TEAMSTERS LOCAL No. 610 TRUST FUND, CONTINENTAL CASUALTY Co. PCS-MISSOURI Drugs covered: Legend drugs; insulin on prescription.1 Drugs not covered: Contraceptives, oral or otherwise, whether used for that purpose or not; dietary drugs. Generics: Lowest price in stock. Maximum quantities: 34-day supply, except nitroglycerin and thyroid in 100's. Refills: One year. Number Rx's per claim form: One. ID card: Plastic. Dependents covered: Salaried employees and their eligible dependents. Co-pay: $2. Profession fee: $2, except insulin covered below. Acquisition cost: Rolodex. Insulin: On prescription only, rolodex cost plus 50 percent. State tax: Sales tax is payable if applicable. Imprinter: Furnished by PCS when volume warrants. Drug identification on claim: Drug code as in manual. Claim distribution: All parts to G.O. accounting. When forwarded: End of each week with sales and cash report. Reorder claim forms from: Pharmaceutical Card System, Post Office Box 678, Phoenix, AZ 85001. PCS-MISSOURI Drugs covered: Legend drugs; insulin on prescription only. Drugs not covered: Contraceptives, oral or otherwise, whether used for that purpose or not; hypodermic needles, syringes, or similar devices. Generics: Lowest price in stock. Maximum quantities: 34-day supply, except nitroglycerin and thyroid in 100's. Dependents covered: Salaried employees and their eligible dependents. Professional fee: $1.95 except insulin covered below. Acquisition cost: Rolodex. Insulin: On prescription only, Rolodex cost plus 50 percent. State tax: Sales tax is payable if applicable. 001 Imprinter: Furnished by PCS when volume warrants. Claim distribution: All parts to G.O. accounting. When forwarded: End of each week with sales and cash report. Reorder claim forms from: Pharmaceutical Card System, Post Office Box 678, Phoenix, AZ 85001. 1 Insulin syringe, insulin needles (two), sugar test tablets, sugar test tapes, acetone test tablets, benedict's solution or equivalent. Syringes, needles or other devices not covered unless for diabetic use. CONTINENTAL CASUALTY PCS-MISSOURI-GOLDEN 65 Drugs covered: Legend drugs; insulin. Drugs not covered: Any drugs or devices other than above. Maximum quantities: Only as ordered on prescription. Number Rx's per claim form: One. ID card: Plastic. Dependents coverd: Only individual policy holders. Co-pay: 20 percent of prescription price.1 Professional fee: $2. Acquisition cost: Rolodex. Insulin: On prescription only. State tax: Charge as a separate item where applicable. Imprinter: Will be sent automatically when volume warrants it. Drug identification on claim: Use drug code in manual. Claim Distribution: All parts to G. O. accounting. When forwarded: End of each week with sales and cash report. Reorder claim forms from: Pharmaceutical Card System, Post Office Box 678, Phoenix, AZ 85001. CATERPILLAR TRACTOR CO.-MISSOURI Drugs covered: Legend drugs; compounds W/A legend; see footnote 1. Drugs not covered: Contraceptives whether prescribed for contraception or not; Rx's whose usual retail is $2 and under; dietary drugs. Generics: When written for, use lowest cost drug in stock. Maximum quantities: 34-day supply except for 100's in nitroglycerin and thyroid. Refills: Up to 1 year. Number Rx's per claim form: Five per claim if for same person. ID card: Cardboard; no expiration date. Dependents covered: Yes. Co-pay: $2. Professional fee: $2.10. Acquisition cost: Rolodex. Insulin: See footnotes 5 and 6. State tax; Tax not charged, is included in professional fee; see footnote 2. Drug identification on claim: Write drug name. Claim distribution: Last copy stays in store, first three copies to G.O. accounting; see footnotes 3 and 4. When forwarded; End of each week with sales and cash report. Recorder claim forms from: Caterpillar Tractor Co., Aurora, Joliet, East Peoria, Decatur, Davenport, Milwaukee (whichever is closest). Any Rx drugs that are used strictly for diets will be paid for by Caterpillar. BLUE CROSS-BLUE SHIELD-ST. LOUIS Drugs covered: Legend drugs; compounds W/A legend; insulin. Drugs not covered: Contraceptives, whether prescribed for contraception or not; Rx's whose usual retail is $2 and under. Generics: When written for, use lowest cost drug in stock. Maximum quantities: 34-day supply, except for 100's of: 1 Refills: Up to 6 months. Number Rx's per claim form: Three per person on one claim. Dependents covered: Stated on ID card. Co-pay: Listed on ID card. Professional fee: $2.05 plus tax. Acquisition cost: Rolodex. 1 We must collect 20 percent of the total retail of the prescription. There are no other limits involved. 1 Drugs covered-Adrenalin, Aveeno, Clinistix, Clinitest, Duo Cvp, Isupresl, Pentrate, Acidolate, Acetaminophen. Add tax to acquisition cost for non-legend drugs where dispensing fee not used. Signature on claim form must be employee or spouse. Don't give patient any part of claim form. Acquisition cost plus dispensing fee or "usual charge", whichever is lower, less co-pay, on insulin. In all States with tax on insulin, tax is added to acquisition cost when "usual charge" is used. If professional fee is used, tax is in fee. CONTACT THE INSURANCE OFFICE FOR A LIST JE ZANTICIPATING PHARMACISE COVERED BY THE PRESCRIPTION DRUG PLAN OF CATERPILLAR TRACTOR CO. & AUTHORIZED SIGNATURES EMPLOYEE Insulin Priced at usual price. State tax Tax is charged to customer. If co-pay, customer pays co-pay amount plus tax. Imprinter: None. Drug identification on claim: Write drug name. 1 Antiarthritic drugs, anticoagulants, anticonvulsants, antidiabetics, hormones, antifungal agents, antihistamines, cardiac drugs, diuretics, hypertensive agents, anticholinergic and parasympatholytic agents for Claim distribution: Both copies to G.O. accounting. When forwarded: End of each week with sales and cash report. Reorder claim forms from: Blue Cross Hospital Service, Director of Prepaid Rx Prog., 1430 Olive Street, St. Louis, MO. 63103. treatment of ulcers, prescriptions requiring vitamins, thyroid preparations, urinary and intestinal anti-infectives. |