ELIGIBLE RETIRED PARTICIPANT AND SPOUSE

All eligible participants will receive an Express Scripts® Prescription Card
No Claim Form is required for the retail program or the Mail at Retail program.
A Prescription Mail Order Form is required with the initial order from Express Scripts Mail Order program.
The Retail Program is administered by: Express Scripts Inc., PO Box 390873, Bloomington, MN 55439.
The Mail Order Program is administered by: Express Scripts, 3684 Marshall Lane, Bensalem, Pa. 19020

BENEFITS

PRESCRIPTION LEGEND DRUGS: The Plan provides benefits for prescription legend drugs or refills thereof when dispensed by a UFCW Tri-State Health and Welfare Centralized network pharmacy, the Mail at Retail network pharmacy or the Express Scripts Mail Order Program pursuant to a physician's prescription. Each prescrip­tion is subject to the co-pay shown below. The co-pays are not eligible under your Medical benefit.

OVER-THE-COUNTER (OTC) DRUGS: The Plan provides benefits for Prilosec OTC®, Claritin® and Zyrtec OTC used for the treatment of seasonal allergies and the private label retail generics (store brands) for these two classes of drugs. Prescriptions must be written by your Doctor and must be filled within the Centralized Pharmacy Network. Each prescription is subject to the co-pay as currently in effect for generic medications.

 UFCW TRI-STATE HEALTH AND WELFARE FUND PROVIDER NETWORK

CENTRALIZED PHARMACY NETWORK
Your Express Scripts Card must be presented to a pharmacy in the UFCW Tri-State Health and Welfare Provider Network. The network includes many of the participating Employer stores, i.e., Acme Markets, Super Fresh, Shop Rite, Stop & Shop, Pathmark, Rite Aid and other independent stores.

MAIL AT RETAIL PROGRAM
The Mail at Retail Drug Program enables you to obtain your mandatory maintenance drugs directly from a store in the Mail at Retail Network: Acme Markets, Shop Rite, Stop & Shop and Rite Aid.

The UFCW Provider Network does not include the following pharmacy chains:
Wal-Mart, CVS, Walgreens, Wegmans, Genuardi’s, Target, Costco, BJ, Sam’s Club, Weis Supermarkets, Price Chopper, Hannaford Supermarkets, and Cost Cutter.

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.

COORDINATION OF BENEFITS

The purpose of this provision is to conserve funds associated with health care. Coordination of Benefits is applicable only when you, your spouse or your dependent(s) are eligible for benefits under more than one group health plan. This provision applies to all benefits except the routine vision care benefit.

When you receive health care services or other benefits that are also covered under another plan, a determination is made as to which plan is “primary” and which plan is “secondary”. The primary plan considers the services without regard to the secondary plan. The secondary plan will then consider the balances on covered services according to the limitation of its program. Refer to the SPD booklet for an explanation of “primary” and “secondary”.

If the plans are determined to be the secondary plan, the Plan will not pay more than they would have, had there been no other coverage.

Accordingly, from time to time all Participants will be required by the Fund office to fill out a personal Insurance Benefit Information form, containing specific information about other coverages available to either you, your spouse or your dependent(s). Failure to complete and return this form when required may affect your eligibility for further benefits.

Benefits payable under another Plan include benefits that would have been payable had the claim been duly made therefore. In no event will the Fund’s payment exceed the amount that would have been payable under this Plan if the Fund were primary.

REIMBURSEMENT OF OTHER INSURANCE CO-PAY

(when the UFCW Tri-State Health and Welfare Fund is your secondary plan)
Other coverage that you have may require a co-pay by you which is higher than the co-pay under the UFCW Tri-State Health and Welfare plan. If this is the case, the Fund will reimburse you the difference between the higher co-pay of the other plan and the UFCW Tri-State Health and Welfare Fund co-pay when eligible prescription drugs are purchased. Although we are working to automate the reimbursement process, at the present time it will be necessary for you to complete a Prescription Coordination Reimbursement Form and submit the pharmacy receipt which should include the co-pay amount, the name of the drug and the name of the person for whom the drug was dispensed.

