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Active Health Summary Plan Description
As of September 1, 2017
En Español (PDF)

Article 8: Mandatory Generic Prescription Drug Plan

This section modified by: Amendment 10. View Previous Language.

Effective 1/1/2022: Article 8, Mandatory Generic Prescription Drug Plan, is deleted in its entirety.

If you are eligible for health benefits provided by the Southern California IBEW-NECA Health Trust Fund (Anthem Blue Cross PPO Plan, Kaiser HMO, or UnitedHealthcare HMO), then you and your eligible dependents are entitled to prescription drug benefits, as described herein.

The Mandatory Generic Prescription Drug Plan is designed to help you meet the cost of prescription drugs prescribed by your doctor, for you or your eligible dependents, for the treatment of illness or injury.

You must use a generic drug substitute whenever it is available. If you or your doctor requests a brand-name drug instead of a generic equivalent, you will be charged the difference in cost between the brand-name drug and the generic, in addition to the co-payment applicable to the quantity and type of drug prescribed. The co-payments, which vary depending on the type of drug prescribed and the quantity dispensed, are detailed in this Article.

To fill your prescription, you can use any of the following:

  • Citizens Rx Walk-In Pharmacy Plan (contracted network of pharmacies)
  • Citizens Rx Mail Service Pharmacy Plan
  • The participant must contact the Administrative Office to request a direct member reimbursement form for purchasing prescriptions out of network.

Each Plan is described in greater detail in the following sections.

In This Section:

  • 8.1 Walk-In Pharmacy Plan (Citizens Rx)
  • 8.2 Mail Service Pharmacy Plan (Citizens Rx)
  • 8.3 Non-Participating Pharmacy Reimbursement Plan
  • 8.4 Covered Benefits
  • 8.5 Limitations
  • 8.6 Exclusions
  • 8.7 Citizens Rx California Pharmacy Chains

8.1 Walk-In Pharmacy Plan (Citizens Rx)

Generic Drug: $0 Co-payment per Prescription for up to a 30-day supply

Brand-Name Drug: $10 Co-payment per Prescription for up to a 30-day supply Maintenance Medications as described below:

Generic Drug: $0 Co-payment per Prescription for up to a 100-day supply

Brand-Name Drug: $20 Co-payment per Prescription for up to a 100-day supply

To obtain a prescription as outlined in this section for a fixed co-payment, you must use a network pharmacy. The pharmacy network is extensive and includes most major chains and many independent pharmacies. A listing of the California network pharmacy chains is included at the end of this section. An up to date listing of nationwide pharmacies can also be found online at www.citizensrx.com or you can call Citizens Rx Customer Service toll free line, (877) 532-7912 to find a pharmacy near you.

You simply pay directly to the pharmacy a co-payment for each prescription. The Plan allows up to a 30-day supply or up to a 100-day supply if a maintenance drug is prescribed by your doctor. As a cost-containment feature, the Plan requires that you use a generic drug substitute when it is available.

It is important to note, however, that if the prescription calls for a brand name, the pharmacist will dispense the generic drug whenever a generic equivalent is in stock and may legally be substituted for the prescribed brand name.

If you or your doctor requests a brand-name drug instead of a generic equivalent, you will be charged the difference in cost between the brand-name drug and the generic, in addition to the co-payment applicable to the quantity and type of drug prescribed. The co-payments, which vary depending on the type of drug prescribed and the quantity dispensed, as set forth above.

8.2 Mail Service Pharmacy Plan (Citizens Rx)

(For Maintenance Medications Only)

Generic Drug: $0 Co-payment per Prescription for up to a 100-day supply

Brand-Name Drug: $20 Co-payment per Prescription for up to a 100-day supply

A Mail Service Prescription Drug Plan is available for maintenance medications. Maintenance medications are prescribed for such conditions as high blood pressure, diabetes, heart disease, ulcers, arthritis and other chronic conditions. You may obtain up to a 100-day supply of a maintenance medication drug for your $0 Generic or $20 Brand-Name co-payment (when there is no generic equivalent for the brand-name drug). Maintenance prescription drugs will be mailed directly to your home by Citizens Rx. Your prescription should arrive within seven (7) working days after your order is received at the Citizens Rx Mail Service Pharmacy. Citizens Rx pays all mailing expense for standard deliveries.

Your co-payment can be paid by check, money order, or credit card. Your prescription can be sent in a pre-printed envelope supplied by Citizens Rx and your medication will be delivered to your home within seven (7) working days after your order is received. You can order refills over the Internet at www.citizensrx.com or by phone by calling (877) 532-7912. You may also call this toll-free number to ask any questions or raise any concerns you may have regarding your prescription.

8.3 Non-Participating Pharmacy Reimbursement Plan

Generic Drug: $5 Co-payment per Prescription – for up to a 30-day supply

Brand-Name Drug: $15 Co-payment per Prescription – for up to a 30-day supply

A. Limits on Drug Claim Reimbursement

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 from non-participating pharmacies. You will be reimbursed for the prescription based on a limited formula, less a co-payment of $5 for each generic drug prescribed or $15 for each brand-name drug prescribed, up to a 30-day supply.

Under this Plan, you may be responsible for most of the drug cost, therefore you are encouraged to use the Citizens Rx Walk-In Pharmacy or Mail Service Prescription Drug Plan whenever possible. This Non-Participating Pharmacy Reimbursement Plan is intended for emergency purposes (for example traveling away from home) or other emergency situations.

