Health Center Pharmacies
All members, including out-of-area EPO members, must use the Health Center pharmacies to receive prescription drug coverage through our Plan. Each Health Center has its own pharmacy.
Drugs on our formulary are available at these co-pays:
|30-day supply of generic drugs|
|90-day supply of certain generic drugs*|
|30-day supply of brand-name drugs that are not available generically|
*90-day formulations and dosages may vary and are at the discretion of the pharmacy.
In the event that a prescribed drug is not included in our formulary, we will attempt to fill the prescription at the actual cost to the member, with no markup in price. Drugs not on formulary may be provided at actual cost to the Fund.
Prescriptions may be written at the Health Centers or by an outside provider. Prescriptions written outside must comply with state law. There is no coverage for prescriptions that are filled outside of the Health Centers, even if you are covered by the out-of-area EPO plan.
Prescriptions written by an outside licensed physician or other outside licensed provider may be filled at the Health Centers, provided they comply with applicable New York State law. The same co-pays described above will be charged for formulary drugs. And drugs not appearing on the formulary may be provided at cost.
About the Formulary
What Is a Generic Drug?
Generic drugs work in exactly the same way as their brand-name counterparts and are ensured by the Food and Drug Administration (FDA) to be equally as safe and effective.
A generic drug has three key characteristics:
- It must have the same active ingredients, dosage form (e.g., tablet or capsule), strength, and route of administration (e.g., oral or IV) as its brand name counterpart.
- It must act on the body in the same manner and to the same degree as the original brand-name drug.
- It must cost less than the brand-name equivalent.
The Health Benefits Fund Drug Formulary includes many generic drugs. Using generic drugs instead of brand-name drugs is one of the easiest ways to reduce your prescription costs. The Health Benefits Fund health plan provides a lower co-payment for covered generic drugs, compared to brand name drugs.
What Is a Brand-Name Drug?
A brand name drug is patented and sold under the original manufacturer’s brand name. Many brand name drugs with no generic equivalent are included in the Health Benefits Fund Drug Formulary.
Whenever a generic equivalent exists, this is the drug that is covered on the formulary, regardless of whether the drug is listed with a generic name or brand name on the formulary.
If you or your doctor chooses a brand name drug when a generic equivalent is available, you will pay the cost for the brand name drug. This does not apply to covered brand name drugs that do not have generic equivalents.
About the Formulary
The formulary is developed and maintained by the Pharmacy and Therapeutics (P&T) Committee. It contains medications approved by the Food and Drug Administration (FDA), which have been reviewed for safety, efficacy, bioequivalency, and cost. The Health Benefits Fund P&T Committee is the governing committee responsible for oversight and approval of policies and procedures concerning formulary management, drug utilization, pharmacy-related quality improvement, educational programs, and other drug-related matters pertaining to patient care. The voting members of the committee include physicians and pharmacists in practice in the Health Centers.
For additional information about your prescription drug benefit, please consult your Health Benefits Fund Summary Plan Description. You can also call the Member Services Department at the Health Benefits Fund main office (212-586-6400).
Note: The Health Benefits Fund Drug Formulary applies to outpatient prescription drug benefits available through the Health Center Pharmacies only.
A formulary, currently used by many health plans, is a list of preferred (covered) medications recommended to prescribing physicians. Health Benefits Fund’s Pharmacy and Therapeutics (P&T) Committee uses medical literature to verify that the formulary drugs chosen are clinically effective and safe. Through the use of a drug formulary, we can maximize treatment quality while keeping your prescription drug costs lower.
The Health Benefits Fund Drug Formulary is a comprehensive list of generic and brand name drugs preferred by your Benefits Fund health plan. The fact that a drug is listed in the formulary does not guarantee that it will be prescribed by your physician.
Using the Benefits Fund Drug Formulary
To ensure that the drug your physician prescribes is covered, and to minimize your out-of-pocket expenses, we recommend that physicians consult the Health Benefits Fund Drug Formulary when writing prescriptions. We also ask that you review this formulary to verify that the medications your doctor has prescribed are listed.
It may be helpful to bring your Health Benefits Fund Drug Formulary when you visit your doctor so that you and your doctor can make decisions about alternative medications, if necessary.
If your doctor prescribes a drug that is not listed in the formulary, consider asking your doctor whether a formulary drug may be just as effective.