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Prescription Drug Program

OptumRx, the Medical Plan’s pharmacy benefits manager, administers the prescription drug program. To maximize your prescription drug benefits

  • share the plan’s drug formulary with your physicians, noting its step therapy and prior authorization requirements;
  • take generic medications when appropriate and available;
  • use your OptumRx ID card for all of your prescription medication needs, including short-term maintenance, 
    specialty, step therapy, and prior authorization medications;
  • check the drug exclusion list on pensions.org before filling a new prescription.

OptumRx Website

Access your prescription drug account by going directly to the OptumRx website. Or to simplify your log in, you can go to Benefits Connect and

  1. select Medical under My Benefits;
  2. click OptumRx (Prescription Drug) under Service Providers.

The first time you link to the site through Benefits Connect, you will be guided through a one-time registration process.

For additional information about the prescription drug program, read Guide to Your Healthcare Benefits, call OptumRx at 855-207-5868, or visit optumrx.com. At the website, you can view your prescription drug costs, order refills, and more.

Maintenance Prescription Medications

Maintenance medications are prescription drugs that a patient takes regularly, often to treat ongoing conditions such as diabetes, high cholesterol, and high blood pressure.

Use OptumRx's home delivery to get a 90-day supply of maintenance drugs delivered to your home for a lower copay than you would be charged at retail pharmacies for the same quantity.*

Once OptumRx receives the original prescription, refills, if available, may be ordered

  • online; or
  • by phone at 855-207-5868.

* Savings will vary depending on the medications.

To order using home delivery, have your physician e-prescribe or fax the prescription to OptumRx, or complete a prescription order form, available at optumrx.com, and mail the form and prescription to the address on the form. 

Specialty Medications

PPO or EPO?

Prescription drug coverage under the PPO and EPO differ in the following ways:

  • The PPO covers non-formulary drugs at 50 percent; the EPO does not cover non-formulary drugs.
  • The PPO has an annual family copayment maximum of $3,000 for prescription drugs; the EPO has no plan maximum for prescription drugs (other than the annual ACA limits of $7,350/ member and $14,700/family).
  • The PPO covers infertility treatment; the EPO does not.
  • The copays differ. (See chart below.)

Specialty medications are typically used to treat complex conditions and often have product handling and distribution requirements. These medications include high-cost injectable or oral medications.

Step Therapy

In some cases, it may be required that you first try certain drugs to treat your medical condition before the plan will cover another drug for that condition. For example, if Drug A and Drug B both treat your condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

Drugs that require step therapy are noted in the drug formulary available on pensions.org or call OptumRx at 855-207-5868. The step therapy list is subject to change.

Prior Authorization

A prior authorization requires you or your physician to get approval from OptumRx before filling prescriptions for certain drugs. If you do not get approval, the drug may not be covered.

Drugs that require prior authorization typically are drugs that are very costly or have significant potential for negative side effects. To find out if a drug requires prior authorization, check the drug formulary available on pensions.org or call OptumRx at 855-207-5868.

Prior authorization must be obtained from Highmark to fill prescriptions for medical injectable drugs.

Excluded Drugs

The drug formulary (for active plan members) excludes certain brand-name medications that medical and clinical experts agree do not offer a clear clinical advantage over other, less costly brand-name or generic drug alternatives.

If you fill a prescription for a medication that is excluded from coverage, you’ll pay the full (unreduced) cost of the drug, and that payment will not count toward your out-of-pocket maximum, if any.

A list of excluded drugs is maintained on pensions.org; the list is updated semi-annually.

Copays

The prescription drug program benefit varies the level of copay by drug type:

  • generic drugs
  • formulary brand-name drugs
  • non-formulary brand-name drugs (PPO only)

Under the PPO, if you choose to fill a prescription for a brand-name medication when a chemically equivalent generic exists, you will be responsible for an ancillary charge, plus the applicable copayment.