Prescription drug benefits are available to all employees and their family members that are enrolled in the State of Ohio medical plan.
Filling a Prescription
Employees have two options for filling their prescriptions:
1. Employees can take their prescription to a pharmacy within the OptumRx network; or
2. Employees can receive prescriptions by mail through OptumRx Home Delivery.
Want to save some money? OptumRx offers a variety of Web-based features intended to put you in touch with valuable health and prescription drug benefit information. Through OptumRx.com, you can review your plan’s benefits, locate a participating pharmacy, view and print your prescription history, and more.
In addition, OptumRx’s online drug pricing tool, Price & Save, can save you money by comparing the price of your prescriptions at local retail pharmacies and through mail service. This allows you to shop for the most competitively priced pharmacy to obtain your prescription and helps save you money. Unlike other drug pricing tools, Price & Save identifies the lowest priced pharmacies without bias, enabling you to become a fully informed consumer.
Prescription Drug Copayment Costs
|PRESCRIPTION DRUG COPAYMENT COSTS|
|OHIO MED PPO and OHIO MED NN
|OHIO MED HDHP
|ALL TYPES OF
|Generic||$10||$10||$30||$25||You pay 100% until the deductible is met, then 20% until the out-of-pocket limit is met.
Deductible amounts: $2,000 single
|$75 plus the difference between the cost of the brand-name and generic drug||$75 plus the difference between the cost of the brand-name and generic drug||$225 plus the difference between the cost of the brand-name and generic drug||$187.50 plus the difference between the cost of the brand-name and generic drug|
|$3,500 single/$7,000 family||$3,500 single
|The amount charged to the individual for generic, preferred brand and non-preferred brand medications will not be greater than the actual cost of the medication. Therefore, the amount charged may be less than the flat-dollar copay.
The maximum copay for oral oncology medications will be $100 for a 30-day supply. For more details, visit das.ohio.gov/prescriptiondrug.
* Pharmacy copays do not apply toward the medical/behavioral health plan deductibles and the annual out-of-pocket maximum for the Ohio Med PPO.
OptumRx Home Delivery
Home delivery is an important element of your care. OptumRx Home Delivery is a full-service, state-of-the-art home delivery pharmacy. It offers an easy, cost-effective and convenient way for you to fill prescriptions for maintenance medications.
You’ll benefit from lower co-pays by refilling a 90-day supply rather than the typical 30-day supply. OptumRx Home Delivery offers convenient delivery to your specified location.
Use the OptumRx Mail Order Registration & Prescription Order Form to register to use the OptumRx mail order program provided by OptumRx Home Delivery.
OptumRx Home Delivery features:
- Convenient and easy-to-use mail service delivery to anywhere in the US
- Prompt, caring and attentive service from a team of registered pharmacists and customer service representatives
- A quality-controlled dispensing process
- Free shipping and delivery for most medications
Submit inquiries to OptumRx at 1-866-854-8850 or visit the OptumRx website at OptumRx.com.
Diabetes Management Program
State of Ohio members are eligible for free diabetic supplies and medications if they have had a Hemoglobin A1c test within the past 12 months while covered by the State. Specific test values and results are not required, only that the member has had the test.
Enrolling is simple – you must first have an A1c test performed by your provider. Once the claim for the test has been processed by your medical third-party administrator, they will send your information to OptumRx. It can take 30 to 60 days for your medical third-party administrator and OptumRx to reflect your eligibility for this program in their respective systems.
For those members that meet these guidelines, the supplies and durable medical equipment listed below are provided at no cost. There is nothing else you need to do.
Durable Medical Equipment
These items are covered by your medical third-party administrator (Anthem or Medical Mutual of Ohio) when purchased through an in-network provider. Please verify coverage with your third-party administrator prior to obtaining equipment.
- Internal insulin pumps
- External insulin pumps
- Insulin pump supplies, including:
- Insertion devices
- Batteries (Lithium only)
- Infusion sets
- Continuous glucose monitoring equipment
- Sensor insertion devices
- Sensor pads
- Replacement parts
- Other items
- Liquid adhesive and adhesive remover wipes
- Tape, adhesive patches, dressings and film
These items are covered by OptumRx through a retail store/pharmacy, specialty provider or traditional mail-order. Prescriptions are needed to fill requests for these supplies at a $0 copay.
- Syringes and Pens
- Insulin syringes and needles
- Insulin pens and needles
- Meters and Testing Supplies:
- Blood glucose meters
- Test strips, tablets (urine and blood)
- Control solution
- Lancing devices
- Alcohol prep wipes/pads
- Glucagon emergency kits
- Glucose chewable tablets
Members that have not met the clinical guidelines will still have coverage for these items, but with copays, coinsurance and deductibles under the normal provisions of the State of Ohio plan.
When A Brand Name Drug Becomes Generic
When a brand name medication becomes available as a generic, its status is evaluated by OptumRx. In most cases, the generic medication is automatically placed at the Tier 1 copay level and the brand medication is placed in Tier 4.
If this happens to a medication you are currently taking and you choose to continue with the brand name, you will be charged a higher copay. The Tier 4 copay is the Tier 3 copay plus the difference in cost between the brand and generic drug.
Due to the frequency of generics becoming available in the marketplace, these types of changes can occur at any time and without advance notice.
OptumRx Formulary Changes and Drug List
OptumRx Advantage Formulary Reference Guide
The OptumRx Advantage Formulary Reference Guide is a complete version of the OptumRx Formulary. However, changes may occur throughout the year and existing plan rules may override this document. Benefit designs may vary with respect to coverage, quantity limits, step therapy, and other plan design requirements. Click the buttons under “Important Prescription Updates” on this page for more information. You may also contact OptumRx Customer Service at 1-866-854-8850.
Specialty Drug List
OptumRx Website Login Instructions
1. Follow the instructions to register for the first time at OptumRx.com.
2. Type your Member ID from your ID card.
3. Type your password.
To access the online drug pricing tool, click on Price & Save, located on the top of the screen, and enter your prescription information.
Prescription Drug Updates
Anti-Obesity Products – The anti-obesity medications require a prior authorization before receiving this medication.
Maternity Medications – A list of covered medications that can be approved for zero copay via prior authorization from providers.
Smoking Cessation Update
Prescription Drug Program Updates
Utilization Management Program Updates
Clinical Program Updates
OptumRx Direct Member Reimbursement
Use this form to request reimbursement from OptumRx for unpaid prescription drug claims.