Prescription Drug Benefits

The Plan’s prescription drug benefit is administered by CVS Caremark. All Participants and their Eligible Dependents are eligible for these benefits, except for those enrolled in an HMO, Plan M, and Medicare Retirees enrolled in a Medicare Advantage Plan.

In general, all medically or dentally necessary FDA approved drugs will be covered under the Plan. However, the Trustees will review all requests for newly approved drugs.

You may obtain your prescriptions through either a retail (walk-in) pharmacy or through mail order (home delivery). If you do not use a CVS Caremark network pharmacy, you have only limited benefits which are reimbursed at a lower amount as outlined below.

Most of your prescriptions can be filled without prior authorization by the Fund Office at a retail pharmacy. However, some drugs are only covered for certain uses or in certain quantities. If you present a prescription to the pharmacy which requires prior authorization, your doctor may need to provide additional information before your prescription is covered. You can call the Fund Office at (866) 400-5200 to determine if your prescription requires prior authorization.

The Plan’s prescription drug benefits are as follows:

^*When a generic drug is available but the pharmacy dispenses the brand-name drug for any reason, you will pay the applicable co-payment plus 50% of the difference in cost between the brand and the generic.
^**You can receive up to a 90-day supply of maintenance type medications directly from your local CVS Caremark Network pharmacy at the lower, mail order co-pays.

Special Reimbursement Limits

• Sleep Aids: The maximum reimbursement for all prescription sleep aid medications is limited to $30 for a 30-day supply.
• Ulcer Drugs (PPIs): The maximum reimbursement for PPI medications is limited to $30 for a 30-day supply.

Immunization Service

As approved by the FDA the following routine vaccinations are available with no co-payment at local CVS Caremark network pharmacies:

• Seasonal Influenza
• Zoster (shingles)
• Tetanus, Diphtheria Toxoids, Pertussis
• Hepatitis A & B
• Measles, Mumps, Rubella, Varicella
• Pneumococcal (pneumonia)
• Human Papillomavirus
• Meningococcal
• COVID-19

CVS Caremark Retail Benefit

To use the CVS Caremark retail pharmacy benefit, simply provide your CVS Caremark or OE Health & Welfare Fund ID card along with your prescription to any participating pharmacy. Major pharmacy chains are participating pharmacies as well as many of the independent pharmacies. You will only be charged the co-payment listed on the previous page. There are no claim forms to file.

If the pharmacist cannot determine your eligibility or has questions regarding your prescription, the pharmacist will call CVS Caremark or the Fund Office for authorization. If this occurs after business hours, you may have to return to the pharmacy for your prescription.

To locate a Network pharmacy near your home, workplace or while on vacation, visit www.caremark.com or call (833) 266-8149.

The Retail Plan generally covers a 30-day supply of your prescription, provided your doctor prescribed that amount, with the following exceptions:

• You can receive up to a 90-day supply of maintenance type medications at CVS Caremark network pharmacies and at the lower Mail Order co-pays.
• You can receive more than a 30-day supply if you need several months of your prescription while you are on vacation. You must contact the Fund Office for pre-authorization at
  (866) 400-5200.

Maintenance Type Medications

Participants and their covered dependents who take medications for chronic conditions, such as high blood pressure, high cholesterol or diabetes, can obtain 90-day supplies of medications resulting in lower co-pays and greater convenience.

Your physician will have to write a prescription for a 90-day supply and it can be filled in one of two ways:

• CVS Caremark Network Pharmacy Maintenance Program: You can obtain up to a 90-day supply at any CVS Caremark network retail pharmacy nationwide.
• CVS Caremark Mail Order Maintenance Medication Program : Mail order service is available nationwide and is generally used for participants who use maintenance-type drugs.

Mail Order Prescription

By using CVS Caremark’s Mail Service Pharmacy, you can have prescriptions delivered to your home. To start filing your medications by mail, you can ask your doctor to send an electronic prescription to CVS Caremark Mail Service Pharmacy or have CVS Caremark contact your doctor and get the process started for you. You can expect to receive your prescriptions within 7 to 10 business days. 

