Prescription drugs

When you enroll in the Aetna HDHP with HSA or Aetna PPO medical plans, your prescription drug coverage is provided by Optum Rx. Contributions for prescription drug coverage are included in your medical plan contributions, but you receive a separate Optum Rx ID card for filling prescriptions. In general, your prescription drug costs depend on the type of medication, where you fill it and the amount you need.

Prescription drugs at a glance
Coverage overview
Resources
Contacts

Prescription drugs at a glance

  • Optum Rx offers a nationwide network of participating pharmacies, and your out-of-pocket costs will generally be lower when you use a network pharmacy.
  • Optum Rx maintains a formulary, which is a list of covered drugs that have negotiated preferred pricing. Drugs on the formulary generally have lower cost sharing. Formulary status, tier placement and coverage are subject to change.
  • Certain Affordable Care Act (ACA)-designated preventive medications are covered at 100% and are not subject to the deductible, while some Optum Rx-designated preventive medications will require a coinsurance or copay but are not subject to the deductible.
  • For non-preventive medications, you pay out of pocket until you meet the deductible, then share in the cost through coinsurance or copays. If you reach the out-of-pocket maximum, the plan pays 100% of covered expenses for the remainder of the calendar year. Both medical and prescription drug costs apply to the plan deductible and out-of-pocket maximum.
  • The Optum Rx mail-order program is designed to be more convenient and less expensive for you to obtain medications you take on an ongoing basis, such as those used to treat chronic conditions.
  • Certain medications are classified as specialty drugs and must be filled through Optum Specialty. Specialty drugs may have supply limits and different cost‑sharing requirements.
  • To help ensure safe, effective and appropriate medication use, some medications may be subject to prior authorization, quantity limits, step-therapy requirements and/or clinical strategies.

You can search for covered medications, participating pharmacies and pricing information through the Optum Rx website or by calling them at 866-837-9242.

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Coverage overview

Tier 1 (Generic)
Tier 2 (Preferred Brand)
Tier 3 (Non-Preferred Brand)
Retail 30-Day Supply
(Any Participating Optum Rx Pharmacy)
10% coinsurance
($7.50 min / $30 max)
20% coinsurance
($20 min / $100 max)
30% coinsurance
($40 min / $200 max)
Retail 90-Day Supply
(Walgreens and Duane Reade Only)
10% coinsurance
($15 min / $60 max)
20% coinsurance
($40 min / $200 max)
30% coinsurance
($80 min / $400 max)
Optum Rx Mail Order
10% coinsurance
($15 min / $60 max)
20% coinsurance
($40 min / $200 max)
30% coinsurance
($80 min / $400 max)

Note: If you insist on a brand-name prescription drug when there is a generic equivalent and your physician does not indicate “Dispense As Written,” you are responsible for the cost difference plus applicable copays or coinsurance.

Specialty (Optum Specialty Mail)

Generic
Preferred Brand
Non-Preferred Brand
30-Day Supply
10% coinsurance
($15 min / $60 max)
20% coinsurance
($40 min / $200 max)
30% coinsurance
($80 min / $600 max)
More Than 30-Day Supply
10% coinsurance
($30 min / $120 max)
20% coinsurance
($80 min / $400 max)
30% coinsurance
($160 min / $800 max)

Note: If you insist on a brand-name prescription drug when there is a generic equivalent and your physician does not indicate “Dispense As Written,” you are responsible for the cost difference plus applicable copays or coinsurance.

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Contacts

Optum Rx (including Optum Rx Specialty)
optumrx.com
866-837-9242

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