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Summary Plan Description (SPD)
Prescription Drug Reimbursement Plan – Out-of-Network Pharmacies
- $0 Co-payment Per Generic Prescription 30-day supply
- $10 Co-payment Per Brand-Name Drug with no generic equivalent 30-day supply
- $10 Co-payment Brand-Name, with Generic available, plus the ingredient cost between Generic and Brand-Name 30-day supply
In addition, Limits on
Drug Claim Reimbursement
If you use the
Health Fund Reimbursement Plan you may go to any non-network pharmacy of your
choice. Under this Plan you must contact the Administrative Office to request a
direct member reimbursement form for purchasing prescriptions out-of-network. You will be reimbursed for the prescription based on a limited formula,
less a co-payment of $0 generic or $10 Brand per prescription, up to a 30-day
supply.
Under this Plan you may be responsible for most of the drug costs, therefore you are encouraged to use the Prescription Solutions Walk-In Pharmacy or Mail Service Plan whenever possible. This Plan is intended for emergency purposes (i.e. while traveling) or other emergency situations.
How to File a
Claim
Claim forms may be obtained from the Administrative
Office. Complete and submit the claim form with the original prescription receipt(s). Cash register and credit card receipts alone are not acceptable proof of purchase.
Claim
Payments
Claims will generally be processed within 30 days
from the date the claim is received by Prescription Solutions.
For covered drugs, medicines, and insulin, the amount payable is based on a formula which uses the same reimbursement as under the Prescription Solutions Walk-In Plan less a $0 generic or $10 per Brand deductible with no generic available, or $10 brand name, with generic available, plus the ingredient cost between generic and brand name but in all cases not more than the price you actually paid, or the cost for the prescription if it had been filled by a network pharmacy.
For compounded dermatological preparations (lotions and ointments), the amount payable is 75% of the price you actually paid. The price for which you will be reimbursed must be comparable to the price prevailing in the area where the preparation is purchased.
Remember, prices can vary greatly from pharmacy to pharmacy. You can often make considerable savings on your drug expenses by checking prices at several different pharmacies. Again, the most economical approach is to use the Prescription Solutions participating PPO Plan. If there is not a Prescription Solutions participating pharmacy near where you live or walk, contact the Administrative Office.
Covered Benefits:
The Mandatory Generic Prescription Drug Plan covers the following services and materials:
- Federal Legend Drugs: Any medicinal substance which bears the legend, "Caution: Federal law prohibits dispensing without a prescription."
- State Restricted Drugs: Any medicinal substance, which may be dispensed by prescription only according to state law.
- Federal legend Oral Contraceptives/Birth control pills.
- Contraceptive products, including, but not limited to Diaphragms, Cervical Caps, Depo-Provera Injection and Ortho-Evra Patches.
- Inhaler extender devices and bags (Aerochamber™, Aerochamber™, w/ mask, Easivent™, Inspirsease™, EZ-Spacer™, Optichamber™, Optihaler™, Ellipse, etc.). are part of the pharmacy benefit.
- Anaphylaxis prevention kits, including but not limited to Epi-Pen®/Epi-Pen Jr. ®, Ana-Kits®, Ana-Kit Jr. ®, Glucagon, Glucagon Emergency Kit, and Ana-Guard®.
- Compounds with at least one federal legend or state restricted ingredient.
- Normal saline for inhalation and irrigation.
- Prescription prenatal vitamins.
- Injectables (see also Exclusions for exceptions).
- Insulin, insulin syringes and needles
- Blood glucose test strips
- Urine glucose test strips
- Sterile lancets
- Novolin Pen, Humulin Pen, Prefilled pens, Penneedles; cartridges