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All eligible in-service UFT members and their dependents have prescription drug coverage through the UFT Welfare Fund. There are no waiting periods for this coverage.
In fact, after enrolling in the Welfare Fund, newly enrolled members who are awaiting their Welfare Fund Express-Scripts (ESI) Prescription ID drug cards can purchase the prescription drugs they need and, once their cards arrive, submit the original receipts to the Fund for reimbursement.
How the plan for in-service members works
There are two types of drugs.
Acute illness drugs are those that you need immediately, such as an antibiotic. This type of drug will be dispensed to you at your local pharmacy.
Maintenance drugs are those that are taken over extended periods of time, such as antihistamines for allergies or drugs for high blood pressure. Typically, you will use the ESI Home Delivery service because you will save money and convenient delivery is made to your home. However, there are certain drugs, such as narcotics or controlled medications, that can only be dispensed in a 30-day supply at the local pharmacy.
Certain drugs require either “step therapy” or “prior authorization.” Step therapy applies to first-time users of a medication, and this may require that you try a first-line medication (usually a generic or an over-the-counter medication). If your doctor finds that the first-line medication is not working well, you will be allowed to try another preferred brand or nonpreferred brand-name drug. These drugs are indicated as STP (step therapy) on the formulary. For download the “Step therapy progam” brochure.
In addition, certain drugs require prior authorization to make sure the therapy and dosage are within FDA guidelines. Prior authorization requires your physician to call a toll-free number (1-800-753-2851) to make the request to cover these drugs before they can be dispensed.
These drugs have the annotation PA (prior authorization) next to them on the drug formulary. (The drug formulary lists drugs that are either generic or preferred brands that are covered by the Welfare Fund.)
How much do I pay for each prescription?
The Welfare Fund has a three-tier co-pay structure for generic, preferred-brand and nonpreferred-brand medications [see chart at top right]. You can save money by using generics (tier 1) or preferred-brand medications (tier 2) whenever possible, but this is a decision between you and your doctor. Nonpreferred brand-name drugs (tier 3 — those not listed on the Fund’s formulary) have the highest co-pays.
At the pharmacy, if your doctor has not indicated that the pharmacist must dispense a brand name, you will get a 30-day supply of a generic drug for $5 provided there is one available. (If your doctor insists on a brand name, there will be a higher co-pay.) At the pharmacy, you can get the first fill of your prescription and up to two refills if your doctor has indicated extra refills. After three fills, you must use the ESI Home Delivery Service (delivered to your home) for a 90-day supply of your maintenance medications (not controlled drugs).
For drugs that you take over an extended period of time, the Welfare Fund provides for a 90-day supply for the price of two months’ supply (two co-pays) through ESI Home Delivery Service, and you can get up to three refills (which is a year’s supply on one prescription).
By getting your drugs through ESI Home Delivery Service, you have the convenience of having the delivery right to your home by having your physician electronically prescribe (e-prescribe) your prescription to ESI.
|Category||Tier #||Retail pharmacy co-payment (30-day supply)||ESI Home Delivery Service co-payment (90-day supply)|
|Preferred Brand (On Formulary)||2||$15||$30|
|Non-Preferred Brand (Not on Formulary)||3||$35||$70|
When visiting your doctor
When visiting your doctor, bring a copy of the UFT Welfare Fund Drug Formulary list. The formulary lists the brands and generic equivalents that are available.
Most plans have their own formulary list; your doctor doesn’t know what is and what is not covered. If you share the list with your doctor, he or she can usually find the appropriate drug for you on that list, thereby saving you money without sacrificing quality.
In addition, the Welfare Fund has created a personal medication form that you should fill out and take with you when you see your doctor. The form asks you to list all prescription and over-the-counter medications that you are taking and suggests questions you should ask when your doctor prescribes a new medication. Download a copy of the Personal Medication Question Guide form, or call the Welfare Fund at 1-212-539-0539.
Families with high drug expenses
There are two components to the Welfare Fund’s plan that affect families with high drug expenses. These are the $1,000 co-pay cap and the Cost Care Program.
The trustees of the UFT Welfare Fund have instituted a co-pay cap for all eligible members and their families. Once your family’s co-pays reach $1,000 in out-of-pocket expenditures, the rest of your drugs in tier 1 and tier 2 are free for the year. Co-pays must still be paid for tier 3 drugs.
Families whose combined prescription drug claim benefits exceed $1,200 (the total cost of the drugs paid for by the Welfare Fund) during the previous months of December through November automatically are enrolled in the Welfare Fund’s Cost Care Program effective in January and receive a Cost Care drug card.
For members and their in-service spouse or domestic partner who is also a member, the threshold is $2,400, due to the special coordination of benefits.
When a brand-name drug has an approved generic equivalent, you can still get the brand-name drug but you will be responsible for the difference in cost between the two drugs in addition to the applicable co-pays (until you hit the $1,000 annual co-pay cap).
This difference is known as an ancillary fee and will be charged to you even if you hit the $1,000 co-pay cap. Your family’s status is reviewed every 12 months; if your total claims fall below $1,200 ($2,400 for members with special coordination of benefits), you return automatically to the regular drug plan the following January.
As a result of a negotiated citywide health benefit agreement, the city-administered PICA (Psychotropic, Injectable, Chemotherapy and Asthma) Drug Program, rather than the UFT Welfare Fund, covers injectables (including EpiPen) and chemotherapy drugs. These specialty drugs have a $100 deductible per calendar year and higher co-pays. The New York City PICA drug plan card should be used to obtain these types of drugs. The PICA program is administered by Express Scripts, which can be reached at 1-800-467-2006.
Also, by state law, diabetes drugs are covered by your health insurance plan, not by the Welfare Fund drug plan. Show your health insurance card at the pharmacy when ordering these drugs.
The Welfare Fund does not cover prescription-strength versions of over-the-counter medications such as Motrin, Aleve and Zantac.
For GHI-CBP in-service members and non-Medicare retirees, as of July 1, 2016, subscribers have access to preventive drugs such as birth control, immunizations and preventive services such as mammography at no cost. Contact GHI (EmblemHealth) at 1-212-501-4444, visit www.emblemhealth.com and sign in to view information on your coverage or visit nyc.gov/olr and choose your plan for more information about covered drugs and services.
Express Scripts Mobile App
Members who use a smartphone should download the Express Scripts Mobile app at the app store or access the site at www.express-scripts.com. This application provides a host of services including Refills and Renewals and Medicine Cabinet (to check interactions, claims and history, great for reviewing a past drug you have taken). Best of all, if you have forgotten your drug card, the app has a copy available by just tapping the Prescription ID Card.