The Fund provides a prescription drug benefit under both medical plans. It is administered by Sav-Rx and only pays a benefit when a prescription is filled at a Sav-Rx participating pharmacy. The benefit level depends on the type of drug—generic, preferred brand name or non-preferred brand name—and if it is filled at a retail pharmacy or through mail order. When you are at a retail pharmacy, present your Sav-Rx identification card and pay your copay amount as indicated in the chart below. Also, be sure to review the Step Therapy Program section below to see if any of your medications are subject to step therapy.
When you have your prescriptions filled at a participating Sav-Rx pharmacy, you save money. Locate participating retail pharmacies at www.savrx.com and enter in group number “IBEWD4” or call Sav-Rx at 1-866-233-IBEW.
Prescription Drug Benefits Summary
|Program||Generic Drugs||Preferred Brand Name Drugs||Non-Preferred Brand Name Drugs|
Up to a 34-day supply or 100 units, whichever is greater
|You pay 10% with a $10 minimum*/$100 maximum copay per initial fill and refill||You pay 20% with a $15 minimum*/$100 maximum copay per initial fill and refill||You pay 30% with a $30 minimum*/$100 maximum copay per initial fill and refill|
|Mail Order Program
Up to a 90-day supply
|You pay a $15 copay per initial fill and refill||You pay 20% with a $40 minimum*/$200 maximum copay per initial fill and refill||You pay 30% with a $60 minimum*/$200 maximum copay copay per initial fill and refill|
|Voluntary Self-Injectable Specialty Drug Program||You pay 10% with a $10 minimum*/$100 maximum copay per initial fill and refill||You pay 20% with a $15 minimum*/$100 maximum copay per initial fill and refill||You pay 30% with a $30 minimum*/$100 maximum copay per initial fill and refill|
|Sav-Rx Network Usage Requirement||Benefits are not payable for prescriptions filled at pharmacies that are not in the Sav-Rx network. Check to make sure that your pharmacy is part of the Sav-Rx network before filling your prescription. Note: Not all chains/pharmacies are in the Sav-Rx network, including Wal Mart, Sam’s Club, and certain Rite-Aid locations.|
|Generic Medication||If your doctor indicates a generic medication is acceptable, but you choose to have your prescription filled with a preferred or non-preferred brand name drug, you must pay the difference in cost between the preferred or non-preferred brand name and the generic medication, plus the preferred or non-preferred brand name copayment amount.|
*Note: If the cost of a medication is less than the minimum copay amount, you are responsible for the actual cost of the medication, plus the dispensing fee. For example, if a preferred brand name medication costs $7 (the Plan’s minimum copay is $15 retail/$40 mail order), you will pay $7, plus the dispensing fee—not the applicable minimum copay.
How the Sav-Rx Program Works
When you become eligible to participate in the Plan, you will receive a personalized Sav-Rx Prescription Benefits ID card (with eligible family status listed). You must present your ID card, along with your doctor’s prescription, to any participating Sav-Rx pharmacy. No benefits are payable for prescriptions filled at a non-network pharmacy.
The pharmacist will fill the prescription and charge you a copay (which is the amount you pay). In addition, the pharmacist will generally ask you to sign a form indicating that you received the prescription. It is permissible for any of your eligible dependents to present your ID card with a prescription to the pharmacist and sign for receipt of the prescription.
When benefits are not payable
A point of sale purchase of a prescription is not a claim for benefits. If you elect to have your prescription filled by a pharmacy other than a participating Sav-Rx pharmacy, no benefits are payable by the Plan.
In addition, if you are not eligible for benefits at the time you contact the pharmacy, or in the event that the prescription is not a covered drug under the Plan, you must contact the Fund’s Administrative Office for additional information regarding the adverse benefit decision.
The Fund’s Administrative Office will provide you with a “Notice of the Adverse Benefit Determination,” in writing, that contains the following:
- The specific reasons for the adverse benefit determination;
- The specific reference to the Plan and/or Summary Plan Description provisions on which the adverse benefit determination was based;
- A description of any additional materials or information necessary for you to perfect your claim and an explanation of why such material or information is necessary;
- The notice of any internal guidelines or protocols used in making the decision, if applicable, and your right to receive a copy;
- A notice of your right to a written explanation of any exclusion which affects your claim; and
- A description of this Plan’s Appeals Procedure.
The annual out-of-pocket maximum is the most you will pay out of your own pocket for covered expenses each year. Once you meet the maximum, the Fund pays 100% of all covered costs for the rest of the year. This means that prescription drugs will be covered as shown above until you reach the out-of-pocket maximum for your Medical Plan (see below). Then, the Fund will pay 100% of eligible prescription expenses for the remainder of the calendar year.
- Building Trades Plan: $2,850 (single); $9,450 (family)
- Flexible Choice Plan: $1,600 (single); $8,200 (family)
Step Therapy Program
Step Therapy is a program especially for people who take prescription drugs regularly for ongoing conditions like arthritis, asthma and high blood pressure. It helps you get an effective medication to treat your condition while keeping costs as low as possible. Step Therapy requires you to first try certain drugs to treat your medical condition before another drug will be covered.
For example, if Drug A and Drug B both treat your medical condition, the Fund may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the Fund will then cover Drug B. In this example, Drug A is the first step in the step program and is usually a generic drug. These drugs should be tried first because they can provide the same health benefit as brand-name drugs but at a lower cost. Drug B is considered a back-up drug (Step 2 and Step 3 drugs). These are brand-name drugs, such as those you see advertised on TV, and their costs are based on the Step number (i.e., Step 2 drugs tend to cost less than Step 3 drugs).
Examples of typical therapeutic classes and medicines that require Step Therapy include, but are not limited to: Proton Pump Inhibitors (like Prevacid/Nexium), statins for cholesterol, sleep aids, SSRI/SNRI antidepressants, nasal sprays, osteoporosis medications, ARB antihypertensives and combination antihypertensive, Lyrica, Nasal Sprays, Overactive Bladder, Tekturina, Glaucoma Agents and Migraine Medications.
For a complete list of medications, or if you have questions about Step Therapy, contact Sav-Rx at 1-866-233-IBEW.