Rx- Active

PRESCRIPTION DRUG BENEFIT

ACTIVE PARTICIPANTS

PHARMACY NETWORK

Effective February 1, 2000, CVS and Eckerd Drug store chains are no longer part of the pharmacy network in the States of NJ, PA, DE. Your prescription card can not be used at any of these pharmacy chain stores in NJ, PA, DE. The prescription will be rejected and will not be filled. If you choose to have a prescription filled at one of these pharmacy chains and pay cash for the prescription, such expenses will not be reimbursable by the Fund office.

Some of the major pharmacy chains that are in the network include Acme Markets, Super Fresh, Shop Rite, etc., as well as many independent stores.

If you have any questions regarding the pharmacy network or to verify that your pharmacy is in the network, please contact the Fund Office at 1-800-228-7484 or Express Scripts at 1-877-432-8991. When calling Express Scripts, be sure to provide your social security number in order to verify that you are in the Tri-State Network.

Retail Program administered by: APS - Express Scripts / Value Rx
http://www.express-scripts.com/

http://www.DrugDigest.org/ - will provide fact-based information on a wide variety of drugs, vitamins, and herbs.

Take your Doctor's prescription to a participating pharmacy and present your APS (Associated Prescription Service) ID Card.
Pay the pharmacist the co-pay described below for each prescription, and sign the appropriate form or log.

This Plan provides benefits for prescription legend drugs or refills when dispensed by a participating retail pharmacy (on-line with APS) pursuant to a Doctor's prescription.

CO-PAY

Generic Drug Co-pay $ 2.50

Brand Name Drug Co-pay:

when no "A" rated generic is FDA approved ² $ 5.00

Brand Name Drug Co-pay:

when the "MEDICAL NECESSITY" form has been approved by APS ² $ 5.00

Brand Name Drug Co-pay:

when an "A" rated generic is FDA approved $2.50 PLUS DIFFERENCE BETWEEN THE BRAND/GENERIC

MAXIMUM SUPPLY PER PRESCRIPTION

of non-maintenance drug 34 days or 100 doses whichever is greater

of approved maintenance drug 90 days

LIMITATIONS

The Plan will not pay any of the cost for:

Prescriptions over the supply indicated in the Summary of Benefits Schedule.

Compounded drugs, unless at least one ingredient is a legend drug.
The Plan retains the right to limit any drug deemed excessive in quantity prescribed or where the cost is prohibitive.

EXCLUSIONS

1. Over-the-counter drugs (i.e. aspirins, etc)

2. Injectable drugs (except Insulin & Imitrex)

3. Any type appliances or devices.

4. Needles or syringes

5. Hair growth or wrinkle removal medicines or similar products

6. Fertility medications

7. Legend drugs used for bodybuilding

8. Drugs prescribed as a result of an automobile accident must be filed with your automobile insurance carrier

Drugs prescribed as the result of a work related injury or work related medical condition must be filed with the Worker's Compensation carrier
New products are subject to scrutiny and approval by the Fund. These will be evaluated individually according to past practices, indications, cost, etc.

¹ Mail Order Program optional for eligible active members ordering any prescription.

² You may apply for approval of a Brand Name drug by contacting the Fund Office.