PRESCRIPTION DRUG BENEFITS
Prescription drug benefits are available for our members through the Superior Officers Council Health and Welfare Fund Prescription Plan administered by OptumRx. Certain specialty drugs not covered by the Fund’s Prescription Drug Plan may be available through the City Health Benefits Plan, commonly referred to as PICA. Also in this section you will find information on guidelines pertaining to diabetes medication, medications covered under the Affordable Care Act and the World Trade Center Drug Program.
HIP HEALTH/PRESCRIPTION RIDER REIMBURSEMENT BENEFIT (RETIREES ONLY)
If you are retired and have HIP coverage, you will no longer be eligible for the prescription drug coverage through the SOC Health and Welfare Fund due to a pre-existing ‘carve-out” agreement with the City.
Those retired members who maintain HIP coverage and pay for the HIP High Option Rider (which includes prescription drug coverage) will be reimbursed up to a maximum of $350 annually from the Fund each March as a partial reimbursement for the cost of the rider
NOTE: If you were not enrolled in the HIP High Option Rider for the entire year (January-December), the reimbursement will be pro-rated based on the number of months you actually paid the premium for the rider.
The Superior Officers Council Retiree Health and Welfare Fund pays up to $7,000 per calendar year for you and your family’s prescription drug expenses or up to $10,000 per calendar year for Medicare eligible individuals and an additional $5,000 for members with families.
The SOC Prescription Plan is a mandatory generic plan. Being a mandatory generic plan means the Plan design eliminates coverage for all brand name medications that have a direct generic available. Should you or your doctor insist on receiving a brand name medication where there is a generic equivalent available, you will be responsible for the FULL COST of the medication.
The SOC Prescription Plan is based on a co-payment schedule. The member is responsible for 35% of the total cost of covered brand name medications and 5% of generic medications.
Prior authorization (PA) review is needed to determine coverage for products involved in the Step Therapy Program. The OptumRx Prior Authorization Program can be initiated by either the pharmacist or the member contacting OptumRx Customer Service Center. OptumRx representatives will work with your doctor’s office and pharmacy to obtain the information required. For further information, your physician can contact the OptumRx Prior Authorizations Department at 1-800-711.4555. option 2.
If the drug that is needed requires prior authorization and you are unable to wait for prior authorization to be reviewed ask your physician if a drug sample is available or your pharmacy may provide you with a short-term supply. You will be responsible for the full copayment at this time. If the prior authorization is approved, your pharmacist can dispense the remainder of the prescription.
In the case of prior authorization denial – the Superior Officers Council Prescription Plan design includes medications that effectively treat most medical conditions. Most likely, there is an alternative product that may be prescribed by your doctor that will not require prior authorization. If no other options are available and the prescribed treatment is medically necessary, you have the option of appealing the denial.
It’s easy to find a participating pharmacy in your local area. With more than 60,000 pharmacies in the OptumRx network, you’re sure to find one that’s close to home or work.
If you need assistance locating the pharmacy closest to you, call OptumRx Customer Service at 800-356-3477 or visit www.optumrx.com.
USING YOUR ID CARD/REPLACEMENT CARDS
Every covered member is issued a prescription drug card that will certify the member’s and the dependent’s eligibility for the OptumRx's Drug Plan. All you must do is present your card to the pharmacy and your claim will be processed electronically. If you lose or misplace your prescription benefit card, you can call the SOC Fund Office at (212) 964-7500, option 1, during regular business hours. You will receive replacement cards within 7-10 business days.
To save money on your prescriptions, try requesting generic products. Not all brand name products have equivalent generic alternatives, but it is a good idea to ask your doctor if your brand name medication can be substituted with a similar generic product before you request it from the pharmacist.
OPTUMRX MAIL ORDER PHARMACY
The Superior Officers Council Prescription Plan offers a program that allows you to order prescription products through the mail. Using OptumRx Mail Order Pharmacy is an easy way to have your prescriptions delivered right to your home. People on maintenance medications (medications that are taken on an ongoing basis) will especially enjoy the convenience of not having to go to the pharmacy as often.
In order to be eligible to enroll in OptumRx Mail Order Pharmacy, you must fill your prescription two times at the retail level. Once you have enrolled in OptumRx Mail Order Pharmacy, you will need a new prescription from your physician for up to a 90-day supply and mail it, along with the completed enrollment forms and correct copayment, to the mail order facility.
