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 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 |
One
bottle per month |
|
Maxalt
tablets |
Six
pills per month |
|
Migranal
nasal spray |
One
bottle per month |
|
Zomig
tablets |
Six
pills per month |
|
Psychotherapeutic
drugs |
|
|
Smoking
cessation products |
$500
lifetime maximum |
|
Nicotine
gum |
Legend
only |
|
Nicotine
patch |
|
|
Nicotine
nasal spray |
|
|
Nicotine
inhaler |
|
|
Zyban
tablets |
|
|
Vitamins
and Minerals |
Only
those listed |
|
Prenatal
vitamins |
|
|
Niacin
500 mg. |
|
|
Niaspan
500 mg. |
|
A Bit of Information
Prescription contraceptives are covered only for
you or your eligible spouse. Coverage for contraception is not provided for
dependent children for any reason.
This
table lists the categories of drugs and specific drugs that are not covered.
|
Drugs That Are Not Covered |
|
·
Non-legend
or over-the-counter (OTC) drugs ·
Therapeutic
devices, support garments and other non-medical substances ·
Drugs
intended for use in a physician’s office or setting other than home use ·
Biological
sera, blood or blood plasma ·
OTC
contraceptives (condoms and spermicides) ·
Alcohol
swabs ·
Glucose
monitors (covered under the medical plan) ·
Fertility
drugs ·
Growth
hormones in injectable form ·
Rogaine ·
Propecia
tablets ·
Vitamins
and minerals unless otherwise listed ·
Ostomy
supplies ·
Syringes
and needles except for insulin and Factor VIII Recombinate |