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OPERATING ENGINEERS
TRUST FUNDS

Prescription Drug Benefits

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.

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.

You may obtain your prescriptions through either a retail (walk-in) pharmacy or through mail order (home delivery). If you do not use a OptumRx network pharmacy, you have only limited benefits which are reimbursed at a lower amount as outlined below.

Most of your prescriptions can be filled without prior authorization by the Fund Office at a retail pharmacy. However, some drugs are only covered for certain uses or in certain quantities. If you present a prescription to the pharmacy which requires prior authorization, your doctor may need to provide additional information before your prescription is covered. You can call the Fund Office at (866) 400-5200 to determine if your prescription requires prior authorization.

The Plan’s prescription drug benefits are as follows:

Prescription Drug 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 up to a 90-day supply of maintenance type medications directly from your local OptumRx Network pharmacy at the lower, mail order co-pays.

Special Reimbursement Limits

  • Sleep Aids: The maximum reimbursement for all prescription sleep aid medications is limited to $30 for a 30-day supply.
  • Ulcer Drugs (PPIs): The maximum reimbursement for PPI 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 network pharmacies:

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

OptumRx Retail Benefit

To use the OptumRx retail pharmacy benefit, simply provide your OptumRx or OE Health & Welfare Fund ID card along with your prescription to any participating pharmacy. Major pharmacy chains are participating pharmacies as well as many of the independent pharmacies. You will only be charged the co-payment listed on the previous page. There are no claim forms to file.

If the pharmacist cannot determine your eligibility or has questions regarding your prescription, the pharmacist will call OptumRx or the Fund Office for authorization. If this occurs after business hours, you may have to return to the pharmacy for your prescription.

To locate a Network pharmacy near your home, workplace or while on vacation, call (855) 295-9140 or visit www.optumrx.com.

The Retail Plan generally covers a 30-day supply of your prescription, provided your doctor prescribed that amount, with the following exceptions:

  • You can receive up to a 90-day supply of maintenance type medications at OptumRx network pharmacies and at the lower Mail Order co-pays.
  • You can receive more than a 30-day supply if you need several months of your prescription while you are on vacation. You must contact the Fund Office for pre-authorization at
    (866) 400-5200.

Maintenance Type Medications

Participants and their covered dependents who take medications for chronic conditions, such as high blood pressure, high cholesterol or diabetes, can obtain 90-day supplies of medications resulting in lower co-pays and greater convenience.

Your physician will have to write a prescription for a 90-day supply and it can be filled in one of two ways:

  • OptumRx Network Pharmacy Maintenance Program: You can obtain up to a 90-day supply at any OptumRx network retail pharmacy nationwide.
  • OptumRx Mail Order Maintenance Medication Program : Mail order service is available nationwide and is generally used for participants who use maintenance-type drugs.

Initial Mail Order Prescription

Initial Mail Order Prescription. Complete the Mail Order Form included in your OptumRx brochure with your first order. Be sure to answer all of the questions and include the Participant’s Social Security number or OEID number on the form. Send the completed form, along with your original prescription and a check or money order for the applicable co-payment to OptumRx, PO Box 2975, Mission, KS 66201. OptumRx will send the prescription drugs directly to you.

Up to a 90-day supply will be sent based on the amount your doctor prescribed. By law, OptumRx must fill your prescription for the exact quantity prescribed by your doctor, up to the 90-day limit. For example, if your prescription states:“30 days plus two refills,” the pharmacy will only dispense a 30 day supply on your first order, not a 90 day supply. You can only get a 90 day supply on the first order if the prescription states you may have a 90 day supply initially.

Mail Order Refills

You can order your refill(s) by Internet, phone or mail. The information included in your last order will show the date you can request a refill and the number of refills you have left.

