Prescription Drugs

Overview

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

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
Retail Program 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 a $50 copay per initial fill and refill	You pay a $65 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.

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.