Prescription Drug Coverage

Prescription Drug Take Back

The proper disposal of unused or expired drugs is important, particularly as our nation faces an opioid crisis. For more info, call 800-882-9539 or click below.

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Your Prescription Drug Coverage

For many, taking medication to treat disease and improve health is an important part of maintaining health and managing disease. For most Trust members, prescription drug coverage is provided by Optum Rx. The plan provides coverage through a nationwide network of retail pharmacies, as well as a convenient mail-order program.

Medications are assigned to one of three copay categories known as tiers. When you fill a prescription, the copay amount will be based on whether the drug is generic or brand name, the applicable tier of the drug and how the drug is dispensed (retail pharmacy or mail-order). If the cost of the drug is less than your copay, you will only pay the cost of the drug. Copay amounts are established annually and announced in Benefit Highlights.

 

Prescription Drug Copays

Copays

for All Plans

Retail

(one month supply)

Mail Order

(90-day supply)

 Medications are assigned to one of three copay categories called tiers. The copay amount for each prescription order or refill is based on:

Tier 1
(Generic & Covered Immunizations)

 $0 $0  1. Whether the drug is generic or brand name.

Tier 2
(Preferred Brand)

  $33  $33  2. How the drug is dispensed (retail pharmacy or mail order).

 Tier 3
(Non-Preferred Brand)

  $115 $115  

If the cost of the drug is less than your copay, you will only pay the cost of the drug. Copay amounts are established annually and announced in Benefit Highlights.

Payment methods for mail-order prescriptions include check, e-check, money order and credit card. Extended payment options are available. We encourage you to join the Optum Rx automatic payment program to allow for credit card payments and uninterrupted service.

Prescription Drug Coverage with Medicare

The Trust provides a Medicare group-sponsored prescription drug plan (excluding some HMO plans) offered through Optum Rx.

The benefit remains similar to the non-Medicare prescription drug coverage:

  • Three-tier copay structure
  • 90-day mail order program
  • Requirement of prior authorization for certain medications

If you are a Medicare member in the TCN, BCNA, HAP or Humana plan, you will receive a separate ID card for prescription drugs from Optum Rx. You will need to present this ID card when receiving prescription drugs through the retail pharmacy.

For other plans, you will not receive a separate prescription drug ID card. You will continue to show your medical ID card when receiving prescription drugs through the retail pharmacy.

Generic/Brand Name & Retail Pharmacy/Mail-Order Delivery

 

 

Medication Type: Generic or Brand Name?

Generic drugs are nothing new and are widely available and carefully regulated. They offer all the same benefits as their brand-name counterpart at a fraction of the cost.

On average, the cost of a generic drug is 80 to 85 percent lower than the brand-name product.

For the greatest cost-savings to you and the Trust, request that your doctor prescribe a generic drug. In most cases, unless your doctor has indicated “Dispense As Written” or DAW, your prescription will be filled with the generic equivalent.

 
 

Filling Prescriptions: Retail Pharmacy or Mail-Order?

Filling prescriptions at an in-network retail pharmacy is appropriate for short-term needs - you can receive up to a 30-day supply at the retail copay (for example, filling a prescription for an antibiotic). Retail pharmacies are also appropriate for situations in which your physician has not established the suitable drug, strength and dosage for ongoing needs. To locate participating network pharmacies near you, contact Optum Rx by phone or use the online pharmacy look-up tool.

The mail-order option is an easier, more convenient and cost-effective way to get your ongoing prescription medications. By using mail-order, prescriptions are delivered right to your home – plus shipping is free. In most cases, you can order up to 90-days of prescription drugs at once. Using mail-order offers a great savings opportunity, since at most you pay the same as the retail copay for three times the amount of medication.

Note: Non-Medicare members must use mail-order for maintenance medications (medications used for an ongoing basis to treat conditions such as high blood pressure or high cholesterol).

To get started, please call Optum Rx.

Blue Blue Shield Medicare Advantage members: 855-856-0537

Medicare members, TCN, BCN, HAP & Humana: 855-409-0219

Non-Medicare members, ECP, BCN & HAP: 855-409-0219

UnitedHealthcare Medicare Advantage: 844-320-5021

Prescription Drug Claims & Appeals

Always present your medical ID card when at the pharmacy to ensure the correct information is submitted for your claim. If a claim is denied in whole or in part, you have the right to file an appeal.

Please call Optum Rx to appeal the rejection. Optum Rx will contact the subscriber with instructions on submitting clinical information to support the script. For each appeal, the member and provider will both get a letter of the determination.

Claim Filing Deadline

Claims are due within 12 months of the date of service. Claims received after this period will be denied unless you can show it was not possible to provide such notice of claim within the required time and the claim was filed as soon as reasonably possible. 

Notice of Claim Decision/Appeals 

Optum Rx will provide you notice of the claim decision. The notice will be in writing and will inform you of the specific reasons for the decision. It will refer to the specific provisions of the plan on which the denial is based and explain whether any additional information is required from you. Optum Rx will decide your claim within the deadline for the type of claim involved (e.g. urgent claim, prior authorization).

First and second level appeals can be sent to Optum Rx. Please call or write: 

Phone: (888) 403-3398

Write to:

C/O Appeals Coordinator

PO Box 2975

Mission, KS 66201

Complete details on filing a claim or appeal can be found in the Summary Plan Description (SPD).