UnitedHealthcare/OptumRx

If you are in the PPO or BlueChoice HMO, your prescription drug ID card is separately provided by UnitedHealthcare®/OptumRx®. When visiting a network pharmacy, you must present your ID card and pay a co-payment for each prescription. Many pharmacies participate in the UnitedHealthcare/OptumRx network. If you fill a prescription at a non-participating pharmacy, you will generally pay the total price for the medication. You must then file a claim with your prescription drug program to reimburse the in-network cost.

Kaiser Permanente

If you are in the Kaiser HMO, your prescription drug ID card is the same as your medical ID card. When visiting a network pharmacy, you must present your ID card and pay a co-payment for each prescription. Many pharmacies participate in the Kaiser Permanente network. If you fill a prescription at a non-participating pharmacy, you are responsible for the entire amount charged by the pharmacy.

Prescription Drug Benefit Comparison

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 is a generic version of the brand-name medication. Generic equivalents have the same active ingredients, safety, quality, and strength as their brand-name counterpart, and they are proven to act the same way in the body. Generics cost less than brand-name medications, so using them may help you save money.

If you use a brand-name medication instead of its generic equivalent, you will pay your plan’s applicable brand copayment plus a penalty. This penalty is the difference in cost between the brand and generic medications. Your out-of-pocket cost for the brand may be up to the entire cost of the medicine. Even if your doctor writes dispense as written (DAW) on the prescription, this penalty will occur.

Limitation and Exclusions

Covered prescription drugs must be medically necessary as determined under the carrier’s rules. In addition, certain prescription drugs may be subject to exclusions, limitations, or prior authorization for medical necessity. Refer to the benefits booklet from your carrier or contact your page for more details.

The Plan participates in the UnitedHealthcare/OptumRx fraud, waste, and abuse program, which monitors patient and prescriber patterns to identify outliers and situations of abnormal utilization or prescribing situations. UnitedHealthcare/OptumRx and the Plan collaborate regarding intervention in identified fraud, waste, and abuse cases. The Plan can determine whether to restrict member access to pharmacies and physicians.