Prescription Drug Coverage

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

Prescription drug card program
This is a self-insured benefit provided by the Fund through Caremark, Inc. 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 $5,000 per fiscal year (April 1 to March 31) for all family prescription drug expenses incurred for illness, injury, or disease.

For Plan A participants, there is a 40 percent member co-payment and the SBA H&W Fund pays 60 percent of the cost of each dispensed prescription drug. However, there is a minimum $5.00 co-payment for single-source brand name drugs (those offered when no generic available) costing less than $50.

For Plan B participants, there is a 30 percent member co-payment and the SBA H&W Fund pays 70 percent of the cost of each dispensed prescription drug. However, there is a minimum $5.00 co-payment for single-source brand name drugs (those offered when no generic available) costing less than $50.

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 30 percent or 40 percent co-payment. As this can be very costly to you, we suggest that you thoroughly discuss generic medications with your physician.

Covered drugs
Covered drugs must be prescribed by a doctor, dentist or physician licensed in the state in which the treatment is given for illness, injury or disease, and must be dispensed by a licensed pharmacist. This benefit covers:

(1) Prescriptions, which require compounding, with certain exceptions (see “Exclusions”)
(2) Prescriptions, which are for Federal Legend drugs (drugs which by law cannot be dispensed by a pharmacy without a prescription), with certain exceptions (see “Exclusions”
(3) State restricted drugs, with certain exceptions (see “Exclusions”)

Coverage of diabetes management
The SBA Health & Welfare Fund does not cover diabetes management equipment, as insulin, syringes, oral agents, diabetes testing and monitoring equipment and supplies for controlling blood sugar are now legally mandated under the basic benefits program of all New York City health plans. The law also provides for diabetes management education to ensure that persons with diabetes are informed as to the proper self-management of their diabetic condition.

PICA prescription plan
The PICA prescription drug plan is a negotiated health benefit gained through collective bargaining between the Municipal Labor Committee and the City of New York., This benefit became effective July 1, 2001 and covers psychotropic, injectable, cancer and asthma drugs. Use your PICA prescription benefit card to obtain these drugs. They are not covered by the SBA H&W Fund prescription drug plan.

Prescription drug purchasing options
Under our prescription drug program you have the option to use the Participating Pharmacy Program, or a non-participating pharmacy. You can obtain a 30-day supply of medication at your participating or non-participating pharmacy. If you have a chronic medical condition which requires long-term use of prescription drugs you should use the Caremark mail-service pharmacy. If you use a non-participating pharmacy you will be reimbursed in accordance with a specific schedule of allowances. You may obtain a direct reimbursement form from the Fund office. Claim data must include member’s name, social security number, patient name, relationship, NDC number, drug name, date dispensed, dosage, pharmacy name and drug cost.

Please Note: Your out-of-pocket costs are likely to be greater when you use a non-participating pharmacy instead of one that is a member of our plan. However, virtually every pharmacy in the United States is a participating pharmacy.

Can my pharmacy join the Caremark participating pharmacy network?
Yes. Please have your pharmacy contact via E-mail at customerservice@caremark.com if they are interested in becoming a participating pharmacy. You may also use this E-mail address to obtain the names of participating pharmacies in your area.

The mail-service pharmacy
If you wish to use the mail service pharmacy for maintenance medication you may do so by accessing Caremark’s online pharmacy at www.caremark.com. For more information on how to enroll, call Caremark at (800) 237-2767.

To ascertain or verify the required co-payment please call Caremark at that same number. There is a 40 percent or 30 percent (depending on your membership in Plan A or Plan B) co-payment consisting of a $5 minimum payment for generic drugs and a minimum $15 co-payment for single source brand name drugs. If you order a brand name drug which has a generic equivalent you will be required to pay the difference between the generic and brand name drugs in addition to the 10 percent co-payment, for a three-months supply of medication.

Prescription plan enrollment
The Fund office enrolls all eligible members at the time of their eligibility. Caremark will be directed to issue you a prescription drug ID card at the time of your enrollment in the SBA H&W Fund. If you wish to add a dependent due to marriage, birth or adoption, please notify the Fund office immediately, so that a new card may be issued to cover your new dependent. If you have an eligible child who attends college away from home, you may request a second card.

What is not covered by the Fund’s prescription plan

(1) Drugs which are not federal legend drugs. These are drugs, which may be purchased without a prescription. Over-the-counter drugs, even if prescribed and dispensed in the manner a federal legend drug would be normally prescribed and dispensed, are not covered.

(2) Allergens, antigens and other prescription drugs purchased from a laboratory or physician directly

(3) Birth control medication

(4) Fertility drugs

(5) Growth hormones

(6) Impotence drugs

(6) Any prescription prescribed for reasons other than illness, injury, or disease.

Important Changes Will Occur To The PICA Drug Program

Effective April 1, 2004

02/22/04

Effective April 1, 2004 important changes will occur in the PICA drug program which covers Psychotropic, Injectable, Chemotherapy, and Asthma medications.

Click here view all the PICA changes PDF (Requires Adobe Reader)

Click here to view PICA Q&A PDF (Requires Adobe Reader)

Click here to download Adobe Reader