Save Money on Prescription Needs

Prescription Drug Program


COVID-19 OPTUM COMMUNICATIONS

  • OptumRx, is globally extending Prior Authorizations on medications considered maintenance that are set to expire between 3/17/2020 and 5/1/2020. Expiring PA’s during this timeframe will be extended 90 days. Opioids and infertility medications are not included in this global extension.
  • The UVA Health Plan continues to offer 90-day maintenance medication prescriptions through mail order and at retail pharmacies. There is no service or shipping fee for mail order (home delivery) orders.
  • OptumRx members with active eligibility may obtain an early refill of their prescription medications if they have refills remaining on file at a participating retail or mail-order pharmacy. The refill obtained will stay consistent with the standard days supply previously filled by the member as allowed by their plan (e.g., 30 or 90 day supply). 
Refill Too Soon Policy Revision Coping with a Public health Event

Prescription Drug Program

Participants in the UVA Health Plan automatically have prescription drug coverage managed by OptumRx. Costs for prescriptions vary for Choice, Value, or Basic Health. Therefore, prescription needs and costs are factors to consider when choosing a UVA Health Plan option, as pricing for prescriptions vary based on your health plan option.

More about UVA Health Plans 

What are the costs?

In order for a prescription drug to be covered under UVA’s health plan, it must be listed on the Formulary. View the Premium Formulary to see the prescription drugs covered by the UVA Health Plan. For the most UpToDate formulary log onto the OptumRx site or download the OptumRx app. 

Both generic and brand name prescriptions are offered. There are different pricing tiers that impact your coinsurance amount, (e.g. the percentage you pay of the approved cost after your deductible is met).

Tier categories are listed in the Formulary as Tier 1, 2, 3 or E. Any drug shown as Tier E is excluded from coverage by the UVA Health plan.

Specialty drugs must be purchased from the UVA Specialty Pharmacy and have specific guidelines (e.g. limits on the supply amount).To determine if a medication is classified as a specialty drug, review the Specialty Drug List. (specialty drug must be on Premium Formulary for coverage). 

UVA Pharmacy

Medication prices at the UVA Pharmacy are often less expensive than those at other pharmacies for UVA employees. You can use the number below to contact the UVA Pharmacy for all of your specialty pharmacy needs.

Premiums

Your UVA Health Plan premiums cover prescription drugs as well.

Drugs with No Cost or That do not Have a Deductible

Contraceptive drugs and over-the-counter preventative items mandated by the Affordable Care Act are covered at no cost to employees.

Medications on the Preventive Medication List do not have a deductible. (2019 Preventive list is current)

Costs by Health Plan Option

Basic Health participants have a deductible that applies to both medical and prescription costs. You must pay for covered health care services and prescriptions up to your deductible amount before the UVA Health Plan begins to pay.

Value and Choice Health participants have a deductible that applies to both medical and prescription costs for tier 2 and tier 3 retail drugs. You must pay for covered prescriptions up to your deductible amount before the UVA Health Plan begins to pay for tier 2 and tier 3 retail prescriptions. Tier 1, mail order, and specialty prescriptions are not subject to the deductible.

See deductible information on the UVA Health Plan webpage.

  • Costs for Retail Pharmacies Outside of UVA Pharmacies

    The table below shows costs for retail Pharmacy outside of UVA Pharmacies (such as a CVS, Kroger, etc.) Excludes Specialty Rx and Mail Order Prescriptions

    Tier Choice Value Basic
    1 (Generic, low cost) $6 co-pay
    30-day supply
    $6 co-pay
    30-day supply
    Deductible + 20% for up to 90-day supply
    2 (Brand, Preferred) Deductible + 20%
    $34 min / $150 max
    30-day supply
    Deductible + 20%
    $34 min / $150 max
    30-day supply
    Deductible + 20% for up to 90-day supply
    3 (Brand, Non-Preferred) Deductible + 20%
    $68 min / $225 max
    30-day supply
    Deductible + 20%
    $68 min / $225 max
    30-day supply
    Deductible + 20% for up to 90-day supply
  • Costs for Retail Pharmacies at UVA Pharmacies

