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Skip Navigation LinksHome » Health Benefit Info Active » Prescription  
 

General Information
The Welfare Fund offers prescription drug benefits to you and your family through Express Scripts, Inc. (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:   

 

ESI Network Retail Pharmacy (Lesser of 100 units or a 30-day supply)

ESI by Mail

(Up to a 90-day supply through mail order)

Diplomat Specialty Pharmacy (For specialty drugs)

Out of Pocket Maximum per Calendar Year $2,000 per individual / $4,000 per family

Generic Co-Payment

$5

$12.50

n/a

Single-Source Brand Co-Payment

(A generic is not available)

20%

$10 minimum and $100 maximum Co-Pay per drug

20%

$25 minimum and $250 maximum  Co-Pay per drug

n/a

Multi-Source Brand Co-Payment

(A generic is available)

35%

$20 minimum Co-Pay

35%

$50 minimum Co-Pay

n/a

Specialty Medications used to treat complex conditions such as cancer, hemophilia, immune deficiency, rheumatoid arthritis, etc. and require a higher level of care

n/a

20%

$20 minimum Co-Pay per drug with a $100 maximum Co-Pay

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

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.   

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.  

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, some knee pain problems 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 pay $5.  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 the 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. You may pay even less when you obtain your prescriptions through the mail order program.

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.

If you meet the individual maximum out of pocket of the plan, there will be no Co-pay for your prescription drugs for the rest of the calendar year.  If your family meets the family maximum out of pocket of the plan, then there will be no Co-pay for your family’s prescriptions for the rest of the year.  Note that the individual or family maximum out of pocket for the medical plan does not apply to the prescription drug maximum out of pocket, nor does the individual or family prescription drug maximum out of pocket apply to the medical one. They are completely separate.

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 card 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, you will be reimbursed the amount ESI would have paid for a generic prescription if you had used an ESI participating pharmacy and presented your ID card; or the amount the Plan would have paid for a brand name prescription had you used an 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.

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

 Example:

John went to an out-of-network pharmacy to fill his prescription for Zithromax, (a multisource 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).
  • In this example, John’s out of pocket for this prescription is $129.75 (the difference between the total he paid at the pharmacy ($185), and what ESI reimbursed him ($55.25)).

If John had used an 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. 

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

If you take a maintenance medication, you will be allowed to fill that prescription at a retail pharmacy (drug store) a maximum of three (3) times.

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

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

Specialty Drug Program
A specialty drug 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 conditions such anemia, cancer, cystic fibrosis, Gaucher’s Disease, Hepatitis C, Huntington’s Disease, immune deficiency, multiple sclerosis, osteoarthritis, rheumatoid arthritis, respiratory syncytial virus, some knee pain and other severe conditions or diseases.

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

If you are eligible for Diplomat's Specialty Drug pharmacy, you will receive support from
Diplomat's 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 Specialty Drug Pharmacy Program, contact Diplomat, at 1-866-722-6110.

Hours are Mon.-Fri. 7am-10pm CST, and Sat. 8am-4pm CST.

There is an after-hours on-call pharmacist available 24 hrs. a day, 7 days a week.

  

 

 

 

 

 
 

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