OCA Prescription Drug Benefits

EmpiRx

The Fund uses EmpiRx as its Plan's Prescription Benefit Manager to provide you the Prescription Drug benefits listed below.

The Plan generally covers generic and brand name prescription drugs. You are responsible for:

  • a co-pay of 20%, with a minimum payment of $10 for generic and $25 for brand name medication for a 30-day supply filled at a retail pharmacy.
  • A co-pay of 20%, with a minimum of $15 for generic and $50 for brand name medication for a 90-day supply filled using mail order.

Beginning on May 1, 2024, you will be responsible for the following co-pays when filling specialty medications:

  • a 10% co-pay for biosimilar medication.
  • a 20% co-pay for preferred medication.
  • a 25% co-pay for non-preferred medication.

The Plan generally covers drugs prescribed by your Physician or Dentist for FDA-approved drugs requiring a written prescription and dispensed by a licensed pharmacist, including;

  • Antibiotics, anti-inflammatories;
  • Maintenance medications to treat chronic conditions such high cholesterol and high blood pressure;
  • Insulin and insulin injection supplies and antigens;
  • Prescription ointments and lotions for treatment of skin problems;
  • Prescription drugs dispensed in a physician's or dentist's office if a separate charge is made for the drug;
  • Prenatal vitamins that contain fluoride or folic acid with diagnosis of pregnancy; and
  • Prescription Drugs used for the treatment of smoking cessation, which includes up to two courses of treatment per year for each eligible participant and eligible dependent.

Mandatory Generic Prescription Drug Program

The program requires that generic drugs be dispensed when available. The only exception to this rule is when your physician specifically indicates to dispense the prescription as written. If you choose a brand name prescription drug when a generic drug is available, you will be responsible for the difference between the generic drug cost and the brand name drug cost.

Mandatory Mail Orders

After you have received two fills for a maintenance medication at a retail pharmacy, further coverage is available under the Mail Order Program only (see below for details).

Specialty Medication Management Program

The Fund has partnered with Payer Matrix to offer assistance and relief to high dollar specialty drug costs. Where applicable, alternative funding for select high-cost specialty drugs may be obtained, and your out-of-pocked costs could be reduced or eliminated. If you or your dependents are taking one of the eligible drugs, you must enroll in the Payer Matrix program or you will be responsible for the full cost of the medication. Contact Payer Matrix at 1-877-305-6202 or via email at customerservice@payermatrix.com for details or to enroll.

Using Network Pharmacies

Should you have any questions about your pharmacy or participating pharmacies in your area, please feel free to contact EmpiRx customer service department using the phone number listed on the back of your EmpiRx ID card.

To have your prescription filled, simply present your drug identification card, and make your co-payment.

Using Non-Network Pharmacies

To have your prescription filled at a non-participating pharmacy, you must pay for the entire cost at the time of your purchase. You should take a prescription claim form with you and have it completed by the pharmacist. You may then seek partial reimbursement by completing your prescription claim form and mailing it to the Fund Office. You must include your original receipts with the form.

After deduction of the co-payment, you will be reimbursed a percentage of the charge for the drug, according to the Schedule of Benefits.

Mail Order Program

EmpiRx's Mail Order Program is designed to provide you with the convenience of receiving prescription maintenance medications, with up to a 90 day supply delivered to your home, if prescribed by your Physician.

How Mail Order Works:

  • Order a 90-day supply of your maintenance medications by visiting hopbenefits.com or by calling the number on the back of your EmpiRx ID card.
    Your doctor can also send your 90-day script directly to EmpiRx
  • EmpiRx fills your order and mails it to you.
  • The medication arrives within 7-10 days; you pay nothing for standard shipping.

Exclusions and Limitations

Benefits shall not be paid for the following:

  • Devices, bandages, heat lamps, splints, dressings or other appliances;
  • Blood and blood plasma;
  • Vitamins, diet pills, health and beauty aids and cosmetics (other than prescribed pre-natal vitamins);
  • More than two fills for a maintenance medication at a retail pharmacy;
  • Drugs administered in rest homes, convalescent homes or sanitariums unless dispensed from a licensed pharmacy; and requiring a prescription;
  • Any drugs or medicines that are not necessary for treatment of any injury or illness;
  • In vitro fertilization or infertility treatment;
  • Oral medications for treatment of sexual dysfunction;
  • Appetite suppressants, even if Medically Necessary for attention deficit disorder, narcolepsy, or other condition;
  • Compounded prescription medications with ingredients not requiring a Physician's authorization by state or federal law;
  • Investigational or Experimental medications;
  • Medications used for Experimental indications and/or dosage regimens determined to be Experimental (e.g. Progesterone suppositories or suspension or Nystatin oral powder);
  • Medications with no approved FDA indications;
  • Over-the-counter (OTC) medications without a prescription;
  • Prescription refills dispensed after one year from original date of dispensing or for any drug refill if it is more than the number of refills specified;
  • Replacement prescriptions resulting from loss, theft or breakage; or
  • Devices or equipment of any type.