• SPD Table of Contents
  1. Important Contact Information
  2. Introduction
  3. Table of Contents
  4. Plan A Schedule of Benefits
  5. Plan B Schedule of Benefits
  6. Plan C Schedule of Benefits
  7. Plan 11 Schedule of Benefits
  8. Plan 11-C Schedule of Benefits
  9. Eligibility for Active Participants
  10. Eligibility for Retiree Coverage
  11. Insurance Coverage
  12. Weekly Loss of Time Benefit
  13. Medical Benefits
  14. Prescription Drug Program
  15. Medicare Part D Prescription Drug Plan (PDP) for Retirees
  16. Members Assistance Program (MAP)
  17. Dental Benefit
  18. Vision Benefit
  19. Hearing Benefit
  20. Special Fund Program
  21. General Plan Exclusions and Limitations
  22. Other Limitations on Your Benefits
  23. Definitions
  24. Claim and Appeal Procedures
  25. General Plan Provisions
  26. Information About the Plan
  27. Board of Trustees

Prescription Drug Program

The Plan’s Prescription Drug Program is administered by Sav-Rx, a pharmacy benefit manager, in accordance with a contract with the Trustees. Your co-pay amounts are listed in the Schedule of Benefits applicable to your benefit plan.

YOUR CO-PAYS

Your co-pay amounts or percentages are shown in the Schedule of Benefits for your benefit class. Co-pays vary depending on your benefit plan, whether the drug is a generic, preferred brand or non-preferred brand. Co-pay amounts also vary according to where you purchase the drugs, and the quantity purchased.

• 30-Day Retail Card Program - Your prescription retail card enables you to purchase covered prescription drugs at any participating pharmacy. The 30-day retail card program is for short-term or acute prescription drugs, such as antibiotics or pain relievers. All the large retail pharmacy chains, and most independent pharmacies participate in the Sav-Rx network.
• Mail-Order Program - The mail-order program is for long-term or maintenance prescription drugs, the prescription medications you take on an on-going basis for chronic conditions such as high blood pressure, heart disease, diabetes, arthritis, etc. For each prescription refill, you can order the amount prescribed by your physician up to a 90-day supply.

• 90-Day Retail Program - You also have the option of obtaining your long-term or maintenance (90-day) prescriptions from any Walgreen pharmacy under the 90-day retail program. Your co-pays will be higher than the mail-order co-pays because the cost of drugs purchased at the retail level is higher than the cost of the mail-order pharmacy.

Out-of-Pocket Limit for Drug Co-Pays

For all benefit plans other than Plans 11 and 11-C, the out-of-pocket limits under the Major Medical Benefit and the Prescription Drug Program are integrated. This means that your prescription drug co-pay amounts apply to the in-network out-of-pocket limit under the medical plan. If your out-of-pocket limit is met during a calendar year, your prescription drug co-pays will be $0 for the remainder of that year. Similarly, if your family’s innetwork out-of-pocket limit is met, your eligible family members will have no prescription drug co-pays for the remainder of that calendar year. The out-of-network out-of-pocket limit will apply if you incur a covered prescription drug expense at out-of-network pharmacy

YOUR CO-PAYS

Plans 11 and 11-C have a separate out-of-pocket limit for prescription drugs. The amount of the individual and family out-of-pocket limits for prescription drugs are shown on the applicable Schedule of Benefits.

Drugs that are excluded from coverage, including the difference in cost between the brand and the generic drug when the mandatory-generic rule applies, do not apply to out-of-pocket limits.

When There Is Other Prescription Drug Coverage

Most pharmacies are automatically able to coordinate coverage between two prescription drug plans. If not, you should use your primary plan’s drug program. If this Plan is the secondary plan, co-pays from the primary plan can be submitted to the Fund Office for consideration under the coordination of benefits provisions.

If You Do Not Use a Participating Pharmacy

If you or your dependents elect not to use the Prescription Drug Program, you may submit a claim for a covered prescription drug to Sav-Rx, the Plan’s pharmacy benefit manager, who will re-price the prescription based on their negotiated rate, and reimburse you for a portion of the cost. Contact the Fund Office for more information.

CLINICAL MANAGEMENT PROGRAMS

Mandatory Generic Substitution

If a covered person declines an available federally-rated generic substitute, the individual will be responsible for the difference in cost between the brand and the generic drug in addition to the brand-name co-pay. The additional payment amount will not apply to the person’s individual or family out-of-pocket limit.

