Prescription Copay

ELIGIBILITY

If you are eligible for FA Benefit Fund benefits, either as a full-time member of the FA or the Guild of Administrative Officers, or you are a retiree enrolled in and paying for either the Enhanced Plan or Enhanced Plus Plan, you are eligible. 

Eligible dependents are dependents who are determined to be eligible by the FA Benefit Fund and enrolled by the covered member. A dependent can be eligible for EMHP coverage but not necessarily eligible for the FA Benefit Fund (e.g., the Fund does not cover adult children up to age 26).

THE BENEFIT

This benefit is provided to reimburse the copayments incurred by covered members (active and retirees in a self-pay plan) and their enrolled dependents for prescription drugs. The FA Benefit Fund will reimburse the copayment incurred by the covered member and/or his or her enrolled dependent, up to $500 per calendar year plus an additional one percent of the copayment per eligible prescription submitted over $500. Prescriptions will be adjudicated in the order they are filled (chronologically). 

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

  • Prescriptions 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.

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 FA Benefit Fund prescription drug coverage is secondary to your primary prescription drug coverage, for 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; or drugs prescribed for cosmetic purposes.

OBTAINING THE BENEFIT

In order to obtain benefits, submit a claim form (obtained from the Fund Office or on the Fund website) along with your pharmacy printout or annual statement from your prescription drug carrier to the Fund Office. The copayment amount must be indicated on the pharmacy’s printout. 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 $500 for prescription drug copayments. If you do not meet the minimum prior to the end of the year, submit your claim for whatever amount below that figure after the last day of the calendar year. 

Your prescription drug claim must be submitted no later than April 30 of the year following the year charges were incurred in order to be eligible for coverage. For example, covered expenses incurred from January 1, 2022, through December 31, 2022, may be claimed up to April 30, 2023.

Note: The same rules and regulations governing Suffolk County’s primary prescription drug plan apply. The FA Benefit Fund does not cover prescription costs incurred by covered 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 FA Benefit Fund unless all costs are supported by proof. Submissions at a later date will not be reconsidered for payments.