Health & Welfare and Pension Funds
of Philadelphia and Vicinity

PRESCRIPTION DRUG EXPENSE (FOR MEMBERS AND DEPENDENTS)

This Plan provides benefits for prescription legend drugs or refills thereof when dispensed by a pharmacy pursuant to a physician's prescription. These benefits are subject to a patient co-pay for each prescription or refill. Consult your Summary of Benefits Schedule for further details.

In addition, benefits are provided for insulin and disposable syringes to be used in administering the insulin (whether or not you have a prescription for the insulin or these disposable syringes).

LIMITATIONS

The Fund will not pay any of the cost for:

1. Vitamins (whether legend or non-legend); cosmetics or other health and beauty aids; dietary aids; therapeutic devices and appliances; hypodermic needles and syringes (other than described above); bandages and similar supplies; support garments; and other non-prescription substances.
   
   
2. Contraceptives.
   
   
3. Administration or injection of any drug.
   
   
4. Refill of covered prescription drugs in excess of the number specified by the physician, or any refill dispensed after one year from the date of the physician's latest order.
   
   
5. Drugs otherwise provided for under the Fund's Hospital, Medical and Surgical Plan.
   
   
6. Drugs otherwise provided for under any government program or law or workmen's compensation or occupational disease laws.
   
   
7. Drugs dispensed prior to the effective date of coverage under this Plan or after the date such coverage terminates.
   
   
8. More than a 34 day supply of any covered prescription drug.
   
   
9. YOUR PHARMACY CARD IS ONLY VALID AS LONG AS YOU MAINTAIN YOUR NORMAL ELIGIBILITY. SHOULD YOU USE YOUR CARD WHEN YOU ARE INELIGIBLE, YOU WILL BE LIABLE FOR THE CHARGES.
    
10. Pre-approval is required for any prescription for (1) injectible drugs; (2) drugs for which the cost of a one month supply exceeds $1,500.00; (3) drugs to treat erectile dysfunction (which will only be approved in those cases in which the condition is secondary to another medical condition); or (4) newly released drugs that have not been approved by the Federal Drug Administration in excess of six (6) months.

 Last Date Updated :  01/10/07