The difference in cost between the brand and the generic will be waived if the prescription benefit manager determines the use of the brand to be medically necessary based on the receipt of a letter of medical necessity from the prescribing physician.

Mandatory Mail-Order for Long-Term Medications

When your physician prescribes a long-term or maintenance medication, you must use a retail pharmacy for the first two short-term fills (each fill can be for up to a 30-day supply) of that medication. You must use the mailorder or 90-day retail option for the fourth and all subsequent fills.

Specialty Drugs

Specialty drugs require pre-certification by Sav-Rx. In addition, each fill is limited to a 30-day supply, and in most cases must be purchased through Sav-Rx’s dedicated specialty pharmacy. The types of medications considered to be “specialty drugs” for this purpose are determined by Sav-Rx and are subject to change.

Prior Authorizations

Certain drugs that are not classified as specialty drugs may also require review and prior authorization by SavRx to determine if the drugs are medically necessary and are being prescribed and used in accordance with accepted medical practice as well as federal guidelines. Medications in this category include, but are not limited to, oral and topical pain medications, topical dermatologics, central nervous system stimulates, and androgens.

Non-Sedating Antihistamines (NSAHs)

Your over-the-counter (OTC) non-sedating antihistamines (NSAHs), such as Claritin, Allegra and Zyrtec, are covered under the Plan’s prescription drug program for the generic co-pay if you have a doctor’s prescription.

Prescription NSAHs will not be covered without prior authorization by the Sav-Rx clinical team. In order to obtain a prior authorization, the prescribing physician must certify that the patient has previously tried OTCs but did not achieve the desired therapeutic benefit.

Step Therapy for Proton Pump Inhibitors (PPIs)

A step therapy program applies to proton pump inhibitors (PPIs), the class of drugs used to reduce gastric acid. This program requires patients who are being treated on a long-term basis with PPIs to try less costly, over-thecounter (OTC) and generic PPIs first. OTCs will be covered for the generic co-pay if there is a written doctor’s prescription.

COVERED DRUGS

This program covers drugs and medicines that require a physician’s written prescription to be dispensed by a licensed pharmacist. The Plan also covers insulin and diabetic supplies, and certain prescription and over-thecounter-products covered under the Preventive Benefit. (See the list of covered preventive services and supplies that starts on page 47.)

PRESCRIPTION DRUG PROGRAM EXCLUSIONS AND LIMITATIONS

The following are not covered under the Prescription Drug Program, regardless of whether you or your dependent has a physician’s prescription:

1. Over-the-counter (non-prescription drugs), except for non-sedating antihistamines (NSAHs) and proton pump inhibitors (PPIs) with a written doctor’s prescription.
2. Experimental, investigative or inappropriate drugs.
3. Drugs to treat infertility or obesity. (These drugs are covered under the Major Medical Benefit – not under the Prescription Drug Program – and are subject to the limits listed in your Schedule of Benefits. You must file a claim with the Fund Office to receive these benefits.)
4. Drugs for treatment of sexual dysfunction except for prescription erectile dysfunction drugs for 12 months after a nerve-sparing radical prostatectomy. In addition, until June 30, 2017, there is a trial program permitting coverage for on-demand erectile dysfunction drugs if erectile dysfunction is the result of a medical condition, such as diabetes or hypertension and prior authorization is obtained from Sav-Rx. Coverage is for up to four doses per month with a patient co-pay of 70%. The program may be extended by the Trustees if it is deemed desirable. In addition, daily dose prescription erectile dysfunction drugs, such as Cialis®, prescribed for benign prostatic hyperplasia (BPH), are covered subject to ordinary co-pays if prior authorization is received from Sav-Rx. There is no current expiration for the prescriptions described in the previous sentence.
5. Drugs for growth disorders (except when pre-authorized by the utilization review organization for treatment of an illness).

6. Drugs filled at Wal-Mart and Sam’s Club pharmacies.
7. Drug supplies to replace lost or stolen medications, or refills earlier than allowed.
8. Any drug for the treatment of any condition, sickness, or injury that is excluded under the Plan, as specified on pages 64-67.

The exclusions above are not directly applicable to the Medicare Part D Plan (PDP). The PDP plan has its own set of exclusions and limitations.

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