United Food and Commercial Workers

UFCW 360 Health and Welfare Fund

Prescription Drug Benefits Benefits

Benefit eligibility varies and is determined based upon the terms and conditions in the
collective bargaining agreement (contract) between your Local Union and your Employer.

If you have any questions regarding the pharmacy network, please call the Fund Office at 1.973.299.6700 ext 5.

Click Below To Go To: www.express-scripts.com

ELIGIBLE PARTICIPANTS/SPOUSES,DEPENDANTS

All eligible participants will receive an Express Scripts® Prescription Card No Claim Form is required for the retail program or the Mail at Retail program. IF YOU HAVE ANY QUESTIONS CALL THE EXPRESS SCRIPTS PATIENT CUSTOMER SERVICE AT:
1-800-451-6245 OR THE FUND OFFICE AT 973-299-6700

Benefits

PRESCRIPTION LEGEND DRUGS: The Plan provides benefits for prescription legend drugs or refills thereof when dispensed by a UFCW 360 Health and Welfare Centralized network pharmacy, the Mail at Retail network pharmacy or the Express Scripts Mail Order Program pursuant to a physician’s prescription. Each prescrip­tion is subject to the co-pay shown below. The co-pays are not eligible under your Medical benefit.

PRESCRIPTION DRUG BENEFITS

Network Pharmacists

Once an Employee becomes a Covered Person, the Plan Administrator will forward a card to the Covered Employee. The Plan Administrator will also provide the Covered Employee with a list of pharmacists who participate under the program selected by the Board of Trustees. When the Covered Person incurs a prescription expense, the Physician’s prescription and the prescription identification card must be presented to the Network pharmacist. The Network pharmacist will complete the prescription and the Covered Employee will make a Co-Payment per prescription.

The Board of Trustees shall set the Co-Payment level at least once each Calendar Year. The CoPayment shall be $25 per prescription for brand name drugs, $10 per prescription for preferred brand name drugs and $5 per prescription for generic brand drugs, and $10 per prescription on mail order prescriptions. Before a Participant may receive drugs by mail order, he or she must first exhaust two 21 -day supplies purchased at a retail pharmacy.

Non-Network Pharmacists

If a Covered Person elects to purchase prescription drugs from a Non-Network pharmacist, the Covered Person will pay the Non-Network pharmacist directly and in full. The Covered Person must then complete an approved direct reimbursement form and send it to the Plan Administrator or its designee. The Fund will reimburse the Covered Person for the prescription drug expense that the Covered Person would have incurred had a Network pharmacist been used, less the CoPayment, subject to the restrictions set fotth below.

Mandatory Maintenance Drug Program

Drugs prescribed which are maintenance drugs must be filled by mail order through the mandatory Maintenance Drug Program in accordance with procedures established by the Plan Administrator. Maintenance drug prescriptions will be filled with up to a 90-day supply.

Diabetes Strip Benefits

The Fund will cover the cost of diabetes strips purchased through the mail-order program in accordance with procedures established by the Plan Administrator. A doctor’s written prescription will be required by the Fund office before any claim will be paid. The Co-Payment will not apply.

Prescription Drug Benefit Limitations

The Fund will pay only for drugs purchased by prescription.

The Fund will not pay for the following unless it is designated otherwise below:

  • Prescription drugs, other than maintenance drugs, in excess of 21 days’ supply.
  • Refills not authorized by the Physician.
  • Contraceptives, oral or other, whether medication or device, regardless of intended use. This exclusion does not apply to Plan IB+ (see page 46).
  • Non-Legend Drugs and over-the-counter drugs, other than insulin.
  • Charges for the administration or injection of any drug.
  • Therapeutic devices or appliances, including needles, syringes, support garments and other non-medicinal substances, regardless of intended use.
  • Prescription drugs that a Covered Person is entitled to receive without charge under any Workers’ Compensation Laws.
  • Drugs labeled “Caution-limited by federal law to investigational use,” or Experimental drugs, even though a charge is made to the individual.
  • Immunization agents, biological sera, blood or blood plasma.
  • Medication which is to be taken by or administered to an individual, in whole or in part, while a patient in a rest home, mental health facility, extended-care facility, convalescent Hospital, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.
  • Any prescription refilled in excess of the number specified by the Physician, or any refill dispensed more than one year after the Physician’s original order.
  • Injectable drugs (including auto-injectables) other than insulin and Epi-Pens (or their generic equivalent), unless they are part of an overall Case Management program.
  • Any prescription drug for the treatment of a disease or Injury other than the disease(s) or Injuries for which the Food and Drug Administration has approved the use of such drug.
  • Any drug or medicine approved by the U.S. Food and Drug Administration on or after August I l , 2015, with a per script cost of $1,000 at retail or $2,500 per 90-day script at mail order, that has not been approved for coverage by the Board of Trustees. However, if a claim for a drug or medicine was nonetheless paid on behalf of a Covered Person prior to April l, 2017, such drug or medicine will continue to be provided to such Covered Person without regard to this exclusion. See the “Case Management” Section for more information.

 

When a generic equivalent to a brand name drug is available, the Fund will pay the cost of the generic brand drug equivalent. The Covered Person shall be responsible for the difference in cost between the brand name and the generic, plus the Co-Payment.