Prescription Drug Coverage

Welcome to the SBA prescription benefits program! We have teamed with True Health Benefits and Innoviant to assist you with your prescription questions and help you to save money in the process. If you have any questions, you may contact the Innoviant customer service center at (877) 559-2955 or the SBA Health & Welfare Fund at (212) 431-6555.

Eligibility
All members and their eligible dependents, otherwise eligible to participate in the SBA’s member benefit plans, are entitled to this benefit as described in the “Eligible FAQs” section.

Prescription drug card program
This is a self-insured benefit provided by the Fund. Every covered member is issued a prescription drug card that will certify the member and dependents for eligibility to the prescription drug program. The Fund pays up to $7,500 per fiscal year (July 1 to June 30) for all family prescription drug expenses incurred for illness, injury, or disease.

Pharmacy Network
You now have access to an extensive national pharmacy network comprised of more than 56,000 independent and chain retail pharmacies. Please visit the Innoviant Web site at www.innoviant.com to view the pharmacy finder feature. Simply input your ZIP code and you will receive a list of participating pharmacies along with their locations and phone numbers. You may also click on the map icon to view directions to the pharmacy.

Using Your Prescription Card
You can present your prescription card at any pharmacy that is part of the network. If you have an existing prescription, with refills remaining, at a participating pharmacy, simply present your new prescription card to the pharmacist. A new written prescription is not required. The pharmacy will electronically process your claim and collect the applicable co-payment.

PICA Carve Out
Injectable and chemotherapy products will continue to be covered under your New York City PICA program. The SBA prescription program will now cover the psychotropics and asthma products previously covered under the New York City PICA program.

SBA Prescription Program Co-pays

• The current SBA prescription percentage co-pays for active members, through the SBA prescription program, is 10%. However, for single-source brand name drugs (those offered when no generic available) member pays a 10 percent co-payment with a $5.00 minimum.
• The PICA component now covered under the SBA prescription program will be subject to the current SBA percentage co-pays.

Is this a mandatory generic drug program?
Yes. However, should you or your doctor insist on receiving a brand name medication where a generic equivalent is available, you have the option to pay the difference between the cost of the brand name and the generic equivalent, in addition to the 10 percent co-payment. As this can be very costly to you, we suggest that you thoroughly discuss generic medications with your physician.

Customer Service

Innoviant has dedicated customer service representatives available to serve you. You may reach Innoviant toll-free at (877) 559-2955 Monday through Friday 8 a.m. to 10 p.m. ; Saturday 10 a.m. to 6 p.m. ; Sunday 1 p.m. to 6 p.m. You may also contact Innoviant customer service via e-mail at RxQuestions@innoviant.com. The SBA Health & Welfare Fund is available at (212) 431-6555.

Rx InStep programs employ “smart edits” requiring patients to use clinically effective products that have the most economic value within specific therapeutic categories. These programs are created for categories where there are a number of products that deliver similar safety and effectiveness but have significant differences in cost.

To ensure continuity of your benefits for coverage of Psychotropic and Asthma Products, as previously administered under the New York City PICA program, the same criteria has been maintained for use in review of these products.*

The Rx InStep includes the following categories and medications:

*Members with utilization history of these medications between April 1 and June 30, 2005, will have their pre-authorization automatically transferred to the new program.

Prior Authorization (PA) review is needed to determine coverage for products listed in the “Step Therapy Required” column if the product(s) in the “Covered” column have not been tried or if therapy on these products has failed*.

Members can request prior authorization by contacting the Innoviant customer service center toll-free at (877) 559-2955. A member service representative can prepare and fax a prior authorization form to the prescribing physician. When the physician returns the completed form to Innoviant, a clinical review of the documented information is completed within two business days. The clinical decision is documented in writing to the physician. A copy of the letter provided to the physician is also provided to the member.

Quantity limits are based upon FDA guidelines, published clinical recommendations, such as the Journal of the American Medical Association (JAMA), as well as FDA approved labeling as described in the manufacturer package insert. Limits are intended to encourage appropriate dosing. These limits are not intended to restrict access to quantities of medications where limits would not be considered functional or appropriate. If you have questions regarding these limits, please contact the SBA Health & Welfare Fund or the Innoviant Customer Service Center . Following is a list of specific products and their defined limits*:

*Members with utilization history of these medications between April 1 and June 30, 2005, will have their pre-authorization automatically transferred to the new program.

*Members with utilization history of these medications between April 1 and June 30, 2005, will have their pre-authorization automatically transferred to the new program.

Products requiring prior authorization are identified based on FDA recommendations, FDA approved labeling as described in manufacturer package inserts, and published clinical recommendations, such as the Journal of the American Medical Association (JAMA). The following products will require prior authorization*:

*Members with utilization history of these medications between April 1 and June 30, 2005, will have their pre-authorization automatically transferred to the new program.

Members can request prior authorization by contacting the Innoviant customer service center toll-free at (877) 559-2955 Monday through Friday 7 a.m. to 9 p.m. ; Saturday 9 a.m. to 5 p.m. ; Sunday 12 p.m. to 5 p.m. CST . A member service representative can prepare and fax a prior authorization form to the prescribing physician. When the physician returns the completed form to Innoviant, a clinical review of the documented information is completed within two business days. The clinical decision is documented in writing to the physician. A copy of the letter provided to the physician is also provided to the member.

How do I get a prescription filled?

• Simply present your prescription card and prescription to the pharmacist. The pharmacist will process your claim electronically and collect the applicable co-payment.

How do I know if a pharmacy is in the network?

• To find a participating pharmacy, simply visit the Innoviant Web site to view the pharmacy finder. Input your ZIP code and you will receive a list of the participating pharmacies along with their locations and phone numbers.

Who should I call with questions or concerns about the program?

• Please call the Innoviant customer service center with questions about your benefits or email us at RxQuestions@innoviant.com. You may also contact the SBA Health and Welfare Fund at (212) 431-6555.

Over-the-Counter Medications at No Cost!

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Mail Order Prescriptions Available In The Near Future

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