Up to a 90-day supply will be sent based on the amount your doctor prescribed. By law, CVS Caremark must fill your prescription for the exact quantity prescribed by your doctor, up to the 90-day limit. For example, if your prescription states:“30 days plus two refills,” the pharmacy will only dispense a 30 day supply on your first order, not a 90 day supply. You can only get a 90 day supply on the first order if the prescription states you may have a 90 day supply initially.

Mail Order Refills

You can order your refill(s) by internet or phone. The information included in your last order will show the date you can request a refill and the number of refills you have left.

1. Internet: This is the most convenient way to order refills and inquire about the status of your order any time of the day or night. You will need to register and log in to access service by going to www.caremark.com.
2. Phone: Call toll-free (833) 266-8149 24 hours a day, 7 days a week for the CVS Caremark refill phone service. Have your Social Security number or OEID number ready. For Participants who are hearing impaired, CVS Caremark supports TTY service to make ordering by telephone easy. To access this service, call TTY 711.

Payment Options

While checks and money orders are accepted, the preferred method of payment is by credit card. For credit card payments, include your VISA, Discover, MasterCard, or American Express card
number and the expiration date in the space provided on the Mail Service Order Form.

Transform Diabetes Care

Available with CVS Caremark, Transform Diabetes Care is a personalized program that can help make it easier to keep your diabetes and other conditions in check.  Managing diabetes can be complex. Achieving and maintaining one’s best health for this chronic condition, which causes higher than normal blood sugar levels, depends on a person’s ability to monitor symptoms, manage complicated medication regimens, control blood glucose and practice healthy behaviors.  This comprehensive program will be available at no cost to all eligible members, including Medicare eligible and non-Medicare eligible retirees and their dependents who are enrolled in the Fund’s PPO Plan. 

As a member of the program, you’ll have access to:

• Two MinuteClinic® vouchers for in-person or virtual visits
• Access to the Health Optimizer™ app to help manage your condition
• Health resources, virtual care visits and more – all at no extra cost to you

    ❖ Enrollment into the program will be automatic for some members based on their diabetic status but have the option to opt-out at any time.

Those who qualify for the Transform Diabetes Care program will receive a Welcome Letter in the mail which will include information about the program along with instructions on how to utilize the health tools which keep track of your progress and help reach your wellness goals.

This program is voluntary.  You can opt out anytime by calling the Transform Diabetes Care team at 1-800-348-5238.

For those who do not participate in the Transform Diabetes Care program, diabetic supplies will continue to be available through CVS Caremark’s prescription drug program with the regular co-pays.

PrudentRx Solution for Specialty Medications

Operating Engineers Health and Welfare Fund has contracted with PrudentRx Solution to help provide a comprehensive and cost-effective prescription drug program for you and your family for certain specialty medications. The PrudentRx Solution assists members by helping them enroll in manufacturer copay assistance programs. Medications on the PrudentRx Program Drug List* are included in the program and will be subject to a 30% co-insurance unless you are participating in the PrudentRx Solution, which includes enrollment in an available manufacturer copay assistance program for your specialty medication.

 IMPORTANT:  You will have a $0 out-of-pocket responsibility for your specialty medications covered under the PrudentRx Solution if you are enrolled in an available manufacturer copay assistance program  for those specialty medications.

Copay assistance is a process in which drug manufacturers provide financial support to patients by covering all or most of the patient cost share for select medications.  The PrudentRx Solution will assist members in obtaining copay assistance from drug manufacturers to reduce a member’s cost share for eligible specialty medications thereby reducing out-of-pocket expenses. Participation in the program requires certain data to be shared with the administrators of these copay assistance programs, but please be assured that this is done in compliance with the privacy rules of HIPAA.

