Prescription drugs

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 (ESI) 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.

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. (If your doctor insists on a brand name, there will be a higher copay.) 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 refills, you must use the ESI Home Delivery Service (delivered to your home) for a 90-day supply of your maintenance medications (not controlled drugs).

There are two components to the Welfare Fund's plan that affect families with high drug expenses. These are the $1,000 copay cap and the Cost Care Program.

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 months of December through November automatically are 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 (until you hit the $1,000 annual copay cap).

This difference is known as an ancillary fee and will be charged to you even if you hit the $1,000 copay cap. Your family's status is reviewed every 12 months; if your total claims fall below $1,200 ($2,400 for members with special coordination of benefits), 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.

Also, 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.

For GHI (EmblemHealth) and HIP in-service members and non-Medicare retirees, subscribers 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. Contact GHI (EmblemHealth) at 212-501-4444, visit the Emblem Health website, sign in to view information on your coverage, or visit the city's Office of Labor Relations website and choose your plan for more information about covered drugs and services. HIP can be reached at 800-HIP-TALK.

Yes, you and your spouse are both eligible for reimbursement of your catastrophic co-payments under your Medicare Part D coverage. Each of you individually has to reach the annual catastrophic limit; your totals cannot be combined. Claims must be submitted by Feb. 1 for the prior year’s reimbursement. The Fund prepares a new form in December of each year for your use in filing for this reimbursement.