For an enrollment application, call OptumRx Customer Service at 800-356-3477 or visit their web site at www.optumrx.com or call the SOC Fund Office at (212) 964-7500, option 1.
Prescriptions filled through the mail order facility should be received 10-14 days from the date the prescriptions are mailed.
On some prescriptions, you will find quantity limitations. Quantity limits are based upon FDA guidelines published clinical recommendations, such as the Journal of the American Medical Association (JAMA), as well as manufacturer packaging and labeling instructions. Limits are intended to encourage appropriate dosing. *Exceptions are generally limited to chronic conditions that necessitate a quantity greater than “normal.” These limits are not intended restrict access to quantities of medications where limits would not be considered functional or appropriate.
*NOTE: If you have a chronic condition that may necessitate a quantity greater than “normal,” you can contact the SOC Fund Office for further assistance.
The PICA Program is a prescription drug benefit that is provided to all NYC employees, non-Medicare retirees, and eligible dependents who are enrolled in a health plan offered by the City’s Health Benefits Program. It is made available through the joint efforts of the City of New York Office of Labor Relations and the Municipal Labor Committee.
MEDICATIONS COVERED BY THE PICA PROGRAM
PICA covers medications in two specific drug categories:
• Injectable — Most injectable medications not requiring administration by a health care professional (self-administered).
• Chemotherapy — Medications used to treat cancer and/or to treat the side effects of chemotherapy.
Retail Pharmacy (up to a 30-day supply):
• $10 for generic medications
• $25 for preferred brand (formulary) medications
• $45 for non-preferred brand (non-formulary) medications
Mail Order Pharmacy (up to a 90-day supply):
• $20 for generic medications
• $50 for preferred brand (formulary) medications
• $90 for non-preferred brand (non-formulary) medications
NOTE: The Superior Officers Council Prescription Plan does not cover medications covered by the City of New York Office of Labor Relations PICA Program. However, if you choose a non-preferred brand name medication that has a generic equivalent, you will be charged the difference in cost between the non-preferred brand name drug and the generic drug plus the non-preferred brand name drug copayment. See Generics Preferred section for additional information.
MANDATORY MAIL ORDER PROGRAM
You must use the Express Scripts Mail Order Pharmacy for maintenance medications. Maintenance medications (those taken regularly during an extended period of time) will not be filled at a retail pharmacy after two (2) fills. If you pay for your prescription at a retail pharmacy and the use of the Express Scripts Mail Order Pharmacy was mandatory, you will not be reimbursed for the cost of the medication.
FERTILITY MEDICATION MAXIMUM
Injectable medication used to treat infertility is only available to PICA members whose health plan covers the treatment that requires this medication. This medication is limited to a lifetime maximum of three cycles of therapy. A cycle is approximately 28 to 30 days. Administration of the medication(s) is usually given daily for seven-10 days early in the cycle. Even though fertility medication(s) is physically administered for about seven-10 days, clinically, it is used as a treatment for one FULL cycle; three cycles is 90 days. If you have already received three cycles of therapy of fertility drugs, you will not be covered for any additional fertility medications.
Effective June 1, 2008, the fertility medication benefit program is available exclusively from Freedom Fertility Pharmacy. The Freedom Advantage® offered to PICA members features personalized care, drug coverage and outstanding service. Key components of this benefit include a dedicated team of fertility only care coordinators, free shipping, free patient education materials, and emergency same-day services. For questions, call Freedom Fertility Pharmacy at (800) 660-4283 or www.freedomfertility.com.
PICA Prescriptions should be mailed to:
PO Box 866
Bensalem, PA 19020-0866
For more information you can visit the web site at www.express-scripts.com.
Customer Service Telephone Numbers:
• Accredo Specialty Care Pharmacy: (866) 848-9876/(800) 233-7139
• Express Scripts General Phone Number: (800) 467-2006
• Freedom Fertility Pharmacy: (800) 660-4283
NOTE: The Superior Officers Council Prescription Plan does not cover medications covered by the City of New York Office of Labor Relations’ PICA Program. However, psychotropic and asthma medications are no longer available through the PICA Program. These medications can be obtained through the Superior Officers Council Prescription Plan and are subject to the Fund’s plan design.
Medications can be refilled over the phone or on the internet.
• By Phone: Interactive Voice Response (IVR) System IVR enables you to renew prescriptions over the telephone at any time of the day or night. Call (800) 467-2006 and follow the instructions.
• Over the Internet: Log onto Express Scripts’ web site at www.express-scripts.com and register as a member. Once you are registered you can order refills online.
