Prescription drug benefits

Prescription drug benefits are automatically included with all medical coverage options.

pill bottle
 Benefits are administered by OptumRx, which
  • offers a national network of participating pharmacies, including a mail-order pharmacy;
  • maintains a formulary of preferred prescription medications; and
  • processes claims.

Key features of the prescription drug benefits include the following.

  • Members can save on their out-of-pocket costs for covered drugs by selecting generics or formulary brand drugs and using the mail-order service when appropriate.
  • The program encourages the use of select preventive prescription drugs that are highly effective in preventing or managing chronic conditions, such as diabetes and high blood pressure.
    • PPO and EPO members pay reduced copays for these drugs.
    • HDHP members pay only a flat-dollar copay with no deductible for these drugs.

Copays

When using your prescription drug benefits, your copay will vary depending on which medical option you are enrolled in (PPO, EPO, or HDHP) as well as 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 an equivalent generic exists, you will be responsible for a charge in addition to the applicable copayment.

Benefit PPO EPO HDHP
Prescription drugsRetail (30 days/90 days)Mail order (90 days)Retail (30 days/90 days)Mail order (90 days)Retail (30 days/90 days)Mail order (90 days)
Preventive generic$5/$15$12.50$6/$18$15$6/$18 (Not subject to deductible)$15 (Not subject to deductible)
Preventive formulary brand$20/$60$50$30/$90$75$30/$90 (Not subject to deductible)$75 (Not subject to deductible)
Preventive non-formulary brandDoes not apply ​Not covered ​Not covered ​
Generic$10/$30$25$12/$36$30

Member pays 100% up to deductible; after deductible, member pays 30% of cost;

30 days: $150 max.

90 days: $450 max.

Member pays 100% up to deductible; after deductible, member pays 30% of cost; $375 max. ​
Formulary brand

30% of cost; 30 days: $50 min to $150 max

90 days: $60 min to $300 max

30% of cost: $50 min to $250 max

35% of cost;

30 days: $35 min to $150 max

90 days: $105 min to $450 max

35% of cost;

$85 min to $375 max

Non-formulary brand

50% of cost; 30 days: $50 min to $150 max

90 days: $150 min to $450 max

 

50% of cost; $125 min to $375 maxNot covered ​Not covered ​
Prescription copayment maximum$3,000 (member & family combined) ​Part of the combined maximum out of pocket ​Part of the combined maximum out of pocket ​
Combined maximumDoes not apply ​$7,900 member*/$15,800 family* ​

$6,650/member*

$13,300/family*

*Includes in-network deductible, office visit copays, copayments, and prescription drug copays.

For more information

Members can call OptumRx at 855-207-5868, or visit the OptumRx website to

  • order and track refills;
  • make payments;
  • get statements;
  • view a personal prescription history;
  • estimate out-of-pocket prescription drug costs;
  • review benefit details, including the formulary;
  • read health and drug information;
  • find a participating pharmacy; and
  • learn about mail-order pharmacy services for maintenance drugs.

Preventive care

​For those enrolled in the Medical Plan, the preventive care benefit covers 100 percent of the plan allowance for eligible preventive screenings and immunizations with a network provider and is not subject to a deductible.

Read more