Under the Prescription Incentive Program (PIP), you can have earned credits whenever you or your eligible dependents (including your spouse) use "other prescription drug coverage" to obtain prescription drugs. 

Earned credits will be recorded to one account under PIP for you and your eligible dependents. This single account rule will apply even if both you and your spouse are Fund participants with prescription drug benefits under the Fund.

 

The earned credits recorded to your account for a calendar year may be used to reimburse you for out-of-pocket health expenses incurred by you and your eligible dependents in that same calendar year, provided that these expenses are not otherwise covered (for example, deductibles, co-payments or coinsurance or other non-covered health care expenses) and are considered deductible medical care expenses in accordance with the Internal Revenue Code (or approved by the Internal Revenue Service (IRS) in pronouncements).

 

You will also be reimbursed for any out-of-pocket costs such as co-pays, deductibles or coinsurance amounts that you incur as a result of using "other prescription drug coverage."

 

Who is Eligible?

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You are eligible for the Prescription Incentive Program under the following circumstances:

You are covered by prescription drug benefits under the Fund and you also have other prescription drug coverage. 

"Other prescription drug coverage" means coverage under any insurance arrangement for prescription drug benefits other than coverage under the Fund, including coverage provided by another employer or your spouse's employer. If you and your spouse both have coverage under this Fund through your respective Contributing Employers, you are not eligible for PIP, unless you or your spouse also has "other prescription drug coverage" (for example, through another employer).

 

Calculation of Earned Credits

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After you or your eligible dependents use other prescription drug coverage to obtain prescription drugs, you should submit a PIP claim form to the Fund Office. Attach (1) your pharmacy receipt showing your out-of-pocket costs and (2) prescription detail information from the pharmacy which identifies the prescription drug filled. 

The Fund will then: 

1. Reimburse you for your out-of-pocket costs incurred in using your other prescription drug coverage and

2. Calculate the earned credits to be recorded to your account based on the net savings to the Fund, as described below.

 

Net Savings

The earned credits to be recorded to your account is a percentage of the net savings to the Fund as a result of your use of the other prescription drug coverage. The Fund's net savings is determined as follows: 
 

1. The amount it would have cost the Fund to provide you or your eligible dependent with the prescription drug under the Fund's plan (the Fund's cost, less the co-pay and other costs you would have incurred under the Fund's Prescription Drug Benefits), minus

2. The amount of any out-of-pocket costs (co-pays, deductibles, coinsurance) that the Fund reimburses you for using your other prescription drug coverage.

Your earned credits will be a percentage of the net savings to the Fund.

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Example

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Assume that you and your eligible dependents have prescription drug benefits under the Fund. Your family also has prescription drug coverage provided by your spouse's employer. Your spouse uses this other coverage to obtain a prescription drug for himself or herself from a Preferred Pharmacy. Under this other coverage, your spouse incurs a $10 co-pay to obtain the prescription drug. 

You should submit a claim form to the Fund Office along with an itemized receipt showing the amount of the co-pay and information to identify the drug. The Fund Office will reimburse you the $10 out-of-pocket expense. The Fund determines that the cost to the Fund to provide that prescription drug to your spouse would have been $50. The Fund Office then calculates the "net savings" to the Fund by subtracting (1) the amount of the co-pay that your spouse would have incurred under the Fund's Prescription Drug Benefit ($5), and (2) the amount of any out-of-pocket costs that the Fund reimburses you for using your "other prescription drug coverage" (in this example, $10). The result ($35) is the amount of the "net savings" to the Fund. Because your spouse used a Preferred Pharmacy to obtain the prescription drug, the earned credits recorded to your account will be an amount equal to 50% of the Fund's "net savings" ($17.50). This example is illustrated as follows:

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Calculation of Net Savings: 
 

$50.00 (Cost of Prescription to the Fund) -  $5.00 (Fund's Co-Pay) - $10.00 (Out-of-Pocket Reimbursement) = $35.00 (Net Savings to Fund from Use of Other Coverage) 
 

Calculation of Earned Credits: 

$35.00 (Net Savings to the Fund) x 50% ("Preferred Pharmacy" Percentage") = $17.50 (Earned Credits Recorded to Account)

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In the above example, if your spouse obtained the prescription drug from a Non-Preferred Pharmacy, the earned credits recorded to your account would be $14 (40% of $35).

If, as a result of a coordination of benefits provision under the other prescription drug coverage, the Fund must pay an amount to a third party insurer, a corresponding adjustment will be made to the earned credits recorded (or to be recorded) to your account under the Program.

