The UFT Welfare Fund provides prescription drug coverage to all eligible in-service UFT members and their dependents. This coverage begins immediately upon enrollment, without any waiting periods. This article aims to provide a detailed overview of the UFT prescription drug coverage, including the types of drugs covered, how to access them, and important considerations for members.
Immediate Access and Reimbursement
Newly enrolled members awaiting their Welfare Fund Express Scripts (ESI) Prescription ID drug cards can still access necessary medications. They can purchase the required prescription drugs and, upon receiving their cards, submit the original receipts to the Fund for reimbursement.
Types of Drugs Covered
The UFT Welfare Fund distinguishes between two main categories of drugs: acute illness drugs and maintenance drugs.
Acute Illness Drugs
Acute illness drugs are medications needed for immediate treatment, such as antibiotics. These drugs are typically dispensed by your local pharmacy.
Maintenance Drugs
Maintenance drugs are medications taken regularly over an extended period, such as antihistamines for allergies or drugs for high blood pressure. For maintenance drugs, the ESI Home Delivery service is generally recommended due to cost savings and convenient home delivery.
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Accessing Medications
Retail Pharmacy
For acute illness drugs and the initial fills of new or changed maintenance medications, members can visit their local retail pharmacy.
ESI Home Delivery Pharmacy
For non-specialty maintenance medications, a supply of up to 90 days is available through the ESI Home Delivery Pharmacy. Non-specialty maintenance medications must be sent to ESI Home Delivery Pharmacy. If a physician changes the strength of a maintenance medication or prescribes a different one, members can obtain up to two 30-day fills from a retail pharmacy before transferring to ESI Home Delivery Pharmacy.
Contact Information:
Express Scripts Home Delivery ServiceP.O Box 66568St. Louis, MO 63166-6568
The Interactive Voice Response (IVR) System allows for prescription renewals over the telephone at any time.
Accredo Specialty Pharmacy
Accredo, an Express Scripts specialty pharmacy, offers personalized care and convenient delivery of specialty medications. All specialty medications, including self-injectables and cancer medications, must be obtained through Accredo Specialty Pharmacy. An exception is made for specialty "stat" drugs, such as Lovenox (a blood thinner) needed immediately after surgery, which can be obtained through a retail pharmacy.
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Specialty Medications and Accredo
Accredo provides individualized care and convenient delivery of specialty medications. All specialty medications such as self-injectables or cancer medications must be obtained through Accredo Specialty Pharmacy. Specialty "stat" drugs are the exception. Medication such as Lovenox which is a blood thinner that is needed immediately after surgery would be allowed to be obtained through your retail pharmacy.
Fertility Medications
The fertility medication benefit program is available exclusively from Freedom Fertility Pharmacy. This benefit is limited to a lifetime maximum of three (3) cycles of therapy. Administration of the medication(s) is usually given daily for 7-10 days early in the cycle. The Freedom Advantage®, offered to PICA members features a dedicated team of fertility only care coordinators, free shipping, free patient education materials and emergency same-day services.
Cost Considerations
Deductible
There is an annual deductible of $100 per person.
Generic vs. Brand-Name Drugs
For brand medications with FDA-approved generic equivalents, PICA will typically only cover the generic medication. If a generic version is available and chosen, the standard copayment for a generic drug applies. Generic drugs offer the same quality and effectiveness as their brand-name counterparts. Drug manufacturers spend large sums of money or the research, development, marketing and advertising of brand-name drugs.
Prior Authorization
Similar to healthcare plans that approve a medical procedure before it's done to ensure the necessity of the test, if you're prescribed a certain medication, that drug may need a prior authorization. This program makes sure you're getting a prescription that is suitable for the intended use and covered by your pharmacy benefit. Your own medical professionals are consulted, since your plan will cover it only when your doctor prescribes it to treat a medical condition that will promote your health and wellness. When your pharmacist tells you that your prescription needs a prior authorization, it simply means that more information is needed to see if your plan covers the drug. The PA team is available 24/7.
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Prior authorization is a process used to ensure that a prescribed medication is appropriate and covered by the pharmacy benefit. It is similar to how healthcare plans approve medical procedures to ensure necessity. If a medication requires prior authorization, it means that additional information is needed to determine if the plan covers the drug. The prior authorization team consults with medical professionals to ensure the prescription is suitable for the intended use and will promote the member's health and wellness. This team is available 24/7 to assist with the prior authorization process.
Step Therapy
Step therapy is a program for people who take certain prescription drugs regularly to treat a medical condition, such as arthritis or high blood pressure. Front-line drugs - the first step - are generic and sometimes lower-cost brand drugs proven to be safe, effective and affordable. Back-up drugs - Step 2 and step 3 drugs - are brand-name drugs that generally are necessary for only a small number of patients.
Step therapy is a program designed for individuals who regularly take prescription drugs for chronic conditions like arthritis or high blood pressure. The program typically involves starting with front-line drugs, which are often generic or lower-cost brand drugs that have been proven safe, effective, and affordable. If these front-line drugs are not effective, the program may move to back-up drugs, which are typically brand-name medications reserved for patients who do not respond to the initial treatment.
Quantity Limits
The UFT Welfare Fund also implements quantity limits on certain prescriptions to ensure safe medication use and prevent waste. It provides the medication you need for your good health and the health of your family, while making sure you receive them in the amount - or quantity - considered safe. Certain prescriptions are included in this program. For these drugs, you can receive an amount to last you a certain number of days. For instance, the program could provide a maximum of 30 pills for a medication you take once a day.
Split-Fill Program
Split-Fill is designed to improve patient therapy adherence and waste reduction. Accredo has clinically identified a select list of specialty drugs which have a very high risk for early discontinuation in new patients. Split-Fill addresses waste associated with unused drug by splitting the initial 28 or 30 day cycle into two equal partial fills (either 14 or 15 days) for the first three months of therapy.