Drug coverage for retirees
At retirement, you must select the Optional Benefits Rider to have prescription drug coverage. 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) NON - MEDICARE
Non-Medicare retirees pay a co-payment at a HIP participating pharmacy or pay a co-payment and use the HIP Mail Order Pharmacy from Express Scripts for maintenance drugs.
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 (for non-MEDICARE members only)
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 prescriptions 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 NAMEmedicines 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 be reimbursed accordingly, after your deductible has been met. Reimbursement will be based on the 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 Express Scripts at 1-877-534-3682 or access them online at www.express-scripts.com.
When you need medication, the doctor can prescribe up to a 60-day supply. Prescriptions will be filled generically UNLESS the doctor indicates “Brand medically necessary,” writing DAW on the prescription.
Prescriptions are sent electronically to Express Scripts (ESI). The co-pay is $10 for each GENERIC prescription or $40 for each BRAND NAME prescription that is on the FORMULARY.
The co-pay is $60 for NON-FORMULARY prescriptions. (Please note: none of these co-pays are part of your deductible.)
Once you begin using Express Scripts for maintenance drugs, you have the option to refill and renew prescriptions from the website or mobile app.
MEDICARE MEMBERS AND MEDICARE DEPENDENTS
V. CITY ENHANCED PART D PLAN
Effective January 1, 2018 (for GHI Senior Care)
Medicare Phase 1
Member/dependent pays 25% co-insurance up to $937.50
Medicare Phase 2
Member/dependent pays 44% for generics and 35% for brand-name medications co-insurance up to $5,000.
Medicare Phase 3
Once the member/dependent pays $5,000 in out-of-pocket co-insurance, they go into the Catastrophic Coverage phase and pay only 5%
The yearly Explanation of Benefits from Emblem Health comes in January for the previous year.
If, in the column marked “You Paid” the amount is greater than $5,000, you can get reimbursed for anything over that amount.
The Reimbursement Claim form is availableat www.uftwf.org or by calling (212) 539-0500.