Pharmacy Consultation Program

The Plan provides pharmacy consulting services at a local pharmacy to participants and family members who take multiple medications or who may be at risk for drug interactions. The purpose of this benefit is make sure that participants are using their medications properly and give them the opportunity to review all of their medications with a registered pharmacist. Participants are contacted by a Plan physician or nurse for referral to the pharmacy program. Each participant or family member is limited to two consultations unless the Plan is advised by a Plan physician or nurse that more visits are necessary. There is no deductible or out-of-pocket cost to you for this benefit.

Preferred and Non-Preferred Drugs

The Plan has a three tiered pharmacy benefit program. In other words, you pay 20% of the cost for generic drugs, 30% of the cost for Preferred Brand drugs and 50% of the cost of Non-Preferred Brand Drugs. You may receive more information on what drugs are Preferred and Non-Preferred from the Plan. From time to time, the PBM revises the Preferred Drug list removing some drugs and adding others. In this case, the Plan will make every attempt to notify you and your physician in advance and in writing of these changes. The notification will advise you and your physician of alternative medications on the Preferred Brand list.

Pre-Certification

Some medications require Pre-Certification. If Pre-Certification is not obtained when required, the medication will not be covered.

The following medications require Pre-Certification:

1. All drugs that cost more than $500 per prescription for a supply of 31 days or less require Pre-Certification from the Plan. Specialty/Injectable drugs which cost more than $500 are covered under the Pipe Trades PPO Plus Self- Funded Indemnity Medical Plan when Pre-Certified by the Plan. See page 22.
2. Pain management drugs costing more than $500 in a twelve month period require Pre-Certification from the Plan unless the patient is in a Hospice program. In addition, the Plan will refer you to a pain management Center of Excellence program. Some of the pain management services may be provided in conjunction with the Fund’s Employee Assistance Program (EAP) described on page 34. Failure to participate in a pain management program when referred by the Plan will make you ineligible for future coverage for pain management drugs.
3. Human Growth Hormone.

Most chain drug stores and some independent pharmacies are PBM Pharmacies. Call the Administrative Office if you need listings in your area.

For reimbursement from the Plan for out-of-area emergency prescriptions received from non-PBM pharmacies, submit a completed claim form and your original receipt to the Administrative Office. Your claim will be denied if it is not submitted within 120 days after your prescription is filled.

At the Network pharmacies, the quantity of covered medication dispensed will be limited to a maximum of a 34 day supply.

Using the Mail Service Pharmacy for Maintenance Medications

Maintenance medications are drugs that you take for longer than 90 days. Maintenance prescriptions can be obtained through the Plan’s mail service pharmacy.

Using the mail service pharmacy is simple. When your doctor prescribes a maintenance drug, ask that the prescription be written for a 90 day supply, with the number of refills indicated. By law, the mail service pharmacy can only fill your prescription up to the quantity indicated by your doctor.

Next, complete an order form and patient profile form. The patient profile will only need to be completed with your first order. The order form, patient profile questionnaire and pre-addressed envelopes are available from the Administrative Office.

You may call the customer service number on the order form to determine what copayment applies to your prescription.

Mail the original prescription (not a photocopy), completed patient profile (if this is your first order) and order form, along with the appropriate copayment to the Fund’s mail service pharmacy, as directed or the order form you obtain from the Administration office. The order forms also include information on how to request refills by phone and over the internet.

The copayment can be paid by check, money order, MasterCard, VISA, American Express or Discover credit cards. Be sure to print your Social Security number on the back of each prescription.

Your mail order prescription will be filled with a generic drug when one is available unless your doctor indicates on the prescription that a generic should not be dispensed.

Medications will be delivered postage paid by first class U.S. mail or United Parcel Service directly to your home. Please allow 14 days for delivery from the day you send your order. Remember to order refills 14 days before you expect to need them.

Covered Drugs

The following are covered expenses under the Plan:

1. All drugs that require a written prescription from a licensed physician for the treatment of an illness or injury that is covered by the Plan, except as excluded or limited below;
2. Retin-A when medically necessary (pre-certification required);
3. Prenatal and well-baby vitamins;
4. Diabetic supplies, including syringes, insulin, and test strips (the applicable generic or preferred brand copay will apply);
5. Contraceptives; and
6. Injectable drugs costing $500 or less when Pre-Certified in advance by the Fund’s PBM. Specialty medications/ injectable drugs costing more than $500 are covered through the medical plan when Pre-Certified by the Plan, see page 22.

Excluded Drugs

The following are not covered under the Plan:

1. Specialty medications/injectable drugs costing more than $500 per prescription for a supply of 31 days or less (these are covered under the medical plan, see page 22);
2. Drugs not requiring a written prescription from a licensed physician, unless specifically shown as a covered drug above;
3. Therapeutic devices or appliances, support garments and other non-medical substances, unless specifically listed as a covered drug above;
4. Drugs intended for use in a physician’s office or in a setting other than for home use;
5. Medication to be taken or administered to any individual, in whole or in part, while he or she is a patient in a licensed hospital;
6. Prescriptions that an eligible person is entitled to receive without charge, such as prescriptions provided under a workers’ compensation law, or any municipal, state, or federal program;
7. Charges for drug administration;
8. Fertility/infertility drugs;
9. Immunization agents, biological sera, blood, or blood plasma;
10. Prescriptions directing parenteral (I.V.) use, as these are covered under the medical plan when Pre-Certified;
11. Pain medications in excess of $500 in a twelve month period, unless the patient is in a Hospice program or the medication is Pre-Certified by the Plan;
12. Retin-A, if the patient is over 19 years of age, unless determined by the Plan to be medically necessary and Pre-Certified by the Plan;
13. Minoxidil and rogaine, unless determined by the Plan to be medically necessary;
14. Drugs labeled "Investigational Use" or "Experimental;"
15. Dietary supplements, anorexiants, diet pills and liquid diets;
16. Vitamins of any kind except vitamins included above;
17. Medication for cosmetic purposes;
18. Smoking deterrents (these are covered under Preventive Care benefit);
19. Non-drowsy antihistamines; and
20. Human growth hormone unless Pre-Certified by the Plan.