Your prescription drug benefit is provided by the Fund through EmpirRX Health.
HOW THE PLAN WORKS
As proof of eligibility for prescription drugs, participants will receive an identification card. Only the member’s name will appear, however, all eligible dependents will be active in the EmpirRX Health system. This card must be presented with your prescriptions. You will be required to pay a co-payment for each prescription received.
1) The Fund will pay the first $4,000.00 for covered prescriptions for you and your eligible dependents. The co-payments are listed below.
2) When The Fund has paid $4,000.00 for you and/or your eligible dependents and you are still in need of prescription medicine, you will have an out-of-pocket expense of $12,700.00 for family coverage or $6,350.00 for member only coverage. (including co-payments)
3) You will be responsible for keeping track of the receipts as proof that you have met the out-of-pocket total. Each pharmacy receipt must contain: name of member (with last 4 digits of your SS#), name of patient (if different), Rx number and amount of payment. After you have reached the out of pocket total amount, mail all necessary paperwork (we suggest you sent it certified or bring it in person) to our office.
4) If everything is in place, you will again be eligible for your prescriptions to be covered in full by The Fund for the remainder of that calendar year. Normal copays will apply.
$1.00 for every generic prescription you receive
$15.00 for every brand prescription you receive
$40.00 per prescription, when you receive a brand when there is a generic available.
WHAT THE PROGRAM COVERS
This program covers all medications which, by federal or state law, require a prescription and are prescribed by a licensed practitioner.
Prescriptions can be written by your physician for up to a 34 day supply plus 3 refills. All refills will be dispensed according to your doctor’s directions.
If you go to a non-participating pharmacist you can receive a partial reimbursement for your prescription. However, you must pay for the prescription when filled and then ask for a direct Reimbursement Claim form from the Fund Office. You must have a separate form for each prescription. After you complete the form, mail it to the EmpirRX Health. You will be reimbursed according to the fee schedule, not what you paid the pharmacy. You are always responsible for the co-payment.
If you have any questions about your claims, call the Fund Office.
WHAT IS NOT COVERED
Under this program, no benefits are paid for:
• Medications for which you don’t need a prescription (over-the-counter)
• Devices or appliances, support garments or other non-medical substances
• Hard Equipment i.e., Syringes, Nebulizer, Glucometer, these are properly covered by your health insurance card (GHI, HIP…)
• Unauthorized refills
• Prescriptions covered under federal, state or local programs including workers’ compensation, Medicare or Medicaid. Medication for eligible members and dependents who are confined to a rest home, sanitarium, extended care facility, hospital or similar institution
• 2 categories of medicine are covered by your IC Card issued directly by NYC: Injectables & Chemotherapy
The following medicines need prior authorization/and/or letter of medical necessity with a diagnosis from a medical doctor.
Smoking Cessation
Enbrel
Anabolic Steroids
Topical Acne Agents
Erectile Disfunction
EXCLUSIONS FROM COVERAGE
Only drugs which by law require a prescription are covered. Diet supplements, infant formulas, vitamins (except pre-natal supplements), transparenteral or other enteral therapies (TNP), supplies and services, and any over-the-counter products are excluded from coverage. No coverage is available for drugs dispensed by anyone other than a duly licensed pharmacist.
The following drugs are also excluded from coverage by the Fund: investigative or experimental drugs, unauthorized refills, lost or stolen medication, immunosuppressants, therapeutic devices or appliances, drugs whose sole purpose is to promote or stimulate hair growth, immunization agents and biological, blood or blood plasma, and drugs used to enhance sexual function, devises or appliances, support garments, medications provided while confined to a rest home, nursing home, sanitarium, extended care facility, hospital or similar facility.
No coverage is available for durable medical equipment, including insulin syringes and needles, under the Fund’s prescription drug benefits program. Coverage for durable medical equipment may be available under your major medial benefits program.
IC Program: Injectables & Chemotherapy
If you have elected medical coverage through NYC then you will also receive a IC Card for these 2 group of medications. Determination of eligibility for you and your dependents (for this card) is determined by NYC. If you do not receive this card please contact Benefits of NYC (646-610-5122).
For complete coverage information, please download the complete Benefits Plan handbook Here >>
