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 Prescription ID drug cards can purchase the prescription drugs they need and, once their cards arrive, submit the original receipts to the Welfare Fund for reimbursement.
Types of prescription drugs
There are two types of drugs: acute illness drugs and maintenance drugs.
Acute illness drugs are those you need immediately, such as an antibiotic. Your local pharmacy dispenses this type of drug to you.
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 Express Scripts Home Delivery service because you will save money and convenient delivery is made to your home. However, there are certain maintenance drugs, such as narcotics or controlled medications, which can only be dispensed in a 30-day supply at the local pharmacy.
Certain drugs require “step therapy,” which applies to first-time users of a medication. 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.
In addition, certain drugs require “prior authorization” to make sure the therapy and dosage are within federal guidelines. Prior authorization requires your physician to call a toll-free number (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 (which lists generic and preferred brands covered by the Welfare Fund).
How much do I pay for each prescription?
The Welfare Fund has a three-tier copay structure for generic, preferred-brand and nonpreferred-brand medications. 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 copays.
At the pharmacy, if your doctor has not indicated that the pharmacist must dispense a brand-name drug, you will get a 30-day supply of a generic drug for $5 provided there is one available. 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 Express Scripts Home Delivery Service, not the pharmacy, for a 90-day supply of your maintenance medications (as long as they are not controlled drugs).
For drugs 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 copays) through the Express Scripts Home Delivery Service, and you can get up to three refills (which is a year’s supply on one prescription).
Beginning on March 1, 2020, you can have maintenance/long-term medication filled at any Walgreens/Duane Reade pharmacy. You still have the option to order these medications through the Express Scripts Mail Order Pharmacy. Whether you use Express Scripts or Walgreens/Duane Reade, your copayments are the same for a three-month supply: $10 for generics, $30 for preferred brand name drugs and $70 for non-preferred brand name drugs.
When visiting your doctor
When visiting your doctor, bring a copy of the UFT Welfare Fund Drug Formulary list. The formulary lists the preferred-brand drugs and generic equivalents that are available.
In addition, the Welfare Fund has created a form for personal medications 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 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.
Families with high drug expenses
The trustees of the UFT Welfare Fund have instituted a copay cap for all eligible members and their families. Once your family’s copays reach $1,000 in out-of-pocket expenditures, the rest of your drugs in Tier 1 and Tier 2 are free for the year. Copays 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 December through November are automatically enrolled in the Welfare Fund’s Cost Care Program effective in January and receive a Cost Care drug card. (For members and an 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 are responsible for the difference in cost between the two drugs, in addition to the applicable copays. This difference in cost, known as an ancillary fee, will be charged to you even if you hit the $1,000 copay cap and stop paying copays. Your family’s status is reviewed every 12 months. If your total claims fall below $1,200 for the year, 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 copays. 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 800-467-2006.
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.
In-service UFT members who have GHI (EmblemHealth) or HIP and non-Medicare retirees have access to preventive drugs such as birth control, immunizations, low-dose statin agents (ages 40–75) and preventive services such as mammography at no cost.
For more information about covered drugs and services, you can contact GHI (EmblemHealth) at 212-501-4444 or visit the Emblem Health website at and sign in. HIP can be reached at 800-HIP-TALK. Or you can visit the city’s Office of Labor Relations website and choose your insurance plan to see more information.
Express Scripts mobile app
Members who use a smartphone should download the Express Scripts Mobile app at the app store for their cellphone. The app provides a host of services, including refills and renewals and a section called Medicine Cabinet (to check interactions, claims and history, which is 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 tapping the Prescription ID Card.
|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|
|Nonpreferred Brand (Not on Formulary)||3||$35||$70|