DC 37 Health & Security Plan Benefits
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Optum Rx Customer Service,
1-800-207-1561, is available 24-hours a day, 7 days a week, or visit the Optum Rx website at www.optumrx.com
Prescription Drug Benefit
Drug Benefit pays most of the cost of prescription drugs. A covered prescription
drug is a drug approved by the Food and Drug Administration ("FDA"),
used for the purpose and time period approved by the FDA and which cannot be purchased
without a Physician's or Dentist's prescription (except prescription medications
that have over the counter counterparts); or drugs, which require compounding,
except that such term shall include prescribed insulin or drugs that have not
been specifically excluded. While allergens are not prescription drugs, they are
covered under the Plan if the medication is purchased from an allergy testing
lab or a Participating Pharmacy and is prescribed by your doctor.
Based Prescription Drug Benefit
The Plan has a generic based Prescription
Drug Program. This means that the Plan will only be responsible for paying covered
prescription medication at the generic rate, except when there is no generic available
and the brand name drug is the only drug available (sole source).
Prescription drug benefit is available to the covered member and eligible dependents.
The prescription drug benefit consists of a three tier co-payment program.
As of January 1, 2017, the co-payments shown below will be in effect.
30 days @ Retail Pharmacy|
90 Rx Pharmacy
If you choose
to obtain a brand name drug that has a generic equivalent, then you will be responsible
for paying the difference in cost between the brand name drug and the generic
drug in addition to the appropriate co-payment. In no case will you be charged
more than the cost of the medication. If a generic equivalent is not available,
instruct your physician to prescribe a preferred brand name medication.
It is important to note that the Food and Drug Administration
requires that generic drugs must meet the same standards for purity, strength
and safety as the brand name drug.
Effective January 2017, members and retirees with prescriptions for cholesterol lowering drugs known as statins will be charged a $10 co-pay for the generic versions of their prescription.
The Psychotropic, Injectable, Chemotherapy & Asthma (PICA) Program
As a result of a benefit bargaining agreement reached between the City of New York Office of Labor Relations and the Municipal Labor Committee of which DC 37 is a member, a program, known as PICA was instituted effective July 1, 2001. This program made these four classes of drugs available to all employees, non-
Medicare eligible retirees and their eligible dependents in a City sponsored health plan.
Medications in these four categories were provided through the PICA program only, except where otherwise covered under a City sponsored basic health plan.
Effective July 1, 2005, the City sponsored program continued to cover two classes of medication, Injectables and Chemotherapy. Psychotropic and Asthma medication coverage reverted to the Plan's responsibility and are subject to Plan rules and co-payments.
DC 37 Health and Security Plan members covered by the program must use their City of New York PICA prescription card for injectable and chemotherapy medication. Questions about the PICA program should be directed to the telephone number on the back of the NYC PICA prescription card. For more information visit http://www.nyc.gov/html/olr/html/health/pica_prog.shtml
The Preferred Products List
Because of the escalating cost of the Prescription Drug Benefit, the Plan has instituted a Preferred Products List. The list identifies prescription drugs that can be used for virtually all illnesses and conditions and will meet the needs of most types of patients. The List was developed by a select group of physicians and pharmacists to ensure that all the drugs are therapeutically sound.
When there is no generic drug available, use a prescription that appears on the Preferred Products List. It will save money for you and the Plan.
The Mail Order Program
The mail order program is a voluntary program designed for persons who have a long-term illness that requires maintenance type medication. You will save money because you get a 90 day supply of medication for the cost of two co-payments as opposed to a 90 day supply at a Retail 90 Rx pharmacy for three co-payments. Please allow 14 days for delivery from the date you mail in the original prescription. Be sure to enclose a check or money order which reflects the cost and/or the co-payments associated with the prescriptions you send to the Mail Service Program. For additional information about the mail order program you can access the DC 37 website at www.dc37.net or contact the Plan's Inquiry Unit at 212-815-1234.
Effective July 1, 2014, the Annual limit for the prescription drug benefit (previously $100,000 per cardholder, per calendar year) no longer applies.
Step Therapy (Rx Instep Program)
The Plan has instituted the mandatory Step Therapy program especially for people who take prescription drugs to treat certain ongoing medical conditions with safety, cost and most importantly your health in mind..
It allows you and your family to receive the affordable treatment you need and helps the Plan contain the rising cost of prescription drug coverage.
The program starts with generic drugs in the "first step". The generics covered by the Plan have been proven to be effective in treating many medical conditions. You will have the lowest co-payment for a first step generic drug.
More costly brand name drugs are usually covered in the second step, even though generics have been proven to be effective in treating many medical conditions. These brand name drugs will have higher co-payments.
The drug categories in the Step Therapy program include high blood pressure, dermatitis and eczema, attention deficit hyperactivity disorder, asthma and allergy, depression, rheumatoid arthritis, diabetes*, pain and arthritis medication and ulcer and gastro-esophageal reflux disease medication.
*Please refer to Important Notes regarding diabetes coverage.
If your doctor is prescribing a medication for a Step Therapy condition for the first time, ask your doctor to prescribe a Step One medication. The Rx Instep program's medication list is available at the Plan's website, www.dc37.net or from the Plan office.
