Know your benefits

Your prescription drug plan

Jan 31, 2008 3:02 PM

Tips for in-service members

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, newly enrolled members who are awaiting their Welfare Fund drug card can purchase the prescription drugs they need and, once their card arrives, submit the original receipt to the Fund for reimbursement.

Here is how the plan 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 should use the “home delivery service” because you will save money and convenient delivery is made to your home.

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 this is not working well, you will be allowed to try another preferred brand or non-preferred brand-name drug. Due to FDA guidelines, certain drugs require a prior authorization to make sure that the therapy is appropriate for you.

How much do I pay for each prescription?

The Welfare Fund has a three-tier co-pay structure for generic, preferred-brand, and non-preferred brand medications [see chart below]. You can save money by using generics (tier 1) or preferred medications (tier 2) whenever possible but this is a decision between you and your doctor. Non-preferred 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, it 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 need a new prescription.

You should share a copy of the drug formulary with your doctor because it will allow him or her to make a safe yet affordable decision for you.

It is important for you to know that after three fills at the local pharmacy, you have to make a decision on how you want to receive your 90-day supply: either through home delivery or by using one of the retail maintenance network pharmacies.

Maintenance drugs

For drugs that you take over an extended period of time, the Fund provides for a 90-day supply for the price of two months (two co-pays) and you can get up to three refills (which is a year’s supply on one prescription).

There are two ways to get your maintenance drugs. By getting your drugs through home delivery, you have the convenience of having the delivery right to your home by simply sending your prescription in a pre-paid envelope, which is available from your chapter leader or by calling the Fund’s forms hotline at 212-539-0539.

If you want to get your 90-day supply locally, bring your prescription to one of the Fund’s “maintenance network” local pharmacies. While the co-pay may be slighter higher, you can eliminate the time you wait for delivery of your prescription. The list of participating pharmacies is available on the UFT Web site at www.uft.org/member/benefits/ under Drug Plan Information.

When visiting your doctor

When visiting your doctor, bring a copy of the UFT Welfare Fund Drug Formulary list (available at the Fund’s Web site, www.uftwf.org). The formulary lists the brands and generic equivalents that are available. Most plans have their own formulary list so 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.

Also, 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. To download a copy, go to www.uft.org/member/

benefits/forms and click on Personal Medication Guide Form or call the Welfare Fund’s Forms Hotline.

Families with high drug expenses

There are two components to the Fund’s plan that affect families with high drug expenses. These are the $1,000 co-pay cap and the Cost Care Program.

Thanks to additional funding in the new contract, the UFT Welfare Fund was able to institute a $1,000 annual cap per family in co-pays for generic and preferred brand drugs (tier 2). Once your family 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.

Families whose combined prescription drug claim benefits exceeded $1,200 (the total cost of the drugs paid for by the Fund) during the previous 12 months are enrolled in the Fund’s Cost Care Program and receive a new drug card. When a brand-name drug has an approved generic equivalent, you can still get the brand 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). Your family’s status is reviewed every 12 months; if your total claims fall below $1,200, you return automatically to the regular drug plan.

Special drugs

As a result of a negotiated citywide health benefit agreement, the city-administered PICA Drug Program, rather than the UFT Welfare Fund, covers injectables (including Epi-pen) and chemotherapy drugs. These special drugs have a $100 deductible per calendar year and higher co-pays.

Also, by state law, diabetic 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.

Certain drugs require prior authorization from the mail-order supplier before they will be dispensed. They have the annotation PA next to them on the formulary. Your doctor’s office must make the request.

The Welfare Fund does not cover prescription-strength versions of over-the-counter medications such as Motrin, Alleve and Zantac.