If you currently take one or more specialty medications included in the PrudentRx Program Drug List, you will receive a Welcome Letter from PrudentRx that provides information about the PrudentRx Solution as it pertains to your medication(s).  All eligible members must call PrudentRx at 1-800-578-4403 to register for any manufacturer copay assistance program available for your specialty medication as some manufacturers require you to sign up to take advantage of the copay assistance that they provide for their medications. If you do not call, PrudentRx will conduct outreach to help you with questions and enrollment. If you choose not to participate in the PrudentRx Solution, you must call 1-800-578-4403 to opt-out of the program.  Eligible members who fail to enroll in an available manufacturer copay assistance program or who opt out of the PrudentRx Solution will be responsible for the full amount of the 30% co-insurance on specialty medications that are eligible for the PrudentRx Solution.

If you or a covered family member are not currently taking but will start a new medication covered under the PrudentRx Solution, you can reach out to PrudentRx.  If you don’t contact PrudentRx, they will proactively contact you to ensure you can take full advantage of the PrudentRx Solution. 

Payments made on your behalf, including amounts paid by a manufacturer’s copay assistance program, for medications covered under the PrudentRx Solution will not count toward your out-of-pocket maximum with the Plan, unless otherwise required by law.  Also, payments made by you for a medication that does not qualify as an “essential health benefit” under the Affordable Care Act, will not count toward your deductible or out-of-pocket maximum (if any), unless otherwise required by law. 

A list of specialty medications that are not considered to be “essential health benefits” under the Affordable Care Act is available from the Fund Office.  An exception process is available for determining whether a medication that is not an “essential health benefit” under the Affordable Care Act is medically necessary for a particular individual. 

If you have any questions regarding the PrudentRx Solution, please call 1-800-578-4403.

*The PrudentRx Program Drug List may be updated periodically.

Over-the-Counter Birth Control

As approved by the FDA, over-the-counter birth control is available with $0 copay when filled at an CVS Caremark network pharmacy and prescribed by a physician. You will be responsible for the full cost of the drug medication if not purchased at a CVS Caremark network pharmacy and/or if it is not prescribed.

Non-Network Benefits

You have the option to go to any drug store of your choice to obtain your prescription on a limited basis. You may have to pay the entire cost of the prescription when you obtain it. You must then submit your claim for reimbursement to the Fund Office, using a form available for printing at www.oefi.org or from the Fund Office.

The Plan will pay 80% of the Reasonable and Customary charge after satisfaction of the PPO Non-Network deductible. Reimbursement is limited to a maximum of 60 days for any one individual drug. Once you have obtained a 60-day supply, you must use a CVS Caremark Network pharmacy for additional refills. Continued purchases outside of a CVS Caremark Network pharmacy will be denied.

Drug Expenses Not Covered

• • 1. Drugs or medications not requiring a physician’s or dentist’s prescription. This would include any medication which can be purchased “over the counter.”
    2. “Over the counter” vitamins. If your doctor prescribes a vitamin which cannot be purchased over the counter, you may obtain the vitamin through the CVS Caremark Plan.
    3. Bandages, heat lamps, splints, wrist supports, non-drug items (over the counter items).
    4. Drugs or drug treatments not approved by the FDA, including but not limited to, compounded medications or experimental drugs.
    5. Retin-A, unless used in the treatment of acne or skin cancer.
    6. Minoxidill, Rogaine, and any other hair growth treatment.
    7. Drugs used in the treatment of infertility.
    8. Homeopathic or holistic medications and herbal remedies. Homeopathic treatment is covered by the Plan only in the State of Nevada.
    9. Unit dose drugs.
    10. Nutritional dietary drugs.
    11. Asthma and diabetic supplies for Medicare members except when a balance remains after the Medicare payment.
    12. Miscellaneous over the counter medical supplies, including but not limited to such items as diapers, Band-Aids, and Ace bandages.
    13. Liquid or powdered food supplements not requiring a prescription.
    14. ED (erectile dysfunction) drugs such as Viagra and Levitra are limited to 8 pills per month if determined to be medically necessary. This means that the dysfunction must be caused by a physiological condition such as heart disease or prostate conditions, as certified in writing by the prescribing physician.