    The table below shows costs for retail Pharmacy at UVA pharmacies only, such as UVA, Emily Couric Clinical Cancer Center, UVA Bookstore, Zion Crossroads, and UVA Cancer Center Augusta Pharmacies. Excludes Specialty Rx and Mail Order Prescriptions

    Tier Choice Value Basic
    1 (Generic, low cost) $6 co-pay
    30-day supply
    $6 co-pay
    30-day supply
    Deductible + 20% for up to 90-day supply
    2 (Brand, Preferred) Deductible + 20%
    $Up to $150 max
    30-day supply
    Deductible + 20%
    $30 min / $150 max
    30-day supply
    Deductible + 20% for up to 90-day supply
    3 (Brand, Non-Preferred) Deductible + 20%
    $60 min / $225 max
    30-day supply
    Deductible + 20%
    $60 min / $225 max
    30-day supply
    Deductible + 20% for up to 90-day supply
  • Costs for Mail Order Through Optum RX Home Delivery

    The table below shows costs for Mail Order through Optum Rx Home Delivery. Excludes Specialty Rx and Retail.

    Tier Choice Value Basic
    1 (Generic, low cost) $14 co-pay
    up to 90-day supply
    $14 co-payup to 90-day supply Deductible + 20% for up to 90-day supply
    2 (Brand, Preferred) 15%
    $75 min / $375 max
    up to 90-day supply
    15%
    $75 min / $375 max
    up to 90-day supply
    Deductible + 20% for up to 90-day supply
    3 (Brand, Non-Preferred) 15%
    $150 min / $475 max
    up to 90-day supply
    15%
    $150 min / $475 max
    up to 90-day supply
    Deductible + 20% for up to 90-day supply
  • Costs for Specialty Pharmacy at UVA

    The table below shows costs for Specialty Pharmacy at UVA, available up to 30-day supply; may only be filled through UVA Specialty Pharmacy*

    Tier Choice Value Basic
    1 (Generic, low cost) 20%
    $100 max
    20%
    $100 max
    Deductible + 20%
    2 (Brand, Preferred) 20%
    $150 max
    20%
    $150 max
    Deductible + 20%
    3 (Brand, Non-Preferred) 20%
    $200 max
    20%
    $200 max
    Deductible + 20%

    In limited circumstances, specialty medications can be filled through OptumRX Specialty. UVA Pharmacy must be contacted first. 

How do I use my prescription drug coverage?

UVA Health Plan prescription coverage varies between Basic Health, Value, and Choice plan options. For specific information about prescription coverage and costs, use the following resources:

  • Register at www.OptumRx.com

    The first time you use the OptumRX website, you will need register.

    • Go to www.optumrx.com and click on “Register now”.
    • Follow the prompts to register. You will need your Member ID number (found on your OptumRx card), so have your card handy.
    • Begin using the OptumRx site.
  • Get a prescription drug card

    When you first sign up for the UVA Health Plan, or switch between options, you will receive an OptumRx card by mail. The OptumRx pharmacy card is separate from your Aetna UVA Health Plan medical insurance card.

    To view or print a temporary card, use the following steps:

    • Go to www.optumrx.com, enter your username and password, and click “Sign in.”
    • Select “Benefits and claims” in the top menu and select “ID card” from the dropdown menu.
    • On the ID Card page, select “Print card.”
  • Review your specific prescription benefits

    To see a summary of your specific prescription benefit information (e.g. progress toward your deductible, information about the out-of-pocket maximum), visit OptumRx and follow these steps:

    • Go to www.optumrx.com, enter your username and password, and click “Sign in.”
    • Select “Benefits and claims” in the top menu and select “Benefits information” from the dropdown menu.
  • Find a pharmacy

    UVA employees have the option to use the UVA Pharmacy. Prices at the UVA Pharmacy are often less expensive than at other pharmacies.

    To search for other pharmacies, use the OptumRx pharmacy locator:

    • Go to www.optumrx.com, enter your username and password, and click “Sign in.”
    • Select “Pharmacy Locator.”
    • Follow the prompts to find a pharmacy.

    For medications classified as Specialty Drugs, use the UVA Specialty Pharmacy. See “Get Specialty Drugs” below for additional information.

  • Set up home delivery

    OptumRX offers home delivery for 90-day supplies of some medications at reduced prices. Shipping is free. 

