Prescription Coverage

For each drug (or refill) administered or prescribed by a physician, the Plan pays for a 30-day supply, (60-day or 90-day supply for maintenance drugs only) after these copays:

*Maintenance-only. Maintenance drugs in excess of a 30-day supply must be purchased through a pharmacy in the custom network which provides special discounts or through WellDyne Mail.
**Appropriate Tier copay plus the difference in cost between the generic and the brand name drug.

• Tier 0 – some selected highly cost-effective medications and other mandated $0 copay drugs.
• Tier 1 – most current generics and potentially some cost-effective brand name drugs.
• Tier 2 – most brand name drugs, or costlier or less desirable generics.
• Tier 3 – non-preferred brand drugs and some more costly brand and generic drugs.

You can contact WellDyne, the Trust Office, or download a Formulary listing and which tier your prescription is in.

The program features a custom network of pharmacies consisting of employers who participate in the Trust which includes pharmacies at many Kaiser clinic facilities. In addition, there is the WellDyne pharmacy network. You can use any pharmacy – the choice is yours each time you fill a prescription. Pharmacies in the custom network and the WellDyne network provide discounted prescriptions to the Plan. However, to receive the most cost-effective copayments, always use the custom network and mail order pharmacy as described below.

• Trust custom network. When you use a Trust custom network pharmacy including participating Kaiser clinic locations, simply take your prescription and your Trust ID card to the pharmacy and pay the appropriate copay.
  Be sure to show your Trust ID card when you fill a prescription. If you do not identify yourself as a Plan participant, the Trust will not receive the discount. If you fill a prescription at a custom network pharmacy but do not show your ID card, you will pay an additional processing fee of $10 for generic and $20 for brand drug prescriptions for each 30-day supply.
• WellDyne network. If you fill your prescription at a WellDyne pharmacy that is not in the Trust custom network, you pay the full cost at the time of purchase, then file a claim with the Trust Office and wait for reimbursement.
  Be sure to show your Trust ID card when you fill a prescription. If you do not identify yourself as a Plan participant, the Trust will not receive the discount. If you fill a prescription at a WellDyne network pharmacy but do not show your ID card, you will pay an additional processing fee of $10 for generic and $20 for brand drug prescriptions for each 30 day supply.
• Out-of-network. For all pharmacies not in the Trust custom or WellDyne networks, you pay the full cost at the time of purchase, then file a claim with the Trust Office and wait for reimbursement.
  If you chose to use a pharmacy that is not in either the custom or WellDyne networks, you will pay an additional processing fee of $10 for generic and $20 for brand drug prescriptions for each 30-day supply.

If you need help locating a custom network pharmacy, call the Trust Office at (800) 225 7620 or download the Trust Custom Network list here. For a WellDyne network pharmacy call WellDyne at (800) 373-1568.

If your dependents have other insurance and the other coverage is primary, they will need to follow that plan’s procedures when purchasing prescriptions. Then, to get reimbursed by the Trust for the copay, submit a copy of the prescription receipt and any explanation of benefits form to the Trust Office.

You also have the option of using WellDyne Mail.

• To use WellDyne Mail, ask your medical provider to send a NEW 90-day prescription for each of your maintenance medications to:
  • E-prescribe: WellDyne Prescription Delivery (NCPDP ID#: 1035371)
    Or They may:
  • Fax: 1 (877) 221-1259 or 1 (888) 830-3608
  • Once WellDyne Mail receives the prescription from your provider, a representative form WellDyne will reach out to arrange delivery and payment of any copay
  • If there are questions about WellDyne Mail please call 1-800-373-1568 to speak to one of their agents.

To make sure you don’t run out of your medicine on your initial fill, allow two or three weeks for receiving your prescription. If you send in a prescription for a new medicine, request a two to three-week supply from your doctor to be filled at a Trust custom network pharmacy while you wait for your mail-order medication. For refills through WellDyne Mail, please allow seven business days for processing.

Certain specialty drugs are provided through WellDyne Specialty Pharmacy and the Trust’s prescription drug program. Specialty drugs include, but are not limited to, the following:

• Certain self – injectable drugs (excluding insulin)
• Oral medications for oncology (cancer), some HIV drugs and a variety of other medications that may require special monitoring or handling, or are extremely costly
• Designated drugs included in the Trust’s Affordable Therapeutics Program which require procurement through WellDyne Specialty Pharmacy and will result in your paying the lowest available copay
• Medications for transplants

You can contact WellDyne Specialty Pharmacy during the hours of 9:00 a.m. to 5:00 p.m. Pacific Time at (800) 641-8475 if you have any questions.

