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Coverage and reimbursement

Who is covered and when?

All in-service covered members and eligible dependents, as defined in the General Information section, are covered for prescription drug benefits.

For retirees: Eligibility for the drug program continues for the month in which you retire or leave on deferred payability plus two (2) months. For example, if you retire February 15, your drug coverage will continue through the end of April.

What types of prescriptions are covered?

Prescriptions for legend drugs (drugs that can be dispensed only by a prescription). These drugs must be for specific use(s) as approved by the Food and Drug Administration (FDA), and obtained at a pharmacy. These usages, referred to as "labeled" uses, include conditions, periods, dosage schedules, etc. for all drugs monitored by the FDA and printed in the manufacturer’s monograph and established industry references as recognized by the Fund. However, the Fund’s Medical Advisor may require a medical justification in order to give authorization for coverage or continued coverage of a particular drug.

For information covering intravenous/infusion therapy, contact your basic health carrier.

What is the UFT Welfare Fund/ESI Prescription Drug Identification (ID) Card?

Each eligible member is issued a UFT Welfare Fund/ESI Prescription Drug Identification (ID) Card authorizing any participating pharmacy to fill prescriptions that come under the scope of the plan. The plastic card is embossed with a UFT Welfare Fund alternate ID number (other than your Social Security Number) and the member’s name. Dependents' names do not appear on the card.

The member receives two (2) cards. Additional cards are available upon request to the Welfare Fund.

New members will be issued cards automatically, provided a properly completed Enrollment Form has been submitted to the Welfare Fund.

It is the responsibility of the member to update all dependent information using an Update Your Information Form.

When does eligibility for prescription drugs terminate?

The front side of the ID card states: “CARD NOT VALID AFTER EMPLOYMENT TERMINATES OR AFTER RETIREMENT*.”

* Eligibility for the drug program continues for the month in which you retire, or leave on deferred payability, plus two (2) months. For example, if you retire February 15, your drug coverage will continue through the end of April.

Members who leave on deferred payabilty should notify the Welfare Fund by submitting their retirement system letter.

Please note: Members on leave with pay are considered to have in-service status. Members on leave without pay do not have coverage unless covered by SLOAC (Special Leave of Absence Coverage).

What is the Prescription Benefit Record (PBR)?

Every December, a Prescription Benefit Record (PBR) is sent to all in service members with information regarding:

  • each prescription drug obtained;
  • where it was obtained;
  • address and dependent information (e.g., name, date of birth...);
  • or whom it was prescribed;
  • cost to the Fund;
  • copayments incurred.

If you discover any discrepancies in any of the above items, contact the Fund Office by indicating the discrepancy directly on the PBR and returning it to the Fund.

How are benefits obtained?

Members may obtain benefits by using any of the following:

  • a participating pharmacy network; or
  • mail order service; or
  • direct reimbursement.

What is direct reimbursement?

Under direct reimbursement, you are required to pay for the full cost of the drug and then submit to the Fund for payment. Reimbursement is made according to the fee schedule or the actual charge, whichever is less. This may arise in the following situations:

  • you present a prescription to a participating pharmacy without your UFT Welfare Fund/ESI Prescription Drug Identification (ID) Card; or
  • the prescription is for a non-listed dependent; or
  • you use a non-participating pharmacy.

In these cases, the pharmacist is allowed to charge the store's regular price.

How am I reimbursed?

In order to receive any reimbursement, you must submit a UFT Welfare Fund “Drug Reimbursement Form for In-Service Members.” The Drug Reimbursement Form for In-Service Members is also available by calling the UFT Welfare Fund Forms Hotline at 212-539- 0539. You must complete and sign the form and attach detailed paid pharmacy receipts, showing the name, strength, and quantity of drug.

The completed form should be mailed to the UFT Welfare Fund at the address preprinted on the form, within ninety (90) days from the date the drug was dispensed.

Reimbursement will be made in accordance with the schedule of allowances limited to the same quantity and package rules, less the copayment that is applicable to participating pharmacies. This will most likely result in an out-of-pocket expense to you, which is in addition to the copayment.

Reimbursement for Controlled Substances is limited to the quantities mandated by federal, state or local laws for controlled substances in the jurisdiction in which the prescription is written.

What is the diabetes program?

In 1994, a mandatory diabetes program was legislated by New York State. The mandate states that all basic health carriers 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.

The Welfare Fund has instituted a procedure to reimburse you for the difference in drug copayments between your basic health carrier and the UFT Welfare Fund.

For reimbursements, you should submit a “Drug Reimbursement Form for In-Service Members” completely filled out with all pharmacy receipts attached and/or a statement from your basic health carrier that they have paid or denied the claims. The form is also available by calling the UFT Welfare Fund Forms Hotline at 212-539-0539.

Members will only be reimbursed for copayment amounts over the applicable UFT Welfare Fund copayment.

What is the NYC PICA program?

Due to a negotiated citywide health benefit agreement, the PICA Drug Program, rather than the UFT Welfare Fund, covers two (2) categories of drugs, Injectible and Chemotherapy. For more information regarding this program call Express Scripts, the program’s administrator, at 800-467-2006.

What is meant by Enteral Formula Coverage?

Enteral formulas are liquid food products that are specially formulated and designed to increase the amount of various food elements and nutrients that will maintain proper physiological function of the body process. They may also be used to correct an existing deficiency.

The New York State law regarding coverage of enteral formulas is not applicable to the Welfare Fund. However, we will cover these formulas providing the following guidelines are met:

  1. Members requesting access to these formulas will be subject to the Fund’s prior approval process.
  2. The formulas are for oral home use and have been prescribed by a physician or other legally authorized health care provider. These formulas are distinguished from nutritional supplements taken electively. They are not covered if they are administered via naso-gastric tube, via feeding gastrostomy or via needle-catheter jejunostomy since the patient’s health insurance plan usually covers it with prior authorization. The patient should contact their health plan.
  3. The patient’s physician must send a letter of medical necessity to the Welfare Fund’s Pharmacy program that states that the enteral formula is clearly medically necessary. This means that the formula has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic disability, mental retardation, or death.
  4. The formulas must be for specific diseases, which include, but are not limited to:
    • inherited diseases of amino-acid or organic acid metabolism;
    • Crohn’s disease;
    • gastroesophageal reflux with failure to thrive;
    • disorders of gastrointestinal motility such as chronic intestinal pseudo-obstruction;
    • multiple severe food allergies.
  5. Coverage for a calendar year for any insured individual shall not exceed two thousand five hundred dollars ($2,500.00).
  6. Quantities are limited to 30-day supplies per dispensing and are considered non-preferred brand (Tier 3) for copayment purposes. (See chart under Drug Program Design).