Post-Service Claims: Prescription Drug Benefits

Prescription drug benefits are administered by the Pharmacy Benefit Manager. Your prescription drug benefit is a so-called card-based system, and your claim is deemed made when you present the prescription and your Citizens Rx identification card to a participating pharmacist.

Within 30 days of filing a post service claim, to the extent that any portion of your claim is denied, you will receive a notice of denial that identifies the specific Plan provision upon which the denial is based. For example, a claim or a portion thereof may not be payable because the annual deductible has not been met.

The 30-day period described above may be extended as permitted by federal regulations if additional information is required to process your post-service claim. You will be notified in writing what additional information is required in order to process your claim.

If your appeal is received in the Administrative Office at least 30 days in advance of a Board of Trustees Meeting, your appeal will be considered at that meeting. Generally, the Trustees meet no less frequently than quarterly.

To the extent permitted by federal regulations, consideration of your appeal may be put over to the next meeting of the Board if additional information is required to consider your appeal.

To assure timely consideration of appeals the Board has established an Appeals Committee comprised of one Union Trustee and one Employer Trustee. This committee is empowered to make final decisions if required to timely deal with appeals. The Appeals Committee would meet, for example, when a regular Board meeting is cancelled.

When the Appeals Committee or the Board of Trustees makes a final determination on your appeal, the Administrative Office will advise you in writing within five days of the decision.