Who Is Eligible

All covered members and their eligible dependents (family coverage) are entitled to this benefit.

Coverage for prescription drugs only continues for a member’s children until their 26th birthday, regardless of whether the child is dependent on the Fund member for support or is a full-time student.

What Is The Benefit

The Fund will pay a maximum of $500 per prescription for a 30 day supply at a retail pharmacy. The Fund will pay a maximum of $1,500 per script for a 90 day supply via mail order through the Fund’s Prescription Benefits Manager, Express Scripts inc. If both spouses/domestic partners are covered members, the Fund will pay a maximum of $1,000 per script for a 30 day supply at a retail pharmacy and a maximum of $3,000 per script for a 90 day supply via mail order.

The Fund covers only prescription drugs prescribed by a doctor, dentist, or osteopathic physician and dispensed under an RX number by a licensed pharmacist.  Prescription drugs that require compounding are covered under the Prescription Drug Benefit. The Fund covers maintenance prescription drugs (blood pressure or cholesterol medications, etc.) dispensed by your local pharmacy, or you may use the Fund’s mail order supply service for maintenance prescription drugs.

Pharmacies for Prescription Drugs

The Fund will pay the cost of the prescription up to $500 for a 30-day supply. Covered members and eligible dependents may fill prescriptions at pharmacies (up to a 30-day supply) where they will only incur a co-payment. There is a 30% or $30 co-payment, whichever is greater for brand name drugs and a $5 co-payment for generic drugs. For additional information, please call the Funds’ office, at (212) 777 9000, ext. 3054 or 3098.

Mail Order Prescription Drug Service

The Fund will pay the cost of the prescription up to $1,500 for a 90-day supply. For prescriptions filled through the mail order pharmacy (up to a 90-day supply) there is a $70 co-payment for a 90-day supply of brand name the drugs and a $10 co-payment for a 90-day supply of generic drugs. The co-payment is prorated for less than a 90-day supply.  For example, for a 30-day supply of brand name drugs, the co-payment is $23.33. For a 30-day supply of generic drugs, the co-payment is $3.33. Using the mail order service may serve to make your Prescription Drug Benefit dollars go further because the mail order pharmacy’s prices for generic and brand name drugs are usually significantly lower than prices charged by local pharmacies.

The mail order service can be accessed via the Union’s website at www.mightyunion.org.

Hardship Prescription Drug Appeals

The Trustees of the Union’s Welfare Fund have adopted a program for Hardship Prescription Drug Appeals. Its purpose is to hear and decide appeals from covered members on coverage under the Fund’s Prescription Drug Benefit. Covered members may appeal for a waiver of the limitation by writing a letter to the Welfare Fund Board of Trustees describing their circumstances, e.g., extreme financial hardship, one-time need for a very expensive prescription drug, etc.

The Board of Trustees will give each appeal expeditious attention. Covered members who have any further questions should call the Welfare Fund’s Prescription Drug Benefit section at (212) 777-9000 Ext. 3054, 3065 or 3098.

Exclusions And Limitations

1. Drugs that may be legally purchased without a prescription are not covered, even if prescribed in writing and dispensed under an RX number.

2. The Fund does not cover antigens, allergens, or other prescription drugs that are purchased from a laboratory or a physician; only prescription drugs (including antigens and allergens) that are prescribed by a physician and dispensed by a license pharmacist under an RX number are eligible for coverage.

3. The Fund does not cover drugs of an experimental nature that have not been approved by the Food and Drug Administration.

4. The Fund does not cover prescription drugs for which coverage is provided by the member’s basic health plan.

5. The Fund’s prescription drug program will provide only secondary coverage for prescription contraceptives for members and their dependents with medical coverage through the City’s EmblemHealth GHI-CBP.  You must seek coverage for prescription contraceptives through EmblemHealth first before the Welfare Fund will consider any claims.

How To Obtain The Benefit

To have a prescription filled at a participating pharmacy, present your SSEU Local 371 Welfare Fund Prescription Drug Card to the pharmacist along with your prescription. If you do not have your Drug Card, provide your Social Security number and the Welfare Fund’s Group Number, SSEU 371, and the name of the drug plan’s prescription benefit manager, Express Scripts Inc., BIN-610014 to the pharmacist. We do not use PCN number.

NOTE: Supplies of several different maintenance prescription drugs may be ordered from the mail order pharmacy at one time; however, your physician must complete a separate prescription form for each drug. Do not leave the completed prescription forms with your physician be sure to mail them yourself.

In the event you utilize a non-participating pharmacy, you must pay for your prescription at the time it is filled.  In order to receive reimbursement for prescription drugs purchased at a non-participating pharmacy, you must complete a claim form and return it to drug plan’s prescription benefit manager, together with original receipts for the item claimed.  Please be sure to include on the claim form the name of the prescription drug for which you are requesting Fund payment.  Reimbursement will be made at the contracted-for price between the participating pharmacies and the drug plan’s prescription benefit manager, less the co-payment.  You will be responsible for the co-payment plus the difference between the contracted-for price and the non-participating pharmacy charge, if greater.

Prescription Drug Claim Forms may be obtained from the Fund Office. For your convenience, Welfare Fund Claim Forms (including Prescription Drug Claim Forms) are often available through the Union delegate at your work location and on our website at www.mightyunion.org

“PICA” Drug Program

All covered members and non-Medicare retirees (under age 65) who have elected a City-provided health plan are covered by the PICA program. Covered members who are not covered by a City-provided health plan – either as the subscriber or as a spouse or domestic partner of a subscriber – are not eligible for the PICA program.  Such covered members are therefore urged to enroll in a City-provided health plan as soon as possible.

The PICA program covers medications in two specific drug categories:  Injectable and Chemotherapy.

Under the PICA program you can obtain up to a 30-day supply of drugs at your local pharmacy.  Refills for PICA drugs are available as prescribed for up to one year from the date of the original prescription.

Mail order benefits are also available. Through the mail order pharmacy you can order a 90-day supply of PICA drugs. Refills are available as prescribed for up to one year from the date of the original prescription.

All covered members will receive a separate prescription drug card for this program, issued by the PICA program prescription benefit manager. This is the only card you will need to obtain any of the PICA drugs.

Diabetic medications continue to be covered by your basic health plan.

If you have any questions concerning the PICA program, you can contact the prescription benefit manager’s customer service department at 1-800-467-2006 or visit their website. The PICA program drug listing will appear on the prescription benefit manager’s website. Questions about mail order should be directed to the mail order pharmacy at 1-800-628-0717.