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Health Fund

Getting The Most From Your Benefits

Retail Purchases

If you have a short-term illnessA sickness or disease that causes loss covered by the plan. Pregnancy is considered a sickness with respect to a covered female participant, the Same-Sex Domestic Partner of a female covered participant and the spouse of a male covered participant only. Pregnancy for dependent children isn't covered, except for complications of pregnancy. or injuryBodily harm caused by an accident. The injury must also result, for the purposes of accidental death and dismemberment coverage, directly and independently of all other causes, in a loss covered by the plan. and need to fill a prescription for up to a 30-day supply and one refill, you can purchase your medication at a retail pharmacy. You may go to any retail pharmacy you wish, but if you use a participating pharmacy, you pay only a copay at the time of purchase. Participating pharmacies have negotiated a lower rate for prescription drugs, so you pay less. If you go to a non-participating pharmacy, you will pay more. You will also have to pay the full cost of the medication up-front, and then send in your receipt (proof of purchase) for reimbursement.

When you go to a participating pharmacy:

For a copy of the participating retail pharmacies within your home state or when traveling, contact Express Scripts or visit their website. (See the Summary Of Benefits, page 16, for contact information.)

When you go to a non-participating pharmacy:

  • Present the pharmacist with your prescription for up to a 30-day supply (and one refill) of medication.
  • Pay the pharmacy the full amount of your prescription.
  • Obtain a copy of the pharmacy claim form from our website at, forms section. Submit your receipt along with this
    claim form to Express Scripts.  You'll receive a reimbursement of the highest dollar amount according to the plan formula. (See "Filing a Claim" on page 60.)


You are eligible to receive a discount off the purchase price of any prescription drug not covered under the Fund's prescription plan. This pricing discount is available at any retail pharmacy that participates in the Express Scripts (E.S.I.) pharmacy network and through E.S.I.'s mail order pharmacy.

At retail - just present your Health Fund ID card to your participating retail pharmacy, they will run your card through the E.S.I. system and obtain your discounted cost. You will pay 100% of the discounted cost for the noncovered drug.

To use E.S.I.'s mail order pharmacy – simply mail your prescription in with your completed "mail order Form" to E.S.I. for processing. You can determine your cost for the medication in advance by logging onto E.S.I.'s website.

Mail-Order Prescriptions

Express Scripts, your mail-order service and online pharmacy, conveniently delivers your long-term maintenance medicationsPrescription drugs that are used on an ongoing basis (e.g., thyroid replacement, diabetes or cardiac medications). for up to a 90-day supply - postage paid - to your home.

After you've completed the first month of your prescription plus one refill, the prescription drug program requires you to use the mail-order service for all maintenance medications. If you go to a retail pharmacy to refill a prescription for a third consecutive month, you will be responsible for the entire cost of the prescription.

To avoid this situation:

  • Ask your physician to prescribe a 90-day supply for your maintenance
    medications with the appropriate number of refills. You may want to share the PDL with your physician. This list is available upon request from the Administrative Office or from Express Scripts. The pharmacist will automatically fill the prescription with a generic equivalent, unless your physician specifies "DAW."
  • If you need to begin a new maintenance medication immediately, have your physician write two prescriptions:
    • One for up to a 30-day supply to be filled immediately at a retail pharmacy; and
    • Another for up to a 90-day supply (plus up to three refills, if applicable) to be filled through the mail-order service.
  • If your physician prescribes a 30-day or 60-day supply of medication and you send the prescription to the mail-order service, you will be charged the full mail-order copayA fixed dollar amount you pay for an eligible expense at the time the service is provided. for a 90-day supply, so it may be more cost-effective to fill the prescription at a retail pharmacy.
  • If you are currently on a maintenance medication that you want to start obtaining through the mail-order service, ask your physician to write a new prescription for a 90-day supply with three refills, if applicable.

Savings Synopsis
When you purchase prescription drugs through the mail-order service, you pay one low copay for up to a 90-day supply, and you pay the lowest copay of all when your physician prescribes genericA prescription drug that has the same active ingredients as a brand-name drug and is subject to the same FDA standards for quality, strength and purity as its brand-name counterpart, but is marketed with its chemical name and typically costs less. Not all brand-name drugs have generic equivalents. medications. Keep in mind that you will pay the same copay for a 90-day supply through the mail-order service as you would pay for a 60-day supply from a retail pharmacy.

You will be asked to complete a patient profile card the first time you use the mail-order service. Every time you fill a new prescription, you will need to complete an order form. The form is available by calling the Administrative Office or by visiting the Express Scripts website. Remember to include your prescription drug ID card number on the form.

Mail the following in the pre-addressed envelope:

  • Patient Profile Card;
  • Order form;
  • Original prescription(s) written by your physician; and
  • Your copay(s). Refer to the Summary Of Benefits, page 12 for the correct amount.

You should receive your medication within 10 to 14 days from the date you mail your order. Due to this short delay, it's important to plan ahead for your long-term medication needs.


Your prescription label lists the date when you can request a refill and indicates the number of refills remaining. Refills will be filled only 30 days or less before your current supply runs out.

The fastest way to receive your refills through the mail-order service is to log on to Express Scripts website. To order a refill, have the following ready:

  • Prescription number;
  • ZIP Code; and
  • Credit card information.

You may also:

  • Call Express Scripts; or
  • Mail in an authorization (sent with your mail-order prescriptions) for refills of medication currently on file.

What You Pay

You're responsible for paying a copayA fixed dollar amount you pay for an eligible expense at the time the service is provided. for each prescription. What you pay depends on:

  • Whether the drug is a generic, a preferred brand or a non-preferred brand;
  • The quantity (e.g., 30-day or 90-day supply); and
  • Whether you purchase it at a participating pharmacy or a non-participating pharmacy, or through the mail-order service.

Whether you use a retail pharmacy or the mail-order service, you do not have to meet a calendar-year deductible The portion of eligible expenses you're responsible for paying each calendar year before the Fund begins to pay certain benefits. before benefits begin. The prescription drug program generally pays 100% of eligible prescription drug costs after you pay a copay for each prescription, and there is no out-of-pocket maximumThe maximum amount you pay in coinsurance each plan year for eligible medical expenses..