Appeals

If your claim for prescription drugs has been denied in whole or in part, you have the right to appeal. The following provides an overview of the CVS Caremark appeals process.

• Letters notifying the member or their representative of a prior authorization denial will include the appeals contact information.
• Once a member or a member’s representative contacts CVS Caremark with a request to appeal, that individual is instructed on how to submit an appeal.
  • Pre-Authorization Review – CVS Caremark will make a decision on a prior authorization request for a Plan benefit within 15 days after it receives the request. If the request relates to an Urgent Care Claim, CVS Caremark will make a decision on the Claim as soon as possible, but not later than 72 hours.
  • Coverage Determination Review – CVS Caremark will make a decision on a Coverage Determination within 15 days after it receives such a request. If the member is requesting the Coverage Determination of an Urgent Care Claim, a decision on such request will be made as soon as possible, but not later than 72 hours.
  • Post-Service Review – CVS Caremark will make a decision on a Post-Service Claim within 30 days after it receives such a request.
• Reviews of appeals are performed based on the Trust Fund’s prescription benefit plan and approved prior authorization criteria. All appeals for prior authorization denials are reviewed by a registered pharmacist.
• A letter is sent to the member or their representative and/or the member’s physician notifying them of the appeal decision and the next step in the appeals process, if another level is offered.

The review process includes the consideration of relevant and supporting documentation submitted by and for the claimant. Supporting documentation may include a letter written by the practitioner (physician) in support of the appeal, a copy of the denial letter sent by CVS Caremark a copy of the member’s payment receipt, medical records, etc. All information received is handled in compliance with HIPAA regulations.

HMO Enrollees

If you are enrolled in an HMO, your prescription drugs must be obtained through your HMO.

Rules for Medicare Retirees Enrolled in a Medicare Advantage PPO or HMO Plan

The prescription drug coverage under the Operating Engineers Health and Welfare is as good as or better than the standard Medicare prescription drug coverage. You do not have to enroll in a Medicare Part D plan. You may enroll in a Medicare Part D plan in the future during the annual enrollment period and you will not be charged a late enrollment penalty if you follow Medicare’s rules when you apply and if you apply timely according to those Medicare rules.

You can keep your current prescription drug coverage under the Plan and enroll in one of the Medicare Part D plans. The Active Plan coverage is primary to Medicare and the Retiree Plan coverage is secondary to Medicare. You will have to pay the Medicare Part D premium out of your own pocket. If you have Retiree Plan coverage, you are legally obligated to provide your Part D plan with information on the benefits you receive from this Plan.

Rules for Medicare Retirees Enrolled in a Medicare Advantage PPO or HMO Plan

Your prescription drug coverage is provided under the Medicare Advantage Plan in which you are enrolled.

Rules for Participants Enrolled in Plan M

Because your prescription drug coverage under Plan M is not, on average, as good as the standard Medicare Part D plans, you should consider whether to enroll in a Medicare Part D plan. Because your Plan M coverage is not creditable, if you do not enroll in a Part D plan before December 31st, you may have a late enrollment penalty on the premium you pay for that Medicare coverage.

You should consider enrolling in a Medicare Advantage Plan. You should compare information about your current prescription drug coverage and the drug coverage under Medicare Part D plans, such as monthly premiums, the covered and non-covered drugs, the deductible and co-payments or coinsurance, mail order service and retail pharmacy locations.

More Information About Medicare Part D

More detailed information about Medicare plans that offer prescription drug coverage is available in the “Medicare & You”  handbook that you receive from Medicare. You can also get more information about Medicare Part D plans from the following places:

• • 1. Visit www.medicare.gov
    2. Call your State Health Insurance Assistance Program (see your copy of “Medicare & You”  for the telephone number).
    3. Call Medicare at (800) 633-4227. TTY users should call (777) 486-2048.

For individuals with limited income and resources, extra help paying for a Medicare Part D plan is available. Information about this extra help is available from the Social Security Administration at www.socialsecurity.gov, or by phone at: (800) 777-1213 (TTY 800-325-0778).

Revised 01/2025