Hudson School Board Medical Benefits: Northern New England Benefit Trust

PRESCRIPTION BENEFIT PRESCRIPTION DRUG BENEFITS
HMO

Benefit

Your Health Plan includes a prescription drug benefit. The prescription drug benefit program includes a card system, currently administered through Teamsters Rx for retail purchases and a mail order system, administered by Teamsters Rx Pharmacy.

Retail Purchases

Generic Drugs: $10.00 co-payment per prescription
Brand Name Drugs(no generic substitution available): $20.00 co-payment per prescription
Brand Name Drugs (generic substitution available): $20.00 plus difference between cost of drugs
For retail purchase there is a dispensing limitation of the lesser of a 30-day supply or 90 units.

Your Cost For Prescriptions Purchased Through The Mail-Order Pharmacy:

Generic Drugs $10.00 co-payment
Brand Name Drugs (no generic substitution available) $20.00 co-payment
The Teamsters Rx Pharmacy will dispense up to a 90-day supply of a drug, subject to the prescription written by your physician. Teamsters Rx Pharmacy will dispense a brand name drug only if no generic drug equivalent is available. Click here to read policy.

The Teamsters Rx Pharmacy will dispense up to a 90-day supply of a drug, subject to the prescription written by your physician. Teamsters Rx Pharmacy will dispense a brand name drug only if no generic drug equivalent is available.

Mail Order Procedure

1. Have your physician write a prescription for up to a 90-day supply with refills;
2. Complete the Teamsters Rx Pharmacy order envelope (download here);

and

3. Enclose either a $10.00 or $20.00 co-payment for each prescription. Make the check or money order payable to: Teamsters Rx Pharmacy.

You may also use a credit or debit card to make your co-payment for prescriptions filled through the Teamsters Rx Pharmacy and it is recommended that you use a credit or debit card. If you want to pay by credit or debit card, you need to request an Authorization Form from the Trust or download the form by

clicking here. You must complete the form and mail it in with your prescription or fax the form to Teamsters Rx Pharmacy at 1-603-413-6410. You will need to update Teamsters Rx Pharmacy if any information, such as the expiration date, changes on your credit or debit card.

If your physician has authorized a refill, simply complete the Teamsters Rx Pharmacy order envelope

(download form by clicking here), enclose the co-payment and mail the envelope to the Teamsters Rx Pharmacy. In placing a mail order, you should allow 10 business days for your prescription to be delivered by the US Postal Service. Some medication will require a signature and will be sent UPS, signature required. Such medication will not be delivered to a P.O. Box. If no one will be home to sign for the delivery, you should supply another address (work, relative etc.) so that a signature may be obtained.

A Teamsters Rx pharmacist is available by telephone to answer any questions concerning your medication and to discuss with you the proper use of your medications. The toll free phone number is 1-866-888-0104.

Limitations And Exclusions

Legend contraceptives, oral or injectable, are covered through mail order only. Depro-Provera contraceptives may be dispensed up to a 90-day supply through mail order only. Note: In instances of therapeutic equivalency, you may be required to obtain approval from NNEBT prior to filling a prescription.

The following drugs are not covered as part of your prescription drug benefit:

Therapeutic devices or appliances, even if medically necessary

Smoking cessation program drugs

Hair loss or experimental drugs

Drugs used to treat substance abuse

Retin-A for individuals age 26 or over

Medication taken or given while you are in a hospital, skilled nursing or other approved facility

Biological sera

Prescriptions for hyperalimentation

Refills beyond the prescribed limit

Refills more than one year from the original prescription order date

Refills prior to finishing 75% of the projected dosage