The prescription drug benefits described below are only for Participants and Eligible Dependents who are enrolled in the Indemnity Medical Plan. These benefits do not apply to Kaiser members.
The Prescription Drug Plan is managed by the Fund’s Pharmacy Benefit Manager (PBM). The PBM uses a variety of tools to provide safe access to approved prescription drugs. In addition to an approved list of drugs, known as a formulary, the PBM employs other edits which may include, but not be limited to: Prior Authorization for certain therapies, step therapy edits that require the use of tried and proven prescription drugs prior to the approval of newer more costly drugs, frequency and dosing limits, retail refill allowance that channels participants into the mail order delivery method, and Genetic and/or Efficacy testing. Prescriptions submitted that do not comply with PBM rules will be denied. Additionally, the PBM actively monitors for fraud, waste, and abuse which does occur, and intervenes to case manage such events.
The Plan provides a retail pharmacy program and a mail order option for your prescription drug needs. When you need a medication for a short time – an antibiotic, for example – it is best to choose the retail pharmacy program. If you are taking a medication on a long-term basis, it is usually less costly and more convenient to have it filled through the mail order program.