UFCW Midwest - Midwest Health and Pension Funds

United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

Prescription Drug Benefit

Your eligible dependents are covered only if you elected Family Coverage and are working enough hours to qualify for full-time coverage.

The Prescription Drug Benefit provides coverage for most drugs that require a doctor’s prescription, for certain over-the-counter medications when prescribed by a doctor and for some diabetic supplies.

Prescription Drug ID Card

You will receive an ID card when you become eligible for benefits. When you use your ID card at a participating pharmacy to fill prescriptions, all you need to do is pay any applicable co-payment. You do not have to complete any claim forms.

If you need a replacement card or an additional card, contact Customer Service at the Fund Office.

Participating Pharmacy Program

The Prescription Drug Benefit is managed by WellDyneRx, a prescription benefit manager with a large network of pharmacies, called “participating pharmacies.” You receive the highest level of benefits when you fill your prescription at a participating pharmacy.

Most pharmacies are participating pharmacies. However, should you have any problem locating a participating pharmacy, visit WellDyneRx at www.myWDRX.com or call 888-479-2000.

Covered Drugs

The Plan covers the following:

  • Most drugs that require the written or oral prescription of a licensed doctor or dentist under federal or state law, up to a 30-day supply maximum per prescription or refill.
  • Exceptions to the 30-day supply maximum are non-specialty (see below) maintenance drugs that are used on a long-term or on-going basis to treat chronic conditions. You can receive up to a 90-day supply of these drugs. Contact WellDyneRx at 888-479-2000 for specific information on maintenance drugs.
  • Certain over-the counter (OTC) drugs when prescribed by a doctor. Currently, OTC Loratadine (Claritin) and OTC Omeprazole (Prilosec) are covered.
  • Injectable insulin, blood glucose testing strips and lancets.
  • Needles and syringes to administer injectable insulin.
  • Needles and syringes for any other use, up to a 30-day supply.

Drug that Require Pre-Approval

Some drugs require pre-approval before your prescription can be filled under the Prescription Drug Benefit. For example, drugs which may require pre-approval include narcotics, amphetamines, anabolic steroids and protein pump inhibitors (stomach drugs) when more than one tablet per day is taken.

The Fund Administrator, in consultation with the Fund’s Medical Consultant and with approval by the Trustees, periodically makes changes regarding which drugs require pre-approval.

Contact WellDyneRx at 888-479-2000 for information on which drugs currently require pre-approval and how to obtain the pre-approval.

Generic Equivalents and Brand-Name Drugs

If you or your eligible dependent request a brand-name drug when a generic equivalent is available (and medically appropriate), you will be responsible for paying the difference in cost between the generic and the brand-name drug, in addition to the brand-name co-payment amount.

In general, using generic drugs usually helps to control the cost of health care while providing quality drugs—and can be a significant source of savings for you and the Fund. Your doctor or pharmacist can assist you in substituting generic drugs when appropriate.

Preferred and Non-Preferred Drugs

For the purpose of controlling costs (both yours and the Fund’s), certain drugs are designated as either preferred or non-preferred. Preferred drugs have the lowest co-payment—non-preferred drugs have the highest co-payment.

Contact WellDyneRx at 888-479-2000 for updated information on which drugs are preferred drugs.

Specialty Drugs—Require Purchase by Mail

What are Specialty Drugs. Drugs that may require special storage, handling or administration (such as injection or infusion) or are for conditions where it may be beneficial to monitor the drug therapy or an underlying medical condition are considered “specialty drugs.” Examples of such drugs are Atripla, Enoxaparin, Humira, Enbrel, Truvada.

The Fund Administrator, in consultation with the Fund’s Medical Consultant and with approval by the Trustees, periodically identifies which drugs are specialty drugs. Inquiries as to whether any drug is on the current specialty drugs list should be directed to the Fund Office.

Specialty Drugs Must be Purchased by Mail from US Specialty Care. Under the Prescription Drug Benefit, specialty drugs can be obtained only by mail through US Specialty Care. Specialty drugs are not covered if obtained at a retail pharmacy.

