What is not covered under the Prescription Drug Plan?
- Legend drugs that are also available over-the-counter regardless of strength variations.
- Drugs, including vitamins, foods, diet and nutritional supplements, homeopathic and natural medicines, etc. which legally can be purchased without a prescription, even if a written prescription is obtained from a prescriber.
- Drugs used for cosmetic purposes.
- Drugs used for hair growth.
- Drugs covered under the NYC PICA program (Injectible and Chemotherapy medications for members with a NYC health plan.)
- Drugs used for the treatment of diabetes.
- Appliances, devices and other companion implements used in the administration of drugs.*
- Prescriptions not dispensed by licensed pharmacists in a retail pharmacy unless authorized by the Fund.
- Experimental or investigational drugs.
- Legend drugs for unapproved (unlabeled) uses(s).
- Immunization agents**, biological sera, blood or plasma unless authorized by the Fund.
- Diagnostic drugs.
- Male sexual dysfunction drugs unless pre-authorized by the Fund.
- Prescriptions covered without charge under federal, state or local programs, including Worker’s Compensation.
- Any charge for the administration of a drug.
- Unauthorized refills.
- Medication for an eligible person confined to a rest home, nursing home, sanitarium, extended care facility, or similar entry, unless pre-authorized by the Fund.
- Any charge where the usual and customary charge is less than the eligible person’s co-payment.
- Drugs filled in a foreign country, unless required by an eligible person in an emergency, and the drug would otherwise be a legend drug in the US, covered by the Fund, and payment is approved by the Fund.
- Direct claims if they are presented for payment later than ninety (90) days from the date on which the drug was dispensed unless authorized by the Fund.
* The Welfare Fund’s Prescription Appliance Benefit covers many of these items for HIP PRIME and HIP PRIME POS enrollees. GHI-CBP and all other health plans cover many of these items in their basic coverage. Check with your individual plan for details.
** Your basic carrier covers Immunizations for dependents up to the age of 19. Check with your individual plan for details.
Is there COB under the Prescription Drug Program?
Yes. If the primary coverage of the spouse/domestic partner of the Fund member is under another prescription drug plan, then the spouse/domestic partner may submit for reimbursement of his/her co-payment or any other out-of-pocket co-insurance required by his/her primary carrier. Here too, all plan parameters will apply, i.e., members will only be reimbursed for co-payment amounts over the applicable UFT Welfare Fund co-payment. Computer printouts, computerized paid receipts from pharmacies, direct reimbursement forms showing proof of other carrier payment, or other similarly marked “coordination of benefits” should be sent to the Fund office.
In the event the primary plan of the spouse/domestic partner does not cover a prescription drug, which is otherwise covered by the UFT Welfare Fund, then the Fund will reimburse the UFTWF member for the spouse/domestic partner prescription, up to a maximum of the UFTWF Prescription Drug Program Schedule of Allowances.
SCOB (Special Coordination of Benefits)
SCOB for prescription drugs is only available to in-service members and their in-service spouse/domestic partner.
Under Special Coordination of Benefits the maximum annual benefit per family per calendar year is $200,000, provided both members are in-service.
For Cost Care determination, $2,400 is used instead of $1,200.
How do I obtain claim forms or additional information?
Call or write to the United Federation of Teachers Welfare Fund. For forms, call the Forms Hotline, 212-539-0539. For other information call 212-539-0500. Information and most forms are available on our website at www.uftwf.org.
The UFT Welfare Fund will take appropriate action to recover from the member, any monies paid out on behalf of or to, members/dependents for prescriptions obtained after eligibility terminates and for drugs used for non-approved or unlabeled uses.