Prescription Drug Plans

PRESCRIPTION DRUG PLANS

When you and your dependents are eligible for the medical and hospital benefits provided by the Operating Engineers Health and Welfare Fund, you are also eligible for the benefits of the Prescription Drug Plan, except for those that have elected HMO coverage. If you are covered by an HMO, you must receive your prescription drug benefits through the HMO directly.

OptumRx. Retail Prescription Program

To use your OptumRx. ID card, present it along with the doctor’s prescription to any participating pharmacy. The pharmacist will fill the prescription and charge you only the co-payment amount, per prescription. There are no claim forms for you to file.

If the pharmacist cannot determine your eligibility or has a question regarding your prescription, he will call OptumRx. for authorization.
OptumRx. has a large network of retail pharmacies, including large national or regional chains and many local retail pharmacies.  Following are just some of the larger chain pharmacies participating in OptumRx.

  • CVS
  • Rite-Aid
  • Walgreen’s
  • Von’s
  • Ralph’s
  • Safeway

 

For more information on OptumRx. participating pharmacies:

  • Visit  www.optumrx.com 
  • Call  1-855-295-9140

    Using the OptumRx. Plan, a 30-day supply is allowable, providing your doctor prescribed that amount.
    If you need several months of your prescription while you are on vacation, you must contact OptumRx. for pre-authorization. You will be required to pay the co-payment for each 30-day supply. If you are away from home and need to fill a prescription, call 1-855-295-9142 for the name and location of the nearest participating pharmacy.

Special Reimbursement Limits

  • Sleep Aids.  The maximum reimbursement for all prescriptions sleep aid medications is limited to $30 for a 30-day supply.
  • Ulcer Drugs (PPls).  The maximum reimbursement for PPl medications is limited to $30 for a 30-day supply.

Immunization Service

As approved by the FDA the following routine vaccinations are available with no co-payment at local OptumRx. pharmacies:

• Seasonal Influenza
• Zoster (shingles)
• Tetanus, Diphtheria Toxoids, Pertussis
• Hepatitis A & B
• Measles, Mumps, Rubella, Varicella
• Pneumococcal (pneumonia)
• Human Papillomavirus
• Meningococcal

Co-payment

Tier 1:  Generic Drugs = $10.00 per 30-day supply
Tier 2:  Preferred Brand drug with no generic available = $25.00 per 30-day supply
Tier 2:  Preferred Brand drug with an available generic = $25.00 per 30-day supply plus 50% of the difference in price between the brand-name drug and the generic.
Tier 3:  Non-Preferred Brand drug with no generic available = $40.00 per 30-day supply
Tier 3:  Non-Preferred Brand drug with an available generic = $40.00 per 30-day supply plus 50% of the difference in price between the brand-name drug and the generic

For more information on on which specific prescription drugs fall under the three Tiers, click here.

Maintenance Medication Program

The Maintenance Medication Program is an easy and cost saving program intended for those that are taking maintenance type medications for several months. Under this program, you can receive up to a 90 day supply with a co-payment that is less than what you would pay for three 30-day supplies under the OptumRx. retail prescription drug program described above.

Co-payment

Tier 1:  Generic Drugs = $25.00 per 90-day supply
Tier 2:  Preferred Brand drug with no generic available = $62.50 per 90-day supply
Tier 2:  Preferred Brand drug with an available generic = $62.50 per 90-day supply plus 50% of the difference in price between the brand-name drug and the generic.
Tier 3:  Non-Preferred Brand drug with no generic available = $100.00 per 90-day supply
Tier 3:  Non-Preferred Brand drug with an available generic = $100.00 per 90-day supply plus 50% of the difference in price between the brand-name drug and the generic

To utilize the Maintenance Medication Program, just ask your Doctor to write you a 90-prescription for your maintenance medication and you can fill it in one of two ways:

Option 1: Refill at any CVS pharmacy

Fill your 90-day supply at any CVS/CareMark pharmacy location and pick up your medications at your convenience.

Option 2: Refill with OptumRx. Mail Service Pharmacy.

Have a 90-day supply of your long-term medicines shipped directly to your home.

Just complete the OptumRx. Mail Service Order Form and mail it with your 90-day prescription for your first order only. The form can be obtained online here or by calling OptumRx. toll free at 855-295-9140. Be sure to answer all the questions on the form for yourself and your eligible dependents, and make certain you include the member’s Social Security Number or the Fund Issued HCID#.

GENERIC DRUG POLICY

What Are Generic Drugs?

Many of the most-prescribed drugs are available under their generic names and many are manufactured by the same company that produces the brand-name drug. Ask your doctor if the medication he is prescribing for you has a generic equivalent.

