A: In 1994, a mandatory diabetes program was legislated by New York State . The law states that all basic health carriers (i.e., GHI, HIP, Blue Cross-Blue Shield, and Aetna ) must cover all drugs, ancillary devices and have a diabetes management educational program for all patients. Since the Welfare Fund supplements your basic city health plan, it was no longer necessary for the Fund to cover these items.

Q: I am a GHI subscriber. How do I obtain my necessary drugs, insulin and syringes?

A: For your oral medications, insulin and syringes, you take your green and white GHI NYC employee Benefits Program medical identification card and your prescription(s) to any GHI/Express-Scripts participating pharmacy. For each prescription and authorized refill there is a $5.00 copay and you will receive a 30-day supply. There are no deductibles or plan maximums for this benefit.

In addition, there is a mail order component. For each prescription and authorized refill, there is a $5.00 copay but you can receive a 60-day supply through GHI's mail order facility Express-Scripts

(1-877-534-3682.) 

Q: How do I know if my pharmacy is a GHI/EXPRESS-SCRIPTS participant?

A: Most UFT/NPA participating pharmacies also belong to the GHI/EXPRESS-SCRIPTS network. In fact there are more than 1,800 in the NY Metropolitan area.

Q: What if I do not use a participating pharmacy and/or pay for my prescription(s). How do I get reimbursed?

A: If you do not use a participating pharmacy and/or pay for your prescription, you must submit it to EXPRESS SCRIPTS for reimbursement. The reimbursement will be limited to the amount GHI would have paid a participating pharmacy, minus the copayment. To obtain claim forms you can call 1-212-501-4444.

Q: What about my blood glucose monitor, test strips, pumps, etc?

A: Under the GHI Durable Medical Equipment (DME) Program, you can obtain these items through their participating providers at no out-of-pocket expense. There are no copays or deductibles. However, if you use a non-participating provider you must submit a paid receipt to GHI. Reimbursement will be based on the GHI/City of New York Schedule of Allowances, not the submitted charge. You will be responsible for any amounts that exceed this schedule. In addition, these purchases go towards your overall contract annual and lifetime maxima. Therefore, it is most advantageous to use a participating provider. For more information, you can call the main GHI number at (212) 501-4444.

Q: Currently, my copay is $2.00 for up to a 30-day supply of a generic drug at a participating pharmacy and $2.00 for all prescriptions at CFI for a 90-day supply. According to this new plan, it will cost me more in copays to obtain the same benefit. Is the Welfare Fund doing anything about this?

A: Yes. The Welfare Fund has instituted a procedure to reimburse you for the difference in generic drug copays and the difference between the EXPRESS SCRIPTS mail order program copays and the CFI mail order program copays.

To expedite reimbursements due you, you must submit a DIABETES DRUG REFUND FORM. The form is obtainable from the Welfare Fund forms hotline (1-212-539-0539) or the website (www.uft.org). It must be completely filled out with all pharmacy receipts attached. For example, if you are a GHI member, it must include EXPRESS-SCRIPTS mail order receipts, pharmacy receipts and/or the Explanation of Benefits that GHI sends to all its subscribers’ quarterly. For members with other carriers, in addition to the pharmacy receipts, it must include a statement from that carrier that they have paid or denied the claims.

Do not submit the form until at least six (6) receipts are attached or you have incurred $50 in out-of-pocket expenses, but do not hold the claims for more than one year from date of purchase.

The Welfare Fund will reimburse you so that your out-of-pocket expense remains equal to the out-of-pocket expense you would have incurred had the Welfare Fund continued its coverage of these drugs. The $5 copayment for a brand drug and the $2 copayment for a generic drug are not reimbursable.

Q: I am a HIP subscriber. How will this affect me?

A: HIP members are covered for diabetic drugs and supplies under their base plan. Strips that are used to test for glucose in urine, all oral prescription drugs, insulin, syringes and needles are covered when dispensed by a HIP participating pharmacy. Only a prescription by a HIP physician is required.

Q: What about other HMO enrollees?

A: HMO's are already providing the benefit and enrollees should contact their HMO to ascertain how these items can be obtained through their medical plan.