ELIGIBLE PARTICIPANTS, RETIREES AND DEPENDENTS

All eligible participants will receive an Express Scripts® Prescription Card
No Claim Form is required for the retail program or the Mail at Retail program.
A Prescription Mail Order Form is required with the initial order from Express Scripts Mail Order program.

BENEFITS

PRESCRIPTION LEGEND DRUGS: The Plan provides benefits for prescription legend drugs or refills thereof when dispensed by a UFCW Health and Welfare Centralized network pharmacy, the Mail at Retail network pharmacy or the Express Scripts Mail Order Program pursuant to a physician's prescription. Each prescrip­tion is subject to a co-pay. The co-pays are not eligible under your Medical benefit.

CENTRALIZED PHARMACY NETWORK
Your Express Scripts Card must be presented to a pharmacy in the UFCW Local 152 Health and Welfare Provider Network. The network includes many of the participating Employer stores, i.e., Acme Markets, Shop Rite, Stop & Shop, Rite Aid and other independent stores.

MAIL AT RETAIL PROGRAM
The Mail at Retail Drug Program enables you to obtain your mandatory maintenance drugs directly from a store in the Mail at Retail Network: Acme Markets, Shop Rite, Stop & Shop and Rite Aid.

The Fund's Provider Network does not include the following pharmacy chains:
Wal-Mart, K-Mart, CVS, Walgreens, Wegmans, Target, Costco, BJ, Sam’s Club, Weis Supermarkets, Price Chopper, Hannaford Supermarkets, Cost Cutter and Drug Fair.

If you choose to have a prescription filled at one of these pharmacy chains and pay cash for the prescription, such expenses will not be reimbursable by the Fund.

MANDATORY MAINTENANCE LEGEND MEDICATION

All active participants and their eligible dependents & eligible retirees and their spouse must use a Mail at Retail network pharmacy or the Express Scripts Mail Order Program. Maintenance legend medications are those, but not all, taken on a long-term basis for such conditions as diabetes, blood pressure, etc.

Option 1 – Mail at Retail - The Mail at Retail Network includes Acme Markets, Shop Rite, Shop & Shop, and Rite Aid. Take your prescriptions to one of these pharmacies. When you pick up the prescriptions, you will be asked to pay two copays for the 90 day supply.

Option 2 – ESI Mail Order - Complete an Express Scripts (ESI) mail order form, attach the prescription(s) and mail to the ESI mail order facility. A 90 day supply of your medication will be delivered to your door. Your cost will be limited to only 2 copayments instead of 3 copayments.

Please be reminded that the Fund has a mandatory generic program in place. If you choose to purchase a brand name drug you will be required to pay the difference between the cost of the generic drug and the brand name drug plus the appropriate co-pay.

Injectable medications, except insulin, are covered with co-insurance and not a co-pay.

ELIGIBILITY

Your Prescription Card (benefit) is only valid as long as you maintain your eligibility. Should you use your Prescription Card when you are ineligible, you will be liable for these charges. The participant named on the Prescription Card is responsible for inappropriate use of the card, and all unauthorized use, unless the Fund has been notified previously of its loss.

IMPORTANT: YOU SHOULD UNDERSTAND THAT IT IS POSSIBLE FOR A CLAIM TO BE PROCESSED AND APPROVED AT THE RETAIL OR MAIL ORDER LEVEL, AND THEN LATER DETERMINED THAT BENEFITS SHOULD HAVE BEEN TERMINATED. IF THIS IS THE CASE, YOU WILL BE RESPONSIBLE TO REIMBURSE THE FUND FOR ALL AMOUNTS PAID ON YOUR BEHALF.

CO-PAYS NOTE: please refer to your SPD for Co-payments.

LIMITATIONS

1. Maximum Supply per Prescription of non-maintenance legend drug
                        using the Centralized Pharmacy Network or Mail at Retail Pharmacy....................... 34 days
                        using the Express Scripts Mail or Online Pharmacy................................................... 90 days
2. Maximum Supply per Prescription of approved maintenance legend drug
                        using Mail at Retail or Express Scripts Mail or Online Pharmacy .............................. 90 days
3. The Plan retains the right to limit any drug deemed excessive in quantity prescribed or where the cost is prohibitive.
4. Products are being introduced regularly and include, but are not limited to, new drugs, changes or new routes of administration, and changes or new indications. All products are subject to review and may be excluded or limited under this benefit.

EXCLUSIONS

1. Prescriptions filled outside the Centralized Pharmacy Network, except as provided above.
2. Over-the-counter drugs or medications except as provided by the OTC assist Program.
3. Drugs used for cosmetic purposes, hair growth or removal treatments, weight control, acne products including Retin-A for individuals over the age of 23, or drugs used to treat and/or prevent gum disease.
4. Fertility or potency drugs, unless noted otherwise in Your Summary of Benefits.
5. Experimental drugs as determined by the Health Care Administrator
6. Any appliances, devices, or syringes or hypodermic needles (except for the administration of insulin).
7. Medications prescribed for work-related conditions.
8. Smoking cessation products.
9. Medication while a person is an Inpatient in a Hospital, a nursing home, or other institution.
10. Medication for any condition related to an automobile accident.
11. Any drug being prescribed for use that is not the drugs's FDA-approved use (no off-label use).