Regardless of the medical plan you select, prescription drug coverage is provided for both you and your family. You have the option to obtain your prescription medications either at a local pharmacy or through mail-order services. Typically, you can obtain a one-month supply of medication at a retail pharmacy. However, if you opt for mail order, you can receive a 90-day supply of your prescription.
Maintenance Medications
If you require regular and ongoing medication, such as for blood pressure or cholesterol management, opting for mail order prescription filling can lead to cost savings. With this option, a single co-payment can cover a 90-day supply of your medication.
- UnitedHealthcare/OptumRx
- Kaiser Permanente
- Prescription Drug Benefit Comparison
- Limitations and Exclusions
UnitedHealthcare/OptumRx
If you are enrolled in the BlueChoice HMO or CareFirst PPO plan, your prescription drug ID card is issued separately by UnitedHealthcare®/OptumRx®. When visiting a network pharmacy, it is necessary to present your ID card and make a co-payment for each prescription. Many pharmacies are part of the UnitedHealthcare/OptumRx network. If you fill a prescription at a pharmacy outside this network, you will typically be responsible for the full medication cost. Subsequently, you must file a claim with your prescription drug program to seek reimbursement for the in-network expenses.
Kaiser Permanente
If you are enrolled in the Kaiser HMO plan, your prescription drug ID card is identical to your medical ID card. When you visit a network pharmacy, it’s essential to present your ID card and pay a co-payment for each prescription. The Kaiser Permanente network includes numerous pharmacies. However, if you choose to fill a prescription at a pharmacy outside of this network, you are responsible for covering the full amount charged by the pharmacy.
Prescription Drug Benefit Comparison
| If your medical plan is: | Your Prescription Program is: | Your Co-payment | |||
|---|---|---|---|---|---|
| Retail Network (30-day supply) | Retail Non-Network (30-day supply) | Mail Order (90-day supply) | |||
| Kaiser Permanente HMO | Kaiser Permanente | Generic Formulary Brand Non-Formulary | $10 $20 $30 | The entire cost of a Drug | $20 $50 $80 |
| BlueChoice HMO | OptumRx/UHC | Generic Formulary Brand Non-Formulary | $10 $25* $40 | The full cost of the drug The full cost of the drug The full cost of the drug | $20 $50 $80 |
| CareFirst PPO | OptumRx/UHC | Generic Formulary Brand Non-Formulary | $10 $25* $40 | The entire cost of the drug The total cost of the drug The entire cost of the drug | $20 $50 $80 |
| BCBS Medicare Advantage Plan w/ part D | BCBS Medicare Advantage | Tier 1 Preferred Generic Tier 2 Generic Tier 3 Preferred Brand Tier 4 Non-Preferred Drug Tier 5 Specialty Tier | $5
$10 $25 $40 $40 | $10
$20 $50 $80 Not available on this tier |
Effective January 1, 2019, Participants enrolled in the Optum Rx or United Health Care Prescription Drug programs, now have a mandatory Generics Program.
A generic equivalent refers to a generic version of a brand-name medication. These generics contain the same active ingredients, ensuring comparable safety, quality, and strength as their brand-name counterparts. Additionally, they are proven to have the same physiological effects in the body. Generics typically come at a lower cost compared to brand-name medications, thus opting for them can potentially lead to cost savings.
If you opt for a brand-name medication instead of its generic equivalent, you will be subject to your plan’s applicable brand copayment along with an additional penalty. This penalty equals the difference in cost between the brand and generic versions of the medication. Consequently, your out-of-pocket expenses for the brand-name medication may amount to the entire cost of the medicine. It’s important to note that even if your doctor specifies “Dispense as Written” (DAW) on the prescription, this penalty will still be applied.
Limitation and Exclusions
Prescription drugs covered by your plan must be deemed medically necessary according to the carrier’s guidelines. Moreover, specific prescription medications may be subject to exclusions, limitations, or prior authorization requirements based on medical necessity. For more information, consult your carrier’s benefits booklet or reach out to your provider for clarification.
The Plan actively engages in the UnitedHealthcare/OptumRx fraud, waste, and abuse program, which scrutinizes patient and prescriber behaviors to detect any unusual patterns or instances of abnormal utilization or prescribing practices. UnitedHealthcare/OptumRx works in collaboration with the Plan to intervene in identified cases of fraud, waste, and abuse. The Plan holds the authority to decide whether to limit member access to pharmacies and physicians as deemed necessary.