Maintenance drugs are certain designated medications used to treat chronic or long-term conditions such as diabetes, arthritis, heart conditions, high cholesterol, digestive, asthma and high blood pressure that are included on the Trust’s Maintenance Medication drug list.
Maintenance prescription drugs written for a 30-day supply can be filled at a retail pharmacy. However, any maintenance prescriptions written in excess of a 30-day supply can only be purchased from:

• Certain custom network pharmacies; for a list of those pharmacies download the Trust Custom Network list or contact the Trust Office at (800) 225 7620
• WellDyne Mail, as described above

After you or your family reach the annual prescription drug out-of-pocket (OOP) maximum, the Plan waives all copays for that person or family for the rest of that calendar year.For covered expenses incurred between January 1, 2021 and December 31, 2021, the prescription drug out-of-pocket maximums that you pay yourself for in-network covered prescription drugs are:

For covered expenses incurred between January 1, 2022 and December 31, 2022, the prescription drug out-of-pocket maximums that you pay yourself for in-network covered prescription drugs are:

For calendar years after 2022 please refer to the annual Summary of Benefits and Coverage (SBC) for the applicable ACA out-of-pocket maximums.

Prescription drug copays apply to the out-of-pocket maximum, but any processing fees, cost differentials or non-covered prescription drug expenses will not apply.

The Plan covers charges for:

• FDA approved legend prescription drugs when used for an FDA approved condition
• Hospital take home prescription drugs, birth control products and diabetic supplies (including insulin, insulin syringe, needles, test strips or equivalent) prescribed by a physician for use outside the hospital until prescriptions can be obtained through the Trust’s prescription drug program
• Prescription drugs, birth control products and diabetic supplies (including insulin, insulin syringe, needles, test strips and equivalent) from licensed pharmacists
• Self-injectable drugs prescribed by a physician
• Some prescription therapeutic vitamins, prenatal vitamins while pregnant, and other medications and vitamins as required by law and prescribed by a physician for a specific illness and received from a licensed pharmacist
• Weight control drugs if prescribed by a physician specifically to treat morbid or severe obesity when used according to the FDA approved package labeling and as part of a comprehensive weight management plan of care. Your provider may be required to obtain pre-authorization before these medications can be approved for coverage.
• Certain over-the-counter (OTC) medications when accompanied by a valid prescription; call the Trust Office or see our Formulary link for details
• Prescription drugs used to treat substance abuse will be covered when used according to the FDA approved package labeling and when part of a comprehensive plan of care Your provider may be required to obtain pre-authorization before these medications can be approved for coverage. Contact the Trust Office for more information.

The Plan does not cover:

1. Any drug not reasonably necessary for the care or treatment of bodily injury or illness and not considered to be Medically Necessary.
2. Appliances, devices, bandages, heat lamps, braces or splints.
3. Blood and blood plasma.
4. Claims received after the 12-month filing limit.
5. Cosmetics or health and beauty aids.
6. Drugs administered or taken while confined in the hospital unless approved by your physician and not available on the hospital formulary
7. Drugs lost, stolen or damaged by neglect.
8. Drugs reimbursable by any government program – national, state, county or municipal.
9. Drugs taken in conjunction with home health, hospice or skilled nursing care.
10. Maintenance prescription drugs in excess of a 30-day supply that are purchased from other than the WellDyne Mail or certain “custom network” pharmacies as described on previously46.
11. Medicines not requiring a prescription, unless otherwise indicated.
12. Multiple or nontherapeutic vitamins or dietary supplements, except as required by law.
13. Non-maintenance drugs from a retail pharmacy in excess of a 30-day supply; maintenance drugs in excess of a 90-day supply.
14. Fertility and infertility drugs.
15. Growth hormones, unless preauthorized in advance by WellDyne Specialty Pharmacy.
16. Refills before eligible (refill too soon).
17. Compound medications unless there is a medical exigency and prior approval is received.

Some of these items may be covered under your medical benefits; contact the Trust Office for details.