Prescription Drug Benefits

FAST FACTS

  • There are three ways to obtain prescription drugs under the plan:

    • By mail service

    • With your EWTF ID card at a network retail pharmacy

    • Without your EWTF ID card at a non-network pharmacy

  • You are allowed two (2) fills at your local pharmacy for a maintenance medication before you are required to order your maintenance medication through the CVS Mail Service Program. You have the option to get your mail order prescription at your local CVS pharmacy. It’s as simple as taking your prescription for 90 days to the local CVS pharmacy. You will receive a three month supply for the cost of two months of retail co-pays.<

  • Your pharmacy benefit manager (Caremark) may periodically remove certain brand name drugs from their formulary list. This will render the drug non-covered. You will be notified when such drugs are either removed from or replaced in the formulary list.

Note: This benefit provided for Standard Plan (full) coverage only; no provision for “H” Plan (limited) coverage. 

The Plan has an agreement with CVS Caremark, a Pharmacy Benefit Manager, to help administer your prescription drug benefit. Under the agreement, if you purchase prescription drugs from pharmacies that participate in the program, you will save money. 

Medicare Part D

The EWTF Plan provides prescription benefits to Retirees. The Plan’s actuary has determined that the benefits provided under the Plan exceed the Medicare Part D prescription coverage for Medicare eligible participants. The Plan therefore receives a subsidy from the Medicare program for providing these benefits. If you or a covered dependent enrolls in a separate Medicare Part D program, you will permanently lose your prescription benefits with EWTF.

Mail Service Program

Purchasing your maintenance medication (medication like insulin or blood pressure medication that you take on an on-going basis) by mail order is the most cost-effective method. You are allowed two (2) fills of a maintenance medication at your local pharmacy before you are required to use the CVS Caremark Mail Service.

To order prescription drugs by mail, go to the CVS Caremark website at
www.caremark.com or contact the Fund Office for a mail order form. You may also contact CVS Caremark at 1-800-386-0329 for a mail order form. Medications can be ordered for pick-up at a CVS pharmacy by going to the CVS website at www.cvs.com.

Using Your Prescription Card

When you need to fill a prescription quickly and your prescription is not subject to the Mandatory Mail Order Program described above, you may use your EWTF Benefit Card at a participating CVS Caremark Network pharmacy and make your co-payment of $10 for each generic prescription, $25 for each preferred (brand) prescription or $35 for each non-preferred brand prescription. You should check with your pharmacy to be sure that it participates in the Caremark Prescription Drug Program. NOTE: Wherever possible, use CVS Caremark’s Mail Order Program or a CVS pharmacy—it saves you time and money!

There is a 34-day limit for prescriptions filled over the counter at local pharmacies other than CVS pharmacies. To reduce your costs, any of your long-term medication needs must be directed to the mail order program or to a CVS pharmacy.

You should always provide your EWTF Benefit Card. But after presenting your card, you should ask your pharmacist for the retail price of the drug you are purchasing. In some cases, the retail price will be less than the co-payment so in such cases it would be to your advantage to self-pay for the prescription.

Using a Non-Network Pharmacy

If you do not use your EWTF Benefit Card, you are required to pay the full cost when you purchase a prescription drug. You may then request a form for direct reimbursement from the Fund Office and submit it along with your bill to:

Caremark Claims Department
PO Box 52196
Phoenix, AZ 85072-2196

For example:

Darrell needs to have his prescription filled. The retail cost for the brand name for his prescription is $150; however, the Plan’s discounted wholesale price for this drug is $55.

With EWTF Benefit Card
(Participating Pharmacy)
Without EWTF Benefit Card
(Non-Participating Pharmacy)
Darrell pays his $25 co-paymentDarrell pays the entire cost of the prescription up front ($150)
Darrell requests a form from the Fund Office for direct
reimbursement
Darrell submits his form with the prescription receipt to CVS Caremark and receives reimbursement for $30. ($55 minus the $25 co-payment)
Darrell’s total out-of-pocket cost—$25 Darrell’s total out-of-pocket cost—$120

Prior Authorization

Prior Authorization (PA) is a tool to screen a prescribed drug or drug class by specific criteria. Caremark’s Prior Authorization tools are comprised of objective criteria that are based on sound clinical evidence.Prior Authorization

If your physician prescribes a brand medication that is no longer on Caremark’s formulary list or another prescribed medication that requires prior authorization, you or your doctor may call the PA team at 1-800-626-3046 to find out what information is needed in order for the PA team to make an informed decision.