To obtain your specialty drug:

Complete the “Patient Prescription Form” available from the Fund Office or from US Specialty Care at 800-641-8475.
  • You complete all sections except Physician Information and Clinical Information. Note that you may use your UFCW ID # instead of your Social Security Number on the form.
  • Have your physician complete the Physician Information and Clinical Information.
  • You or your physician should fax the completed form to US Specialty Care at 800-530-8589. Or you may mail it to US Specialty Care, PO Box 4517, Englewood CO 80155-4517.

A professional from US Specialty Care will call you to confirm when and where you would like your prescription drugs delivered (along with any needed supplies). Drugs are packaged in unmarked, temperature-controlled containers and can be delivered to any secure location of your choice.

US Specialty Care pharmacists and staff are available to answer any questions. They can give you detailed instructions and support for how and when to take your drugs. They also offer refill reminder calls.

You can reach US Specialty Care at 800-641-8475, FAX at 800-530-8589, or by mail at PO Box 4517, Englewood CO 80155-4517.

Co-Payments

Co-payments are based on tiers established by the Trustees to encourage cost-effective use of the Prescription Drug Benefit.
 
You’ll pay the following, effective February 1, 2017:

30-Day Supply Co-Payment
Tier Zero
preferred drugs $5
Tier One
most generic drugs $12
Tier Two
most brand-name drugs $20
Tier Three
non-preferred drugs $33
Maintenance Drug (90-Day Supply) Co-Payment
Tier Zero
preferred drugs $5
Tier One
most generic drugs $19
Tier Two
most brand-name drugs $40
Tier Three
non-preferred drugs $67

 
You will also be responsible for paying the difference in cost between the generic and the brand-name drug if you request a brand-name drug when a generic drug is available and medically appropriate.

Contact WellDyneRx at 888-479-2000 for updated information on which drugs are preferred drugs.

What’s Not Covered

In addition to the Plan’s General Exclusions and Limitations, the following expenses are not covered:

  • drugs or medications that are payable under any other benefit provided by the Plan
  • medicines that do not require a prescription (over-the-counter), except as otherwise specifically noted
  • drugs or medications that require pre-approval when you did not obtain approval before they were dispensed to you
  • the difference in cost if you request a brand-name drug when a generic drug is available and medically appropriate, except for certain medical conditions as determined from time to time by the Trustees
  • specialty drugs when dispensed by a retail pharmacy instead of by mail through US Specialty Care
  • drugs dispensed for use while medically confined
  • drugs (except Lupron) consumed at the time and place of prescription
  • drugs that are considered experimental or not approved by the US Food and Drug Administration for the condition, dose, rate or frequency prescribed
  • research drugs
  • appliances and devices
  • blood and blood plasma, immunization agents and biological sera
  • contraceptives or implanted drugs or devices, regardless of intended use
  • fertility drugs
  • erectile dysfunction drugs in excess of six tablets per 30 days
  • drugs used for cosmetic purposes
  • drugs to promote hair growth
  • drugs used as an aid to weight loss
  • lifestyle drugs
  • non-drug items including nutritional supplements, regardless of intended use
  • smoking cessation drugs or products, including Nicorette and nicotine transdermal patches
  • vitamins, except prescription pre-natal vitamins
  • any prescription order or refill for which the pharmacist’s usual and customary charge is less than the co-pay amount
  • drugs which will be covered by any Workers’ Compensation law, Medicare, or similar governmental program, or any other prescription program or group plan unless prohibited by federal law
  • any prescription order or refill filled outside the United States, except for emergencies
  • drugs intended for any purpose other than the manufacturer’s published use or drugs prescribed in quantities in excess of the dosage recommended by the manufacturer

Other drugs, as determined by the Trustees from time to time, may be excluded from coverage.

Direct Reimbursement

You receive the highest level of benefits when you fill your prescription using your ID card at a participating pharmacy. If for some reason you cannot use a participating pharmacy or your ID card, you may submit a “Direct Reimbursement” claim form to request reimbursement.

Creditable Coverage Under Medicare

The prescription drug benefit provided by this Plan D5 classification has been determined to be “creditable coverage” under Medicare. This means that if you are eligible for Medicare, you may defer electing Medicare Part D Prescription Drug Coverage while you remain covered under the Plan and you will not be penalized if you then elect it at a later date. For more detailed information, you may refer to the Notice of Prescription Drug Creditable Coverage Coverage under Medicare.

  

(Updated 01/13/17)