Prescription Plan

Any plan participant who does not want drug coverage under the SilverScript Medicare Part D plan may opt out of Welfare Fund Drug coverage and enroll in any of a multitude of Part D plans through private insurance companies. The PSC-CUNY Welfare Fund will not provide reimbursement or benefit support. Enrollment in another Medicare Part D plan makes Welfare Fund participants ineligible for the Express Scripts Medicare Prescription Plan.