  1. Internet: This is the most convenient way to order refills and inquire about the status of your order any time of the day or night. You will need to register and log in to access service by
    going to www.optumrx.com.
  2. Phone: Call toll-free (855) 295-9140, 24 hours a day, 7 days a week for the OptumRx refill phone service. Have your Social Security number or OEID number ready. For Participants who are hearing impaired, OptumRx supports TTY service to make ordering by telephone easy. To access this service, call TTY 711.
  3. Mail: Include the refill label provided with your last order with a Mail Service Order Form and mail the completed form and payment to OptumRx PO Box 2975, Mission, KS 66201.

Payment Options

While checks and money orders are accepted, the preferred method of payment is by credit card. For credit card payments, include your VISA, Discover, MasterCard, or American Express card
number and the expiration date in the space provided on the Mail Service Order Form.

Managed Diabetes Program

A Managed Diabetes Program is available to Active Members, Retirees and their eligible Dependents enrolled in the Operating Engineers PPO Plan through CerCare Health. This is a voluntary program where most diabetic supplies will be provided at no cost in exchange for using a monitored blood glucose meter. By having glucose readings monitored 24/7, diabetes care becomes proactive rather than reactive avoiding more serious complications and avoidable doctor or hospital care. The testing results are sent in real time to you, your physician and others you designate. Studies show this program will improve self-management, saves time and delivers better results such as lower A1C scores. Supplies listed below are covered at 100% with no deductible, co-pay or co-insurance.

  • Cellular Enabled Blood Glucose Meter (one every two years)
  • Diabetic test strips (90 day supply per shipment)
  • Lancing device (once a year)
  • Lancets (90 day supply per shipment)
  • Control Solution (one bottle every 6 months)
  • Alcohol swabs (90 day supply per shipment)

Insulin will continue to be obtained through the Fund’s OptumRx prescription drug program with the regular co-pays.

The CerCare Health Managed Diabetes Program includes:

  • Three FDA cleared cellular enabled blood glucose meters to choose from
  • A secure web-portal for test results
  • Continuous A1C readings
  • Reminder alerts
  • Test result alerts for up to 5 people;
  • Coordination of test results to your Physician on a real-time basis.

Participating in this program is easy. Just call CerCare Health at (888) 675-4524. Your Blood Glucose Meter, test strips, lancets, and alcohol swabs will be shipped directly to your home.

For those that choose not to participate in the Managed Diabetes Program, diabetic supplies will continue to be available through the Fund’s OptumRx prescription drug program with the regular co-pays .

Non-Network Benefits

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.

Drug Expenses Not Covered

  1. Drugs or medications not requiring a physician’s or dentist’s prescription. This would include any medication which can be purchased “over the counter.”
  2. “Over the counter” vitamins. If your doctor prescribes a vitamin which cannot be purchased over the counter, you may obtain the vitamin through the OptumRx Plan.
  3. Bandages, heat lamps, splints, wrist supports, non-drug items (over the counter items).
  4. Drugs or drug treatments not approved by the FDA, including but not limited to, compounded medications or experimental drugs.
  5. Retin-A, unless used in the treatment of acne or skin cancer.
  6. Minoxidill, Rogaine, and any other hair growth treatment.
  7. Drugs used in the treatment of infertility.
  8. Homeopathic or holistic medications and herbal remedies. Homeopathic treatment is covered by the Plan only in the State of Nevada.
  9. Unit dose drugs.
  10. Nutritional dietary drugs.
  11. Asthma and diabetic supplies for Medicare members except when a balance remains after the Medicare payment.
  12. Miscellaneous over the counter medical supplies, including but not limited to such items as diapers, Band-Aids, and Ace bandages.
  13. Liquid or powdered food supplements not requiring a prescription.
  14. ED (erectile dysfunction) drugs such as Viagra and Levitra 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 such as heart disease or prostate conditions, as certified in writing by the prescribing physician.

Appeals

If your claim for prescription drugs has been denied in whole or in part, you have the right to appeal. The following provides an overview of the OptumRx appeals process.

