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Example
Assume that you and your eligible dependents have prescription drug benefits under the Fund. Your family also has prescription drug coverage provided by your spouse's employer. Your spouse uses this other coverage to obtain a prescription drug for himself or herself from a Preferred Pharmacy. Under this other coverage, your spouse incurs a $10 co-pay to obtain the prescription drug.
You should submit a claim form to the Fund office along with an itemized receipt showing the amount of the co-pay and information to identify the drug. The Fund office will reimburse you the $10 out-of-pocket expense. The Fund determines that the cost to the Fund to provide that prescription drug to your spouse would have been $50. The Fund office then calculates the "net savings" to the Fund by subtracting (1) the amount of the co-pay that your spouse would have incurred under the Fund's Prescription Drug Benefit ($5), and (2) the amount of any out-of-pocket costs that the Fund reimburses you for using your "other prescription drug coverage" (in this example, $10). The result ($35) is the amount of the "net savings" to the Fund. Because your spouse used a Preferred Pharmacy to obtain the prescription drug, the earned credits recorded to your account will be an amount equal to 50% of the Fund's "net savings" ($17.50). This example is illustrated as follows:
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| Calculation of Net Savings |
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| Cost of prescription to the Fund |
$50.00 |
| Less Fund's co-pay |
5.00 |
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$45.00 |
| Less Out-of-pocket reimbursement to you |
10.00 |
| Net Savings to Fund from use of other coverage |
$35.00 |
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| Calculation of Earned Credits |
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| Net Savings to Fund |
$35.00 |
| "Preferred Pharmacy" percentage |
* 50% |
| Earned Credits recorded to Account |
$17.50 |
In the above example, if your spouse obtained the prescription drug from a Non-Preferred Pharmacy, the earned credits recorded to your account would be $14 (40% of $35).
If, as a result of a coordination of benefits provision under the other prescription drug coverage, the Fund must pay an amount to a third party insurer, a corresponding adjustment will be made to the earned credits recorded (or to be recorded) to your account under the Program. |
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