Starting July 1, 2020, OptumRx will lift the on-hold status of their e-prescribing for controlled substances (ECPS) requirement and will no longer fill prescriptions received by hard copy, fax or phone for opioids and other controlled substances. This is an effort to increase patient safety and reduce potential fraud.
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.
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.
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 Formularyfor 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.
UVA Pharmacy: Available to members of all the UVA Health Plan options (Choice, Value, and Basic Health).
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, and specialty prescriptions are not subject to the deductible.
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
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
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:
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.
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.
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.
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.
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.
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.
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.