NOTE: This reimbursement applies only to the co-pay charged by a plan other than the UFCW Tri-State Health and Welfare Fund prescription plan through Express Scripts.

MANDATORY MAINTENANCE LEGEND MEDICATION

All active participants and their eligible dependents & eligible retirees and their spouse must use a Mail at Retail network pharmacy or the Express Scripts Mail Order Program. Maintenance legend medications are those, but not all, taken on a long-term basis for such conditions as diabetes, blood pressure, etc.

Option 1 – Mail at Retail - The Mail at Retail Network includes Acme Markets, Super Fresh, Shop Rite, Pathmark, Shop & Shop, and Rite Aid. Take your prescriptions to one of these pharmacies. When you pick up the prescriptions, you will be asked to pay one copay for the 90 day supply.

Option 2 – ESI Mail Order - Complete an Express Scripts (ESI) mail order form, attach the prescription(s) and mail to the ESI mail order facility. A 90 day supply of your medication will be delivered to your door. Your cost will be limited to only 2 copayments instead of 3 copayments.

Please be reminded that the Fund has a mandatory generic program in place. If you choose to purchase a brand name drug you will be required to pay the difference between the cost of the generic drug and the brand name drug plus the appropriate co-pay.

ELIGIBILITY

Your Prescription Card (benefit) is only valid as long as you maintain your eligibility. Should you use your Prescription Card when you are ineligible, you will be liable for these charges. The participant named on the Prescription Card is respon­sible for inappropriate use of the card, and all unauthorized use unless the Fund has been notified previously of its loss.

IMPORTANT: YOU SHOULD UNDERSTAND THAT IT IS POSSIBLE FOR A CLAIM TO BE PROCESSED AND APPROVED AT THE RETAIL OR MAIL ORDER LEVEL, AND THEN LATER DETERMINED THAT BENEFITS SHOULD HAVE BEEN TERMINATED. IF THIS IS THE CASE, YOU WILL BE RESPONSIBLE TO REIMBURSE THE FUND FOR ALL AMOUNTS PAID ON YOUR BEHALF.

CO-PAYS NOTE: please refer to your SPD for Co-payments.

MAXIMUM ALLOWANCES - Prescriptions over $ 1000.00 must be pre-approved. The pharmacy will receive a message that pre-approval is required and may contact Express Scripts or the Fund Office. Additional information may be required, especially if this is a new product or new indication, but this should not cause any undue delay in processing.

LIMITATIONS

1. Maximum Supply per Prescription of non-maintenance legend drug
                        using the Centralized Pharmacy Network or Mail at Retail Pharmacy....................... 34 days
                        using the Express Scripts Mail or Online Pharmacy................................................... 90 days
2. Maximum Supply per Prescription of approved maintenance legend drug
                        using Mail at Retail or Express Scripts Mail or Online Pharmacy .............................. 90 days
3. Compounded drugs, unless at least one ingredient is a legend drug.
4. The Plan retains the right to limit any drug deemed excessive in quantity prescribed or where the cost is prohibitive.
5. Products are being introduced regularly and include, but are not limited to, new drugs, changes or new routes of administration, and changes or new indications. All products are subject to review and may be excluded or limited under this benefit.

EXCLUSIONS

1. Over-the-Counter drugs except for Prilosec OTC®, Claritin® and Zyrtec OTC.
2. Medications for or related to weight loss (i.e. Wegovy).
3. Any type of appliances or devices.
4. Hair growth or wrinkle removal medicines or similar products.
5. Legend drugs used for bodybuilding.
6. Fertility medications.
7. Drugs prescribed as a result of an automobile accident must be filed with your automobile insurance carrier.
8. Drugs prescribed as a result of a work related injury or work related medical condition must be filed with the Worker's Compen­sation carrier.
9. Drugs filled at a pharmacy that is not included in the UFCW provider network.
10. Charges for services and/or treatment related to methadone maintenance.
11. New products released after this booklet is printed are subject to scrutiny and approval by the Fund. Products include, but are not limited to, new drugs, changes or new routes of administration, and changes or new indications. All products are subject to review and may be excluded or limited under this benefit.