GENERICS PREFERRED PROGRAM
A generic drug is a medication produced after the original drug manufacturer’s brand name patent has expired. Every generic drug manufacturer must meet the same strict FDA guidelines required of the original brand name manufacturer. If you receive a brand name medication that has a generic equivalent, you will be responsible for the difference in cost between the non-preferred brand name medication and the generic medication plus the non-preferred brand name copayment. You can call the Express Scripts Customer Service Department at (800) 467-2006 or visit www.express-scripts.com.
PRIOR AUTHORIZATION PROGRAM
The Prior Authorization process will be required for certain medications. These medications require the prescribing physician to provide a letter of medical necessity and diagnosis. PICA medications requiring prior authorization are:
• Erythropoetins (e.g. Epogen or Procrit)
• Growth hormones
If you are currently prescribed any of the PICA medications requiring prior authorization [Erythropoetins (e.g. Epogen or Procrit), Botox/Myobloc, Growth hormones, Forteo], you must have your physician call the Express Scripts Prior Authorization Department at (866) 374-5549. If approved, prior authorizations will be set up immediately. If the doctor cannot call, he/she may fax a letter of medical necessity, which includes a diagnosis, to (866) 374-5547. Please allow two business days for faxed requests to be processed. If the diagnosis meets approved criteria for that medication and the diagnosis is within the scope of coverage of the plan, prior authorization will be set up so your prescription can be filled under the plan.
There is an annual deductible of $100 per person for Injectable and Chemotherapy medications. This deductible is independent of any other deductibles and must be satisfied before copayments are applied.
STEP THERAPY PROGRAM
Step Therapy is a program that encourages the use of the best medication for your condition. The first steps in this process are well-established treatments known to be safe and effective. Known as first-line therapy, this treatment is the preferred therapy for most people. If the first-line therapy does not work or causes problems, second-line therapy can be tried. When a prescription for a second-line medication is processed at your pharmacy, the computer system reviews your recent prescription history. If a prescription for a first-line drug is found, the medication will be dispensed. If the system does not find a prescription for a first-line drug, the second-line prescription is not covered. The pharmacist will be alerted that the medication is not covered and will suggest covered first-line alternatives to your physician.
ACCREDO SPECIALTY CARE PHARMACY
Certain specialty injectable medications such as those used to treat hepatitis C and multiple sclerosis will be filled by Accredo, Express Scripts’ Specialty Care Mail Service Pharmacy (you may receive your first fill at a retail pharmacy). Accredo will supply the prescribed medication and related supplies such as needles and syringes, and also provide clinical support to you to help improve compliance, as well as provide convenient delivery. To find out more information, you may call Accredo's Customer Service at (866) 848-9876.
PICA AND OTHER DRUG PLANS
In general, PICA drugs are not covered by a health plan’s optional prescription drug rider or union welfare fund. Use your prescription drug card for medications not covered by PICA.
The Superior Officers Council Health and Welfare Fund does not cover diabetes medication for non-Medicare members.
Under New York State Law, insurance companies are mandated to cover diabetes related medications for non-Medicare members. These medications are covered under the basic medical benefits by all New York City health benefits plans. Diabetes management education is also provided to educate members on the proper self-management of their condition. Members requiring diabetes products should bring their medical benefits ID card to their pharmacy along with their prescription.
Those members enrolled in Medicare or who have eligible dependents enrolled in Medicare will be covered for diabetes medication through the SOC Prescription Plan (limitations apply). Please contact the SOC Fund Office at (212) 964-7500, option 1, to get more information on covered products.
NOTE: The SOC Prescription Plan does not cover management equipment, syringes, diabetes testing, or monitoring equipment or supplies for controlling blood sugar.
Effective July 1, 2016, certain medications are covered for City of New York employees with medical coverage through Emblem Health (GHI and HIP) ONLY at $0 copay. For a complete list of covered Affordable Care Act medications go to:
LOW DOSE GENERIC STATINS
Effective July 1, 2018, EmblemHealth will also cover low to moderate dose generic statins for eligible members and non-Medicare eligible retirees ages 40-75 under GHI CBP and/or HIP HMO plan in accordance with the Affordable Care Act. For a complete list of statin medications covered under the Affordable Care Act go to: www.emblemhealth.com/Members/City-of-New-York-Employees.
NOTE: All products including those designated as over the counter will require a prescription from your physician to apply the applicable coverage.