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Using Your Earned Credits

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The earned credits recorded to your account for any calendar year can be used to reimburse you for medical expenses incurred by you and your eligible dependents during that same calendar year that are not reimbursable to you from any other source.  Medical expenses means expenses incurred for medically necessary health care. For purpose of the earned credits, medically necessary health care means amounts paid for “medical care” as defined in Section 213(d) of the Internal Revenue Code, including, for example, amounts incurred for certain hospital bills, doctor and dental bills, prescription drugs and vision care.

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After you or your eligible dependents incur such medical expenses, you should submit a claim form to request reimbursement of these expenses from the earned credits in your account.  You will have to certify on the claim form that these medical expenses are not eligible for reimbursement to you or your eligible dependents under any other insurance plan of the Fund, under any other insurance arrangement that covers you or your eligible dependents, or from any other source.  You will also have to submit itemized bills to show that the medical expenses were actually incurred by you or your eligible dependents.

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Important Limitations

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All earned credits are recorded to an account with respect to a calendar year, up to a maximum amount of $10,000 in any calendar year. 

 

The earned credits recorded to your account for any calendar year can be used to reimburse you for medical expenses incurred by you and your eligible dependents during that same calendar year.  These earned credits can be used only for medical expenses that are not reimbursable to you from any other source.

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After you or your eligible dependents incur such medical expenses, you should submit a claim form to request reimbursement of these expenses from the earned credits in your account.  You will have to certify on the claim form that these medical expenses are not eligible for reimbursement to you or your eligible dependents under any other insurance plan of the Fund, under any other insurance arrangement that covers you or your eligible dependents, or from any other source.  You will also have to submit itemized bills to show that the medical expenses were actually incurred by you or your eligible dependents.

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All earned credits are recorded to an account with respect to a calendar year, up to a maximum amount of $10,000 in any calendar year.  Earned credits in any calendar year can be used to reimburse you for medical expenses incurred only in that same calendar year. You must submit claim forms for earned credits and reimbursements under the Program for a calendar year by June 30 following the end of that year.  Any earned credits with respect to a calendar year for which you do not submit a claim form for reimbursement will be forfeited and cannot be carried forward to any subsequent calendar year.  Under NO circumstances will any earned credits be redeemable for cash, except as reimbursement for medical expenses in accordance with the rules and regulations of this Program as described in this booklet.  Earned credits may not be transferred or sold to any other participant of the Fund.  All other rules, regulations and eligibility requirements of the Prescription Drug Benefits under the Fund shall also apply to this Program.

 

Claim Forms and Deadlines

 

Claims forms for earned credits and reimbursement of out-of-pocket costs for using “other prescription drug coverage” must be submitted no later than June 30 following the calendar year in which you or your eligible dependents use the “other prescription drug coverage.” Also, claims for reimbursement from your account for medical expenses which were incurred in a calendar year must be filed no later than June 30 following that year.

 

Medical Expenses Reimbursable Under the Program

 

You can be reimbursed from your earned credits in your account for medical care expenses which are not covered under your medical, dental or vision plans or under your other available coverage (for example, deductibles, co-payments or coinsurance or other non-covered health care expenses) and which are deductible in accordance with the Internal Revenue Code and related IRS pronouncements (IRS Publication 502).  If the IRS does not allow an expense as an eligible medical expense, you will not be reimbursed under the Program for that expense.   You should call the Fund office for more details.  for medical expenses incurred only in that same calendar year. You must submit claim forms for earned credits and reimbursements under the Program for a calendar year by June 30 following the end of that year.  Any earned credits with respect to a calendar year for which you do not submit a claim form for reimbursement will be forfeited and cannot be carried forward to any subsequent calendar year.  Under NO circumstances will any earned credits be redeemable for cash, except as reimbursement for medical expenses in accordance with the rules and regulations of this Program as described in this booklet.  Earned credits may not be transferred or sold to any other participant of the Fund.  All other rules, regulations and eligibility requirements of the Prescription Drug Benefits under the Fund shall also apply to this Program.

 

Claim Forms and Deadlines 

 

Claims forms for earned credits and reimbursement of out-of-pocket costs for using “other prescription drug coverage” must be submitted no later than June 30 following the calendar year in which you or your eligible dependents use the “other prescription drug coverage.” Also, claims for reimbursement from your account for medical expenses which were incurred in a calendar year must be filed no later than June 30 following that year.

 

Medical Expenses Reimbursable Under the Program

 

You can be reimbursed from your earned credits in your account for medical care expenses which are not covered under your medical, dental or vision plans or under your other available coverage (for example, deductibles, co-payments or coinsurance or other non-covered health care expenses) and which are deductible in accordance with the Internal Revenue Code and related IRS pronouncements (IRS Publication 502).  If the IRS does not allow an expense as an eligible medical expense, you will not be reimbursed under the Program for that expense.   You should call the Fund Office for more details.