Drug Coverage for Retiree

Apr 13, 2007 10:42 AM

At retirement, you must select the Optional Benefits Rider to have prescription drug coverage. Please note that it may take several months before your pension check stub indicates the health insurance deduction for the Optional Rider. Your health insurance carrier will then issue to you a new identification card.

The following paragraphs tell you how to use your drug benefit. Please refer to the paragraph(s) listed under your medical insurance carrier, i.e. HIP PRIME, GHI-CBP, etc.

I. A. HIP PRIME (HMO)

Subscribers pay nothing for prescriptions as long as a HIP pharmacy is used (a list is available at any HIP center). The subscriber must show a HIP card. In addition, a HIP doctor must write the presciptions on the HIP form provided to each physician in the plan.

B. HIP VIP PREMIER MEDICARE PLAN

Medicare-eligible retirees. Must have prescriptions prescribed by a HIP doctor and filled at a participating pharmacy. There is a co-pay for generic and formulary drugs and a charge of 50% of the drug cost for non-formulary drugs.

II. OTHER HMO PROGRAMS AETNA US HEALTHCARE (NON-MEDICARE), AETNA US HEALTHCARE GOLDEN MEDICARE (MEDICARE), ETC.

Your HMO doctor must write the prescription, which you must fill at a participating pharmacy. You are responsible for any necessary co-payments and deductibles.

III. PICA DRUG PROGRAM

If you use injectable or chemotherapy drugs, and are non-Medicare, you will be covered by the PICA Drug Program. The customer service number is 1-800-467-2006.

NON – MEDICARE MEMBERS AND NON-MEDICARE DEPENDENTS

IV. GHI COVERAGE (GHI-CBP has two programs – one is for prescription on a short-term basis; the other is for maintenance drugs. (You can use one or the other or both).

a. REIMBURSEMENT/CO-PAY PROGRAM (SHORT-TERM BASIS)

You will take your GHI card to a participating pharmacy. The exact amount you must pay is based on whether or not your deductible has been met, and whether you purchase generic or brand name drugs.

After a deductible of $150 per person ($450 maximum for a family of three or more), the member pays 20 percent of the cost of GENERIC medicines or 40 percent of the cost of BRAND NAME medicines, if it is on the FORMULARY; 50 percent, if NON-FORMULARY.

If a non-participating pharmacy is used, pay in full, and submit a claim to Express Scripts, Inc., P.O. Box 66773 St. Louis, MO 63166-6773 Attention: Claims Department You will then be reimbursed the same 80 or 60 percent or 50 percent rate as above, AFTER the deductible. However, reimbursement will be based on allowable amount, and not the actual cost of the drug.

b. GHI DRUG MAINTENANCE PROGRAM

For prescription drugs that you will be taking over an extended period of time, you can call at 1-877-534-3682 or access the internet at www.express-scripts.com.*

When you need medication, you can get a prescription for up to 60-day supply from your doctor, who may allow a maximum of five refills. Prescriptions will be filled generically UNLESS the doctor indicates “Brand medically necessary,” writing DAW, on the prescription.

Mail the prescription, your name and address, and all required information, including your social security number, and $10 for each GENERIC prescription or $40 for each BRAND NAME prescription, FORMULARY; $60, NON-FORMULARY, (the $10 or $40 or $60 is not part of your deductible) to Express Scripts, 3684 Marshall Lane, Bensalem, PA 19020-5997.

· If this is your first prescription, include a mail service participant profile form which you can get by calling the above telephone number or log on to the above internet website.

MEDICARE MEMBERS AND MEDICARE DEPENDENTS

V. GHI COVERAGE - NYC Enhanced Medicare Part D

GHI Medicare Part D Enhanced plan gives you up to a 90 day supply at a retail pharmacy or through Express Scripts (You can call 1-877-534-3682). The rates

are as follows: (there are no deductibles).

From $0 - $2,250 (actual drug cost)	Member pays 25% of drug cost (up to $563 out-of-pocket)
From $2, 251 to $7,729	Member pays 60% of drug cost (up to $3,287 out-of-pocket)
After $3,850 in member out-of-pocket costs	The Welfare Fund will reimburse the retired Medicare Part D member their 5% co-pay when they reach this catastrophic tier.

Revised January 11, 2006