Prescription Drug Benefit Pharmacy care built around you
This page provides basic information about the prescription drug benefits available through the UNITE HERE Local 11 Health Benefit Fund. For eligibility rules and full plan details, see the Summary Plan Description.
- Getting started
- What’s covered
- Retail pharmacy co-pays
- Find a network pharmacy
- Mail Order Pharmacy Program (for maintenance drugs)
- Specialty drugs
Getting started
The UNITE HERE Local 11 Health Benefit Fund has contracted with Express Scripts to provide you and your dependents with prescription drug benefits including maintenance and specialty drugs.
Get started in three easy steps:
Check the mail for your Express Scripts member ID card. If you do not receive your insurance card within two weeks, or if you need care before receiving your card, call Express Scripts at (800) 282-2881.
Create your account. Setting up your account is easy. Just register on the Express Scripts website and follow the instructions online. You will need your member ID to register.
Find a pharmacy. Start by selecting a convenient local network pharmacy, and setting up your mail order or specialty prescriptions (if needed). See below for more information.
Attention Kaiser Permanente members: Kaiser pharmacies are not in network! Make sure to tell your Kaiser doctor and medical team that your prescription benefit is through Express Scripts and NOT through Kaiser and ask them to send your prescription to your chosen in-network pharmacy. Additionally, many pharmacies will ask for your “medical card”- present your Express Scripts card, not your Kaiser card, when they ask this.
What’s covered
Prescription drug benefits are provided by Express Scripts to all eligible employees and dependents enrolled in a medical plan. You have the same Express Scripts prescription drug benefits regardless of the medical plan in which you are enrolled. Details about the prescription drug benefit are described in Summary Plan Description in the Find Forms & Documents section of this website.
In-network pharmacies
Prescriptions must be filled at pharmacies contracted with Express Scripts in order to be covered by the Plan. These “contracted” pharmacies are called “network pharmacies.” A list of network pharmacies in your area can be found on the Express Scripts website or by calling the number below.
Website: Log in to the Express Scripts website http://www.express-scripts.com and search for a pharmacy by your zip code.
Phone: Call (800) 606-5667 and provide your address to get a list of network pharmacies near you.
Any prescription filled at a pharmacy NOT in the Express Scripts network will not be covered, except in case of an emergency.
Preventive care medications and products
Certain preventive care medications (prescription and over the counter) and products are covered at 100% if prescribed by a physician or other appropriate health care professional.
You must have a prescription for your preventative care medication or product to be covered, even if the medication or product is available over the counter (“OTC”).
Preventive care medications and products are subject to change. Here is a partial list of covered products and medications (a written prescription is required for coverage):
FDA-approved generic contraceptive drugs and devices for women (subject to quantity limits)
Preparation products for colon cancer screening test
Breast cancer prevention drugs – Risk reducing medications such as tamoxifen, soltamox, or raloxifene for women 35 years or older with increased risk for breast cancer and at low risk for adverse medication effects
Tobacco cessation products – FDA-approved generic tobacco cessation medications (including both prescription and over-the-counter medications) for up to two 90-day treatment regimens per calendar year
Statin preventive medication – Adults ages 40-75 years with no history of cardiovascular disease (CVD), 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater
Retail pharmacy co-pays
In accordance with your drug benefit program, for drugs purchased at a retail pharmacy your copayment per prescription is:
| Retail (limited to 30-day supply): | |
|---|---|
| Formulary generic drugs | $3 copayment |
| Brand name drugs | $6 copayment |
Note: If you get a brand name drug when a generic is available, you will pay the difference in price between the brand name and the generic drug, plus the applicable copay. See the Summary Plan Description for complete details.
Find a network pharmacy
Prescriptions must be filled at pharmacies contracted with Express Scripts to be covered by the Plan. These “contracted” pharmacies are called “network pharmacies.” A list of network pharmacies in your area can be found on the Express Scripts website or by calling the number below.
Website: Log in to the Express Scripts website and search for a pharmacy by your zip code.
Phone: Call (800) 606-5667 and provide your address to get a list of network pharmacies near you.
Any prescription filled at a pharmacy NOT in the Express Scripts network will not be covered, except in case of an emergency.
Mail Order Pharmacy Program (for maintenance drugs)
Low copays that cover a 90-day supply
Maintenance drugs are drugs that you take daily for a long time, like high blood pressure medication. Maintenance drugs are ones that you fill each month with the same dosage. These medications are available through Express Scripts Mail Order Pharmacy and are delivered directly to your home every 90 days. It’s less costly, and convenient!
A letter will be sent to you asking you to sign up for Express Scripts Mail Order after you’ve filled a prescription for 2 months. Once you get the letter, you must call Express Scripts to sign up for mail order, and you will pay the lower copays shown in the chart below. You will pay $3 for 90 days instead of $3 for a month, so you will save money on your medications!
If you don’t want to sign up for mail order, you must call Express Scripts to opt out of mail order. If you don’t call Express Scripts, you will be charged the full amount of the medication cost when you go to the pharmacy and will need to call Express Scripts to avoid paying the full cost.
Your copayment when purchasing maintenance drugs through mail order will be:
| Mail Order (up to 90-day supply): | |
|---|---|
| Generic drugs | $3 copayment |
| Brand name drugs | $5 copayment |
Specialty drugs
Express Scripts identifies certain prescription drugs as specialty drugs. Typically, specialty drugs are prescription drugs that require professional administration or special handling, that have a high cost, or drugs used to treat rare or severe medical conditions. These drugs are usually not available at a regular pharmacy and must be mailed to you.
In general, co-pays for specialty drugs are the same as for the retail drugs listed above. However, effective October 1, 2021, the copayment for certain specialty drugs designated by Express Scripts as non-essential health benefits will substantially exceed those amounts. These designated specialty drugs, and the copay for each of them, may change from time to time.
The designated specialty drugs and copays are maintained by Express Scripts on its SaveOn SP Drug list. You may contact Express Scripts for information about drugs on the SaveOn SP Drug list.
If you have been prescribed a specialty drug and have been informed about a high copay, call Accredo at 800-803-2523 and they will help guide you through the process. Usually, members pay $0 under Accredo and SaveOn SP.
For more information about this program or to obtain information about specialty drugs contact Express Scripts at (877) 248-1164.