Health & Welfare Plan
Health and Welfare Benefit Summaries
The Plan’s prescription drug benefit is administered by OptumRx. All Participants and their Eligible Dependents are eligible for these benefits, except for those enrolled in an HMO, Plan M and Medicare Retirees enrolled in a Medicare Advantage Plan.
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.
What is Covered
In general, all medically or dentally necessary FDA approved drugs will be covered under the Plan. However,the Trustees will review all requests for newly approved drugs.
Retail Co-payment Mail Order Co-payment Tier 1: Generic Drugs $10 per 30-day supply** $25 per 90-day supply Tier 2: Preferred Brand Drugs * $25 per 30-day supply $62.50 per 90-day supply Tier 3: Non-Preferred Brand Drugs * $40 per 30-day supply** $100 per 90-day supply
*When a generic drug is available but the pharmacy dispenses the brand-name drug for any reason, you will pay the applicable co-payment plus 50% of the difference in cost between the brand and the generic.
**You can receive a 90-day supply of maintenance type medications directly from your local OptumRx Network pharmacy at the lower, mail order co-pays.
You have the option to go to any drug store of your choice to obtain your prescription on a limited basis.You may have to pay the entire cost of the prescription when you obtain it. You must then submit your claim for reimbursement, to the Fund Office, using a form available for printing at www.oefi.org or from the Fund Office.The Plan will pay 80% of the Reasonable and Customary charge after satisfaction of the PPO Non-Network deductible. Reimbursement is limited to a maximum of 60 days for any one individual drug. Once you have obtained a 60-day supply, you must use a OptumRx Network pharmacy for additional refills. Continued purchases outside of a OptumRx Network pharmacy will be denied.
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.
Finding a Provider
To locate a Network pharmacy near your home, workplace or while on vacation, call (855) 295-9140 or visit www.optumrx.com.