Your prescription drug benefit is provided by the Fund through EmpirRX Health.

​

How the Plan Works

ID Card & Eligibility

• You will receive an EmpirRX Health prescription ID card as proof of eligibility.

• The card lists only the member’s name, but all eligible dependents are active in the EmpirRX Health system.

• Present your ID card when filling prescriptions.

• A copayment is required for each prescription.

Annual Coverage & Out-of-Pocket Limits

1. Initial Coverage
   The Fund pays the first $4,000 in covered prescription costs for you and your eligible dependents.

2. Out-of-Pocket Phase
   After the Fund has paid $4,000, you are responsible for:

   • $12,700 (family coverage), or

   • $6,350 (member-only coverage)
     (These amounts include copayments.)

3. Tracking Expenses
   You must keep all pharmacy receipts as proof that you’ve met the out-of-pocket maximum.
   Each receipt must include:

   • Member name (with last 4 digits of SSN)

   • Patient name (if different)

   • Prescription number

   • Amount paid

   Once you reach the required out-of-pocket amount, mail all documentation to the Fund Office
   (certified mail is recommended, or documents may be delivered in person).

4. Catastrophic Coverage
   After verification, the Fund will again cover prescriptions in full for the remainder of the calendar year.
   Normal copayments still apply.

Copayments

• $1 — Generic prescriptions

• $15 — Brand-name prescriptions

• $40 — Brand-name prescription when a generic equivalent is available

What the Program Covers

• All medications that require a prescription by federal or state law

• Must be prescribed by a licensed practitioner

• Prescriptions may be written for:

  • Up to a 34-day supply, plus

  • Three refills, dispensed per your doctor’s instructions

Using a Non-Participating Pharmacy

• You must pay the full cost upfront

• Request a Prescription Reimbursement Claim Form from the Fund Office

• A separate form is required for each prescription

• Mail completed forms to EmpirRX Health

• Reimbursement is based on the Fund’s fee schedule, not what you paid

• You are always responsible for the applicable copayment

For claim questions, contact the Fund Office.

What Is Not Covered

No benefits are paid for:

• Over-the-counter medications

• Devices, appliances, support garments, or non-medical substances

• Durable medical equipment (e.g., syringes, nebulizers, glucometers)
  (These may be covered under your health insurance plan, such as GHI or HIP.)

• Unauthorized refills

• Medications covered by workers’ compensation, Medicare, Medicaid, or other government programs

• Medications provided while confined to a hospital, nursing home, rest home, sanitarium, or extended care facility

Prior Authorization Required

The following medications require prior authorization and/or a letter of medical necessity with a diagnosis from a medical doctor:

• Smoking cessation medications

• Enbrel

• Anabolic steroids

• Topical acne agents

• Erectile dysfunction medications

Exclusions from Coverage

The Fund does not cover:

• Diet supplements

• Infant formulas

• Vitamins (except prenatal supplements)

• Enteral or parenteral therapies (TPN)

• Investigational or experimental drugs

• Lost or stolen medications

• Immunosuppressants

• Drugs for hair growth

• Immunization agents, biologicals, blood, or plasma

• Drugs used to enhance sexual function

• Drugs dispensed by anyone other than a licensed pharmacist

Durable medical equipment, including insulin syringes and needles, is not covered under this program but may be available through your major medical benefits.

IC Program: Injectables & Chemotherapy

• Members enrolled in NYC medical coverage receive a separate IC Card for:

  • Injectables

  • Chemotherapy

• Eligibility is determined by NYC

• If you do not receive an IC Card, contact NYC Benefits at 646.610.5122

​