A generic drug is identified by its official chemical name rather than a brand name. Because of existing patent laws, some medications are supplied only under their trademarked brand names. For example: St. Joseph’s and Bayer are brand names for “aspirin” which is the generic name. They have the same active ingredients. They have the same effect on the body, and they meet the same Federal Government standards as their brand name equivalents.

You don’t have to know the generic name of your prescription or how to pronounce it. Your doctor or pharmacist will know. All you have to do is ask your doctor if a generic drug is available and if so, to prescribe it instead of a higher priced brand name drug.

Many doctors just don’t realize how much money you can save if they prescribe generic drugs. Most doctors are not opposed to generics, and your doctor would probably like to help you save money. If so, the next time he prescribes medicine for you, ask him to prescribe generically, if possible.

If your doctor is unsure of a drug’s generic name (this is common), ask him to add the phrase “or generic equivalent” to your prescription. This will help your pharmacist provide you with a more reasonably priced product.

The Plan requires that your prescription be filled with the generic equivalent, if one exists. Therefore, you are encouraged to use generic medications when appropriate.
If you request a brand-name drug for which a generic is available, you will have to pay 50% of the difference in price between the brand-name and generic drug PLUS your required co-payment.

DIABETIC SUPPLIES

The Fund will pay for the purchase of insulin, needles, syringes and most over-the-counter diabetic supplies for diabetic patients. You may also purchase insulin, needles, syringes and supplies through the OptumRx. Program and OptumRx. Mail Order Program by paying a co-payment for each prescription. This would be the least expensive option.

Insulin injectors are a covered expense for diabetics who require multiple daily injections of insulin. The Fund will reimburse 100% up to a maximum payment of $500.00. You are entitled to benefits for a new insulin injector once every four years.

If you use a home glucose monitor and you are covered by Medicare, Medicare may provide benefits for the monitor and for the supplies used with the device; however, there are limitations. Therefore, you must submit your claims to Medicare before the Fund will provide payment.

The Fund will pay a one-time allowance of $200.00 for diabetic training and educational materials subject to satisfaction of the Calendar Year Deductible for an eligible individual.

The Fund will pay for orthopedic shoes and shoe inserts to treat or prevent ulcers resulting from severe diabetic foot disease if the individual meets the following conditions: Amputation of the foot or part of the foot; pre-ulcerative callus formation or peripheral neuropathy with a history of callus formation; foot deformity or poor circulation in one or both feet.

OVER-THE-COUNTER DRUGS

Doctors may instruct you to take aspirin, Vitamin C, Maalox™ and similar types of medication which can be purchased “over-the-counter,” without a prescription. The Fund will not pay for “over-the-counter” medications.

Some examples of “over-the-counter” drugs that are not covered by the Fund are:

  • Alcohol swabs
  • Tylenol™ and Tylenol PM™’
  • Theragran™
  • Actifed™
  • Robitussin DM™
  • Poly-vi-sol™
  • Dimetane™
  • Mylanta™
  • And other similar drugs

The only exception is that the Fund will provide benefits for:

  • Infant formula if the infant suffers from cystic fibrosis or cerebral palsy.

PRESCRIPTION VITAMINS

If your doctor prescribes a vitamin which cannot be purchased “over-the-counter,” you may obtain the prescription vitamins through the OptumRx. Prescription Program.

NEW DRUGS APPROVED BY THE FDA

New drugs that are approved by the Federal Food and Drug Administration will generally be covered under the Plan. However, the Trustees will review all requests for newly approved drugs.

DRUG EXPENSES NOT COVERED

  • Drugs or medications not requiring a physician’s or dentist’s prescription. (This would include any medication which can be purchased “over the counter.”)
  • “Over the counter” vitamins.
  • Bandages, heat lamps, splints, non-drug items (over-the-counter items).
  • Nutritional dietary drugs.
  • Drugs or drug treatments not approved by the Food and Drug Administration (FDA), including, but not limited to, compounded medications, or experimental drugs.
  • Retin-A™, unless used in the treatment of acne and skin cancer.
  • Minoxidil™, Rogaine™, and any other hair growth treatments.
  • Drugs used in the treatment of infertility.
  • Homeopathic or holistic medications and herbal remedies. (Homeopathic treatment is covered by the Fund only in the State of Nevada).
  • EDC (erectile dysfunction) drugs such as Viagra™ are limited to 8 pills per month if determined to be medically necessary. This means that the dysfunction must be caused by a physiological condition, as certified by the physician.
  • Unit dose drugs.

IMPORTANT NOTES:

If you are enrolled in the Kaiser, Anthem Blue Cross HMO, Health Plan of Nevada  or the United HealthCare Medicare Advantage PPO plans,  your prescription drugs must be obtained through that Plan.