Prescription Copay Benefit

 

This benefit is provided to reimburse the co-payments incurred by covered members and their eligible dependents for prescription drugs.  Effective with prescriptions filled in called year 2010, you will be reimbursed up to $450 per family per calendar year.  The same rules and regulations governing the basic health plan's prescription drug program apply regarding maximum reimbursement per prescription.  These rules include reimbursement up to the co-pay amount for the generic equivalent of brand name drugs when a brand name is selected over it generic equivalent. The member will be reimbursed up to the copayment for the generic equivalent only.

Prescription drugs covered under this program must have been prescribed by a medical doctor, osteopath or dentist and dispensed by a licensed pharmacist.  Prescription services which are covered include:

Prescription which require compounding;
Prescriptions for legend drugs;
Insulin on prescriptions;
Allergic solutions or extracts normally purchased at a pharmacy authorized by a doctor;
Prescription vitamins;
Birth control pills

Obtaining Benefits:

 In order to obtain benefits, submit a claim form (obtained from the Fund Office or downloaded from our website) along with photocopies of your pharmacy printout, annual statement from your medical or prescription drug carrier, or receipts to the Fund Office*. Pharmacy drug printouts may be used in lieu of filling out individual prescription lines providing that the patient's name, date of purchase, prescription number, prescribing doctor's name, dispensing pharmacy and the cost of the prescription to the patient is entered**.  The co-payment amount MUST be indicated either on the claim form or the pharmacy's print-out.  All claim forms MUST contain a total dollar amount or the claim may be returned to you without payment.  All items listed will be subject to verification

Submit your completed and signed form only after you have accumulated a minimum amount of $450 for prescription drug co-payments.  If you do not meet the minimum prior to the end of the year, submit your claim for whatever the amount below that figure after the last day of the calendar year.  Your prescription drug claim MUST be submitted no later than April 30th of the year following the year charges were incurred in order to be eligible for coverage.

(Example: Covered expenses incurred from 1/1/11 through 12/31/11 may be claimed up to 4/30/12.)

  • Do not submit original receipts.  The Fund is not responsible for loss if originals are submitted.
  • The fund does not require the names of the drugs you and your covered dependents purchase to process a claim.

Note:  The same rules and regulations governing Suffolk County's primary prescription drug plan apply.  The Fund does not cover prescription costs incurred by members beyond the amount payable by your primary prescription drug plan.  If for some reason you had to pay full price for a prescription (perhaps your card was unavailable, or you were out-of-state), you MUST first submit the costs to your primary prescription plan prior to claiming.  Do not submit your claim to the fund unless all costs are supported by proof. Submissions at a later date will NOT be reconsidered for payments.

Limitations

  • Only one claim per family, per calendar year is eligible.
  • Individual records of prescriptions not accompanied by a pharmacy printout or a copy of a receipt will not be honored.
  • The Fund prescription drug coverage is secondary to your primary prescription drug coverage. (Example: Employee Medical Health Plan of Suffolk Country, HMO or spouse's coverage.)
  • No coverage is provided for "over the counter" drugs, vitamins, diet supplements, etc., which, even though prescribed by physician, can be legally purchased without a prescription; allergy prescriptions unable to be filled at a licensed pharmacy; drugs prescribed for cosmetic purposes.