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.
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
Medical under My Benefits;
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 the
Guide to Your Healthcare Benefits, call OptumRx at 855-207-5868, or visit
optumrx.com/mycatamaranrx. 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 may be ordered
- 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/mycatamaranrx, and mail the form and prescription to the address on the form.
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.
- For 2017, 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 $7,150/ member and $14,300/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 Medications
In step therapy, specific high-cost Step 2 drugs are covered by the plan only after you try clinically appropriate, more cost-effective Step 1 drugs — usually generics. If the Step 1 drugs do not provide the desired therapeutic benefit, you will be authorized to take a formulary (Step 2) drug, and it will be covered at the brand-name drug rate.
Some of the step therapy program categories are
asthma, attention deficit disorder, depression, diabetes,
high blood pressure,high blood cholesterol,
pain and inflammation,
skin inflammation, and
stomach acid reduction.
Prior Authorization Medications
Prior authorization is another program designed to help you get the most from your healthcare dollars. Prior authorization is required when more clinical information is needed about a patient’s particular medical condition before OptumRx can confirm the medical necessity for the recommended prescription. Your doctor or nurse can provide that information and request a prior authorization. The goal is to ensure patients receive appropriate medications for their diagnoses.
Some examples of medications that require prior authorization are Epogen, Procrit, Aranesp, Regranex, Forteo, Remicade, Topamax, Zonegran, infertility medications, and growth hormones.
The OptumRx 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.
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.