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Newspaper Guild of New YorkThe New York Times
Benefits Fund • Pension Plan • Scholarship Fund
1501 Broadway, Suite 1724 • New York, NY 10036Phone (646)
237-1670 • Fax (212) 395-9299
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2
If the prescription is approved,
the letter will tell you the
length of your coverage approval.
If the prescription is denied,
the letter will include the
reason for coverage denial and
instructions on how to submit
an appeal, if you choose to
do so. If you want the
prescription immediately without waiting
for the prior authorization, you
will have to pay the full
retail price at the pharmacy.
If the prescription is approved,
your claim should be sent
to Express Scripts for reimbursement.
Step Therapy For certain
prescription drugs to be covered,
the Plan requires covered individuals
with certain conditions – including
high blood pressure, nasal allergies
or acid reflux – to try
effective and more affordable
prescription drugs first before
“stepping up” to more expensive
drugs.
• Step 1 drugs – These front-‐line
drugs are generic and sometimes
lower-‐cost brand name drugs that
have generally proven to be
safe, effective and affordable. In
most cases you should try
these drugs first because they
usually provide the same health
benefit as a more expensive
drug, at a lower cost to
you and the Plan.
• Step 2 and Step 3 drugs
– Second-‐line drugs are brand
name alternative drugs that
generally are necessary for only
a small number of patients for
whom front-‐line drugs have failed.
Third-‐line drugs are the most
expensive option and have not
shown greater clinical efficacy than
lower cost drugs.
The Plan’s step therapy
requirements have been developed and
are updated regularly under the
guidance and direction of
licensed physicians, pharmacists and
other medical experts. Together with
Express Scripts, they review the
most current research on thousands
of drugs tested and approved
by the FDA for safety and
effectiveness. Only some medications
are subject to the step
therapy requirements, and the
prescription drugs that are may
change from time to time. Your
pharmacist can tell you if your
prescription requires step therapy.
Or, at any time you can
find out yourself by logging in
to www.express-‐scripts.com and clicking
“Price a Medication.” With
step therapy, more expensive
brand-‐name drugs are usually covered
as second-‐line alternative drugs
if any of the following
applies:
• You have already tried the
generic drugs covered in the
step therapy program and they
were unsuccessful.
• You cannot take a specific
generic drug (for example, because
of a documented allergy). • Your
physician demonstrates, for medical
reasons, that you need a
brand-‐name drug.
If one of these situations
applies to you, your physician
may request an override from
Express Scripts, allowing you to
take a second-‐line prescription
drug. If the override is
approved, you will pay the
appropriate copay for the drug.
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3
If your physician’s request for an
override is denied, you may
follow the appeals process. If
you choose not to appeal or
your appeal is denied, you
can talk to your physician
again about prescribing one of
the front-‐line drugs covered by
the step therapy program. Or
you can choose to pay the
full price for the drug.
Drug Quantity Management The
drug quantity management program
helps make the use of
prescription drugs safer and more
affordable by limiting the quantity
dispensed for certain medications.
This provides the right amount
to take the daily dose
considered safe and effective,
according to the recommendations of
the U.S. Food and Drug
Administration (FDA). For more
information or a list of drugs
that are subject to quantity
limits, you may call Express
Scripts at (866) 544-‐2926. 3.
Special Enrollment Right Normally
you can only change your
coverage elections during open
enrollment (which begins February
15th each year, with changes
effective April 1st). However,
if this change results in a
significant increase in the cost
of your coverage within the
meaning of the tax law, you
may be permitted to drop your
coverage effective February 1, 2018.
Contact the Fund Administrator
at (646) 237-‐1670 immediately if
you wish to do so.
Please place this information with
your Summary Plan Description
document for permanent reference.
If you have any questions
concerning the changes summarized above,
please call the Fund Administrator
at (646) 237-‐1670.
Sincerely,
BOARD OF TRUSTEES
OF THE NEWSPAPER
GUILD OF NEW YORK –
THE NEW YORK TIMES BENEFITS FUND
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ACA Section 1557 Notice of Nondiscrimination
The Newspaper Guild of New York – The New York Times Benefits
Plan (“the Plan”) complies with applicable Federal civil rights
laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. The Plan does not exclude
people or treat them differently because of race, color, national
origin, age, disability, or sex.
The Plan:
• Provides free aids and services to people with disabilities to
communicate effectively with us, such as: • Qualified sign language
interpreters • Written information in other formats (large print,
audio, accessible electronic
formats, other formats)
• Provides free language services to people whose primary
language is not English, such as: • Qualified interpreters •
Information written in other languages
If you need these services, contact the Fund Administrator at
(646) 237-1670
If you believe that the Plan has failed to provide these
services or discriminated in another way on the basis of race,
color, national origin, age, disability, or sex, you can file a
grievance with:
Robert Costello C&R Consulting, Inc. 1501 Broadway, Suite
1724 New York, NY 10036
You can file a grievance in person or by mail, fax, or email. If
you need help filing a grievance, Robert Costello is available to
help you.
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint
Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at:
U.S. Department of Health and Human Services 200 Independence
Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html
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5
ATTENTION: FREE LANGUAGE ASSISTANCE
This chart displays, in various languages, the phone number to
call for free language assistance services for individuals with
limited English proficiency.
Language Message About Language Assistance
1. Spanish ATENCIÓN: si habla español, tiene a su disposición
servicios gratuitos de asistencia lingüística. Llame al
212-924-2473
2. Chinese
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 212-924-2473
3. French ATTENTION : Si vous parlez français, des services
d'aide linguistique vous sont proposés gratuitement. Appelez le
212-924-2473
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sono disponibili servizi di assistenza linguistica gratuiti.
Chiamare il numero 212-924-2473
5. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen
kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.
Rufnummer: 212-924-2473
6. Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang
gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.
Tumawag sa 212-924-2473
7. Arabic ةظوحلم: اذإ تنك ثدحتت ركذا ،ةغلال نإف تامدخ ةدعاسمال
ةیوغلال رفاوتت كل ناجمالب. لصتا مقرب 212-924-2473
8. Korean
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.
212-924-2473 번으로 전화해 주십시오.
9. Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам
доступны бесплатные услуги перевода. Звоните 212-924-2473
10. Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z
bezpłatnej pomocy językowej. Zadzwoń pod numer 212-924-2473
11. Urdu 2473-924-212 نیرک رادربخ: رگا پآ ودرا ےتلوب ،نیہ وت پآ
وک نابز یک ددم یک تامدخ تفم نیم بایتسد نیہ ۔ الک
12. Yiddish ביוא ריא טדער שידיא, ןענעז ןאהראפ ראפ ךייא ךארפש
ףליה סעסיוורעס יירפ ןופ לאצפא. טפור -1 212-924-2473
םאזקרעמפיוא:
13. Bengali লয্ করনঃ যযদ আযিন বাাংলা, কথা বললত িাল রন, তালেল য
নঃখরচায় ভাষা সোয়তা যিলরষবা
উিল আআছ। আ ফান করন 212-924-2473
14. French Creole (Haitian)
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki
disponib gratis pou ou. Rele 212-924-2473
15. Portuguese ATENÇÃO: Se fala português, encontram-se
disponíveis serviços linguísticos, grátis. Ligue para
212-924-2473
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