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Skip Navigation LinksHome » Health Benefit Retiree Info » Prescription  
 

The Welfare Fund offers prescription drug benefits to you and your family through Express Scripts (ESI), the Plan's prescription drug network.

These benefits are designed to cover the major portion of prescription drug costs through retail (drug store) and mail order.

If you use a pharmacy that participates in the ESI pharmacy network, your co-insurance amounts are as follows:
 

  Lesser of 100 pills or a 30-day supply at a Medco participating retail pharmacy Up to a 90-day supply through mail order
For specialty drugs only: Through Diplomat specialty pharmacy
Generic $5 $12.50 n/a
Single source brand
(Generic not available)
20%
$10 minimum/$100 maximum
20%
$25 minimum/$250 maximum
n/a
Multiple source brand
(Generic is available)
35%
$20 minimum
35%
$50 minimum
n/a
Specialty medications n/a n/a 20%
$20 minimum/
$100 maximum

NOTE: If the cost of the medication is less than the coinsurance, you will only pay the cost of the medication.

Under the prescription plan, there is an in-network $1,500 out-of-pocket maximum (OOP maximum) for single-source drugs and a $1,500 OOP maximum for specialty drugs. Effective July 1, 2015, the Board of Trustees elected to implement an in-network $1,500 OOP maximum for generic and multi-source brand drugs (combined). If you are taking several medications this may reduce your yearly out of pocket expenses.
 
Preferred Drug Step Therapy Program
The Plan also provides for a Preferred Drug Step Therapy program that identifies generic or brand medications in certain drug classes and recommends FDA-approved lower cost generic options to the brand name medication. If your doctor prescribes a non-preferred brand, you will need to switch to a generic or preferred brand for the Plan to cover the medication. In certain cases, if your doctor believes you cannot switch medications, he can request a coverage review by ESI.
 
To find out more about the Preferred Drug Step Therapy program contact ESI at 800-939-2089 or visit their website at www.express-scripts.com. Service Representatives are available 24 hours a day, 7 days a week.

A single source brand is a brand-name drug that does not have a generic equivalent available for prescription. A multiple source brand is a brand-name drug that does have an available generic equivalent. Specialty drugs are medications used to treat complex conditions, such as cancer, hemophilia, immune deficiency, and rheumatoid arthritis, and they require an enhanced level of service.

If you or your family member is eligible for prescription drug coverage and your medication is dispensed as a generic drug you will pay $5 at a participating ESI retail pharmacy and $12.50 using ESI by mail. A generic equivalent has the same active ingredient as the brand-name drug, even though it may have a different color and shape.

If your prescription is filled at a participating ESI retail pharmacy as a single source brand name drug, where there is no generic equivalent, you will pay 20% of the total cost of the drug. Your minimum co-payment is always $10.00 or a maximum of $100.00. 

When you fill your prescription and do not accept the offer of a generic equivalent, your prescription is filled as a multiple source brand name drug. You will pay more out of your pocket if you or your doctor refuse a generic substitute when one is available.

Retail Prescription Drug Program
In order to receive the best level of benefits for you and your family, you must choose a pharmacy participating in the ESI pharmacy network and show your ESI ID to the pharmacist.

If you do not have your ESI ID card with you, or you do not use a participating pharmacy, you must pay the full cost of the prescription and submit a completed claim form to ESI for reimbursement.

 If you do not use a pharmacy that participates in the ESI network, ESI will reimburse you. The amount ESI would have paid for the prescription had you used a ESI participating pharmacy and presented your ID card less the required co-payment.
 

Save Money, Use a Retail Pharmacy that Participates in the ESI Network.

Example:

John went to an out-of-network pharmacy to fill his prescription for Zithromax, (a multi source brand name antibiotic).
  • John will have to pay the pharmacy the full cost of the drug, in this example $185.
  • John will need to submit a claim form to ESI for reimbursement.
  • ESI will reimburse John $55.25, the amount it would have paid a participating pharmacy ($120) less his 35% co-payment ($64.75).
If John had used a ESI network pharmacy he would have paid a total of $24.00 for the prescription. If John had taken a generic substitution, his cost for the medication would have been $5.
Formulary
The plan participates in Express Scripts National Preferred Formulary. The formulary is a broad list of preferred medications used by ESI clients nationwide. The formulary is subject to change from time to time. In the event that your medication is removed from ESI's formulary, ESI will notify you in advance and inform you of other drugs available to you in the same therapeutic class. Medications not on the National Preferred Formulary are not covered by the Plan.

Mail Order Prescription Drug Program
Long term medications are prescription medications that are continually taken on a regular basis for a chronic condition. Examples of conditions where long term medications are often prescribed are high blood pressure, cholesterol and allergies.

If you take a long term medication, you will be allowed to have that prescription filled at a retail pharmacy (drug store) a maximum of three (3) times (original fill plus 2 refills).

After the third refill at the retail pharmacy, your long term medication prescription(s) will only be covered under the Plan when you use the ESI mail order program.

Contact ESI Health Solutions at 1-800-939-2089 for more information on the mail order program. Or visit the website at www.expresscripts.com.

Special Care Pharmacy Program
Special care pharmacy is the term used to describe certain medications and a set of services designed to meet your particular needs if you take medication to treat certain conditions such anemia, cancer, cystic fibrosis, Gaucher’s Disease, Hepatitis C, Huntington’s Disease, immune deficiency, multiple sclerosis, osteoarthritis, rheumatoid arthritis, respiratory syncytial virus and other severe conditions or diseases.

Many of these medications require injection and have special shipping and handling needs. These medications could also be oral or infusion medications.

If you are eligible for Diplomat special care pharmacy, you will receive support from Diplomat pharmacists and nurses who are trained in specialty pharmacy medications, their side effects, and the conditions they treat. Also, because many of these medications require injection or special handling, you will receive:
  • Expedited shipping of specialty medication to a your home or physician’s office,
  • Supplemental supplies, such as needles and syringes, that are needed to administer the medication, and
  • Scheduling of refills and coordination of services with home care providers, case managers, and physicians or other health care professionals.
For information on the Special Care Pharmacy Program, contact Diplomat, at 1-866-722-6110.
 
 

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