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The Welfare Fund offers prescription drug benefits to you and your family through Medco Health Solutions, Inc. (Medco), the Plan's prescription drug network.
These benefits are designed to cover the major portion of prescription drug costs through retail (drug store) and mail order.
If you use a pharmacy that participates in the Medco pharmacy network, your co-insurance amounts are as follows:
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Lesser of 100 pills or a 30-day supply at a Medco participating retail pharmacy |
Up to a 90-day supply through mail order (Medco By Mail) |
For specialty drugs only: Through Accredo, Medco’s specialty pharmacy |
| Generic |
$5 |
$12.50 |
n/a |
Single source brand
(Generic not available) |
20%
$10 minimum/$100 maximum |
20%
$25 minimum/$250 maximum |
n/a |
Multiple source brand
(Generic is available) |
35%
$20 minimum |
35%
$50 minimum |
n/a |
| Specialty medications |
n/a |
n/a |
20%
$20 minimum/
$100 maximum |
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NOTE: If the cost of the medication is less than the coinsurance, you will only pay the cost of the medication.
$1500 Out Of Pocket Maximum
The Board of Trustees recognizes that you do not have the option of electing a generic equivalent for a single source brand name drug. Therefore, there is a $1500 per person out of pocket maximum per calendar year for single source brand name drugs. This means that, if at any point during the calendar year, your co-payments for single source brand name drugs that you have obtained during that calendar year total $1500, you will not be subject to co-payments for single source brand name drugs for the balance of that calendar year.
Preferred Drug Program
The Plan has coverage limitations on the following types of medications:
- Proton Pump Inhibitors (to treat certain stomach conditions): Plan only covers Nexium and omeprazole
- Sleep Aids: Plan only covers generic sleep aids.
- Anti-Depressants: For all new anti-depressant medication, the plan requires that you try the generic-equivalent drug first.
A single source brand is a brand-name drug that does not have a generic equivalent available for prescription. A multiple source brand is a brand-name drug that does have an available generic equivalent. Specialty drugs are medications used to treat complex conditions, such as cancer, hemophilia, immune deficiency, and rheumatoid arthritis, and they require an enhanced level of service.
If you or your family member is eligible for prescription drug coverage and your medication is dispensed as a generic drug you will pay $5 at a participating Medco retail pharmacy and $12.50 using Medco by mail. A generic equivalent has the same active ingredient as the brand-name drug, even though it may have a different color and shape.
If your prescription is filled at a participating Medco retail pharmacy as a single source brand name drug, where there is no generic equivalent, you will pay 20% of the total cost of the drug. Your minimum co-payment is always $10.00 or a maximum of $100.00.
When you fill your prescription and do not accept the offer of a generic equivalent, your prescription is filled as a multiple source brand name drug. You will pay more out of your pocket if you or your doctor refuse a generic substitute when one is available.
Retail Prescription Drug Program
In order to receive the best level of benefits for you and your family, you must choose a pharmacy participating in the Medco pharmacy network and show your Medco ID to the pharmacist.
If you do not have your Medco ID card with you, or you do not use a participating pharmacy, you must pay the full cost of the prescription and submit a completed claim form to Medco for reimbursement.
If you do not use a pharmacy that participates in the Medco network, Medco will reimburse you. The amount Medco would have paid for the prescription had you used a Medco participating pharmacy and presented your ID card less the required co-payment.
Save Money, Use a Retail Pharmacy that Participates in the Medco Network.
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Example:
John went to an out-of-network pharmacy to fill his prescription for Zithromax, (a multi source brand name antibiotic).
- John will have to pay the pharmacy the full cost of the drug, in this example $185.
- John will need to submit a claim form to Medco for reimbursement.
- Medco will reimburse John $55.25, the amount it would have paid a participating pharmacy ($120) less his 35% co-payment ($64.75).
If John had used a Medco network pharmacy he would have paid a total of $24.00 for the prescription. If John had taken a generic substitution, his cost for the medication would have been $5. |
Mail Order Prescription Drug Program
Long term medications are prescription medications that are continually taken on a regular basis for a chronic condition. Examples of conditions where long term medications are often prescribed are high blood pressure, cholesterol and allergies.
If you take a long term medication, you will be allowed to have that prescription filled at a retail pharmacy (drug store) a maximum of three (3) times (original fill plus 2 refills).
After the third refill at the retail pharmacy, your long term medication prescription(s) will only be covered under the Plan when you use the Medco mail order program.
Contact Medco Health Solutions at 1-800-939-2089 for more information on the mail order program. Or visit the website at www.medco.com.
Special Care Pharmacy Program
Special care pharmacy is the term used to describe certain medications and a set of services designed to meet your particular needs if you take medication to treat certain conditions such anemia, cancer, cystic fibrosis, Gaucher’s Disease, Hepatitis C, Huntington’s Disease, immune deficiency, multiple sclerosis, osteoarthritis, rheumatoid arthritis, respiratory syncytial virus and other severe conditions or diseases.
Many of these medications require injection and have special shipping and handling needs. These medications could also be oral or infusion medications.
If you are eligible for Medco’s special care pharmacy, you will receive support from Medco’s pharmacists and nurses who are trained in specialty pharmacy medications, their side effects, and the conditions they treat. Also, because many of these medications require injection or special handling, you will receive:
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- Expedited shipping of specialty medication to a your home or physician’s office,
- Supplemental supplies, such as needles and syringes, that are needed to administer the medication, and
- Scheduling of refills and coordination of services with home care providers, case managers, and physicians or other health care professionals.
| For information on the Special Care Pharmacy Program, contact Accredo Health Group, a subsidiary of Medco Health Solutions, at 1-800-803-2523. |
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