If I have any additional questions, where can I get them answered?
- You can call the ESI Customer Service number at 800-723-9182, 24 hours a day, seven days a week.
- You can call the Welfare Fund office at 212- 539-0500 during business hours.
- In addition, information is also available at www.express-scripts.com.
What is not covered under the Prescription Drug Plan?
- Legend drugs that are also available over-the-counter, regardless of strength variations.
- Drugs, including vitamins, foods, diet and nutritional supplements, homeopathic and natural medicines, etc. which legally can be purchased without a prescription, even if a written prescription is obtained from a prescriber.
- Drugs used for cosmetic purposes.
- Drugs used for hair growth.
- Drugs covered under the NYC PICA program (Injectable and Chemotherapy medications for members with a NYC health plan.)
- Preventive care drugs, covered by other organizations (such as Emblem GHI and HIP City Health Plans) as mandated by the Patient Protection and Affordable Care Act.
- Drugs, appliances and devices used for the treatment of diabetes.
- Appliances, devices and other companion implements used in the administration of drugs.*
- Prescriptions not dispensed by licensed pharmacists in a retail pharmacy unless authorized by the Fund.
- Experimental or investigational drugs.
- Legend drugs used solely or in compound prescriptions for unapproved (unlabeled) use(s)
- Immunization agents**, biological sera, blood or plasma unless authorized by the Fund.
- Diagnostic drugs.
- Prescriptions covered without charge under federal, state, or local programs, including Worker’s Compensation.
- Any charge for the administration of a drug.
- Unauthorized refills.
- Medication for an eligible person confined to a rest home, nursing home, sanitarium, extended care facility, or similar entry, unless pre-authorized by the Fund.
- Drugs filled in a foreign country, unless required by an eligible person in an emergency, and the drug would otherwise be a legend drug in the US, covered by the Fund, and payment is approved by the Fund.
- Direct claims if they are presented for payment later than ninety (90) days from the date on which the drug was dispensed unless authorized by the Fund or if the three (3) fill limit has been exceeded.
- Direct claims for enteral formulas if purchased at a non-pharmacy and/or bought before prior approval was obtained.
- Medications packaged as a kit.
- Items classified by the FDA as medical devices, botanical drugs, wound debridement or cleansing medications even if they require a prescription.
* The Welfare Fund’s Prescription Appliance Benefit covers many of these items for HIP PRIME and HIP PRIME POS enrollees. GHI-CBP and all other health plans cover many of these items in their basic coverage. Check with your individual plan for details.
** Your basic carrier covers immunizations for dependents up to the age of 19. Check with your individual plan for details.
Is there COB under the Prescription Drug Program?
Yes. If the primary coverage of the spouse/domestic partner of the Fund member is under another prescription drug plan (which must be used first), then the spouse/domestic partner may submit for reimbursement of his/her copayment or any other out-of-pocket coinsurance required by his/her primary carrier. Here too, all plan parameters will apply, i.e., members will only be reimbursed for copayment amounts over the applicable UFT Welfare Fund copayment. Computer printouts, computerized paid receipts from pharmacies, direct reimbursement forms showing proof of other carrier payment, or other similarly marked "coordination of benefits" should be sent to the Fund office.
In the event the primary plan of the spouse/domestic partner does not cover a prescription drug, which is otherwise covered by the UFT Welfare Fund, then the Fund will reimburse the UFTWF member for the spouse/domestic partner prescription, up to a maximum of the UFTWF Prescription Drug Program Schedule of Allowances.
How do I obtain claim forms or additional information?
Call or write to the United Federation of Teachers Welfare Fund. For forms, call the Forms Hotline, 212-539-0539. For other information, call 212-539-0500. Information and most forms are available online.