The PICA Program is a prescription drug benefit that is provided to all NYC employees, non-Medicare retirees and their eligible dependents who are enrolled in a health plan offered by the City's Health Benefits Program. It is made available through the joint efforts of the City of New York Office of Labor Relations and the Municipal Labor Committee.
PICA Benefit Overview
Medications Covered by the PICA Program
PICA covers medications in two specific drug categories:
Copayments for PICA drugs
Retail Pharmacy (up to a 30-day supply)
$ 10 for generic medications
$ 25 for preferred brand (formulary) medications
$ 45 for non-preferred brand (non-formulary) medications*
Mail Order Pharmacy (up to a 90-day supply)
$ 20 for generic medications
$ 50 preferred brand (formulary) medications
$ 90 non-preferred brand (non-formulary) medications*
* If you choose a non-preferred brand name medication that has a generic equivalent, you will be charged the difference in cost between the non-preferred brand name drug and the generic drug plus the non-preferred brand name drug copay. See Generics Preferred section for additional information.
There is an annual deductible of $100 per person for Injectable and Chemotherapy medications. This deductible is independent of any other deductibles.
Mandatory Mail Order Program
You must use the Express Scripts Mail Order pharmacy for maintenance medications. Maintenance medications (those taken regularly over an extended period of time) will not be filled at a retail pharmacy after two (2) fills. If you pay for your prescription at a retail pharmacy and the use of the Express Scripts mail order pharmacy was mandatory, you will not be reimbursed for the cost of the medication.
By Phone: Interactive Voice Response (IVR) System IVR enables you to renew prescriptions over the telephone at any time of the day or night. Call (800) 233-7139 and follow the instructions that are given to you over the phone. Over the Internet: Log onto Express Scripts' website at www.express-scripts.com and register as a member. Once you are registered you can order refills online.
Generics Preferred Program
A generic drug is a medication
produced after the original drug manufacturer’s brand name patent has expired.
Every generic drug manufacturer must meet the same strict FDA guidelines
required of the original brand name manufacturer.
If you receive a brand name medication that has a generic equivalent, you will be responsible for the difference in cost between the non-preferred brand name medication and the generic medication plus the non-preferred brand name copay.
How to find out if medication is Preferred or Non-preferred
You can call Express Scripts' Customer Service Department at (800) 467-2006 or visit www.express-scripts.com
Prior Authorization Program
The Prior Authorization process will be required for certain medications. These medications require that the prescribing physician provide a letter of medical necessity and diagnosis. PICA medications requiring prior authorization are:
Erythropoetins (e.g. Epogen or Procrit)
If you are currently prescribed any of these medications, you must have your physician call the Express Scripts Prior Authorization Department at (866) 374-5549. If approved, prior authorizations will be set up immediately. If the doctor can not call, he/she may fax a letter of medical necessity, which includes a diagnosis, to (866) 374-5547. Please allow 2 business days for faxed requests to be processed. If the diagnosis meets approved criteria for that medication and the diagnosis is within the scope of coverage of the plan, prior authorization will be set up so your prescription can be filled under the plan.
Step Therapy Program
Step Therapy is a program that encourages the use of the best medication for your condition. The first steps in this process are well established treatments known to be safe and effective. Known as first-line therapy, this treatment is the preferred therapy for most people. If the first-line therapy does not work or causes problems, second-line therapy can be tried. When a prescription for a second-line medication is processed at your pharmacy, the computer system reviews your recent prescription history. If a prescription for a first-line drug is found, the medication will be dispensed. If the system does not find a prescription for a first-line drug, the second-line prescription is not covered. The pharmacist will be alerted that the medication is not covered and will suggest covered first-line alternatives to your physician.
Fertility Medication Maximum
Injectable medication used to treat infertility is only available to PICA members whose health plan covers the treatment that require this medication. This medication is limited to a lifetime maximum of three (3) cycles of therapy. A cycle is approximately 28 to 30 days. 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; 3 cycles is 90 days. If you have already received 3 cycles of therapy of fertility drugs, you will not be covered for any additional fertility medications.
Effective June 1, 2008 the fertility medication benefit
program is available exclusively from Freedom Fertility Pharmacy. The Freedom
Advantage®, offered to PICA members features personalized care, drug coverage
and outstanding service. Key components of this benefit include a dedicated team
of fertility only care coordinators, free shipping, free patient education
materials and emergency same-day services. Questions? Call Freedom Fertility Pharmacy at 800.660.4283 or visit www.freedomfertility.com
CuraScript Specialty Care Pharmacy
Certain specialty injectable medications such as those used to treat Hepatitis C and Multiple Sclerosis, will be filled by the Curascript, ESI's specialty care mail service pharmacy (you may receive your first fill at a retail pharmacy). Curascript will supply the prescribed medication and related supplies such as needles and syringes, and also provide clinical support to you to help improve compliance as well as provide convenient delivery. If you are currently being prescribed a medication that will be filled as part of this program, you will receive more information under separate cover. To find out more information you may call Curascript's customer service at (866) 848-9876.
PICA and ESI Prescription Drug Benefits Through Your Welfare Fund
If you have prescription benefits with ESI through your welfare fund continue to use the same prescription drug card. PICA and non-PICA drugs will be covered by the same card.
PICA and other Drug Plans
In general, PICA drugs are not covered by a health plan's optional prescription drug rider or union welfare fund. Use your prescription drug card for medications not covered by PICA.
Customer Service Telephone Numbers
| CuraScript Specialty Care Pharmacy:
General Phone Number:
| (800) 467-2006/
| Freedom Fertility Pharmacy:
PICA Prescriptions should be
4415 Lewis Rd.
PO Box 69301
Harrisburg, PA 17106- 9301
You can visit the website at www.express-scripts.com
Updated to reflect
plan benefit changes July 2008.