Our medical plan provide comprehensive prescription coverage, administered by OptumRx. By choosing in-network pharmacies and generic medications, you’ll keep more dollars in your pocket.
Show your OhioHealthy ID Card at the pharmacy to make sure you receive any discounts, and that the prescription cost counts toward your deductible and out-of-pocket maximum.
Visit OptumRx.com to see whether a medication is covered, find the Formulary/Prescription Drug List (updated quarterly), research prices, and locate an in-network pharmacy. You’ll need to create an OptumRx account first.
Good to know
|Formulary/Prescription Drug List (PDL)||A list of medications covered by your medical plan, organized into tiers - the higher the tier, the higher the cost of the medication. This list is updated quarterly. If you are prescribed a medication, check to see if it appears on this list; if not, discuss the possible alternatives with your healthcare provider to save money.|
|Mandatory generic||If you choose a brand name medication when a generic is available, you will pay the coinsurance, plus the cost difference between the two drugs (the difference does not count toward your deductible or out-of-pocket maximum).|
|Specialty medication||A medication that requires special handling, administration or monitoring — typically one used to treat complex conditions. Prescriptions for these must be filled through Optum Specialty Pharmacy. Visit specialty.optumrx.com or call 1 (855) 427.4682.|
|Step therapy||For some medical conditions, there are drugs with similar clinical effectiveness but wide variation in price. You may need to try a 'step 1' medication before a 'step 2' medication is covered.|
|Prior authorization||Some medications require prior authorization before a prescription can be filled. Your doctor or your pharmacist will let you know if you need prior authorization.|
|Quantity limits||Some medications have quantity limits to promote the appropriate use of medications, prevent waste and help control costs.|
|Medication therapy management - targeted medication reviews||A double check by a pharmacist to ensure your medication plan is the best that it can be, including lowering the risk for potential drug related problems, providing helpful tips for taking your medications, and identifying ways to reduce medication costs. A pharmacist may call you or send you a letter in the mail if they have recommendations to improve your medication therapy. Participation is voluntary and does not change your drug coverage. If you have questions about this benefit or do not want to participate in targeted medication reviews, please call (614) 788-9355.|
|Maintenance medications/90-day supplies||Some medications that are taken regularly or for an ongoing condition are called maintenance medications. (You do not need to follow the maintenance medication requirement if your medication is a specialty medication.) You have the option of filling a three-month supply of your maintenance medication at any in-network retail pharmacy. OptumRx offers an easy payment plan, which splits the cost of a 90-day prescription over three payments.|
|Preventive care medication||Under the Affordable Care Act (ACA), your pharmacy benefits must cover certain preventive care medications at 100%, with no copay, no coinsurance and no deductible. Download the Preventive Care Medication List below.|
|Using coupons|| Drug manufacturers often issue coupons to encourage continued use of a more expensive brand name drug, even though less expensive similar or equivalent options have become available. OptumRx Home Delivery does not accept coupons for associates covered by our medical plan, regardless of the type of medication. Some retail pharmacies may allow the use of coupons. |
Note that the coupon value is often counted toward your deductible, even though you are not paying that amount out-of-pocket. This may have tax reporting implications for you.
|Diabetes and Asthma||If you’re enrolled in our medical plan and are actively participating in the OhioHealth disease management program for Diabetes or Asthma, you may qualify to have certain medications paid for at 100%. (If you are enrolled in the OhioHealthy HDHP+HSA, you will need to meet your deductible first.)|
How much does this benefit cost?
Prescription coverage is included in your medical plan premiums. The way you pay for prescription medications depends on the medical plan option you choose:
- OhioHealthy HDHP+HSA: You pay the full cost of covered medications until you meet your deductible. Then, the plan pays 80% of the cost of most covered medications, and you pay 20%. You may use your HSA funds to pay for medications.
- OhioHealthy PPO plan/PPO Assist: There are flat copays or coinsurance for different tiers of medication; there is no deductible to meet.
How to make the most of this benefit
- Ask your healthcare provider for generic medication or one listed on our Formulary/Prescription Drug List that might work for you
- Download the OptumRx app so you can discuss medication options with your healthcare provider on the go during your consultation
- Use the OptumRx website or app to research the cost of a medication at different pharmacies (you must use Optum Specialty Pharmacy for specialty medications), see lower-cost alternatives and explore pricing for different dosage options (for example, occasionally two 50mg capsules can cost less than one 100mg tablet)
- Follow all instructions and take your medications according to the prescribed schedule
- Call your physician or pharmacy if you have questions or any concerns about drug interactions
- Combine this benefit with a Health Savings Account (HSA) or Healthcare Flexible Spending Account (Healthcare FSA) to get eligible out-of-pocket expenses reimbursed
- If you have an HSA or Healthcare FSA, use your debit card to pay for your prescription medicines and save your receipts on the HealthEquity mobile app