SUMMARY OF MATERIAL MODIFICATIONS November 2023
Tuesday, November 14, 2023
SUMMARY OF MATERIAL MODIFICATIONS
FOR ACTIVE PARTICIPANTS, PRE-MEDICARE RETIREES, AND PRE-MEDICARE ELIGIBLE DEPENDENTS
November 2023
Dear Participant:
This notice, referred to as a Summary of Material Modifications (SMM), describes important changes to the benefits offered by the National Automatic Sprinkler Industry (NASI) Welfare Fund. We encourage you to read this notice carefully and to keep it with your Summary Plan Description and Plan Document (Plan). If you have any questions, please contact the Fund Office.
OptumRx Will Replace Express Scripts as the Fund’s Pharmacy Benefit Manager Effective January 1, 2024
The Trustees of the Welfare Fund are committed to providing you and your family the best possible benefits in exchange for the lowest possible price. For this reason, they periodically review the benefits offered by the Fund and the way they are delivered. With that in mind, they are pleased to announce that OptumRx will replace Express Scripts as the Fund’s pharmacy benefit manager for active participants, pre-Medicare retirees, and pre-Medicare eligible dependents effective January 1, 2024.
The Trustees made this decision after extensive due diligence in an effort to improve participant service, capture savings for the Fund, and pave the way for two important benefit improvements that should save money for sprinkler fitter families.
In the coming weeks, you will receive more information about OptumRx’s pharmacy benefit program. In the meantime, please keep using your current Blue Cross Blue Shield ID card to obtain prescription medications from Express Scripts through the end of 2023. In December, you will be issued a new Blue Cross Blue Shield ID card that you should use for prescriptions filled on and after January 1, 2024.
As a reminder, mail order is still mandatory for maintenance medications. For maintenance medications currently being filled through Express Scripts Mail Order, most prescriptions will be transferred automatically to OptumRx Mail Order (sometimes called Home Delivery). However, some medications for controlled substances and prescriptions with no remaining refills will require a new prescription from your doctor. OptumRx will be sending you more information on how to sign up for Mail Order for medications filled on and after January 1, 2024.
We are committed to working with you, your family, and OptumRx to make the transition from Express Scripts to OptumRx as smooth and seamless as possible. However, with any change of this nature, disruption to some degree is unavoidable. To help ease the burden of any issues that arise, the Trustees are proud to implement two pharmacy benefit improvements summarized on the following page. In addition, as always, the Fund Office stands ready to help you resolve any problem you experience in connection with this move.
We emphasize that this notice is merely a preliminary announcement letter regarding the transition to OptumRx. You will receive additional details as we approach the end of 2023. In addition, the changes described in this notice do not impact Medicare-eligible retirees, disabled participants, and eligible dependents who are covered by Aetna’s Medicare Advantage Prescription Drug (MAPD) Plan. Benefits for those individuals will remain the same in 2024.
Generic (Non-Specialty) Formulary Medications Filled On and After January 1, 2024 Are Free for Your Family
The Trustees are pleased to announce that generic (non-specialty) formulary medications filled on and after January 1, 2024 will be filled at no cost to you and your family under the Level 1, 2, and 3 Schedules of Benefits. Previously, such medications were subject to a 20% coinsurance rate under Level 1, and a 25% coinsurance rate under Levels 2 and 3. Consequently, when you go to the pharmacy and fill an eligible generic drug, you may present your ID card, pay nothing ($0.00) out of pocket, and leave with the drug in hand as prescribed. This improvement also applies to eligible generic drugs ordered through OptumRx’s Home Delivery (Mail Order) service. All other Plan rules remain unchanged and in effect.
Improvement to the Plan’s Coinsurance Rate for Preferred Brand (Non-Specialty) Formulary Medications to 15%
The Trustees are also pleased to announce that preferred brand (non-specialty) formulary medications filled on and after January 1, 2024 will be subject to a 15% coinsurance rate under the Level 1, 2, and 3 Schedules of Benefits. Previously, such medications were subject to a 20% coinsurance rate under Level 1, and a 25% coinsurance rate under Levels 2 and 3. Consequently, when you go to the pharmacy and fill an eligible preferred drug, you will be responsible for 15% of the discounted cost of the drug instead of 20% or 25% of such cost. This improvement also applies to eligible preferred drugs ordered through OptumRx’s Home Delivery (Mail Order) service. All other Plan rules remain unchanged and in effect.
Conclusion
The Trustees will continue to monitor and manage the Fund’s resources in an effort to ensure that it is able to provide high quality health coverage to members and their families for years to come. As always, if you have any questions about this correspondence, or the Fund in general, please feel free to contact the Fund Office.
This summary of material modifications is intended as a non-technical summary of certain changes to the rules of the NASI Welfare Fund, so it does not contain all the details. It modifies the information set forth in the Fund’s Summary Plan Description and Plan Document that was previously provided to you. In the event of a discrepancy between this summary of material modifications and the official Plan documents, the official Plan documents, as interpreted and applied solely by the Trustees pursuant to their exclusive discretionary authority, will prevail. The Trustees reserve the right to modify the official Plan documents and the benefits offered by the NASI Welfare Fund at any time.
