Prescription Drug Plan

Envision RxOptions

Retail Co-Payment per Prescription
  Brand Name Prescription Drug (34 day supply)
Generic Prescription Drug (34 day supply)

Mail Order Co-Payment per Prescription
  Brand Name Prescription Drug (100 day supply)
Generic Prescription Drug (100 day supply)

This plan includes a mandatory Generic substitution program. Whenever a Generic drug is available, the Prescription Drug Plan shall only pay the amount normally allowed for the Generic drug. This means, in addition to paying the Generic Drug Co-Pay of $20.00, you will also be responsible for the difference in the cost of the Brand Name Drug and the Generic Drug. If your doctor mandates the Brand Name Drug, the difference in cost will not apply.

The plan also includes a mail order option. This option is useful for maintenance drugs prescribed on a regular basis. Please note that you receive a 100 day supply of your prescription drug through the mail order program for only $15.00 (Generic) and $20.00 (Brand Name)

Additional mail order forms are available at Sheet Metal Workers’ Local 270 Health & Welfare Office located at 1863 North 105th East Ave. in Tulsa, Oklahoma.


The Prescription Drug Coverage excludes the following items or prescription drugs. If it is not listed as exclusion, it is considered to be a covered expense.

  Alcohol Swabs                
Contraceptives-Foams & Devices        

Cosmetic Products
Growth Hormone (i.e., Humatrope)
Medications-Injectible (Other than Insulin)
Over the Counter Drugs
Syringes & Needles (Other than to administer Insulin)


Pre-Approval is required for the purchase of all Oxycodone medications.

Immunization agents, biological serum, blood or blood plasma.

Minoxidil (Rogaine) for treatment of alopecia.

Non-Legend drugs, other than insulin.

Therapeutic devices or appliances, including needles, syringes (other than to administer insulin), support garments and other non-medicinal substances, regardless of intended use.

Charges for the administration or injection of any drug.

Prescriptions of which an eligible person is entitled to receive, without charge, for any Workers’ Compensation Laws.

Drugs labeled “Caution-limited by federal law to investigational use, or experimental drugs” even though a charge is made to the individual.

Medication which is to be taken by or administered to an individual, in whole or in part, while he/she is a patient in a licensed hospital, rest home sanitarium, extended care facility, convalescent hospital, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals.

Any prescription filled in excess of the number of re-fills specified by the prescribing physician, or any refill dispensed after one year from the physician’s original order.

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