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How Your Prescription Drug Benefits Work Under the PPO Plan and Low Option Plan

Outpatient prescription drug benefits are not available if you enroll in the Low Option Plan.

Prescription Drug Benefits

The prescription drug program is administered by Express Scripts, an independent Claims Administrator. You and your dependents are covered for the cost of prescription medication for all outpatient needs through our outside Claims Administrator. You can purchase your medication from retail pharmacies and through the mail-order service.

Who's Covered

You and your covered dependents are covered for outpatient prescription drugs if you're enrolled in the PPO Plan. Your coverage begins when you become eligible for medical benefits. Coverage for your dependents begins after you enroll them in the plan and pay the required dependent coverage premium.

Coordination of Benefits (COB)

The COB provision will be applied to the Prescription Drug Program. COB will apply when you obtain your prescription at a retail pharmacy or when you use Express Scripts by Mail. If your primary plan requires you to pay a portion of the drug cost, you will then have an opportunity to submit that portion to the Fund for reimbursement consideration. This will not apply to
Certified Retirees, whose primary medical coverage is Medicare — we will continue as the primary plan for their prescription drugs.

If your coverage through the Fund is secondary, the COB claim form is available on our website at www.wgaplans.org, click "Forms/Health Fund". You will need to submit an Express Scripts COB claim form along with the following information:

  • The primary plan's explanation of benefits (EOB) statement; and
  • A copy of the pharmacy receipt or invoice that supports the prescription submitted to the primary plan.

Express Scripts will coordinate with your primary plan and reimburse you the lesser of:

  • The amount your primary plan did not cover for you; or
  • What the Fund would have paid on your behalf if it was the primary plan.

Claim Example:  Participant uses their primary plan's RX card at the pharmacy and was responsible for the primary plan's $20 copayA fixed dollar amount you pay for an eligible expense at the time the service is provided.. This is how the claim was coordinated with the primary plan and benefits paid:

Fund's Primary
Calculation
Amount Submitted For
Secondary Payment
Fund's approved
amount
$ 50.00   Primary Plan's
copay amount
$  20.00 
Less copay  $(10.00)   _____________________________
Fund's normal
benefits
$ 40.00   Amount submitted for reimbursement $  20.00 
Reimbursement amount will be the lesser of the two
Amount Reimbursed To The Participant $20.00
Participant's Out-of-Pocket: $0.00


How The Prescription Drug Program Works

There are three categories of prescription drugs under your prescription drug benefit:


You will pay a lower copayA fixed dollar amount you pay for an eligible expense at the time the service is provided. for generic and preferred-brand drugs than you will for non-preferred drugs. You'll automatically receive a copy of the PDL at no charge. To obtain a copy of the PDL, contact Express Scripts or visit their website. Their contact info is listed in the Summary Of Benefits on page 16.

You can fill your prescriptions in these three ways:

  • For short-term medication, you can fill a prescription for up to a two month supply (initial plus one refill) at:
    • A participating retail pharmacy; or
    • A non-participating pharmacy.
  • For long-term (maintenance) medication, you must use the mail-order service when you fill a prescription. Otherwise, you'll be required to pay the full cost of the medication.

Important!

Using the mail-order program is your most effective option when purchasing long-term maintenance medicationsPrescription drugs that are used on an ongoing basis (e.g., thyroid replacement, diabetes or cardiac medications).. Ask your physician to write a prescription for a 90-day supply of each of the maintenance medications you need (including refills) and mail it with your order form and applicable copay(s) to Express Scripts.


Because both you and the Fund pay the least when you purchase prescription drugs through the convenient mail-order service, using this service whenever possible is the most cost-effective way to fill your prescriptions.


Important!

Both the Fund and you will pay the least when you purchase generic drugs through the mail-order service and the most when you purchase non-preferred brand-name drugs at retail pharmacies.

If you purchase a brandname drug when a generic drug is available - even if the physician prescribes "Dispense as Written" (DAW) - you'll pay the generic copayA fixed dollar amount you pay for an eligible expense at the time the service is provided. plus the difference in price between the generic and the brand-name drug. Keep in mind that the price difference can be considerable, so you may want to ask your pharmacist to give you the price information before you make your decision.  At the time your physician writes the prescription, you may also want to ask him/her whether a generic equivalent can be substituted.