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Sergeants Benevolent Association Official Document Prescription Drug Retiree Plan B Benefit Information
Using Your
You may present your SBA prescription benefit card at any pharmacy. The Prescription
pharmacy will electronically process your claim and collect the applicable co- Pharmacy
You have access to an extensive national pharmacy network comprised of more than 64,000 independent and chain retail pharmacies. Please visit the
Prescription Solutions Web site ato use the
Locate a Pharmacy feature to find the pharmacy nearest to you. 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.
Mail Order
Maintenance medications are available through our mail service pharmacy Prescription Solutions Mail Service Pharmacy. For registration, order forms, or information on covered medications please contact Prescription Solutions Mail Service Pharmacy at (800) 562-6223 or the SBA Health & Welfare office at (212) 431-6555. Mandatory
The SBA Prescription Drug plan is a mandatory generic reimbursement Generic Drug
program. Under the mandatory generic program, when there is a generic equivalent available, the SBA will cover the cost of that generic equivalent less your co-pay. Should you or your doctor insist on receiving a brand name medication where a generic equivalent is available, you will be responsible for the full cost of the brand name medication. You will not be reimbursed by the SBA Fund. As this can be very costly to you, we recommend that you thoroughly discuss generic medications with your physician. Non-Medicare:
Prescription
Plan B non-medicare eligible participants have a 30% + $5.00 co-payment for Program Co-
single source brand medications and a 20% co-payment for multi source generic drug claims. Plan B non- medicare members have a family maximum allowable benefit of $6,000. Sergeants Benevolent Association Official Document Prescription Drug Retiree Plan B Benefit Information, Continued
Medicare:
Prescription
Plan B medicare eligible participants have a 30% + $5.00 co-payment for Program Co-
single source brand medications and a 20% co-payment for multi source Pays (continued) generic drug claims. Plan B medicare eligible participants (husband, spouse
etc.) have an individual maximum allowable benefit of $7,500. Please be aware that your medicare eligible spouse’s and/or medicare eligible dependent’s Social Security number is need so the SBA can notify Medicare/CMS that they have “creditable” prescription drug coverage under the SBA prescription drug plan. If your spouse or eligible dependent become medicare eligible, it is imperative that you complete theand forward it to the SBA Health & Welfare office via fax (212) 431-6487, attention: Medicare Eligibility Unit or mail to: Sergeants Benevolent Association Attn: Medicare Eligibility Unit 35 Worth Street New York, NY 10013 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. Coverage of
The SBA Health & Welfare Fund does not cover diabetic medications and Diabetes
related medical equipment for non-Medicare members and their non- Management
Medicare eligible dependents. These medications are covered under the basic medical benefits by all New York City health plans. Diabetes management education is also provided to educate members on the proper self-management of their condition. Members requiring diabetes products should bring their health benefits ID card to their pharmacy along with their prescriptions. Those members that are enrolled in Medicare, or have eligible dependents enrolled in Medicare, should contact the SBA Health & Welfare Funds office so arrangements may be made for them to obtain their diabetic medications through the SBA Prescription Plan. Sergeants Benevolent Association Official Document Prescription Drug Retiree Plan B Benefit Information, Continued
Over-the-
If you currently take a prescription medication for allergy symptoms there are alternatives that can save you money. The SBA prescription plan now offers Medications at
coverage for two over-the-counter (OTC) products – Loratadine (generic Alavert/Claritin) and Cetirizine (generic Zyrtec) – at no cost to you! Members will realize savings of $10-$50 per 30-day supply. These products are equally safe and effective alternatives to similar prescription-only medications. • If you currently take a non-sedating antihistamine such as Allegra, Zyrtec or Clarinex, or generic Fexofenadine you now have the option of receiving Loratadine or Cetirizine at absolutely no cost to you! Plan Coverage
All participants presenting a new prescription for brand name Statin class of “Statin”
medications are subject to a step therapy program. This step therapy program necessitates participants initially utilizing first line generic Statins. The Medications
member co-pay for all generic stain class medications is waived. The following generic medications are eligible under this program Lovastatin (generic of Mevacor), Pravastatin (generic of Pravachol) and Simvastatin (generic of Zocor). Plan Coverage
Brand name Proton Pump Inhibitor (PPI) class medications (Prilosec, for Proton
Nexium, Aciphex, Prevacid, and Zegerid) are not be covered by the SBA Fund. Generic PPI medications Omeprazole (generic Prilosec) and Inhibitors Class Pantopazole (generic Protonix) are covered at no cost to the member.
Medications
The PICA prescription drug plan is a negotiated health benefit gained through Prescription
collective bargaining between the Municipal Labor Committee and the City of New York. Effective July 1, 2005 PICA covers drugs that are injected and
cancer drugs only. Use your PICA prescription benefit card to obtain these
drugs. They are not covered by the SBA Health &Welfare Fund prescription
drug plan. To obtain more information regarding PICA, you can call Express
Scripts Customer Services at (800) 467-2006 or visit
Members or dependents who are Medicare qualified are not eligible for
PICA drugs.
For more information, please clic
Sergeants Benevolent Association Official Document Prescription Drug Retiree Plan B Benefit Information, Continued
Customer
Prescription Solutions has dedicated customer service representatives available to serve you 24 hours a day, 7 days a week. You may reach Prescription Solutions toll-free at (877) 559-2955. The SBA Health & Welfare Fund is also available to answer questions or assist members at (212) 431-6555. Prescription Solutions’ physicians and pharmacists, who serve on the Pharmacy Authorizations
& Therapeutics (P&T) Committee, along with a Pharmacist representative of True Health Benefits, are responsible for reviewing all new medications as they come to market. With each agent, they consider whether a medication should be covered under the prescription benefit. In addition, they may recommend quantity limits and prior authorization to ensure appropriate use. When making a recommendation, the P&T Committee focuses on the medication's overall health benefit as well as the cost. The P&T Committee will consider FDA recommendations, manufacturer package labeling instructions, and published clinical recommendations, such as the Journal of the American Medical Association (JAMA). Based on the P&T committee decisions certain medications have prior authorization guidelines established. Physicians can call Prescription Solutions’ Prior Authorization representatives directly at (866)-565-7723. If approved the prior authorization is entered automatically into the system. If denied, the physician is informed over the phone and the reason why it was denied. Quantity Limits 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 office at (212) 431-6555 or the Prescription Solutions Customer Service Center (877) 559-2955.

Source: http://sbanyc.org/documents/benefits/health&Welfare/prescriptions/prescriptionDrugRetireePlanBBenefitInformation.pdf