  • Letters notifying the member or their representative of a prior authorization denial will include the appeals contact information.
  • Once a member or a member’s representative contacts OptumRx with a request to appeal, that individual is instructed on how to submit an appeal.
  • The member services representative mails the request or the appropriate form to complete. The member or their representative may submit the appeal either on the OptumRx Prescription Claim Appeals form or in other written form. Acceptable submission methods include fax, mail, or telephone (for urgent appeals).
  • Completed appeals forms and supporting documentation are sent directly to the Appeals Process Analyst in the Medical Affairs Department for processing.
  • Appeals are to be processed within the following time frames from the date the complete information is received:
    • Pre-Authorization Review – OptumRx will make a decision on a prior authorization request for a Plan benefit within 15 days after it receives the request. If the request relates to an
      Urgent Care Claim, OptumRx will make a decision on the Claim as soon as possible, but not later than 72 hours.
    • Coverage Determination Review – OptumRx will make a decision on a Coverage Determination within 15 days after it receives such a request. If the member is requesting
      the Coverage Determination of an Urgent Care Claim, a decision on such request will be made as soon as possible, but not later than 72 hours.
    • Post-Service Review – OptumRx will make a decision on a Post-Service Claim within 30 days after it receives such a request.
  • Reviews of appeals are performed based on the Trust Fund’s prescription benefit plan and approved prior authorization criteria. All appeals for prior authorization denials are reviewed by a
    registered pharmacist.
  • A letter is sent to the member or their representative and/or the member’s physician notifyingthem of the appeal decision and the next step in the appeals process, if another level is offered.

The review process includes the consideration of relevant and supporting documentation submitted by and for the claimant. Supporting documentation may include a letter written by the practitioner (physician) in support of the appeal, a copy of the denial letter sent by OptumRx a copy of the member’s payment receipt, medical records, etc. All information received is handled in compliance with HIPAA regulations.

HMO Enrollees

If you are enrolled in an HMO, your prescription drugs must be obtained through your HMO.

Rules for Medicare Retirees Enrolled in a Medicare Advantage PPO or HMO Plan

The prescription drug coverage under the Operating Engineers Health and Welfare is as good as or better than the standard Medicare prescription drug coverage. You do not have to enroll in a Medicare Part D plan. You may enroll in a Medicare Part D plan in the future during the annual enrollment period and you will not be charged a late enrollment penalty if you follow Medicare’s rules when you apply and if you apply timely according to those Medicare rules.

You can keep your current prescription drug coverage under the Plan and enroll in one of the Medicare Part D plans. The Active Plan coverage is primary to Medicare and the Retiree Plan coverage is secondary to Medicare. You will have to pay the Medicare Part D premium out of your own pocket. If you have Retiree Plan coverage, you are legally obligated to provide your Part D plan with information on the benefits you receive from this Plan.

Rules for Medicare Retirees Enrolled in a Medicare Advantage PPO or HMO Plan

Your prescription drug coverage is provided under the Medicare Advantage Plan in which you are enrolled.

Rules for Participants Enrolled in Plan M

Because your prescription drug coverage under Plan M is not, on average, as good as the standard Medicare Part D plans, you should consider whether to enroll in a Medicare Part D plan. Because your Plan M coverage is not creditable, if you do not enroll in a Part D plan before December 31st, you may have a late enrollment penalty on the premium you pay for that Medicare coverage.

You should consider enrolling in a Medicare Advantage Plan. You should compare information about your current prescription drug coverage and the drug coverage under Medicare Part D plans, such as monthly premiums, the covered and non-covered drugs, the deductible and co-payments or coinsurance, mail order service and retail pharmacy locations.

More Information About Medicare Part D

More detailed information about Medicare plans that offer prescription drug coverage is available in the “Medicare & You”  handbook that you receive from Medicare. You can also get more information about Medicare Part D plans from the following places:

  1. Visit www.medicare.gov
  2. Call your State Health Insurance Assistance Program (see your copy of “Medicare & You”  for the telephone number).
  3. Call Medicare at (800) 633-4227. TTY users should call (777) 486-2048.

For individuals with limited income and resources, extra help paying for a Medicare Part D plan is available. Information about this extra help is available from the Social Security Administration at www.socialsecurity.gov, or by phone at: (800) 777-1213 (TTY 800-325-0778).

Revised 07/2020

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