For Non-Medicare Retirees:
– Reimbursement of drug co-payment expenses is 80% after the annual $100 deductible, with an annual maximum of $10,000 for members enrolled in a City basic health plan with the optional rider for prescription drugs.
– This benefit is separate from the CSA Retiree Welfare Fund’s Supplemental Medical or Catastrophic Medical benefit.
– The same guidelines apply to eligible spouses (or registered domestic partners) who have their own prescription drug plan. Please include a description of the spouse/partner’s plan along with the claim submission to determine the allowable benefit.
– If the spouse is a retired UFT member with membership in SHIP, copayments should be submitted to SHIP first. Please submit the explanation of benefits or denial from SHIP for applicable coordination of benefits.
GHI City Plan + Optional Rider:
– An Express Scripts Summary of Benefits is sent out quarterly from GHI. This statement is the only acceptable document used for processing. Submit all 4 quarters at the end of the year, and processing takes place during March/April of the following year.
Emblem Health HIP or Other HMO City Plan + Optional Rider:
– Submit a printout from the pharmacy or mail service used for purchases. The printout must include: total amount paid by insurance, name of drug, strength, quantity, date dispensed, and amount paid by the member.
– If a printout is not accessible, request receipt submission forms from the CSA Retiree Welfare Fund. Paste or tape individual receipts from the pharmacy in chronological order on the form. Use a separate form for each patient, and ensure the receipts contain the information listed above.
– Internet-generated printouts will not be accepted.
PLEASE NOTE:
– If the drug plan pays $0, the out-of-pocket cost is not considered a co-pay, and there will be no reimbursement.
For Medicare Retirees:
GHI SENIOR CARE + OPTIONAL RIDER (MEDICARE D ENHANCED PDP RX PLAN) OR NYC MEDICARE ADVANTAGE PLUS PLAN WITH OPTIONAL RIDER PRESCRIPTION DRUG PLAN:
- There is an automatic reimbursement of $480 to offset the rider premium cost for one person in the family.
- If your out-of-pocket costs (TrOOP) exceed the yearly maximum, you will receive 100% reimbursement of additional co-pay costs, with an annual maximum of $5,000.
- To request reimbursement for these costs, submit copies of all pages of the GHI ENHANCED MEDICARE PDP printouts, including the first page showing the name and address of the recipient, only when your TrOOP (“Amount You Paid” column) exceeds the amount applicable for that year.
GHI SENIOR CARE – NO OPTIONAL RIDER:
- No co-pay reimbursement or premium reimbursement is available.
GHI SENIOR CARE without Optional Rider + ANY OTHER MEDICARE D RX PLAN (e.g., AARP):
- You can receive reimbursement for drug co-payment expenses at 80% after the annual $100 deductible, with an annual maximum of $5,000.
- Along with the pharmacy or mail service printout, please submit a description of the drug plan for determination of the allowed benefit. The printout must also include the plan’s share of the cost of the medication.
HIP/VIP Medicare Plan OR OTHER HMO Medicare CITY PLAN + OPTIONAL RIDER:
- HIP/VIP members must submit the Enhanced Medicare PDP Printout listing their prescription drug purchases. For other HMO Medicare plan participants, submit the printout from the pharmacy or mail service used for purchases, including details like total amount paid by insurance, name of drug, strength, quantity, date dispensed, and the amount you paid.
- If you can’t access a printout from your plan, request receipt submission forms from the CSA Retiree Welfare Fund. Paste or tape individual receipts from the pharmacy in chronological order on separate forms for each patient, ensuring they contain the information listed above.
- Internet-generated printouts will not be accepted.
IMPORTANT: If a CSA retiree has waived their City health plan and/or optional rider and is covered by a spouse/partner’s plan, the CSA Retiree Welfare Fund must have a detailed description of the plan being used to determine the allowed benefit. Medicare eligible members covered by another GHI-Senior Care City plan are not eligible for drug co-pay reimbursement unless they exceed the TrOOP applicable for that year.
Survivors of Deceased CSA Retirees
For survivors of deceased CSA retirees who have different prescription drug plans, the reimbursement guidelines are as follows:
CITY COBRA + RIDER (Medicare & Non-Medicare):
- Reimbursement of drug co-payment expenses at 80% after the annual $100 deductible, with an annual maximum of $5,000.
GHI:
- Submit the Express Scripts Summary of Benefits or the GHI PDP printout sent from GHI. This statement is the only acceptable document used for processing. Submit each quarterly report as it is received throughout the year.
HMO RX PLANS:
- Submit the printout from the pharmacy or mail service used for purchases. The printout must include: total amount paid by insurance, name of drug, strength, quantity, date dispensed, and the amount you paid.
- If you cannot access a printout, call the CSA Retiree Welfare Fund to request receipt submission forms. Paste or tape individual receipts from the pharmacy in chronological order on separate forms for each patient. These receipts should also contain the information listed above. Internet-generated printouts will not be accepted.
OTHER MEDICARE SUPPLEMENTAL PLAN WITH RX BENEFITS:
- Reimbursement of drug co-payment expenses at 80% after the annual $100 deductible, with an annual maximum of $5,000.
OWN PLAN + RX PLAN (Non-Medicare):
- Reimbursement of drug co-payment expenses at 80% after an annual $100 deductible, with an annual maximum of $5,000.
- Please submit a detailed description of the prescription drug plan being used for determination of the allowed benefit.
For all survivors, the CSA Retiree Welfare Fund provides drug co-payment reimbursements based on the respective plan’s guidelines, with an 80% reimbursement after the annual $100 deductible, and a maximum annual reimbursement of $5,000. Please ensure to follow the specific documentation requirements mentioned for each plan to facilitate the claim processing.
