C o n n e c t i c u t C a r p e n t e r s H e a l t h F u n d P l a n

Prescription Drugs

With the cost of prescription drugs on the rise, prescription drug coverage is more important than ever. The Health Fund contracts with Express Scripts, Inc. (ESI) to handle your prescription drug coverage. ESI chooses the pharmacies it uses and monitors them for licensing and the quality of service they give. Like your medical benefits, you’re covered for certain prescriptions that are medically necessary and recognized as legend drugs to treat an illness or the effects of an injury. Drugs that are given to you in the doctor’s office, sold over the counter, or are experimental, investigational or unproven are not covered. ESI does not coordinate benefits with other prescription drug carriers. To maintain cost-effectiveness for the prescription drug benefit, your prescriptions will be filled with generic drug equivalents unless your doctor writes “Dispense as Written” on your prescription or you request that a brand name drug be used. Your drugstore receipt will show you if a generic substitution has been made. You must pay the $12 copay plus the extra cost for brand name drugs if a substitution is allowed but you choose the brand name drug. You and your dependents are covered for specified prescriptions that are: · filled at participating pharmacies · filled from the mail prescription service If you have prescription drug coverage under the Medicare Supplemental Plan, you pay 20% of the cost of covered prescriptions and the Health Fund reimburses you for 80% of the allowable cost of the covered drug after the deductible. ESI is not involved. A Bit of Information A drug may be considered medically necessary but not be covered by the Health Fund. Always check the lists of drugs that are and are not covered. Your doctor may be able to prescribe an alternative.

Prescription Drugs Full Spectrum Full Health Medical/Drug Only Disabled Member Retiree Full

How Much Can You Buy?

At the drugstore, you can buy up to a 30-day supply of your medication. If you need to take prescription medication for a chronic condition, the mail order program lets you buy a 90-day supply with only one copay.

To use the mail order program you must complete and sign an ESI profile form and mail it along with your prescription to ESI. You’ll be billed for the copay or you may put it on your credit card. You can get refills for your mail order prescriptions by phone — call 1.800.451.6245.

Your medication will be sent “postage paid” to the address you request.

A Bit of Information

You can save money on prescriptions if you use ESI pharmacies or ESI’s mail order program. You pay a copay — $3 for generic or $12 for non-generic (brand) drugs.

If you don’t use ESI you must pay for your prescription at the drugstore and then complete, sign and return a claim form with your receipt to ESI to get reimbursed. The reimbursement amount is not as great as the amount of coverage you get through ESI because you don’t get the discount from a participating pharmacy and you must pay an extra ingredient cost, a dispensing fee and an administrative fee.

You must present your ESI identification card at the pharmacy in order to pay only the copay amount at the drugstore.

The tables list many of the drugs that are covered under the Health Fund Plan. Please call your pharmacist or ESI if you have questions about a prescription.

Drugs That Are Covered
Type of Medication	Limitations (if any)
Acne treatment
Accutane
AIDS treatment
Alcohol and drug treatment
Revia
Antabuse
Anabolic Steroids	Prior authorization required
Antibiotics
Anorexiants	Only those listed
Adderall	Through age 18, then prior authorization required for narcolepsy ADD and ADHD
Desoxyn
Dexedrine
Ritilin
Compounds	Must contain at least one legend ingredient
Contraceptives	Only those listed Member or spouse only Dependent children not covered for any reason
Depo-Provera	Injectable form only
Diaphragm
IUD
Norplant
Oral contraceptives

Type or Name of Medication	Limitations (if any)
Cosmetic Drugs	Only those listed Covered through age 25, then prior authorization required
Avita
Differin
Renova
Retin-A
Chemotherapy
Cox-2 Inhibitors
Diabetic needs	Only those listed
Insulin
Novopen/needles
BD Pen/needles
Syringes
Blood glucose test strips
Urine glucose test strips
Lancets
Insulin pump needles
Quick release soft Teflon infusion set
Lancet devices
Fluoride products and Peridex
Hemantinics (Iron preparations)
Immunosuppressants
Impotence treatments	Only those listed
Caverject	Injectable form only
Edex
Muse	Pellet
Viagra	Six tablets per month
Yohimbine (Yocon)
Injectables	Only those listed
Allergy extracts
Bee sting kits	Two kits per month
Factor VIII /Recombinate	With needles and syringes
Glucagon
Imitrix	Prior authorization required
Limerix
Lupron	Prior authorization required
Low molecular weight heparins
Pneumovax 23	One vaccination every four years
Prevnar
Rebetron
Tamiflu
Interferons	Only those listed
Alferon-A	Injectable form only
Avonex
Betaseron
Intron-A
Roferon-A

Type of Medication	Limitations (if any)
Laxatives	e.g. Golytely
Migraine medications
Amerge tablets	Nine pills per month
Imitrix tablets	Nine pills per month
Imitrix nasal spray