Prescription Co-Pay Reimbursement
Prescription Claim Form
Prescription Claim Form (PDF)
Who is eligible
Member, and eligible dependents as defined by the Fund.
What is the Benefit
Once annually the Fund reimburses to a member the out-of-pocket costs that have been paid within the calendar year for drugs prescribed by a medical doctor, osteopath or dentist. Prescriptions must be dispensed by a licensed pharmacist. Please contact the Fund for the yearly maximum amount or the allowable copayment amount. All rules and regulations governing Suffolk County’s primary prescription plan apply to your Fund coverage.
- Prescriptions that require compounding;
- Prescriptions for legend drugs (drugs that cannot be dispensed by a pharmacist without a prescription);
- All other drugs covered by the plan in accordance with the terms and conditions set forth by the plan.
- OTC (over the counter) drugs, vitamins, diet supplements, etc., which even if prescribed by a physician can be legally purchased without a prescription.
- Drugs covered by this plan must be prescribed by a licensed medical doctor, osteopathic physician or dentist
- All drugs must be dispensed by a registered pharmacy.
- Drugs which are administered to in-patients of any hospital are not eligible.
- Single prescriptions that exceed a 3-month supply (this does apply to refills obtained at a later date).
- Growth stimulating drugs, food supplements, cosmetic drugs, or any other drug prescribed for conditions other than injury, illness or disease are not covered by the plan.
- Expenses not submitted prior to December 31st of the current year for the previous year will not be eligible for reimbursement. Example: Claims for 2013 may be claimed only up to 12/31/2014
Note: The Fund will not pay prescription costs incurred by members in excess of the co-payment maximum. If you use a pharmacy that does not participate with your primary prescription carrier, you will be required to pay the full cost of the prescription to the pharmacy. To receive your benefit, submit a completed reimbursement form to your medical plan. The Fund will only pay the co-payment amount that the plan would have paid if you used a participating pharmacy.
- Duplicate claims cannot be honored.
- Prescriptions for allergies dispensed at a laboratory will be allowed only if the prescriptions would normally be filled at a licensed pharmacy.
- Claims for prescription drug co-payments can only be filed ONCE annually per family. Submit only after you have accumulated the annual maximum for co-payment costs. If you do not meet the maximum total prior to the end of the year, submit your claim for whatever the amount is below that figure after the last day of that calendar year. Any claim paid by the Fund will NOT be reconsidered at a later date, even if you discover that you failed to include several co-pays on your original claim. Make sure that you have acquired all of the necessary pharmacy print-outs and primary prescription statements before making claim to the Fund. It is your responsibility to ensure that your original claim contains all of your families’ co-payments.
Obtain a Prescription Drug claim form from your payroll representative or the Fund. Complete instructions for filing are included on the back of the claim form. Proof of payment must be attached.
Pharmacy Printout Filings
Complete the claim form for all persons covered under the insured’s benefit. Prescriptions for the member, spouse, and covered children must be on the same form. Identify each family member and list all printouts for that person, including the total of each one. Do this for each individual you are submitting for. Please complete all required areas of information.
Remember to sign and date the bottom of the form.
We do not accept individual receipts.