Prescription Drug Benefit (Full-Time Actives)

The plan covers most drugs that legally require a prescription and have FDA approval for treatment of the specified condition(s). 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 when a generic is available, you will pay the full cost of the brand name drug.

CVS/Caremark has determined a list of drugs that treat medical conditions in the most cost-efficient manner. The Welfare Fund Drug List is regularly reviewed and updated by physicians, pharmacists and cost analysts.

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 30 day fill and 2 subsequent 30 day fills at a local pharmacy, higher levels of co-payment will be assessed for continued use of 30 day fills instead of 90 day (maintenance) fills.

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, preferred and non-preferred) and place of purchase (retail pharmacy or mail-order pharmacy).

How Much You Pay for a Covered Prescription Drug*

*On July 1, 2014, the maximum benefit limit was lifted in compliance with the Affordable Care Act. Under the current benefit, the member will continue to pay a 20% co-pay until the cost to the Fund reaches $10,000. When the cost to the Fund is between $10,000 and $15,000, the member’s co-pay will be 50%.

For Annual Plan Expenditures Between $10K and $15K

When the cost to the Fund exceeds $15,000, the member’s co-pay will become 80%.

For Annual Plan Expenditures Over $15K

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, 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 Welfare Fund expenditure of $500, with a maximum of 18 tablets every 90 days.
• Smoking cessation drugs up to an 84-day supply

Prescriptions filled at participating pharmacies (CVS, Duane Reade, Rite Aid, Walgreen, etc.) 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 (very rare) 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.

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

Standard shipping and handling are 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.

Travel or vacation

If a larger-than-normal supply of medication is required, a participant may contact CVS 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. 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.

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

NYC PICA Program through Express Scripts

There are some drugs for which participants do not use the CVS/Caremark card, but instead use another card, not issued by the Welfare Fund. For eligible full-time active participants, Injectable and Chemotherapy medications are available only through the PICA Drug Program, which is sponsored by the N.Y. City Employee Health Benefits Program and the Municipal Labor Committee. At the time of this writing it is administered by Express Scripts. Call the NYC Health Benefits PICA Drug Program (212-306-7464) for further detail and updates. Eligible individuals will be issued a drug card for PICA coverage.

Stipend for Rx coverage in lieu of CVS/Caremark

Eligible full-time active participants 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 employment or during any open enrollment period through the city of New York. The plan participant will receive a stipend to offset out-of-pocket costs. 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 Welfare Fund drug plan.

Active, Adjunct members and Retirees under 65 enrolled in the PSC-CUNY Welfare Fund Prescription Plan have no copay when filling a prescription for a generic drug included in the PSC-CUNY Welfare Fund Drug List and when the prescription is filled at a CVS pharmacy or through the CVS Mail program. Generic drugs purchased outside of a CVS pharmacy are not included in the program.

How does the $0 Generic Copay Program work?

Here are examples of prescription fills to clarify the service eligible for the benefit:

Example: A member who fills a prescription for a generic drug listed on the Welfare Fund Drug List at CVS or CVS mail facility would not pay a copay.

Example: A member who fills a prescription for a generic drug listed on the Welfare Fund Drug List at a retail pharmacy other than CVS will not have a reduced copay, and the claim will be processed according to the Welfare Fund Prescription Plan’s current tiered copay schedule. This means most members using non-CVS pharmacies will continue to pay a 20% copay.

Member copays for generic drugs on the Welfare Fund Drug List purchased at non-CVS pharmacies are 20% until the Welfare Fund’s costs reach the Tier 1 limit (when the Fund has paid $10,000 in annual drug expenses).

When the member reaches the Tier 1 limit, the copay for generics purchased at non-CVS pharmacies will increase to the Tier 2 copay of 50% until the Tier 2 limit is reached (when the Fund has paid $15,000 in annual drug expenses).

At that point the copay for generics purchased at non-CVS pharmacies will move up to the Tier 3 copay of 80%.

Importantly, when the member reaches the Tier 1 limit they should then be eligible to apply for copay reimbursement under the new High-Cost Rx Program.

Therefore, members who anticipate their drug costs may exceed the annual Tier 1 limit ($10,000 in the Welfare Fund’s drug expenses) should save all CVS prescription receipts! Receipts for all CVS prescription purchases will be required for High-Cost Rx Program reimbursement claims.

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, 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 Jennifer Melfi at the Welfare Fund, jmelfi@psccunywf.org:

• High-Cost Rx Program Claim Form
• Receipts (CVS pharmacy cashier’s receipt, CVS mail order invoice or CVS Specialty Pharmacy invoice) AND
• Rx package receipt that shows:
  • Patient’s full name
  • Name of Drug
  • Date of Service
  • Amount paid
  • Any Coupons

Here are examples of eligible receipts:

• Pharmacy Cashier’s Receipt
• Mail Order Invoice/Receipt
• Specialty Pharmacy Invoice

CVS/Caremark member portal claims printouts are NOT accepted as receipts. Generic drugs that cost less than $10 do not require receipts but must still be listed on the Claim Form.

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 ONLY through 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.