Pharmacy Benefits

You are eligible to use this prescription drug program if you are enrolled in the Active Employee Trust Plan. If you are enrolled in the Kaiser Permanente Plan, prescription benefits are provided by Kaiser Permanente. If you are enrolled in the Providence Health Plan, prescription benefits are provided by the Providence Health Plan. Click here for more information about the Kaiser Permanente Plan or the Providence Health Plan

Four prescription drug options are available if you are enrolled in the Active Employee Plan. You decide which option to use at the time of purchase.

Covered Prescriptions
The Plan covers drugs that require a written prescription from a doctor, that must be dispensed by a licensed pharmacist or doctor, do not exceed a 30-day supply (except for Mail Order or Option 90 that allows for a 90-day supply), and are not subject to any limitations or exclusions in the Benefit Booklet. Oral contraceptives are covered by the Retired Trust Plan. Viagra and like drugs are limited to three pills per week.
Special Rules for Allergy and Stomach Acid Suppression Drugs

A number of brand name prescription drugs for allergies and stomach acid suppression now have generic equivalents or over-the-counter equivalents that can be obtained without a prescription. Therefore, brand name prescription drugs for allergies and stomach acid suppression are non-covered items unless the criteria in the next paragraph is met. This policy applies regardless of whether you obtain a brand name prescription drug for allergies or stomach acid suppression from the Kroger/Safeway Preferred Pharmacy Network, an out-of-network pharmacy, Option 90 or the Mail Order Pharmacy Drug Program. A partial list of brand name prescription drugs that will no longer be covered are set forth below.

 
Some Popular Brand Name Prescription Medication for Allergies Not Covered:
  • Allegra
  • Allegra-D
  • Clarinex
  • Zyrtec
  • Zyrtec-D
Some Popular Brand Name Prescription Medication for Stomach Acid Suppression Not Covered:
  • Aciphex
  • Nexium
  • Prevacid
  • Prilosec
  • Protonix

A participant must try a generic or over-the-counter drug for allergies and stomach acid suppression before the Retired Trust Plan will cover a brand name prescription drug. In the event the generic or over-the-counter drug is not effective, the participant must do the following:

  • Your physician can obtain a Medical Exception Form by calling 1-800-482-1285. A form will be faxed to your physician.

    Once completed, the physician or patient faxes the Medical Exception form to
    1-630-328-2187.

  • The Medical Exception Form is valid for one year.

The pharmacy will dispense the authorized medication prescribed by your physician for allergies or stomach acid suppression based on the normal co-payment provisions.
Prescription Drug Supply Maximum
Retail Network Pharmacies (Kroger/Safeway)
You can purchase up to a 30-day supply of a prescription drug through a preferred network pharmacy (Kroger/Safeway) by paying the normal co-payment.
Out of Network Pharmacies
You can purchase up to a 30-day supply of prescription drug through an out-of-network pharmacy by paying 100% of the cost and submitting your receipts for reimbursement. Reimbursement for an out-of-network prescription is based on a 30-day supply. If you get more than a 30-day supply, you will only be reimbursed for a 30-day supply.
Option 90 (Kroger pharmacies only such as Fred Meyer, QFC)
You can purchase a 90-day supply of a prescription drug at Kroger owned pharmacies locally known as Fred Meyer and QFC. Medications taken on a long term basis (called maintenance medication), can be dispensed for 90-days. Obtain a prescription from your doctor authorizing a 90-day supply with three refills. There will be a lower out-of-pocket cost if you obtain your maintenance medication through Option 90 from Kroger Owned Pharmacies only such as Fred Meyer and QFC.
Mail Order (90 Day Supply)
You can purchase a 90-day supply of a prescription drug from Postal Prescription Services (PPS). Medications taken on a long term basis (called maintenance medication), can be dispensed for 90-days. Obtain a prescription from your doctor authorizing a 90-day supply with three refills. There will be a lower out-of-pocket cost if you obtain your maintenance medication through Postal Prescription Services. Click here to print a PPS Mail Order Pharmacy form.

Retail Pharmacies Outside the Kroger / Safeway Preferred Pharmacy Network
You do not have to obtain prescription drugs from the Kroger/Safeway Preferred Pharmacy Network. To obtain a prescription drug from a pharmacy other than a Kroger/Safeway pharmacy, you must pay for the prescription at the time of purchase. Obtain a pharmacy receipt that lists the drug name, quantity dispensed and date of service. Contact the Trust Office for a reimbursement claim form or you may download and print one here. Mail the pharmacy receipt together with your name, address, social security number and the Kroger Reimbursement Claim form to:

SXC Health Solutions
PO Box 3163
Lisle IL 60532-3163

All information provided on this web site is in summary and intended to provide highlights of your plans. We strongly recommend referring to the Plan booklet for complete details before making any decisions related to your eligibility, benefits and coverage.