PRESCRIPTIONS

The SBA provides a prescription benefit to their members and eligible dependents. This benefit is administered by OptumRx. Members can visit www.sbanyc.org for a full description of the prescription plan. Please contact Charlene at the SBA Health & Welfare Fund at (212) 431-6555, with any questions or OptumRx Customer Service at (877) 559-2955 or visit www.optumrx.com. Prescription Forms: Prescription Mail Order Form Prescription Reimbursement Form SBA Medicare Informational Datasheet
 
Members are responsible to notify the SBA Health & Welfare Fund as well NYC Health Benefits Program when you or your dependent becomes Medicare eligible. The SBA is required to notify Medicare/CMS that you or your Medicare eligible dependent has “creditable” prescription drug coverage under the SBA prescription drug plan. If your spouse or eligible dependent become Medicare eligible, it is imperative that you complete the SBA Medicare Informational Datasheet and forward it to the SBA Health & Welfare office via fax (212) 431-6487, attention: Anthony Amato or mail to: Sergeants Benevolent Association Attn: Anthony Amato 35 Worth Street New York, NY 10013 For additional information on Medicare Part D, creditable prescription drug coverage, please contact the SBA Health & Welfare Fund office at (212) 431-6555.
The RSA has requested that the SBA reimburse members for covered Brand prescriptions obtain from Canadian pharmacies. These prescriptions are obtained at a highly reduced price which results in savings for both the SBA Fund and our members. In order for members to be eligible for this benefit, members must contact Rosa at the SBA Health & Welfare Fund at (212) 431-6555 before obtaining prescriptions from a Canadian pharmacy.
PICA (Injectable/Chemotherapy) Prescription Plan The PICA Program is a prescription drug benefit that is provided to all NYC employees, non-Medicare retirees and their eligible non-Medicare dependents who are enrolled in a health plan offered by the City’s Health Benefits Program. The PICA Program is made available through collective bargaining between the Municipal Labor Committee and the City of New York Office of Labor Relations. The PICA Program covers medications in the following two specific drug categories: Injectable and Chemotherapy. You must use your PICA prescription benefit card to obtain medication in these drug categories. They are not covered by the SBA Health &Welfare Fund prescription drug plan. For the PICA Program benefit overview, please visit http://www1.nyc.gov/site/olr/health/summaryofplans/health-pica.page. To obtain additional information regarding the PICA Program or to obtain a replacement PICA prescription drug card, you can call Express Scripts Customer Services at (800) 467-2006 or visit www.express-scripts.com.
Coverage of Diabetic Medication/Management: Non-Medicare Members/Dependents The SBA Health & Welfare Fund does not cover diabetic medications and related medical equipment for non-Medicare members and their non-Medicare eligible dependents. These medications are covered under the basic medical benefits by all New York City health plans. Diabetes management education is also provided to educate members on the proper self-management of their condition. Members requiring diabetes products should bring their health benefits ID card to their pharmacy along with their prescriptions. Those members that are enrolled in Medicare, or have eligible dependents enrolled in Medicare, should contact the SBA Health & Welfare Funds office so arrangements may be made for them to obtain their diabetic medications through the SBA Prescription Plan. Medicare Members/Dependents The SBA Health & Welfare Fund covers diabetic medications for Medicare members and their Medicare eligible dependents. Members are responsible for notifying the SBA Health & Welfare Fund when they or an eligible dependent become Medicare eligible.
EmblemHealth (Non-Medicare GHI & HIP) City of New York Affordable Care Act Coverage Guidelines Re: Medications: Starting July 1, 2017, the medications listed below will be covered for City of New York members with Medical Coverage. You will pay a $0 copay for these medications through EmblemHealth. This is an Affordable Care Act (ACA) mandate. To get this coverage, you must get a prescription from your doctor in our network, even for over-the-counter medications.
  • Aspirin: All genders, through age 59, can get 325mg or less for the prevention of cardiovascular events and preeclampsia.
  • Fluoride: Generic only, for children age six months – five years old. A generic has the same strength, dose, and effectiveness as a brand name drug. This applies to over-the-counter and prescription drugs.
  • Folic Acid: Generic only, for all members through age 50. This applies to over-the-counter and prescription drugs.
  • Immunizations: Covers all recommendations made by the Advisory Committee on Immunization Practices (ACIP). You will only be able to get vaccination at a $0 copay if the member is the age appropriate for the vaccine. Some vaccines may be covered through your medical plan.
  • Contraceptives: All contraceptives, or birth control, are covered until age 50. These are permissible as written by your doctor:
    • All approved prescriptions and over-the-counter products.
    • Single source brands (drugs that do not have a generic version).
    • Generic drugs and Multisource brands (drugs that are made by more than one company).

This is called Dispense-As-Written and is covered for codes 1, 4, 5, and 8. Implants and IUDs are covered under your medical plan.

  • Smoking Cessation: These prescription and over-the-counter products for members age 18 and older are approved to help you quit smoking. Both brand name and generic drugs apply, but after 180 days of therapy (in one year), you will be charged the full prescription copay.
  • Vitamin D: Generic prescription and over-the-counter drugs only, for members age 65 and older.
  • Bowel Prep Products: Generic prescription and over-the-counter drugs only, for members age 50 to 75. There is a limit of two prescriptions per year (365 days), after which you will be charged your full prescription copay.
  • Primary Prevention of Breast Cancer: These drugs are reviewed when a member or doctor requests an exception.
    • Raloxifene (the generic version of brand name Evista) is only covered for the primary prevention of Breast Cancer in women age 35 and older. Your doctor will need to provide the diagnosis to receive coverage at no cost.
    • All other drugs from Primary Prevention, or the reduction, of breast cancer are covered through New York City’s PICA Program not through EmblemHealth.
FOR ADDITIONAL INFORMATION PLEASE VISIT: www.emblemhealth.com.