B. How to File a Claim

Claim forms may be obtained from the Administrative Office. One portion of the claim form is to be completed by you, the other by the pharmacy. Claim forms must be filed within 15 months of the date of the drug charge to be eligible for reimbursement. Completed claim forms may be mailed to the following address:

Citizens Rx
1144 Lake Street - 4th Floor
Oak Park, IL 60301

C. Claim Payments

Claims will generally be processed within 30 days from the date the claim is received by Citizens Rx.

8.4 Covered Benefits

The Mandatory Generic Prescription Drug Plan covers the following services and materials:

  1. Federal Legend Drugs: Any medicinal substance which bears the legend, "Caution: Federal law prohibits dispensing without a prescription."
  2. State Restricted Drugs: Any medicinal substance, which may be dispensed by prescription only according to state law.
  3. Federal legend Oral Contraceptives/Birth control pills
  4. Contraceptive products, including, but not limited to Diaphragms, Cervical Caps, Depo-Provera Injection and Ortho-Evra Patches.
  5. Inhaler extender devices and bags (Aerochamber™, Aerochamber™, w/ mask, Easivent™, Inspirsease™, EZ-Spacer™, Optichamber™, Optihaler™, Ellipse, etc.) are part of the pharmacy benefit.
  6. 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™.
  7. Compounds with at least one federal legend or state restricted ingredient
  8. Normal saline for inhalation and irrigation
  9. Prescription prenatal vitamins
  10. Injectables (see the Exclusions subsection below for exceptions)

The following non-prescription items are also covered when prescribed in writing by a physician and dispensed by a licensed pharmacist:

  1. Insulin, insulin syringes and needles
  2. Blood glucose test strips
  3. Urine glucose test strips
  4. Sterile lancets
  5. Novolin Pen, Humulin Pen, Prefilled pens, Pen needles; cartridges

8.5 Limitations

The following items are a covered benefit subject to the limitations as stated below:

  1. Drugs for sexual dysfunction for both males and females are limited to a maximum of eight (8) pills for a 30-day supply and the co-payment will be the same as any other drug.
  2. Smoking deterrents when prescribed in writing, by a physician, subject to the following limitations: up to 90 days' supply per year; lifetime maximum benefit, 180 days' supply.

    This limitation applies to smoking deterrents received from both retail and mail pharmacy outlets. It is recommended you discuss a treatment plan with your physician. There are many products to assist you in smoking Cessation. These include the following:
    1. Nicotine Patches
    2. Nicotine Gum
    3. Nicotine Nasal Spray (Rx Required)
    4. Nicotine Inhalers (Rx Required)
    5. Nicotine Lozenges
    6. Zyban (Bupropion) (Rx Required)
  3. Morning after pills and kits (i.e., Preven, Plan B) - (limited to two (2) total per person per 365 days)

8.6 Exclusions

The following items are not covered:

  1. If enrolled in an HMO (Kaiser or UnitedHealthcare), all injectables, except insulin, which are included as part of your medical benefit to be administered in a doctor's office, and are an exclusion, Citizens Rx, and out-of-network plans.
  2. Drugs for which no charges are made, or which are provided under any Workers' Compensation or similar benefit or for which reimbursement is provided by any federal, state, or other governmental agency.
  3. Medications available without a prescription (over-the-counter) or prescription medications for which there is a non-prescription equivalent available, even if ordered by a physician via a prescription, except as listed under Covered Drugs
  4. Infertility drugs.
  5. Anorexiants/appetite suppression weight loss drugs.
  6. Medications to be taken or administered to the eligible member while he is a patient in a hospital, nursing home (skilled nursing care only), rest home, sanitarium, etc.
  7. Medications used for cosmetic purposes (For example: Renova, Rogaine, Vaniqa, Penlac, Pigmenting and Depigmenting agents).
  8. Medical devices, therapeutic devices or appliances including hypodermic needle syringes, (except insulin syringes) support garments and other non-medicinal substances (unless listed as covered).
  9. Drugs or medicines purchased and received prior to the member's effective date or subsequent to the member's termination.
  10. Drugs or medicines purchased or administered to the participant by a prescriber or prescriber's staff. For example, drugs administered, injected or dispensed by a physician. However, injectables obtained at a pharmacy shall be covered.
  11. Medications prescribed for experimental or non-FDA approved indications unless prescribed in a manner consistent with a specific indication in Drug Information for the Health Care Professional, published by the United States Pharmacopoeial Convention, or in the American Hospital Formulary Services edition of Drug Information; medications limited to investigational use by law.
  12. All homeopathic medications.
  13. Unit dose drugs (unless only available as unit dose).
  14. Vitamins (other than prescription prenatal vitamins).
  15. Dental related products (prescription oral and topical fluoride, Peridex, Atridox, Periostat).
  16. Drug claims submitted after 15 months of the date the drug was dispensed.
  17. Biological sera.
  18. Blood and Blood plasma.

8.7 Citizens Rx California Pharmacy Chains

The following is a list of Citizens Rx contracted California chains as of the date of printing of this Summary Plan Description:

  • Albertsons
  • Big "A" Drug Stores
  • Costco
  • CVS
  • Gemmel Pharmacy
  • Horton and Converse
  • K-Mart
  • Longs
  • Pavilions Pharmacies
  • Raley's Super Stores
  • Ralphs
  • Rite Aid
  • Safeway
  • Save Mart Supermarkets
  • Sav-On Drugs
  • Shopko Stores
  • Target
  • Vons/Pavilions Pharmacies
  • Walgreens