Drug Choice Management Program

Please Note: In order to help control costs for you, your eligible family members and for the EWTF Plan, the CVS Caremark network will, if appropriate, recommend a “preferred medication” for some prescriptions. When you present a prescription to a participating pharmacy, the pharmacist, “on-line” with CVS Caremark, may receive information that there is a “preferred” medication that is a less costly alternative. If you and the pharmacist agree to the alternative, the preferred medication will be dispensed. If you do not agree, the original prescription will be filled. Either way you receive your prescription without delay.

If the alternative medicine is not chosen, CVS Caremark will write to your physician communicating the alternative medicine. If the doctor agrees with the change, the preferred medication will be written on a replacement prescription and sent to the pharmacy. Then, the preferred medication will be provided when your prescription is refilled. If the physician does not agree, the original medication will continue to be provided on refills. No change is made without the approval of your physician.

If your physician mandates the use of the drug prescribed and would not authorize substitution of an equivalent medication, a network preferred medication, or a generic substitute, the physician can make that clear when writing the prescription.

Specialty Pharmacy

Specialty drugs are medications that are typically high-cost and require a customized medication management program, including medication use review, patient training, coordination of care, and adherence management for successful use. These drugs are used to target chronic or complex disease states. 

CVS Caremark operates specialty pharmacies to deal with this class of medications, including handling and delivery of specialty pharmaceuticals that have very limited stability and shelf lives.

More information about the CVS Specialty Pharmacy can be found at: www.cvscaremarkspecialtyrx.com.

Opioid Utilization Management Program

The Plan works with CVS Caremark to address opioid abuse and/or misuse by providing no more than a 3 day supply of an immediate release (IR) opioid prescription for recipients age 19 or younger unless:

  • A Prior Authorization (PA) is obtained; or
  • The prescription is for cancer treatment; or
  • The prescription is for sickle cell disease treatment; or
  • The prescription is for palliative care.

CVS Health Vaccination Program

The Plan has implemented the CVS Health Vaccination Program to cover the administration of seasonal influenza vaccinations under the prescription drug benefit at participating pharmacies in CVS Health’s broad retail vaccination network. Under this program, the influenza vaccine is covered at 100%, with no cost to you and your eligible dependents. Please note that the program is effective from August through April (or per individual state requirements) and the seasonal vaccines can only be administered once the vaccine has been released to the marketplace by the manufacturer. 

Covered Expenses

The Plan covers a portion of the cost of covered prescription drugs, including:

  • Legend drugs; 
  • Injectable insulin and a limited coverage for diabetic supplies;
  • Other state-controlled drugs prescribed by a doctor and dispensed by a pharmacy for treatment of a non-occupational illness or injury;
  • Vitamins available by prescription only and which do not contain mineral supplements, provided there is no over-the-counter equivalent; and
  • Anti-obesity drugs (which must be prior authorized by having the prescribing provider contact CVS Caremark at 1-800-626-3046).

What’s Not Covered

No benefits are payable under this provision for:

  • Any drug removed from the formulary list by the pharmacy benefit manager;
  • Any drug not requiring a prescription, unless the drug is a compound of two or more drugs which may be compounded only by prescription;
  • Any experimental or investigational drug;
  • νFees for administration of a drug or insulin;
  • Medication to be taken at the place it is dispensed;
  • Medication taken while hospitalized or a patient in an approved facility (The cost of some medication taken while in a nursing home may qualify for reimbursement under the medical plan. For more information, contact the Fund Office.);
  • Refills exceeding five in a six-month period, or the number specified by the prescribing doctor;
  • Refills more than six months from the date of the original prescription;
  • Medication otherwise available free under a local, state or federal program (e.g., workers’ compensation);
  • Fertility drugs;
  • Erectile dysfunction drugs;
  • Laetrile, enzymes, vitamins, minerals and dietary supplements (except as specifically covered under this Plan);
  • Drugs to enhance sexual performance; 
  • Drugs, medicines and supplies intended for personal hygiene use, such as toothpaste and cleaning devices;
  • Wigs;
  • Therapeutic devices such as support garments, hypodermic needles, or syringes, except if used for insulin; and
  • Take-home drugs or medicines, except when provided as part of emergency room treatment under special urgent circumstances which do not permit use of the regular prescription drug benefit procedures.
  • Drugs excluded under the CVS Drug Exclusion Plan Design Strategy Program

Please see Specific Plan / Benefits Exclusions and General Plan Exclusions for an in-depth listing of your Plan’s exclusions.

If you have a question about whether or not a new drug is covered by the Plan, contact the Fund Office at 301-731-1050 or at 1-800-929-3983.