    For more information, or to set up home delivery, use the following steps:

    • Go to www.optumrx.com, enter your username and password, and click “Sign in.”
    • Select “Home delivery.”
    • To learn more about home delivery, click on “What is Home Delivery?” in the introductory paragraph.
    • To order medications for home delivery, follow the prompts.
  • Get medication information and pricing

    The following resources will be helpful:

    • Preventive Prescription Coverage – provides information about preventive medications (e.g. contraceptives or aspirin).
    • Medications Covered by OptumRx – the Premium Formulary lists covered medications, explains how prescription coverage works, and gives specifics requirements (e.g. Specialty Drugs).
    • Exclusions – shows medications that are not covered by OptumRx and provides preferred alternatives.
    • Specialty Drugs – identifies medications classified as Specialty Drugs by OptumRx. For more information, see “Get Specialty Drugs” below.

    You may also research medications, and pricing, on the OptumRx website:

    • Go to www.optumrx.com, enter your username and password, and click “Sign in.”
    • Select “Drug search.”
    • Begin typing the name of the medication you want and select it from the list that appears.
    • On the page for that medication, you may view drug info, pricing, or lower-cost options- if available.
  • Get Specialty Drugs

    Some medications have been classified by OptumRx as Specialty Drugs for a variety of reasons, including: cost, availability, special storage requirements, etc. Specialty Drugs may be subject to quantity limits, require step therapy for users, or require prior authorization.

    To get Specialty Drugs, you must use the UVA Specialty Pharmacy, which can be reached at 434.297.5500 or specialtymedsrx@virginia.edu.

  • Understand Step Therapy

    Certain medications have been classified by OptumRx as part of the Step Therapy Program. This helps to reduce costs for expensive medications by first offering cost-effective alternatives. The Premium Formulary, a list of medications covered by OptumRx, shows if a drug requires Step Therapy.

  • Learn about Quantity Limits

    OptumRx limits the quantities of some covered medications to remain within clinical dosing guidelines. Quantity-limited medications are more likely to be overused, or may be prescribed outside of clinical dosing guidelines. In some cases, there are also specific recommended dosages based on medical guidelines.

    If you are prescribed a medication underneath the quantity limit, it will be covered and no additional steps need to be taken.

    If you are prescribed a quantity-limited medication above the limit, you need to get a prior authorization (see below) for the full prescription.

    See the Quantity Limit Program Frequently Asked Questions for additional information.

  • Get a Prior Authorization

    Some medications require approval before they are covered by OptumRx. These drugs are noted in the Premium Formulary. Prior authorization is required for medications that are more likely to be overused or prescribed outside of clinical dosing guidelines. In some cases, there are specific dosages based on medical guidelines. Prior authorization is required for all specialty drugs.

    If your medication requires prior authorization, OptumRx will contact your doctor to get the necessary information.

    If your request for a prior authorization is denied, you may still fill your prescription - but OptumRx will not cover its usual portion of the costs.

    You may start a prior authorization request online:

    • Go to www.optumrx.com, enter your username and password, and click “Sign in.”
    • Select “Benefits and claims” in the top menu and select “Prior authorization” from the dropdown menu.
    • Select “Start request now”and follow the prompts to request a prior authorization. You may also see the status of in-process requests.
  • Review claims

    You can see your claims history for varying date ranges on the OptumRx website:

    • Go to www.optumrx.com, enter your username and password, and click “Sign in.”
    • Click on “Benefits and claims” in the top menu and select “Claim history” from the dropdown menu.

How do I prepare for out-of-pocket expenses?

To help UVA employees get the most out of your money for prescriptions, medical, dental, vision, and dependent-care expenses, the University offers benefits-related savings and spending accounts. These accounts allow you to put aside money for eligible expenses, by payroll deduction, before taxes.

Visit the UVA Basic Health with Health Savings Account page (HSA) to learn more about the HSA that can be used for prescription and other allowable expenses.

For information about UVA's medical and dependent daycare flexible spending accounts (FSAs), visit the Flexible Spending Account page.

Who do I contact for help?

For questions about UVA Health Plan’s prescription coverage, (prior authorizations, quantity limits, and step therapy), contact OptumRx: