NYC Health Benefits Program


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The PICA Program

PICA is a prescription drug benefit program, administered by Express Scripts, Inc., that is provided to you and your eligible dependents.  It is made available through the joint efforts of the City of New York Office of Labor Relations and the Municipal Labor Committee.

All employees, non-Medicare retirees, and their non-Medicare dependents enrolled in a health plan offered by the City's Health Benefits Program receive coverage for certain categories of prescription drugs.

 

What drugs are covered?View the Answer

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PICA covers medications in two specific drug categories:

Self-Injectable Medications

1. Most injectable medications not requiring administration by a health care professional

 

Chemotherapy Medications

1. Medications used to treat cancer
2. Medications used to treat certain side effects of chemotherapy.


Copayments

What are the co-payments for PICA drugs?View the Answer

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Retail (Up to a 30-day supply at a retail pharmacy):

  • $10 Generic
  • $25 Preferred Brand (Formulary)
  • $45 Non-Preferred Brand (Non-Formulary)

Express Scripts (ESI) Home Delivery Pharmacy (Up to a 90-day supply at ESI Home Delivery for non-specialty medications):

  • $20 Generic
  • $50 Preferred Brand (Formulary)
  • $90 Non-Preferred Brand (Non-Formulary)

 

Specialty Medications (Up to a 30-day supply at Accredo Specialty Pharmacy or Freedom Fertility Pharmacy):

  • $10 Generic
  • $25 Preferred (Formulary)
  • $45 Non-preferred (Non-Formulary)

 

For brand medications that have FDA approved generic equivalents, PICA will pay for the generic medication only. If the brand is dispensed, the member must pay the difference in cost between the generic and brand drug plus the applicable brand copay.

There is an annual deductible of $100 per person. This deductible is independent of any other deductible and must be satisfied before copayments are applied.

to find out if your medication is Preferred or Non-preferred, you may call Express Scripts Customer Service at (800) 467-2006 or visit www.Express-Scripts.com.


Mandatory Mail Order 

Specialty Maintenance Medications
Up to a 30 day supply of specialty medication is available through Accredo Specialty Pharmacy.Read More

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Accredo, an Express Scripts specialty pharmacy, provides individualized care and convenient delivery of specialty medications. All specialty medications such as self-injectables or cancer medications must be obtained through Accredo Specialty Pharmacy. Specialty "stat" drugs are the exception. Medication such as Lovenox which is a blood thinner that is needed immediately after surgery would be allowed to be obtained through your retail pharmacy. A member may obtain up to 2 fills of a specialty "stat" medication at the retail pharmacy per year.

To order/refill specialty medications or determine if your medication qualifies as a specialty "stat drug", please call Accredo Specialty Pharmacy at 877-895-9697.

 

Non-Specialty Maintenance Medications
Up to a 90 day supply of non-specialty maintenance medication is available through ESI Home Delivery Pharmacy. A member may receive up to a 3 month supply for 2 retail copayments.Read More

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Non-specialty maintenance medications must be sent to ESI Home Delivery Pharmacy. A maintenance drug is a medication that you will be utilizing on a regular basis over an extended period of time. Please note that if your physician changes the strength of your maintenance medication or prescribes a different maintenance medication, you may go to a retail pharmacy for up to two 30 day fills and then you must transfer to ESI Home Delivery Pharmacy. Medications a member may take for an extended period of time such as those to treat nausea while undergoing cancer treatment would be considered non-specialty maintenance medications.

You may mail your prescription to:

Express Scripts Home Delivery Service
P.O Box 66568
St. Louis, MO 63166-6568

You may also call Express Scripts' Customer Service at 800-467-2006.

 

To Refill Medication by ESI Home Delivery

By Phone:

The Interactive Voice Response (IVR) System enables you to renew prescriptions over the telephone at any time of the day or night. Simply call 800-467-2006 and follow the instructions that are given to you over the phone.

Over the Internet:

Log onto Express Scripts’ website at www.express­scripts.com and register as a member. Once you have registered you can order refills through the web and verify your copay.

 

Fertility Medications
The fertility medication benefit program is available exclusively from Freedom Fertility Pharmacy. Injectable medication used to treat infertility is only available to PICA members whose health plan covers the treatment that require this medication.Read More

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This medication is limited to a lifetime maximum of three (3) cycles of therapy. Administration of the medication(s) is usually given daily for 7-10 days early in the cycle. Even though fertility medication(s) is physically administered for about 7-10 days, clinically, it is used as a treatment for 1 FULL cycle.

The Freedom Advantage®, offered to PICA members features a dedicated team of fertility only care coordinators, free shipping, free patient education materials and emergency same-day services. For questions, call Freedom Fertility Pharmacy at (800) 660-4283 or visit www.freedomfertility.com.


Generics Preferred Program

When you fill a prescription, the pharmacy will see if a generic equivalent is available.

If a generic is available and you choose it, you pay the standard copayment for a generic drug. This will be less than for a brand name drug.

If there is a generic equivalent and you choose a brand name medication, you will pay the brand name copay, PLUS the difference in cost between the generic and the brand name drug.

Are generics and brand name drugs the same?  View the Answer

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A generic drug contains the same active ingredient in the same dosage forms and strengths as the brand name drug.

Why do generics cost less than brand name drugs?  View the Answer

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Drug manufacturers spend large sums of money or the research, development, marketing and advertising of brand-name drugs. Manufacturers of generics have lower costs.

Why should you choose generics?  View the Answer

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You get the same quality and effectiveness as a brand-name drug. By choosing a generic medication, you can save on your copayment.

How do you know generics are safe?  View the Answer

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The U.S. Food and Drug Administration (FDA) approves both brand-name and generic drugs before they are marketed in the U.S.  The FDA requires the generic drugs contain the same active ingredients a brand-name drugs and be used in the body in the same way.  This ensures that generics are as safe and effective as brand-name drugs.


Prior Authorization

Prior authorization is a program that monitors certain prescription drugs to get you the medication you require while monitoring your safety.  Read More

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Similar to healthcare plans that approve a medical procedure before it's done to ensure the necessity of the test, if you're prescribed a certain medication, that drug may need a prior authorization. This program makes sure you're getting a prescription that is suitable for the intended use and covered by your pharmacy benefit. Your own medical professionals are consulted, since your plan will cover it only when your doctor prescribes it to treat a medical condition that will promote your health and wellness. When your pharmacist tells you that your prescription needs a prior authorization, it simply means that more information is needed to see if your plan covers the drug. Only your physician can provide this information and request a prior authorization.

How does my Physician obtain a Prior Authorization?  View the Answer

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Your physician may call Express Scripts at 800-753-2851 to obtain a Prior Authorization (PA). The PA team is available 24/7. The physician may fax information to the PA team at 800-357-9577. The turnaround time for a request is 48 hours.

What if I am currently taking one of these medications?  View the Answer

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If you are currently taking one of these medications, your physician will still need to call Express Scripts to obtain a prior authorization to ensure the medication is suitable for the intended use and to promote your health and wellness.

What kinds of drugs need a prior authorization in my program?  View the Answer

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Drugs impacted by your prior authorization program include:

  • Prescriptions used outside of the specific, approved medical conditions 
  • Prescriptions that could be used for non-medical purposes

Step Therapy

Step therapy is a program for people who take certain prescription drugs regularly to treat a medical condition, such as arthritis or high blood pressure. It allows you and your family to receive the affordable treatment you need and helps your organization continue with prescription-drug coverage.  Read More

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In step therapy, drugs are grouped in categories, based on treatment and cost:

  • Front-line drugs - the first step - are generic and sometimes lower-cost brand drugs proven to be safe, effective and affordable. In most cases, you should try these drugs first because they usually provide the same health benefit as a more expensive drug, at a lower cost.
  • Back-up drugs - Step 2 and step 3 drugs - are brand-name drugs that generally are necessary for only a small number of patients. Back-up drugs are the most expensive option.

Drug Quantity Management

Drug quantity management, also known as DQM, is a program in your pharmacy benefit that's designed to make the use of prescription drugs safer and more affordable.  Read More

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It provides the medication you need for your good health and the health of your family, while making sure you receive them in the amount - or quantity - considered safe. Certain prescriptions are included in this program. For these drugs, you can receive an amount to last you a certain number of days. For instance, the program could provide a maximum of 30 pills for a medication you take once a day. This gives you the right amount to take the daily dose considered safe and effective, according to guidelines from the U.S Food & Drug Administration (FDA).

 

Split Fill:

Split-Fill is designed to improve patient therapy adherence and waste reduction. Accredo has clinically identified a select list of specialty drugs which have a very high risk for early discontinuation in new patients. Reasons include:

• Side effect intolerance
• Therapy ineffectiveness
• Drug switching
• Dose changes
• Hospitalization
• Death

Split-Fill addresses waste associated with unused drug by splitting the initial 28 or 30 day cycle into two equal partial fills (either 14 or 15 days) for the first three months of therapy. Split-Fill addresses therapy adherence by reducing the high drop-off rate as a result of increased member contact and clinical support during the first three months of therapy.

Member copays will be prorated as the member will only pay half of the 30-day copay when only a 14 or 15day supply of medication is dispensed.