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General Information
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 |
NOTE: If the cost of the medication is less than the coinsurance, you will only pay the cost of the medication.
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 pay $5. 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 the 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. You may pay even less when you obtain your prescriptions through the mail order program.
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 refuses 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 a generic prescription if you had used a Medco participating pharmacy and presented your ID card; or The amount the Plan would have paid for a brand name 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.
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.
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Example:
John went to an out-of-network pharmacy to fill his prescription for Zithromax, (a multisource 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.
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Mail Order Prescription Drug Program
Maintenance medications are prescription medications that are continually taken on a regular basis for a chronic condition. Examples of conditions where maintenance medications are often prescribed are high blood pressure, cholesterol and allergies.
If you take a maintenance medication, you will be allowed to have that prescription filled at a retail pharmacy (drug store) a maximum of three (3) times.
After the third refill at the retail pharmacy, your maintenance 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: http://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:
- 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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