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Pharmacy

Effective January 1, 2018, the pharmacy administrator is changing from OptumRx to Anthem Blue Cross, along with other benefit changes. Learn more. Register with optumrx.com by December 31, 2017 for access to 2017 prescription information.

How the Plan Works

Pharmacy benefits are administered by OptumRx. You may use any in-network or out-of-network pharmacy, but you’ll pay less when you use an in-network pharmacy—including UC pharmacies, participating OptumRx retail pharmacies and the mail-service pharmacy. If you use an out-of-network pharmacy, you’ll pay up front and be reimbursed by OptumRx at 50% of billed charges for covered drugs, with an out-of-pocket copayment maximum.

OptumRx provides resources for managing your prescription drug coverage. Visit optumrx.com to access a variety of tools to find local in-network pharmacies, choose the lowest-cost medication option, view the formulary, access forms and get information about home delivery.

What You Pay for Prescription Drugs

 

In-Network

UC Pharmacies & Participating OptumRx Pharmacies

Out-of-Network

Non-Participating Pharmacies

Calendar-Year Deductible

No deductible

No deductible

Pharmacy Out-of-Pocket Copayment Maximum (Combined with Medical/ Behavioral Health Out-of-Pocket expenses)1

The most you’ll pay for covered services in a calendar year.

Self: $5,100

Family: $8,700

Self: $8,600

Family: $19,200

Contraceptive Drugs and Devices

Retail (30-day supply): $0

Mail Service (up to a 90-day supply): $0

Retail (30-day supply): $0

Mail Service (up to a 90-day supply): Not covered

Formulary Generic Drugs

Retail (30-day supply): $5

Mail Service (up to a 90-day supply): $10

Retail (30-day supply): 50%

Mail Service (up to a 90-day supply): Not covered

Formulary Brand Name Drugs

Retail (30-day supply): $25

Mail Service (up to a 90-day supply): $50

Retail (30-day supply): 50%

Mail Service (up to a 90-day supply): Not covered

Non-Formulary Brand Name Drugs Retail (30-day supply): $40 Mail Service (up to a 90-day supply): $80

Retail (30-day supply): 50%

Mail Service (up to a 90-day supply): Not covered

Specialty Drugs BriovaRx and select UC Pharmacies (30-day supply): 30% (up to $150 maximum per prescription) Not covered
Smoking Cessation—Over-the-Counter and Prescription Drugs (prescription required) Retail (30-day supply): No charge Not covered
Diabetic Supplies (excluding syringes, needles, and non-formulary test strips) Retail (30-day supply): No charge Not covered

1. In-network (Anthem Preferred and UC Select) medical, behavioral health and prescription drug out-of-pocket copayment maximums count toward each other. In-network and out-of-network medical copayment maximums are separate—what you pay toward one doesn’t count toward the other. Annual out-of-pocket maximums include deductibles, copays, coinsurance and prescription drugs.

Filling Prescriptions

At a Retail Pharmacy

You can fill up to a 30-day supply at a retail pharmacy. If you are on a maintenance medication for a chronic condition, you can receive up to a 90-day supply from participating in-network retail pharmacies or UC pharmacies.

Mail-Service Prescriptions

You can receive up to a 90-day supply when you use the OptumRx home delivery service. Home delivery makes it quick and convenient to fill maintenance medications, such as those taken on an ongoing basis to treat chronic conditions like asthma, diabetes, high blood pressure or high cholesterol.

You can order prescriptions and request refills online, and your prescription is delivered to you by mail.

Maintenance Medications

You can fill or refill prescriptions at participating in-network pharmacies for a 30-day supply of specialty drugs, as well as an extended, 90-day supply of maintenance medications, at:

Specialty Medication Prescriptions

For prescription drugs used to treat complex conditions, OptumRx offers members access to a specialty pharmacy called BriovaRx. In addition to filling specialty medications, BriovaRx is an educational resource and trusted advisor, providing 24/7 support to patients and every member of the patient’s care team.

OptumRx Formulary

The OptumRx formulary determines what’s covered by the prescription plan. However, not all covered drugs are listed in the formulary. For the most current information about what’s covered, go to optumrx.com or call OptumRx, toll-free, at (855) 489-0651, 24/7.

Generic Drug Program

When a generic drug is available—and your physician prescribes the brand name drug—you must pay the generic copayment plus the difference between the cost of the brand name drug and the generic equivalent.

  • Your physician may provide information supporting medical necessity for the brand name drug through the OptumRx Prior Authorization process.
  • If the request is approved, you will pay the applicable brand name copayment.
  • Please note: Generic copayments vary depending on pharmacy location (retail or mail service).

Over-the-Counter Tobacco Cessation Products

Under the Affordable Care Act (ACA) rules, you can purchase any FDA-approved tobacco-cessation products without prior authorization and with no copayment.

This covers both prescription and over-the-counter medications used for a 90-day treatment regimen when prescribed by a health care provider.