Prescription Drug Benefits

No matter which medical plan you choose, prescription drug coverage is included for you and your family. You can purchase your prescription medications at a pharmacy or through a mail order program. Generally, you can fill a prescription for up to a one-month supply at a retail pharmacy. If you use mail order, your prescription can be filled for up to 90 days.

Maintenance Medications

If you are on medication that you must take on a regular and continuing basis, like blood pressure or cholesterol medication, you will pay less by getting your prescription filled by mail order because one co-payment can purchase a 90-day supply.

If you are in the PPO or BlueChoice HMO, your prescription drug ID card is a separate card provided by UnitedHealthcare®/OptumRx®. When you visit a network pharmacy, you will need to present your ID card and pay a co-payment for each prescription. Many pharmacies participate in the UnitedHealthcare/OptumRx network. If you fill a prescription at a non-participating pharmacy, you will generally pay full price for the prescription. You must then file a claim with your prescription drug program to be reimbursed for the in-network price.

If you are in the Kaiser HMO, your prescription drug ID card is the same as your medical ID card. When you visit a network pharmacy, you will need to present your ID card and pay a co-payment for each prescription. Many pharmacies participate in the Kaiser Permanente network. If you fill a prescription at a non-participating pharmacy, you are responsible for the entire amount charged by the pharmacy.

Your Prescription Drug Benefits
If Your Medical Plan Is:Your Prescription Drug Program Is: Your Co-Payment Is:
Retail Network (30-day supply)Non-Network(30-day supply)Mail Order (90-day supply)
Kaiser Permanente HMO Kaiser Permanente Generic $5 $10 $10
Formulary brand $20 $40 $40
BlueChoice HMO UnitedHealthcare/OptumRx Generic $5 Full cost of drug $10
Formulary brand $20 Full cost of drug $40
Non-Formulary $30 Full cost of drug $60
CareFirst PPO UnitedHealthcare/OptumRx Generic $5 Full cost of drug $10
Formulary brand $20 Full cost of drug $40
Non-Formulary $30 Full cost of drug $60

Covered prescription drugs must be medically necessary as determined under the rules of the carrier. In addition, certain prescription drugs may be subject to exclusions, limitations or prior authorization for medical necessity. Refer to the benefit booklet from your carrier or contact your carrier for more details.

The Plan participates in the UnitedHealthcare/OptumRx fraud, waste and abuse program, which monitors patient and prescriber patterns to identify outliers and situations of abnormal utilization or prescribing. UnitedHealthcare/OptumRxand the Plan collaborate in identified cases of fraud, waste and abuse. The Plan can determine whether to restrict member access to pharmacies and physicians.

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FAQs

I am not working. Can I stay on the Plan’s coverage?

If you are not working, but you are still eligible for Plan coverage under the collective bargaining agreement, you may continue your coverage under the Plan by making monthly payments to the Plan during your period(s) of leave. You must notify the Health and Welfare office when you return to work.

If you are out on Workers’ Compensation, you must also make your monthly payments directly to the Health & Welfare Plan because they are not deducted from your paycheck or from your Workers’ Compensation benefits.

Payments are due on the first of the month. It is your responsibility to make your Health & Welfare payments on time. The Plan does not send notices of delinquent payments, nor will it send you a bill. If you do not make your payments on time, your coverage under the Plan will end. Consider permitting the Plan to deduct payments from your bank account. Contact the Plan for more information.

Coverage will retroactively end as of the monthly premium payment due date if the required monthly premium payment is not paid within 30 days from the due date (e.g., if the monthly premium payment for September, which is due on September 1, is not paid by September 30th, coverage would be terminated as of September 1). If coverage is terminated due to non-payment of the required monthly premium payment, you may again become covered (on a prospective basis) by sending in the required monthly premium payment for future coverage. Your coverage will re-start as of the first day of the month following receipt of the required monthly premium payment. You will not be permitted to retroactively reinstate coverage for any period of coverage that terminated due to non-payment of the required monthly premium payment.

If you are on a leave of absence for military duty, you are permitted to continue medical, dental, prescription drug, and vision benefit coverage under this Plan for you and your covered dependents in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). Please see the “If You Enter Military Service”  section on the Life Events page for more information.

If your coverage ends due to termination of your employment with METRO, you may be eligible for COBRA for you and your family. Although METRO will notify the Health & Welfare Plan of your termination, you are also encouraged to inform the Health & Welfare Plan to avoid any delay.

If you lose Plan coverage due to the termination of your employment or any other reason, you may want to look into purchasing health coverage through a Health Insurance Marketplace.

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