DC 37 Health & Security Plan Benefits
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. The
following co-payments are in effect as of July 1, 2006:
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 2010, members and
retirees with prescriptions for cholesterol lowering drugs known as statins won't
be charged co-pays for the generic versions of their medication. For a flyer with
here. (PDF format*)
The Psychotropic, Injectable, Chemotherapy & Asthma
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 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
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.
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 all 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.
The Annual limit for the prescription drug benefit is $100,000
per cardholder, per calendar year. The cardholder includes the total prescription
utilization of the member and all eligible dependents. The Plan's annual limit
consists of Plan approved medications and is subject to all Plan rules and guidelines.
Drug Reimbursement Claims
If a member does not have the drug
card with him/her, or does not go to a participating pharmacy, then the direct
reimbursement method must be used. Drug re-imbursement claim
forms (PDF format*) are
posted on the Prescription Solutions website. The member will be reimbursed based on the amount
listed in the Plan's drug schedule in accordance with the generic based program,
minus the appropriate co-payment, regardless of the actual amount spent for the
Rx Instep (Step Therapy Program)
The Plan has
instituted the mandatory Rx Instep 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.
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.
drug categories in the Rx Instep 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
If your doctor is prescribing a medication for an Rx Instep
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 an Rx Instep 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 Actively Working Members and the DC 37 Prescription
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.
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
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.
DC 37 Health & Security Plan's prescription drug benefit will be directly
impacted if you choose to enroll in an independent Medicare prescription drug
benefit plan or receive a Medicare prescription drug benefit through your enrollment
in a Medicare Advantage health insurance plan.
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, Prescription Solutions 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
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.
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 Rend
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;
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;
foods and diet supplements that may be purchased with or without a prescription;
drugs supplied by a treating physician;
or experimental drugs;
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;
agents and biological sera;
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;
medication for active members and non-Medicare eligible retirees and eligible
dependents except as noted;
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;
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
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;
fertility medication, up to 12 treatments per lifetime;
for the class of prescription drugs used to treat male sexual dysfunction will
require pre-approval by the Plan, must be dispensed through our mail service program
and will have a 50% co-payment and an annual cap of $500.00.
for the class of prescription drugs used to treat obesity will require pre-approval
by the Plan and will have a 50% co-payment and an annual cap of $500.00
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.
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 Plan annual limit or coverage gap.
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, Medicare,
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.
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
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