If the initial treatment with a Step One drug does not work well, the patient can be given a more costly Step Two drug. You will not need an approval to fill the new prescription at the pharmacy because we will have a record of the use of the Step One drug.
If you are being prescribed medication for a Step Therapy condition for the first time, and your doctor did not prescribe a Step One drug, your pharmacist will receive a message indicating that our Plan has a Step Therapy program. The pharmacist will generally contact the physician to request a new prescription for a step one drug. If a physician is unavailable, the member or patient will be responsible for obtaining the new prescription. If you choose to get your written prescription filled as is, you will pay the full cost for it, and the medication will not be covered by the Plan.
If you were prescribed a Step Two medication in the past and have not filled a prescription for it in 120 days or longer, you will not be able to re-start that medication without first trying a Step One drug.
How To Use
The Prescription Drug Card
The most effective way of using your Prescription Drug benefit for short-term medication is with the prescription drug card issued by the Plan. You take the card and your prescription, which must be written on your Physician's prescription pad, to a Participating Pharmacy. When getting medication from your neighborhood participating pharmacy, you can obtain a 30 day supply or 90 day supply based on your written prescription for the appropriate Plan co-payment. In the event that you did not receive a valid prescription drug card, or if your card has been stolen, lost or destroyed, you must notify the Plan office by calling the Inquiry Unit at 212-815-1234.
How To Use The
In case you do not have your prescription drug card with you, or if you do not go to a Participating pharmacy, you must then utilize the Direct Reimbursement Method to obtain your prescription drugs. You must complete the Prescription Drug Benefit Reimbursement form available at the Plan office. You must send the form along with the prescription receipt to the Plan's Prescription Drug Benefit Administrator in order to be reimbursed. Your reimbursement amount is based on the participating pharmacy's contracted rate minus your co-payment and will be subject to Plan rules and restrictions. If you obtained a brand name drug that had a generic equivalent, then you will be responsible for paying the difference in cost between the brand name drug and the generic drug in addition to the appropriate co-payment. Reimbursement is based on a specific fee schedule, minus the appropriate co payment, regardless of what the pharmacist's charges are. The same fee schedule is used to reimburse a participating pharmacy when a member uses his/her prescription drug card.
Medicare Eligible Retirees and the
DC 37 Prescription Benefit
Actuaries for the Plan, using guidelines established by the Centers for Medicare and Medicaid Services, have determined that your prescription drug coverage with the Plan is, for all plan participants, expected to pay out as much as or more than the standard Medicare prescription drug coverage.
Because your existing coverage is at least as good as or better than standard Medicare prescription drug coverage, you can keep this coverage and choose not to enroll in Medicare Part D coverage.
Should you no longer be eligible for the Plan's prescription drug coverage and choose to elect a Medicare Drug Plan you may not be subject to late enrollment penalties because your current Health & Security Plan benefit is considered creditable coverage. A copy of the Notice of Creditable Coverage is available on the Plan's website or by calling the Inquiry Unit at 212-815-1234.
As a retiree, Medicare coverage is primary. This means that if you are eligible to receive a prescription drug benefit through a Medicare Drug or Medicare Advantage plan, that prescription drug benefit will be primary. You will be covered first by that Medicare Drug or Medicare Advantage plan and subject to coverage rules including premiums, deductibles and co-payments and these costs are not reimbursable by the Health & Security Plan. Your DC 37 Health & Security Plan's prescription drug benefit will be a secondary coverage and will "wrap around" your primary plan.
If you are enrolled in a Medicare drug plan or Medicare Advantage health insurance plan that provides a "creditable" drug plan, your DC 37 drug benefit will be unavailable until you have used and exhausted your Medicare Drug benefit annual limit or reached your coverage gap.
A copy of the Notice of Creditable Coverage is available on this website along with Important Information for Retirees about Medicare Drug Plans.
Questions relating to specific prescription drug availability or benefit usage should be directed to the Plan's prescription benefit administrator, Optum Rx at 1-800-207-1561.
Questions or problems relating to eligibility should be directed to the Inquiry Unit at 212-815-1234.
COVERAGE FOR CERTAIN PRESCRIPTION DRUGS
The Prescription Drug Benefit normally provides coverage for prescription medication when used only for purposes approved by the FDA. However, effective January 1, 1991, the Board of Trustees extended coverage of prescription drugs for unlabelled cancer therapy under the following conditions:
Before cancer drug claims can be considered for payment, all three conditions must be met:
1. Medical records must be provided to the Plan by the treating physician;
2. Submission of proof that your basic health insurance carrier (i.e. GHI, HIP, Blue Cross, etc.) rejected the prescription drug claims for payment;
3. The patient's treating physician must demonstrate to the Plan that the medication being prescribed has been recognized by experts in the field as being effective. Recognition is shown by the presentation or reference to articles that have appeared in certain established medical publications.
