Out of Network Pharmacies - Harrison Electrical Workers Trust Fund

Pharmacy Benefits

You are eligible to use this prescription drug program if you are enrolled in the Early Retiree Plan. If you are less than 65 years of age and not eligible for the Early Retirement Plan you must select the Kaiser or Providence options, unless you are not within either of their service areas.

Four prescription drug options are available in this program. You decide which option to use at the time of purchase.

Pharmacies Outside The Kroger/Safeway 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. 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

SUMMARY OF BENEFITS
Copayment Minimum	Reimbursement Percentage	Reimbursement Percentage for a Brand Name Drug if a Generic is Available	Prescription Drug Supply Maximum
$30	70% of the cost had the prescription been obtained from a Kroger/Safeway Network Pharmacy	50% of cost had the prescription been obtained from a Kroger/Safeway Network Pharmacy	Up to a 30-day supply

Reimbursement will be at 70 % of the cost of the prescription drug had it been obtained from a Kroger/Safeway Network Pharmacy. However, if a brand name prescription drug is requested and a generic is available, you will be reimbursed at 50 % of the cost of the brand name drug had it been obtained from a Kroger/Safeway Network Pharmacy. If your doctor writes the prescription “dispense as written,” reimbursement will be at 70 % of the cost of the brand name drug had it been obtained from a Kroger or Safeway Network Pharmacy. Your co-payment for all prescriptions will be subject to a minimum payment of $30.00

Examples of Out-of-Network Pharmacy Reimbursement
Retail Cost Prescription	Cost of Prescription Through Kroger/ Safeway Network	Plan Reimbursement Calculation	Reimbursement to You	You Pay
$100.00	$80.00	$80.00 x 70% = $56.00	$56.00	$44.00
$40.00**	$35.00	$35.00 x 70% = $24.50	$10.00	$30.00
**This second example shows how the minimum co-payment is applied. The calculated reimbursement is $24.50; however, since your minimum co-payment is $30.00, your reimbursement has been lowered to $10.00.

Examples of Out-of-Network Pharmacy Reimbursement Brand Name Drug (30-day supply) When Generic Available but Brand Name Selected (unless prescription is written “dispense as written”)
Retail Cost Prescription	Cost of Prescription Through Kroger/ Safeway Network	Plan Reimbursement Calculation	Reimbursement to You	You Pay
$100.00	$80.00	$80.00 x 50% = $40.00	$40.00	$60.00

The only prescriptions that are reimbursed outside the Kroger/Safeway Pharmacy Network are for drugs that require a written prescription from a doctor, which must be dispensed by a licensed pharmacist or doctor, do not exceed a 30-day supply and are not subject to any limitations and exclusions in the Benefit Booklet.