It must be noted that, for cancer drug claims, the Prescription Drug Benefit will pay 50% of the Plan's allowance of the drug up to a lifetime maximum of $5,000, using the direct reimbursement method only. Please send your treating physician's records; basic health insurance carrier rejection; and medical authority documentation to the:
DC 37 Health & Security Plan
125 Barclay Street
York, NY 10007
Attention: Prescription Drug Unit
1. Effective January 1, 1995, for all active members, non-Medicare eligible retirees, and dependents enrolled in the City of New York's Health Benefits Program, diabetes medication will be provided by the various health plans as part of the basic benefit package.
2. Effective July 1, 2005, for all active members, non-Medicare eligible retirees, and dependents enrolled in the City of New York's Health Benefits Program, coverage for the following categories of medication: injectables and chemotherapy will be provided by the PICA program.
3, All active and retired members of the Triborough Bridge and Tunnel Authority will receive coverage for diabetes medication, injectables and chemotherapy through the DC37 Health & Security Plan.,
4. Effective January 1, 2001, active employees and retirees of the Office of Court Administration and the State Rent Regulations Services Unit will no longer be covered for prescription drug benefits through the DC 37 Health & Security Plan. Prescription drug coverage will be provided through the New York State Health Insurance Program (NYSHIP).
The Prescription Drug
Benefit will not cover the cost of:
- drugs prescribed for a patient confined to a rest home, nursing home, extended care facility, hospital or similar in-patient care facility or drugs prescribed for a member or eligible dependent residing in an assisted living facility where such drugs are covered in whole or in part by a federal, state, or local program or other insurance. Where only a portion of the cost of such drug is covered by another plan or insurer, the remaining cost of such uncovered drug will be covered to the extent permitted under the Plan's prescription drug benefit. The covered employee and eligible dependent will be responsible for all applicable co-pays and special shipping costs;
- drugs prescribed for any condition covered by Workers' Compensation, No Fault Automobile Insurance, or in any situation where third party medical insurance is available;
- chemotherapy obtained by a non-Medicare eligible member and/or eligible dependent; administered on an out-patient basis in a hospital; or administered in a doctor's office;
- vitamins, foods and diet supplements that may be purchased with or without a prescription;
- drugs supplied by a treating physician;
- investigational or experimental drugs;
- over-the counter drugs (drugs purchased with or without a prescription);
- prescription medications that have over the counter counterparts.
- appliances and all companion implements (devices), including syringes and needles, for the administration of prescription drugs;
- drugs prescribed for cosmetic purposes;
- prescription drugs used for Intravenous Drug Therapy, which is infused in the home; and any charge for the administration of home infusion of the drug;
- immunization agents and biological sera;
- refills of medication covered by the benefit described in this section in excess of eleven (11) 30-day refills in any one (1) year, except for narcotics which is five (5) 30-day refills in any six (6) month period.
- refills of maintenance drugs covered by the benefit described in this section in excess of three (3) 90 day supplies in any twelve (12) month period filled at the Plan's mail order program or a Retail 90 Pharmacy;
- diabetes medication for active members and non-Medicare eligible retirees and eligible dependents except as noted;
- chemotherapy and related medication for active members, non-Medicare eligible retirees and eligible dependents enrolled in the City of New York's Health Benefits program except as noted;
- injectable medication for active members, non-Medicare eligible retirees and eligible dependents enrolled in the City of New York's Health Benefits program except as noted;
- any medication for active employees and retirees of the Office of Court Administration and the State Rent Regulations Services Unit enrolled in the New York State Health Insurance Program.
The Prescription Drug Benefit will limit the coverage and cost of:
- drugs used in amounts or quantities which exceed FDA, approved guidelines, e.g. Proton Pump Inhibitors (PPI's) for longer than three (3) months per lifetime;
- FDA approved fertility medication, up to 12 treatments per lifetime;
- Coverage for the class of prescription drugs used to treat male sexual dysfunction will require pre-approval by the Plan and will have a 50% co-payment with a maximum of 6 pills per month.
- coverage for the class of prescription drugs used to treat obesity will require pre-approval by the Plan and will have a 50% co-payment.
- prescription drugs if a health insurance carrier provides for prescription drug coverage, then that carrier is Primary for prescription drugs. Should there by an out-of-pocket expense after the basic health insurance carrier processes drug related claims, the Plan will consider Coordinating Benefits. Members are reminded that when the spouse has separate prescription drug coverage (whether through the spouses' employment or other sources such as Veterans Administration Benefits, Workers' Compensation, Medicaid, No Fault Insurance, etc.), the Plan deems this coverage to be the primary coverage for the spouse and the spouse must use his/her own coverage.
- prescription drugs covered through enrollment in a Medicare Part D Drug Plan. The Medicare Part D Drug Plan will be considered Primary and the Plan will provide benefits after meeting the Med D Planís annual limit or coverage gap.
The Plan has increased costs due to improper use and/or abuse of the Prescription Drug Card. Members who, through carelessness or negligence, allow their Drug Card to fall into the hands of unauthorized persons whether known to them or not will be held responsible for the misuse of the card that was entrusted to the member for his/her use and/ or for the use of his/her eligible dependents. Such unauthorized or improper use can also result in the suspension of all your DC 37 Health & Security Plan benefits.
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